STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
U.T., CHANDIGARH
Appeal No. | : | 147 of 2022 |
Date of Institution | : | 27.10.2022 |
Date of Decision | : | 22-12-2022 |
- The Star Union Dai-ichi Life Insurance Company Ltd. SCO 830 (FF), NAC, Manimajra, Chandigarh 160101.
2. The Star Union Dai-inchi Life Insurance Co. Ltd. SCO 830, (FF), NAC, Manimajra, Chandigarh 160101, both through its authorized signatory Mr.Karun Battar, Vice President, Legal and compliance, available at 11th & 10th Floor, Vishwaroop IT Park, Plot No.34,35 & 36th of IIP, Vashi, Navi Mumbai-400703.
…Appellants
V e r s u s
Awadhesh Singh S/o Sh. Arjun Singh, presently residing at # 15, near Railway Station, Village Daria, Chandigarh 160101 ...Respondent
Appeal under Section 41 of the Consumer Protection Act, 2019 against order dated 31.08.2022 passed by District Consumer Disputes Redressal Commission-II,U.T. Chandigarh in Consumer Complaint No.1002/2019.
BEFORE: JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT
MRS. PADMA PANDEY, MEMBER
Mr.RAJESH K.ARYA, MEMBER
Mr.PREETINDER SINGH,MEMBER
Present : Sh.Sanjeev Goyal, Advocate for the appellants.
PER PADMA PANDEY, MEMBER
This appeal is directed against the order dated 31.08.2022, rendered by the District Consumer Disputes Redressal Commission-II, U.T. Chandigarh (hereinafter to be referred as “the Ld. Lower Commission”), vide which, it allowed the complaint bearing No.CC/1002/2019 and directed the Opposite Parties in the following terms;-
- To refund sum assured of Rs.5.27 lakhs to the complainant.
- To pay to the complainant Rs.15,000/- as compensation for mental agony and harassment.
- To pay to the complainant Rs.10,000/- as costs of litigation. This order has been ordered to be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they have been made liable to pay an additional amount of Rs. 5000/- to the complainant.”
2. Before the Ld. Lower Commission, it was case of the complainant/respondent that he purchased Health Insurance Policy bearing No. 00968614 from the Opposite Parties/appellants commencing from 31/5/2016 for a sum assured of Rs.5.27 lakhs @ monthly premium of Rs.2126/- which are being regularly paid. The policy was valid for 10 years and as per policy terms, the amount equal to 100% of sum assured was payable on claim. In September 2018, the complainant suffered health problem regarding urinary disorder and remained admitted at Chanakya Hospital, Patna from 27.9.2018 to 6.10.2018. During hospitalization the complainant incurred Rs.80,000/- towards medicines and treatment etc. After discharge from Chanakya Hospital, Patna, on 6.10.2018, he stayed at Hotel and again felt uneasiness. On 8.10.2018, he was taken to Indira Gandhi Institute of Medical Sciences, Patna where he remained admitted from 19.12.2018 to 31.12.2018. He incurred medical expenses of approximately Rs.1.00 lakhs including medicine, treatment as well as hotel expenses etc. at IGIMS, Patna. Thereafter, he submitted the claim form with requisite documents to the opposite parties on 08.05.2019 and also to the surveyor appointed by the insurance company on 26.07.2019. However, the opposite parties illegally repudiated the claim vide letter dated 8.8.2019. Alleging deficiency in service and unfair trade practice on the part of the Opposite Parties, a consumer complaint was filed before the Ld. Lower Commission.
3. The Opposite Parties/appellants in their joint written reply before the Ld. Lower Commission admitted that the complainant took the insurance policy No. 00968614 viz. ‘SUD Life Aarogyam Plan’ from the company and that the complainant was treated for urinary Tract Infection with urosepsis with Urethral Stricture with Type-II Diabetes Mellitus with Bilateral Hydrocele. However, it was pleaded that the said ailment was not covered as per the list of critical illness mentioned in the policy and, they are liable to pay the sum assured. It was further stated that the complainant was provided a free look period of 30 days from the date of receipt of the policy, to opt or to cancel the policy, in case there was any discrepancy in the policy. However, the complainant failed to approach within the free look period with any grievances with respect to the terms and conditions of the policy, thereby implying that the terms and conditions of the policy were in order. On 27.5.2019, the complainant submitted claim stating that he was admitted in Chanakya Hospital Patna for treatment of Urinary disorder form 27.09.2019 to 06/10.2018 and, thereafter, form 8.10.2019 to 31.12.2018 in Indira Gandhi Institute of Medical Sciences, Patna. It was further stated that the parties to the said contract were bound by its terms and conditions. By denying remaining allegations, it was pleaded that there was no deficiency in service on their part and a prayer was made for dismissal of the complaint.
4. On appraisal of the pleadings, and the evidence adduced on record, Ld. Lower Commission allowed the Complaint of the Respondent/ Complainant, as noticed in the opening para of this order.
5. Aggrieved against the aforesaid order passed by the Ld. Lower Commission, the instant Appeal has been filed by the Appellants/Opposite Parties.
6. We have heard Learned Counsel for the appellants, and have gone through the evidence and record of the case with utmost care and circumspection.
7. The main ground, in the appeal, taken by the appellants is that the respondent/complainant was treated for urinary tract infection with urosepsis with Urethral stricture with Type-II Diabetes mellitus with bilateral Hydrocele which disease is not covered under the ailments given in the list of 40 critical illness as defined in the Policy document Annexure-I. The other grouse of the appellants is that the Ld. Lower Commission, on one hand, held that the claim of the complainant does not fall with the parameters of the terms and conditions of the policy, and on the other hand, it held that the claim has been wrongly and illegally rejected.
8. This Commission finds that while allowing the complaint partly, the Ld Lower Commission in para-6 of the impugned order observed as under ;
“Pertinently, all the major/critical and ailment(s) are covered under the terms and conditions of the insurance policy issued to the LA. However, to our astonishment the claim of the complainant submitted alongwith requisite documents with the OPs for release of the sum assured to the tune of Rs.5,27,000/- under the insurance policy on account of the treatment of the ailment i.e. urinary disorder for which the complainant took the treatment from the hospitals aforesaid has been rejected. In our considered opinion, the claim of the complainant does not fall within the parameters of the terms and conditions of the insurance policy and has wrongly and illegally been rejected by the OPs vide letter dated 08.08.2019. By rejecting the genuine claim of the complainant, the OPs have committed deficiency in service.
To our surprise, after holding that the claim of the complainant does not fall within the parameters of the terms and conditions of the insurance Policy, the Ld.Lower Commission still allowed the complaint partly and granted relief, as noted in the opening para of this appeal.
9. In these facts and circumstances of the case, this Commission feels it appropriate to remand back the matter to the District Commission-II, U.T.Chandigarh, to adjudicate afresh and give a specific finding in the consumer complaint. It is made clear that since the consumer complaint pertains to the year 2019, it should be decided expeditiously.
10. In view of the above discussion, this appeal is accepted and the impugned order is set aside. The case is remanded back to the Ld. Lower Commission for deciding the same afresh and give a specific finding.
11. Certified copies of this order be sent to the parties free of charge.
12. The file be consigned to Record Room, after completion.
Sd/-
( RAJ SHEKHAR ATTRI)
PRESIDENT
Sd/-
(PADMA PANDEY)
MEMBER
Sd/-
(RAJESH K.ARYA)
MEMBER
Sd/-
(PREETINDER SINGH)
MEMBER
Pronounced
22.12.2022
Js
