DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.
Complaint No. 291
Instituted on: 20.06.2017
Decided on: 18.10.2017
Balinder Singh Dhaliwal S/O Ujjagar Singh R/O # 319, Ward No.8, Preet Vihar colony, Dhuri, District Sangrur 148024.
…Complainant
Versus
1. Axis Bank Limited, Ward No.17, Ground Floor, Dhuri, District Sangrur through its Branch Manager.
2. TATA AIG General Insurance Company Ltd. Peninsula Business Park, Tower A, 15th Floor, Ganpatrao Kadam Marg, Lower Parel, Mumbai 400 013 through its National Head Operation and Systems.
..Opposite parties.
For the complainant : Shri Harpreet Singla, Adv.
For Opp.Party No.1 : Shri N.S.Sahni, Adv.
For Opp.Party No.2 : Shri Ashish Garg, Adv.
Quorum: Sukhpal Singh Gill, President
Sarita Garg, Member
Vinod Kumar Gulati, Member
Order by : Sukhpal Singh Gill, President.
1. Shri Balinder Singh Dhaliwal, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant is having a saving bank account number 915010025246027 with the OP number 1 and as such in the month of December 2014 the complainant purchased an insurance policy bearing number 0200337885 of OP number 2 through OP number 1 namely family floater plan by paying the requisite premium of Rs.14642/- under which the complainant and his wife were covered for Rs.4,00,000/- for the period from 1.1.2015 to 31.12.2015.
2. The case of the complainant is that during the subsistence of the insurance policy on 19.6.2015, when the complainant was coming from Barnala to Dhuri in his car, suddenly the car met with an accident near village Sekhan and the car struck with the kikkar tree, as such the complainant was got admitted in the Civil Hospital, Barnala and thereafter he was referred to Satgur Partap Singh Apollo Hospital, Ludhiana, where he was diagnosed a case of multiple rib fractures and multiple lacerations over limbs and remained admitted from 19.6.2015 to 23.6.2015 in the hospital, where he spent an amount of Rs.1,11,915/-. The complainant also got lodged the DDR number 22 dated 24.6.2015. But the grievance of the complainant is that the OP number 2 repudiated the claim of the complainant on the ground that he was suffering from some liver disease due to intake of alcohol and opium. As such, the complainant has averred in the complaint that the Ops have wrongly repudiated the claim without assigning any reason. Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.1,11,915/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.
3. In reply of complaint filed by OP number 1, it is admitted that the complainant obtained the policy in question. However, it is stated that as per the law, the complainant is bound to disclose his earlier disease at the time of getting the policy. However, it is stated that the matter in dispute is between the complainant and OP number 2 and the premium was received by OP number 2. However, any deficiency in service on the part of OP number 1 has been denied.
4. In reply filed by OP number 2, legal objections are taken up on the grounds that the OP number 2 has been dragged into unnecessary litigation, that there are complicated questions of law and facts and that the complaint is not maintainable. On merits, it is admitted that the policy in question was issued in favour of the complainant for the period from 1.1.2015 to 31.12.2015 for Rs.4,00,000/- on floater basis. It is stated that the complainant had met with an accident on 19.6.2015 and pre authorisation request was raised by Satgur Pratap Singh Apollo Hospital Ludhiana for providing cashless approval to the TPA , but as per the pre authorisation request and the documents submitted along with the request, the complainant had h/o liver cirrhosis with portal and hypertension and further it was observed that the complainant had not disclosed the fact that he was suffering from liver cirrhosis whilst preferring present policy with the OP and the complainant was under the influence of alcohol at the time of accident. As such, it is stated that the claim of the complainant has rightly been repudiated. The other allegations levelled in the complaint have been denied in toto.
5. The learned counsel for the complainant has produced Ex.C-1 to Ex.C-17 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OP number 1 has produced Ex.OP1/1 affidavit and closed evidence. The learned counsel for OP number 2 has produced Ex.OP2/1 to Ex.OP2/9 copies of documents and affidavit and closed evidence.
6 We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.
7 It is an admitted fact between the parties that the complainant availed the services of OP number 2 by getting a medical insurance policy for Rs.4,00,00/- for the period from 1.1.2015 to 31.12.2015. It is also not in dispute that the complainant met with an accident near village Sekhan during the subsistence of the insurance policy on 19.6.2015, as is evident from the copy of DDR on record as Ex.C-10. It is also admitted fact that the complainant took treatment from Satgur Partap Singh Hospital Ludhiana and remained admitted for the period from 19.6.2015 to 23.6.2016 and spent an amount of Rs.1,11,915/- and thereafter submitted the bills to the OP number 2 for reimbursement. But, the grievance of the complainant is that the OP number 2 repudiated the claim of the complainant on the ground that he was suffering from pre existing disease and as such the claim is not payable. The learned counsel for the complainant has contended vehemently that no medical tests were required under the policy and as such no medical test was done before issuance of the policy and it does not seem to be fair in the mouth of the OP number 2 that the complainant was suffering from any pre existing disease when there is no conclusive proof on record. It is contended further by the learned counsel for the OP number 2 that the policy of the complainant was cancelled vide letter dated 5.9.2015, but the fact remains that the accident of the complainant took place on 19.6.2015 and he remained admitted in the above said hospital upto 23.6.2015, as such, we feel that at the time of the accident of the complainant on 19.6.2015, the policy in question was in existence. We have also perused the copy of proposal form Ex.OP2/1, but it does not show that the complainant was suffering from any pre existing disease at the time of taking the insurance policy in question. It is further worth mentioning here that though the OP number 2 has produced on record the copy of certificate dated 23.6.2015 as Ex.OP2/5 issued by the doctor of Satguru Partap Singh Apollo Hospital, whereby it has been clearly mentioned that the complainant while driving the car lost the control over the vehicle and hit a tree and he was not an alcoholic at that time. It is further mentioned in the certificate that the complainant was suffering from liver cirrhosis and portal hypertension along with HCV reactivity for which he had been on medical management in the past. But, no such evidence showing that the complainant was under the treatment in past has been produced on record. No affidavit of such a doctor, who issued the certificate is on record. The same view has also been taken by the Bihar State Commission in SBI Life Insurance Co. Ltd. versus Baijnath Tanti 2017(3) CLT 174, wherein it has been held that the onus of proving the pre existing disease if any of the life assured lies on the insurance company. The Ops have not produced the original documents of the treatment card of the life assured prior to take the policy and evidence on affidavit has not been taken of the doctor who treated the life assured and further held that the reason for repudiation has not been substantiated and there is no evidence to prove the allegations which is essential under section 13 of (4) of the Consumer Protection Act, 1986. As such, we feel that this certificate has no value in the eye of law. In the circumstances of the case, we feel that the Op number 2 has illegally and arbitrarily repudiated the rightful claim of the complainant.
8. The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.
9. Accordingly, in view of our above discussion, we allow the complaint and direct the OP number 2 to pay to the complainant an amount of Rs.1,11,915/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 20.06.2017 till realisation. We further order the OP number 2 to pay to the complainant an amount of Rs.5000/- on account of litigation expenses.
10. This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.
Pronounced.
October 18, 2017.
(Sukhpal Singh Gill)
President
(Sarita Garg)
Member
(Vinod Kumar Gulati)
Member
