Delhi

East Delhi

CC/581/2014

SACHIN - Complainant(s)

Versus

BAJAJ ALL. INS. - Opp.Party(s)

27 Oct 2014

ORDER

           DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi

              CONVENIENT SHOPPING CENTRE, 1^st FLOOR, SAINI ENCLAVE, DELHI 110092  

 

                                                                                                   Consumer complaint no.-      581/2014

                                                                                                   Date of Institution               26/06/2014

                                                                                                   Order reserved on               26/10/2016        

                                                                                                   Date of Order                        27/10/2016                                                                                     

 

In matter of

Mr Sachin Singhal, adult   

s/o Sh Dev Raj Singhal    

R/o- 619/C, 2^nd Floor, Nr Shiv Mandir

Shastri Gali, Pandav Nagar,

Vishwas Nagar, Shadara, Delhi 110032………………...…………….Complainant

                                                                    Vs

1-Bajaj Allience General Insurance Co. Ltd.  

28, 12^th Floor, Barakhamba Road,

New Delhi1

 

2- Bajaj Allience General Insurance Co. Ltd.  

208 B-1, Bajaj Finserve Building,

B/h Weikfield IT Park,

Off Nagar Road, Viman Nagar, Pune-411014 ..……….…………..Respondents

 

Complainant’s Advocate          In Person    

Opponent 1 & 2 Advocate       Sujeet Kesari

 

Quorum   Sh Sukhdev  Singh       President

                  Dr P N Tiwari                Member

                  Mrs Harpreet Kaur      Member                                                                                              

 

Order by Dr P N Tiwari  Member 

 

Brief Facts of the case …Complainant’s brother was having mediclaim policy from OP since 2004 and over 8 years, he was having policy without break and had not taken any claim.

 

 

In the present policy, vide no. OG-13-1101-8401-00000103, having its tenure from 21/04/2013 to 20/04/2014, his brother’s (Manish Singhal, insured) health got deteriorating, so was admitted at St Stephens’ Hospital, Tis Hazari, Delhi. He requested for cashless from OP, which was denied. After paying hospital bill, he claimed from OP, which was rejected on 27/02/2014. OP also sent a policy cancellation letter. Complainant sent its reply to CEO on email by stating correctness of policy with claim on 21/03/2014. He received reply from OP on dated 25/03/2014. Complainant also sent request to continue his policy on 20/04/2014, which was not done. Hence, this filed this complaint praying for renewal of policy with compensation of Rs 2,50,000/- and mental harassment Rs 1,50,000/-and additional compensation of Rs 50,000/- for accident caused fracture in his hand. He had also claimed Rs 5,000/- as litigation charges.

Notices were served. OP submitted their reply on behalf of OP 1 & 2. OP denied all the facts of complaint on the ground of non disclosure of material facts. OP stated that the present complainant was not maintainable for having no contractual relation with the complainant. As far as, claim under policy bearing no. OG-14-1101-8401-00000132 in question, complainant was neither insured nor a claimant but a proposer in the said policy.  So, proposer was not a claimant as he had no insurable interest. OP submitted all the policy zerox marked here as RW1/1-8. The complainant had suppressed material facts intentionally and willfully, which were brought out by their investigator that insured / Manish Singhal had past history of Post urethral valve ablation, done on dated 28/05/1993 which was beyond the policy inception. The hospital discharge summary reads as “patient was a chronic smoker and chronic alcoholic for the past 5-7 years. The insured Manish Singhal had never declared these facts in his policy proposal form at the time of taking policy from OP. OP had submitted their investigation report, marked here as RW1/4. OP issues policy to its policy seekers on the principle of “Uberrima fides” basis. But after claim investigation report, it was found that all the material facts and information had been hidden by insured.  The stated facts about his health were declared by himself and declaration was signed. So, on the basis of investigation report, hospital documents and treatment details, OP has invoked the cancellation clause and had sent a intimation letter also as per requirement of 15 days which complainant had stated in his complaint also.  The policy cancellation letter was sent on 26/02/2014 as per IRDA rules and not receiving its reply from insured, policy was cancelled.  OP stated further that their act was totally based on the terms and conditions of the policy and based on the declaration signed by insured.  There was deliberately non disclosure of material facts about his past health history which were violating the basic principle of Insurance. So, OP requested for dismissal of this complaint.

 

Complainant did not file his rejoinder and evidences on affidavit, OP submitted their evidences, which were on record.  Despite of serving notices for arguments, complainant did not appear. OP was present. Arguments heard and order reserved.   

We have gone through all the facts and evidences on record and observed that under this mediclaim policy, present complainant is neither insured nor claimant, but he is a proposer of the policy. So, he cannot be a claimant or entitled to take benefit from OP. More so, even complaint and affidavit is not signed by the claimant.

 

By going through all the policies zerox on record, it has been noted that insured had CB zero though mediclaim policies were in continuity, but complainant had not disclosed any facts pertaining to previous claims or about his brother’s health. This clearly showed that the version submitted by OP was correct as complainant had intentionally hidden material facts before the OP and us.

Even policy proposal form marked as Ex RW5 reading under clause 7 (a) which clearly asked about any ailment or treatment pertaining to urinary tract or kidneys has ever suffered in past by person seeking policy, the policy seeker had ticked NO and had signed  declaration on date 18/04/2009.

In addition to this, after going through discharge summary, under Diagnosis as “CKD Stage IV (bilateral contracted kidneys) with LV dysfunction LVF 40%, Anemia of chronic disease.” All these mentioned ailments are the complications of Chronic Kidney disease where both the kidneys are contracted and having poor functions. All the complications and treatment of multiple ailments due to kidneys were known to him prior taking mediclaim policy from OP as these ailments are of very log duration. This clearly proves that rejection of claim and cancellation of mediclaim policy by OP for insured/ brother of complainant, was justified.

Therefore, complainant has failed to prove OP’s conduct deficient nor dealing in unfair trade practice during their course of claim processing.

Hence, we come to the conclusion that the complainant is neither entitled for any such claim from OP nor entitled for renewable of cancelled policy as insured had violated the terms and conditions of the mediclaim policy besides submitted wrong facts before OP for taking benefit after hiding material facts. So, based on facts and evidences, there is no merit in this complaint and deserve to be dismissed with cost; so dismissed with cost of Rs 2000/ to be deposited in the Consumer Legal Aid account of this Forum.

The copy of this order be sent to the parties as per Act and file be consigned to the Record Room.

 Mrs Harpreet Kaur- Member                                    (Dr) P N Tiwari – Member                                                          

                                       

                                           Mr Sukhdev Singh - President