Delhi

New Delhi

CC/366/2015

pardyumma Kumar Jain - Complainant(s)

Versus

Bajaj Allianz General Insurance co Ltd - Opp.Party(s)

Sanjay kumar

23 Jan 2019

ORDER

 

 

CONSUMER DISPUTES REDRESSAL FORUM-VI

(DISTT. NEW DELHI), ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN,

I.P.ESTATE, NEW DELHI-110002.

 

Case No.CC.366/2015                                 Dated:

In the matter of:

Pardyumna Kumar Jain,

S/o Sh. S.C. Jain,

R/o 127, Pkt.-B, Sukhdev Vihar,

South Delhi,  New Delhi..

                           ……..COMPLAINANT

VERSUS

 

1. Bajaj Allianz General Insurance  Co. Ltd.,

         Having its Registered Office at:

         Regd. & Head Office : GE PLAZA, Airport Road, Yerwada,

         Pune-411006.

 

To be served also at:

 

Bajaj Allianz General InsuranceCo. Ltd.,

           2^nd Floor, Bajaj Finserv Building, Survey No.208/81,

           Behind Weikfield IT Park, Off Nagar Road,

             Viman Nagar, Pune, Maharastra-411014.

 

2.         Bajaj Allianz General Insurance  Co. Ltd.,

Operating from:

Block No.4, 7^th Floor, DLF Towers,

15, Shivaji Marg,New Delhi-110015.

 

3.      M/s Indraprastha Apollo Hospital,

Sarita Vihar, Mathura Road, New Delhi-110076.

                      

   Opposite Parties.

NIPUR CHANDNA, MEMBER

ORDER

The complainant has filed the present complaint against the OPs under section 12 of Consumer Protection Act, 1986.  The brief facts as alleged in the complaint are that the complainant purchased a  mediclaim policy known at ‘BAJAJ ALLIANZ GENERAL INSURNCE CO. LTD.” from OP-1 for himself, wife, his son and daughter  vide Policy bearing No.OG-15-1101-8427-00000021 w.e.f. 17.9.2015 to 16.9.2015  with the total risk cover for a sum assured Rs. 5 lacs. 

2.     It is alleged on behalf of complainant that on 9.2.2015, his wife  went to Apollo Hospital as she was suffering from  right middle 1/3^rd parasaggital tumor  and Dr. K.C. Jain, Neurologist, advised her for immediate surgery, she was hospitalized from 9.2.2015 to 15.2.2015 and discharged on 15.2.2015.  It is submitted that during hospitalization, the information was given to OP-1 & 2 in this regard and final bills were paid by the complainant at the time of discharge.  The complainant lodged a claim with OP-1 & 2 for reimbursement and submitted all the requisite documents including discharge summary treatment details and Invoice generated by OP-3 but the claim was repudiated by the OP on the ground that  the claim filed by the complainant  falls in Exclusion Clause, as the aforesaid claimant was hospitalized for the treatment of right middle 1/3^rd parasaggital tumor with memory impairment and left upper limb focal fits and further the claimant is known to be suffering from memory impairment since one year and left upper limb focal fits since one year which is related to the tumor and the ailment is pre-existing to the policy and has not been disclosed in the disposal from.  The discharge summary issued by OP-2 categorically indicated the reasons of hospitalization followed by the treatment and investigations carried out at the hospital of OP-3, however, to consider the observation made by OP-2 in letter dated 17.3.15, the patient requested Sr. Consultant of OP-3 to clarify the above said issue on which, the certificate was given by Dr. A.K. Banerji and stated that “her neck pain is no specific and may not be related to her intracranial pathology.  She is having focal fits since November 2014 as per record and memory impairment was subtle, and could be evaluated only after repeated questioning.  It is submitted that on the basis of certificate, issued by Dr. Banerji, the complainant made a representation to the OP-2 for settling his genuine claim but the same was again declined.  Complainant, therefore, approached this Forum for redressal of his grievance.

 3.     Complaint has been contested by OP-1.  In its written statement, OP-1 has denied any deficiency in service on its part.  It was stated on behalf of OP-1 that the wife of the complainant was having a history neck pain since four years, which is prior to the inception of the policy and thus the Co. has rightly repudiated the claim on the basis of non disclosure of material  facts.  However, it is admitted that the health card and portability was issued to the complainant.

4.     Complainant and OP-1 have filed their evidence by way of affidavit.

5.     We have heard arguments advanced at the Bar on behalf of complainant.  Since none appeared on behalf of OP-1 for addressing arguments,  despite several opportunities, therefore it was ordered to be proceeded ex-parte on 8.5.2018.

6.     We have gone through the complaint as well as annxures attached with it.  Perusal of the repudiation letter dated 17.3.2015 shows that OP-1 has repudiated the claim of the complainant on the ground of non disclosure of material facts  that his wife was having the history of neck pain since four years. The claimant is known to be suffering from memory impairment since one year and left upper limb focal fits since one year, and the same is not disclosed in the proposal form.  Against the repudiation, the complainant has drawn our attention towards the certificate issued by the Dr. V.P. Singh in which he clearly states as under:

“The neck pain of 4 years duration has NO correlation or connection with the brain tumour which has been treated as this admission”.

7.     Perusal of the certificate issued by the treating doctor clearly shows that no pre-existing ailment was present at the time of the surgery, which need to be disclosed by the complainant in his proposal form.  Moreover,  OP has failed to place on record any documentary evidence such as proposal form to substantiate its contention that claim was rightly repudiated on the ground of non disclosure of material facts by the complainant in the proposal form.  It is not denied by OP-1 that it had issued the present policy to the complainant against portability, which means that the benefits accrued in the previous policy would be carried out in the current policy.  The complainant was purchasing the mediclaim policy since 2004 from New India Insurance Co. and had purchased the present policy from OP-1 on the assurance by its agent that he would get portability benefits.  The repudiation of the claim by the OP  on the ground of non disclosure of material  facts was not justified in the light of the certificate issued by the treating Dr. V.P. Singh, particularly, in the present case when the complainant has availed portability facility from OP-1.

 8.    Keeping in view the discussion stated above, we are of the considered view that the repudiation of claim filed on behalf of the complainant was wholly unwarranted and unjustified on the part of OP-1 which amounted to deficiency in service. The complainant has placed on record, the payments receipts issued by Apollo Hospital, according to which on following three occasion, he deposited the amount with the Hospital:

S.N.	Receipt No.	Receipt date	Amount deposited (in Rupees)
1.	2840081	9.2.2015	50,000/-
2.	2842594	10.2.15	2,50,000/-
3.	2863090	15.2.15	2,44,833

 

We therefore hold, OP-1 guilty of deficiency in services and direct it as under:

1. Pay to the complainant sum of Rs.5,00,000/- (sum assured) along with 9% interest from the date of filing of complaint i.e. 2/06/2015 till its realization.

 

2. Pay to the complainant a sum of Rs.25,000/- toward compensation for pain and  mental agony suffered by her which will include cost  of litigation.

 

The order shall be complied  within 30 days of the receipt of the copy of the order. If the said amount is not paid by the OP within a period of one month from the date of receipt of this order, the same shall be recovered by the complainant along with simple interest at the rate of 9% per annum from the date of this order till recovery of the said amount. This final order be sent to server (www.confonet.nic.in ). A copy each of this order each be sent to both parties free of cost by post.

Announced in open Forum on 22/01/2019. 

 

 

(ARUN KUMAR ARYA)

          PRESIDENT

(NIPUR CHANDNA)                                                  (H M VYAS)

       MEMBER                                                                MEMBER