Haryana

Ambala

CC/182/2019

Gian Chand - Complainant(s)

Versus

Bajaj Allianz Gen Insurance Co LTd - Opp.Party(s)

Ms Hans Kumari Pali

05 Oct 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

 

                                                          Complaint case no.         :    182 of 2019

                                                          Date of Institution           :     27.05.2019

                                                          Date of decision     :     05.10.2021.

 

          Gian Chand son of late Sh. Ram Lal, resident of # 77, Kumhar Mandi,       Ambala Cantt.

                                                                             ……. Complainant.

 

1.       Bajaj Allianz General Insurance Co. Ltd., Bajaj Finserv, 3^rd Floor, Survey, 208/1-B, Bajaj Finserv, Viman Nagar, Pune-411014 through its Authorized Signatory.

          Second Address :- GE Plaza, Airport Road, Yerwada Pune 411006,

2.       Bajaj Allianz General and Life Insurance Company Ltd., Pary Hotel, Opp. First Floor, Staff Road, Ambala Cantt 133001, through Manager.

                                                                    ….…. Opposite Parties.

 

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member,

Shri Vinod Kumar Sharma, Member.         

                            

Present:       Ms. Hans Kumari, Advocate, counsel for the complainant.

Shri R.K.Vig, Advocate, counsel for the OPs.

 

Order:        Smt. Neena Sandhu, President

Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay Rs.25,000/- as medical claim, as per the policy.
2. To pay Rs.10 lakh as compensation for financial loss and the mental agony and physical harassment suffered by him.
3. To pay Rs.33,000/- as litigation expenses.
382.  

     Any other relief which this Hon’ble Commission may deem fit.

2.           Brief facts of the case are that the complainant obtained Family Mediclaim Insurance Policy no.OGI17999999000000004 and Health and Wellness Card Gian Chand Policy No. is OG 19-10006021-00089544, valid from 07.11.2017 to 06.11.2018 and paid premium through Punjab National Bank. As per rules, he got renewed the said policy, which was effective for the period from 07.11.2018 to 6.11.2019.  His wife, who was duly insured under the policy was having some problem in her eyes. On 21.01.2019, he visited Bansal Eye Hospital Ambala City and got checked his wife and doctor advised her for lenses and surgery and thereafter, on 28.01.2019, he visited the said Hospital for treatment of her wife. On 25.02.2019, the wife of the complainant took treatment from Sanjivni Eye and Medicare Centre, Ambala City and incurred more than Rs.25,000/-. Thereafter, complainant visited the office of OPs at Ambala and enquired about the matter, thereupon the official of the local branch asked the complainant to enquire about the policy from the head office.  On further enquiry, it came to the notice that the medical policy was cancelled by the OPs, without any fault of the complainant. In the mid of April 2019, OPs sent the renewed policy, which shows that policy is in subsistence. The OPs wrongly and illegally refused to pay the claim amount. Hence, the present complaint.  

3.           Upon notice, OP appeared and filed written version and raised preliminary objections with regard to maintainability and cause of action etc. On merits, it is stated that claim of the complainant was rejected because the alleged loss not covered under the policy as the said clause of loss was covered in 3^rd year of continuous policy whereas in this case, the loss occurred during the 2^nd year of the policy. Thus repudiation by OP is fully backed by terms and conditions of the policy. Rest of the averments of the complainant were denied and prayer has been made for dismissal of the complaint with heavy cost.

4.           Learned counsel for the complainant tendered affidavit of the complainant as Annexure CW-1/A along with documents Annexure C-1 to Annexure C-22 and closed the evidence on behalf of complainant. On the other hand, learned counsel for the OPs tendered affidavit of Shri Sarpreet Kaur Ahluwalia, Assistant Manager Legal, Authorized Signatory, # Bajaj Allianz General Insurance Company Ltd., SCO No.156-159, 2^nd floor, Sector 9-C, Chandigarh as Annexure OP-1/A along with documents Annexure OP-1/1 to OP-1/13 and closed the evidence on behalf of OPs.

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

6.                     The learned counsel for the complainant has contended that for the first time complainant obtained the policy bearing No.OGI79999996000000004, for the period from 07.11.2017 to 06.11.2018 from the OPs. He got renewed the said policy for the period from 07.11.2018 to 06.11.2019. On 25.02.2019, wife of the complainant took treatment from Sanjivni Eye and Medicare Centre Ambala City and incurred expenses of Rs.25,000/-, but the OPs refused to pay the said amount to the complainant.

7.           On the contrary, the learned counsel for the OPs submitted that the claim of the complainant was rightly rejected by the OPs because as per terms and conditions of the policy, complainant was entitled to get the claim in the 3^rd year of continuous policy, whereas, the complainant had taken the treatment during the subsistence of the policy for the 2^nd year.  

8.           It is an admitted fact that the complainant had taken Mediclaim Insurance Policy Schedule, from the OPs, for the period from 07.11.2017 to 06.11.2018 and got it renewed for the period from 07.11.2018 to 06.11.2019. It is also not disputed that the wife of the complainant was duly insured under the policy in question. From the discharge card dated 25.02.2019, Annexure C-14, it is apparent that the wife of the complainant took treatment from the Sanjivni Eye & Medicare Centre. From the said card, it is quite clear that the cataract surgery of the right eye of the wife of the complainant was conducted during the subsistence of the policy for the 2^nd year.  As per term No.C-2 of terms and conditions of the policy, Annexure OP1/13, which reads as under:

(c) what we will not pay (exclusions) under this policy?

2.  We will also not pay for claims arising out of or howsoever connected to the following for the first 24 months of Mediclaim Insurance Policy.

1. Any types of gastric or duodenal ulcers	10. Cataracts
2. Benign prostatic hypertrophy	11.Hernia of all types
3. All types of sinuses	12. Fistulae, Fissure in ano
4. Haemorrhoids	13. Hydrocele
5. Dysfunctional uterine bleeding	14. Fibromyoma
6. Endometriosis	15. Hysterectomy
7. Stones in the urinary and biliary systems	16. Surgery for any skin ailment
8. Surgery on ears/tonsils/adenoids/paranasal sinuses	17. Surgery on all internal or external tumours/cysts/nodules/polyps of any kind including breast lumps with exception of Malignant tumor or growth.
9. Hypertension and its complications	18. Diabetes and its complications.

complainant was entitled to get the benefits under the policy after completion of 24 months i.e two years,  of the medi-claim policy in question, whereas, the wife of the complainant had taken the treatment for removal of cataract within the 2^nd year from the date of inception of the policy. Taking all these facts and circumstances into consideration, we are of the view that there is no merit in the present complaint, consequently, we dismiss the same. Parties are left to bear their own costs. Certified copy of this order be supplied to the parties, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

      Announced on: 05.10.2021.

 

 

          (Vinod Kumar Sharma)        (Ruby Sharma)                   (Neena Sandhu)

              Member                             Member                            President