Haryana

Ambala

CC/381/2016

Nanu Singh Gill - Complainant(s)

Versus

Bajaj Allianz Gen Inss Co. - Opp.Party(s)

Rohin Kumar

28 Feb 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM:

                                                AMBALA

 

                                                Complaint Case No.      :         381 of 2016.

                                                Date of Institution                   :         13.10.2016.

                                                Date of Decision            :         28.02.2018.

 

Nanu Singh Gill aged 68 years son of late Sh.Shiv Charan Singh r/o H.No.76-B Ram Nagar, Ambala Cantt.

………….Complainant.

Versus

1.Bajaj Allianz General Insurance Company Limited situated at 167/8 Hazara Singh Building New Vijay Ratan Chowk, Ambala Cantt.

2.Bajaj Allianz General Insurance Company Limited A-Wing, 2^nd Floor Bajaj Finserv Building, Survey No.208/B-1, Behind Weikfield IT Park, Off Nagar Road, Viman Nagar Pune (Maharashtra) through its authorized sigtnatory.

…………Opposite Parties.

          Complaint Under Section 12 of the Consumer Protection Act.

CORAM:             SH. DINA NATH ARORA, PRESIDENT

                             MS. PUSHPENDER KUMAR, MEMBER

MS. ANAMIKA GUPTA, MEMBER

 

Present: -              Sh. Rohin Kumar, Adv, counsel for complainant.

                             Sh. R.KVig, counsel for the OPs.

                  

ORDER:

 

                             Brief facts of the present complaint are that in the month of May, 2012 the complainant had purchased Travel Care Insurance Policy from OPs bearing No.OG-16-1201-9910-00005226 on 18.12.2015 having validity from 20.12.2015 to 18.03.2016 for covering medical expenses upto $ 50000. The complainant had gone to Australia on 20.12.2016 alongwith his wife Smt.Gurmail Kaur and returned back to India on 11.03.2016. During this tour he stayed at the house of his son. On 01.01.2016 complainant felt severe chest pain for which he took treatment from Dr.Olugbeng A Afilka of Aveley Medical Centre, Perth and spent 1524 Australian Doller. The complainant intimated about this to the OPs and also lodged claim for reimbursement of the amount and also submitted original bills and other necessary documents but it was shocking for him when the insurance company had repudiated his claim vide letter dated 30.03.2016 on the ground that the complainant was having pre-existing disease as he was suffering from hypertension and diabetes Mellitus. The OPs have repudiated his claim on wrong and flimsy grounds despite the fact that he was diagnosed with heart disease and bronchitis for the first time. Before issuance of policy no enquiry was made from the complainant regarding medical history and no medical examination was ever conducted and the signatures of the complainant were obtained on unfilled forms in good faith without giving any opportunity to the complainant to read and understand the nature of terms and conditions of the policy.  The act and conduct of the Ops clearly amounts to deficiency in service and unfair trade practice on their part. In evidence, the complainant has tendered affidavit Annexure CX and documents Annexure C1 to Annexure C18.

2.                          On notice Ops appeared and filed their joint reply wherein it has been submitted that the insurance policy is a contract and both the parties are under obligation to obey all the terms and conditions thereof and the complainant cannot escape his responsibility from the terms and conditions. Relevant Conditions are as under:

2.4 :The Company shall be under no liability to make payment hereunder in respect of any claim directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following”

Condition No.2.4.12: Any medical condition or complication arising from it which existed before the commencement of the policy period, or for which care, treatment or advice was sought, recommended by or received from a physician.

There is no deficiency in service and unfair trade practice on the part of OPs as at the time of obtaining the policy the complainant had concealed the disease which was detected during his treatment at Australia. The claim of the complainant has rightly been rejected as non-disclosure of pre-existing ailment is violation of principle of insurance contract i.e. utmost good faith. The Ops are not guilty of any deficiency in service rather the complainant is guilty of perpetuating fraud. Other contentions have been controverted and prayer for dismissal of the complaint has been made. In evidence, the Ops have tendered affidavit Annexure RA and documents Annexure R1 to Annexure R9.

3.                          We have heard learned counsel for the parties and gone through the case file very carefully.

4.                          The complainant has come with the plea that the OPs have wrongly and illegally repudiated the medical claim (vide letter Annexure C17) submitted on account of his felling ill at Australia for the first time during the subsistence of insurance policy having validity from 20.12.2015 to 18.03.2016 (Annexure C1).

5.                          On the other hand the OPs have come with the plea that the complainant was having pre-existing disease and the present policy was obtained by the complainant after concealing the material facts qua his health from the insurance company. In support of his contentions he drew the attention of this Forum towards Annexure R3 and Annexure R4 i.e. treatment record of the complainant. It has been further argued that the claim has rightly been repudiated as the complainant has violated the terms and conditions of the policy by concealing the material facts qua his health status from the insurance company. In support of his contentions he placed reliance of case law titled as United India Insurance Company Limited Vs. MKJ Corporation III (1996) CPJ 8 (SC), Satwant Kaur Sandhu Versus New India Assurance Company decided by Hon’ble Supreme Court of India on 10.07.2009 in Civil Appeal No.2776 of 2002 and Jai Kishan Vs. LIC (NC) Revision Petition No.1883 of 2015 decided on 12.08.2015.

6.                          Undisputedly the complainant had obtained Travel Policy Annexure C1 from the OPs and he felt ill during the subsistence of the policy and further spent 1524 Austrian Dollar on his treatment. The complainant in his complaint has specifically mentioned that for the very first time he was diagnosed with heart disease and bronchitis and took treatment for the same. It has been further specifically mentioned by the complainant in his complaint that he was not medically examined by the OPs nor any enquiry qua medical status was put to him at the time of issuance of policy in question.  In response to this plea that OPs remained mum whether the complainant was medically examined or not before issuing the Travel Policy (Annexure C10), therefore, the Ops are ceased to take such plea that the complainant was having pre-existing disease of Hypertension besides diabetic problem. It is strange that the Ops have repudiated the claim of the complainant without producing any previous medical history of the complainant, though the Ops have produced on the case file claim summary (Annexure R1) but it is not enough to deny the claim of the complainant. Moreover, it is quite surprising that, no where it was stated that, the duration of diabetes/hypertension that how long the complaint was suffering. Therefore, it appears to be a just vague, which did not carry any evidentiary value.  Even also, the OPs did not produce any evidence to prove that which medication and for how long the complainant was taking for diabetes/hypertension. The counsel vehemently argued that, diabetes and hypertension are chronic diseases, having long duration. It is known that, many times the healthy persons are unaware of such silent aliments of diabetes and hypertension, which come to their knowledge first time during health checkup camps or in any emergent situation. Thus, OPs can not apply a hard and fast rule to presume that, the complainant was suffering for long duration i.e. before taking the policy. Therefore, we are not convinced with this argument. No doubt the medical literature states that, the Hypertension and Diabetes are risk factors for Coronary Artery Disease, but the OPs failed to prove that those diseases were pre-existing in this case. It was just a hypothetical presumption of OPs to repudiate the claim of complainant. Such argument is bereft of any merit and has no medical basis. The verdict made in the case laws relied upon by learned counsel for the OPs is not disputed but it is not applicable to the present case, therefore, same are being distinguished.

7.                          Keeping in view the above discussion as well as facts and circumstances of the case we are of the considered view that the complainant has been able to prove his case against the Ops by leading cogent and reliable evidence. The Ops have wrongly and illegally declined the genuine claim of the complainant, therefore, the repudiation letter 30.07.2018 (Annexure C18) is hereby quashed. Accordingly, we allow the present complaint with cost which is assessed at Rs.5,000/-. The OPs are also directed either to pay 1524 Austrian Dollar or the amount equally to Indian Rupees alongwith interest @ 9% per annum  to the complainant from the date of filing of the complaint till its realization. Copy of this order be sent to the parties concerned, free of costs.  File be consigned to the record room after due compliance. 

Announced on: 28.02.2018    

                                                                                                                   

 

(Pushpender Kumar)    (Anamika Gupta)                      (D.N.Arora)

Member                         Member                             President

                                                                   District Consumer Disputes                                                                                 Redressal Forum, Ambala.