- (1.) THIS appeal is directed against order dated 23.08.2012 of District Consumer Disputes Redressal Forum, Durg (C.G.) (herein after called "District Forum" for short), passed in Complaint Case No. 206/2011, whereby the appellant/Insurance Company, has been directed to pay Rs.40,000/ - to the complainant/ respondent No. 1, alongwith interest @ 7% p.a. from the date of filing of the complaint till date of payment and also to pay Rs.1,000/ - as compensation for mental agony and Rs. 1,000/ - as cost of litigation, on the allegation that it committed deficiency in service in not paying the amount spent by the complainant/respondent No. 1 on his treatment, though he was covered by a medical insurance policy issued by the appellant/Insurance Company 'in favour of the agents of a group of the respondent Nos.2 & 3/Insurance Corporation.
(2.) IN nutshell, the facts of the case are that in the year 2005 -06, Mediclaim Insurance Policy for a period between 01.09.2007 to 31.08.2008 was issued by the appellant/Insurance Company in favour of the Agents of respondent Nos.2 and 3/ Insurance Corporation, who were members of Club for the year 2005 -06 of the Agents. Complainant/ respondent No. 1 was also agent of the Insurance Corporation in that year and was covered under the aforesaid insurance policy. He all of sudden felt chest pain on 10.02.2008, then he was admitted to Apollo Hospital, Bhilai, where he was treated from that day to 14.02.2008 and was required to spend an amount of Rs.1,25,470/ - on treatment. On completion of the treatment, a claim was filed before the Insurance Corporation, alongwith all necessary documents on 25.02.2008 which was sent by the Insurance Corporation to the appellant/Insurance Company on 27.02.2008. The claim was sent for settlement to Medi Assist India Pvt. Ltd. Bangalore, who was T.P.A. for such medical claims, but thereafter claim was not settled. therefore, a consumer complaint was filed before District Forum, seeking compensation from the appellant/Insurance Company.
(3.) APPELLANT /Insurance Company in the written version refuted allegation of deficiency in service and averred that in the discharge summary of the complainant/respondent No. 1, it has been mentioned that he was suffering from Hypertension for four years and heart disease was result of that disease of Hypertension. This fact was not mentioned by the complainant/respondent No. 1 in the proposal form, therefore, the claim was not paid. District Forum, did not agree with the defence taken by the appellant/Insurance Company and allowed the complaint by directing the appellant/Insurance Company to pay sum assured Rs.40,000/ - alongwith interest, compensation for mental agony and cost of litigation.;