SAHARA INDIA Vs. REKHA DEY

JUDGEMENT

(1.) The Branch Manager, Sahara India and another (hereinafter referred to as the 'Petitioner') has filed this revision petition against the orders of the State Consumer Disputes Redressal Commission, Tripura (hereinafter referred to as the 'State Commission') in Appeal No.11/2007 which was decided in favour of Rekha Dey, Respondent herein who was the original complainant before the District Forum.

(2.) The facts of the case according to the Respondent/Complainant are that she had converted her investments of Rs.1,17,415/- to the Silver Year Labh Yojna Scheme of the Petitioner on 16.01.2004 and as per the provisions of this Scheme, any person who invests Rs.67,000/- or more can claim and realize insurance coverage upto Rs.10 lakh in respect of critical illness and personal accident. During the subsistence of the policy on 24.03.2004, Respondent experienced chest pain and consulted Dr.Johan Cristopher in the Tripura Super Specialty Hospital, Agartala. After diagnostic tests which included ECG etc. she was diagnosed with critical rheumatic heart disease and advised an operation. Respondent thereafter got admitted to the Department of Cardiothoracic Surgery at the Christian Medical College(CMC) Hospital, Vellore on 01.06.2004 and underwent a mitral valve replacement on 04.06.2004. She was discharged from this hospital on 11.06.2004 with an advice to continue medication. Respondent had informed the Petitioner vide her letter dated 27.04.2004 of the above developments and after the operation she submitted a claim on 29.06.2004 along with relevant documents. However, after reminders, she was finally informed on 31.08.2004 that since mitral valve replacement is not covered under the special contingency policy as critical illness, the claim was repudiated. Since Coronary Artery Surgery is covered as per the Scheme within the definition of critical illness, Respondent was aggrieved by the unjustified decision of the Petitioner to repudiate the claim and therefore, filed a complaint before the District Forum on grounds of deficiency in service and requested that Petitioner be directed to pay her Rs.1,37,106/- for hospitalization and operation expenses at CMC Hospital, Vellore, Rs.11,463/- for the medicines purchased from 01.06.2004 to 18.06.2004, Rs.10,000/- for treatment and tests and Rs.1 lakh as compensation for mental agony with interest @ 12% per annum from 29.06.2004 till realization. Rs.10,000/- were sought as litigation costs.

(3.) The above contentions were denied by the Petitioner who stated that the claim was rightly repudiated because mitral valve replacement per se is not included as a critical illness under the Silver Year Labh Yojna Scheme which only covered coronary artery surgery, cancer, renal failure, stroke, multiple sclerosis and major organ transplant. During the arguments before the District Forum, Counsel for Petitioner also stated that as per the Discharge Summary issued from CMC Hospital, Vellore it appears that the patient was suffering from this disease prior to her having invested the amount in the present policy but she had suppressed this fact since no such declaration was made by her at the time of making the investments.