BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.231 of 2014

Date of Instt. 11.07.2014

Date of Decision :02.03.2015

Anthony Varghese aged about 56 years R/o House No.407, Guru Gobind Singh Avenue, Near Trinity College, Jalandhar City.

..........Complainant

Versus

1. Bajaj Alliance General Insurance Company Ltd, through its Manager, 2nd Floor Satnam Complex, BMC Chowk, GT Road, Jalandhar City.

2. Bajaj Alliance General Insurance Company Ltd, through its authorized signatory, Regd.Office GE Plaza, Airport Road, Yerwada, Pune-411006.

.........Opposite parties

Complaint Under Section 12 of the Consumer Protection Act.

Before: S. Jaspal Singh Bhatia (President)

Ms. Jyotsna Thatai (Member)

Sh.Parminder Sharma (Member)

Present: Sh.DS Dhillon Adv., counsel for complainant.

Sh.Raman Sharma Adv., counsel for opposite parties.

Order

J.S Bhatia (President)

1. The complainant has filed the present complaint under section 12 of the Consumer Protection Act, against the opposite parties on the averments that the complainant has taken family medical insurance claim policy on 4.12.2012 having policy No.OG-13-1202-8409-00000016 from opposite party and secured himself and other family members for Rs.2 Lacs cover in case of any medical urgency. The said policy was renewed on 18.3.2014 and new policy was issued to the complainant bearing No.OG-14-1202-8409-00000103 vide which the complainant, his wife Lizy Anthony, sons Robert Anthony and Albert Anthony all were covered under this policy for medical purpose. While issuing above mentioned policy and its renewal, complainant who was principal applicant for the policy was, medically checked. At the time of execution of the above mentioned policy, the agent of the opposite party has specifically mentioned that in case of any medical treatment of any member of the family who are covered under this policy, will be treated free of cost upto a sum of Rs.2 Lacs. Unfortunately, the wife of the complainant Lizy Anthony suffered from heart disease and got admitted in Tagore Hospital and Heart Care Centre Pvt Ltd on 27.3.2014, where she has undergone heart surgery and discharged from the hospital on 29.3.2014. During the treatment, the complainant has spent almost Rs.1,75,000/-. After that the complainant has made a claim before the opposite party. On 29.4.2014 a person came from the office of opposite party for verification for the claim made and he took all the statements and relevant documents as required by him for claim purpose. Out of sheer surprise, the complainant had received a telephonic call from the same person who has taken the statement and relevant documents, who demanded Rs.10,000/- to clear the verification report in order to process for the claim settlement. After hearing the same from the person of the opposite party, the complainant was traumatized. The opposite party even sent a registered letter dated 22.5.2014 to the complainant regarding the cancellation of policy mentioned above to which the complainant had even sent a reply on 31.5.2014 mentioning the above mentioned demand and stating all the facts. However, opposite party refused to accept the claim and informed the complainant that as per the verification from the hospital concerned, they came to know that the patient (Lizy Anthony) was a diabetic from last 15 years. So the claim is not acceptable. On such like averments, the complainant has prayed for directing the opposite parties to pay Rs.2 Lacs to him. He has also demanded Rs.50,000/- as compensation and Rs.10,000/- as litigation expenses.

2. Upon notice, opposite parties appeared and filed a written reply pleading that the complaint is not maintainable against the Bajaj Allianz General Insurance Co.Ltd/opposite parties No.1 and 2. Insured Lizy Anthony was suffering from Diabetes Mallitus from 15 years and no medication. The treating Dr.Nitish Garg of Tagore Hospital and Heart Care Centre, Jalandhar in answers of questionnaire for treating doctor with regard Health Claim of patient/insured Lizy Anthony has specifically mentioned that the insured was suffering from Diabetes for last 5 years. The said document is duly signed with seal of the doctor. In admission note also, it has been mentioned that the history of Diabetes Mellitus from last 15 years. The insurance policy also does not cover any expenses incurred on investigations and treatment of any illness which is diagnosed or was diagnosable during first 30 days of the first year policy. It is submitted that the policy No. OG-14-1202-8409-00000103 for the period 18.3.2014 to 17.3.2015 is not renewal of the previous policy bearing No. OG-13-1202-8409-00000016, but a fresh policy as the previous policy had expired in December 2013 and insurance policy issued after a gap is considered as fresh policy. However, it is pertinent to mention that the each insured including patient Lizy Anthony was insured up to maximum limit of Rs.50,000/- and without admitting any liability it is submitted that had there been any liability, it would had been at the most Rs.50,000/-. They denied other material averments of the complainant/

3. In support of his complaint, learned counsel for the complainant has tendered affidavit Ex.CA alongwith copies of documents Ex.C1 to Ex.C9 and closed evidence.

4. On the other hand, learned counsel for opposite parties has tendered affidavit Ex.OA alongwith copies of documents Ex.O1 to Ex.O5 and evidence of opposite parties was closed by order.

5. We have carefully gone through the record and also heard the learned counsels for the parties.

6. Complainant has himself produced the earlier policy Ex.C1 which was valid from 4.12.2012 to 3.12.2013. The complainant has also produced the policy in question Ex.C2 which was issued on 24.3.2014 and was valid from 18.3.2014 to 17.3.2015. Now the question which falls for determination is whether policy in question Ex.C2 is to be considered as fresh policy or renewal of earlier policy which expired on 3.12.2013? Counsel for the complainant contended that policy Ex.C2 has been issued as renewal to the previous policy. On the other hand, it has been contended by learned counsel for the opposite parties that the policy in question Ex.C2 was issued after more than 3-1/2 months after the expiry of the previous policy and policy in question is fresh policy and can not be considered as renewal of the old policy. We have carefully considered the contentions advanced by learned counsel for both the parties. In the policy in question Ex.C2 in the coloum of first policy inception date 18.3.2014 is mentioned which clearly proves that policy Ex.C2 was issued as a fresh policy and not as renewal of the old policy. However, in order to satisfy ourselves, the opposite party insurance company was directed to produce proposal form of the fresh policy Ex.C2 and opposite party insurance company produced the same on record. In case, the policy in question Ex.C2 has been issued as renewal to the earlier policy then there was no need of got filling fresh proposal form. The fact that fresh proposal form was got filled at the time of issuing policy Ex.C2 also tends to prove that it was issued as a fresh policy. There was a gap of more than 3-1/2 months in the previous policy and in the policy in question Ex.C2. Counsel for the complainant contended that proposal form produced by opposite party insurance company is forged one. There is nothing on record to come to this conclusion. Ex.O2 are terms and conditions of the policy. Condition No.5 of the policy lays down as under:-

"Any medical expenses incurred for any illness diagnosed or diagnosable within 30 days of the commencement of the policy period except those incurred as a result of accidental bodily injury. This exclusion shall apply only to the extent of the amount by which the limit of indemnity has been increased if the policy is a renewal without break in cover".

7. So from this condition it is evident that any medical expenses incurred for any illness within 30 days from the commencement of the policy except as a result of accidental body injury are not payable. In the present case, the policy commenced on 18.3.2014 and according to the own version of the complainant his wife suffered heart disease and was admitted in Tagore Hospital on 27.3.2014 i.e within 30 days of the inception of the policy. So as per above condition the claim is not payable. Counsel for the complainant has relied upon Union of India Vs.Smt.Kamla Devi, 1998(3) RCR (Civil) 671, IFFCO TOKIO General Insurance Company Ltd Vs. Permanent Lok Adalat (Public Utility Services), Gurgaon and others, 2012(1) RCR (Civil) 901, M/s Narne Construction P.Lvt etc Vs. Union of India and Ors, 2012(3) RCR (Civil) 127, New India Assurance company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) 111. We have carefully considered the above authorities relied upon by the learned counsel for the complainant but the same are on different facts and in different context. In the present case, the claim is not payable as per condition No.5 of the terms and conditions of the policy as medical expenses incurred by complainant in respect of illness of his wife are within 30 days from the commencement of the policy period. The complainant has himself produced terms and conditions which are attached with the earlier policy Ex.C1. So he can not say that he was not aware about the terms and conditions of the policy. So opposite party insurance company has rightly repudiated the claim of the complainant vide letter dated 21.5.2014 Ex.O3 of this ground.

8. In view of above discussion, we hold that there is no merit in the present complaint and same is hereby dismissed with no order as to cost. Copies of the order be sent to the parties free of costs under rules. File be consigned to the record room.

Dated Parminder Sharma Jyotsna Thatai Jaspal Singh Bhatia

02.03.2015 Member Member President