DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/183/2021
Date of Institution: 25.08.2021
Date of Decision: 13.08.2024
Sh. Subhash Kumar Goyal son of Madal Lal resident of opposite new palace theater, Dhanaula road Goyal Iron Store, Barnala, Tehsil and District Barnala.
…Complainant
Versus
1. Bajaj Allianz General Insurance Company Limited, 2nd floor, A-Wing, Bajaj Finserve Building, Behind Weikfield IT Park, Off Nagar, Pune-411014 through its Manager/Authorized Signatory.
2. Bajaj Allianz General Insurance Company Limited, Sandhu Tower, 5th floor, B-XX-3369, Gurdev Nagar, Ludhiana-141001 through its Manager/Authorized Signatory;
3. Canara Bank, Barnala, KC Road, Barnala, Tehsil and District Barnala through its Manager/Authorized Signatory.
…Opposite Parties
Complaint under Section 35 of the Consumer Protection Act, 2019
Present: Sh. Varun Singla Adv counsel for complainant.
Sh. N.K. Garg Adv counsel for opposite parties 1 & 2.
Sh. A.K. Jindal Adv counsel for opposite party No. 3.
Quorum.-
1. Sh. Ashish Kumar Grover : President
2. Smt. Urmila Kumari: Member
3. Sh. Navdeep Kumar Garg : Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Bajaj Allianz General Insurance Company Limited, 2nd floor, A-Wing, Bajaj Finserve Building, Behind Weikfield IT Park, Off Nagar, Pune-411014 through its Manager/Authorized Signatory & others (in short the opposite parties).
2. The facts leading to the present complaint as stated by the complainant are that one of the official/agent of Canara Bank, Barnala approached the complainant in the year 2019 and told about their various insurance schemes and on believing on words, the complainant purchased the "Group Assurance Health Plan" insurance policy with Apollo Munich Insurance Co. bearing number 120100/12586/2019/A012586/PE01342393 having group policy holder name as Canara Bank by paying the gross premium of Rs. 15,176/- dated 22 Jan 2019 which was valid upto 21 Jan 2020. It is further alleged that in the said policy, the insured persons are Subhash Kumar Goyal and her wife namely Sunita Rani and the complainant was issued policy bearing number 120100/22001/2019/A012596/PE01342394 in the name of Subhash Kumar Goyal by paying gross premium of Rs. 295/-. So, total Gross Premium of Rs. 15,471/- was paid for the year 2019-2020. Thereafter, the complainant continued the said policy regularly without any discrimination and paid the premium amount for year 2020-2021 and issued Renewal policy No. 120100/22001/2020/A017525/PE01977244 in the name of Subhash Kumar Goyal which was valid till 21 Jan 2021. It is further alleged that thereafter the Apollo Munich Insurance Co. left and therefore the Canara Bank i.e. opposite party No. 3 assured the complainant that they will continue the previous policy only and get it renewed with the new company namely Bajaj Allianz General Insurance Company Limited. Thereafter, the complainant paid the premium amount of Rs. 15,471/- and get it renewed for the sum insured of Rs. 5,00,000/- which was valid from 22 Jan 2021 to 21 Jan 2022 Midnight issued on 03 Feb 2021. It is further alleged that during the subsistence of the said policy the complainant started suffering from some chest pain and also pain in both the arms and due to this health issues the complainant was taken to Pragma Hospital, A Super Specialist Hospital, Bhatti Road, Bathinda for consultation on 12.3.2021, where an expenditure of Rs.1,390/- occurred and the doctor said that there is blockage in the heart and the treatment is required as early as possible and then the next day the complainant was taken to Dayanand Medical College and Hospital, Ludhiana for further treatment where the complainant was got admitted on 13.03.2021 and was discharged on 19.03.2021 and an amount of about Rs. 2,42,920/- has been spent on the treatment of the complainant till now. It is further alleged that thereafter the complainant approached opposite parties for the medical claim which is covered under the policy and the complainant submitted the claim form with all the required details and all the documents with opposite parties as said by them along with a copy of cancelled cheque bearing number 095995 of State Bank Of India having account number 38858947668 and opposite parties assured the complainant that they will incur all the expenses of treatment as per the policy bought and will give the claim amount within a week. But the opposite parties repudiated the claim and sent claim denial letter dated 03 June 2021 to the complainant where the reason for rejection was that the complainant was suffering from Diabetes and Hypertension since 1 year which is pre-existing to the policy and didn't pay even a single penny of claim as assured to the complainant till today which is withheld by the opposite parties without any justified cause which amounts to deficiency in service and unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.-
1) The opposite parties be directed to pay the amount of Rs. 2,42,920/-.
2) To pay Rs. 50,000/- on account of compensation for mental agony and harassment and Rs. 15,000/- as litigation expenses.
3. Upon notice of this complaint, opposite parties No. 1 & 2 appeared and filed written reply by taking preliminary objections on the grounds that the present complaint filed by the complainant is gross abuse of process of law, and is absolutely false, frivolous and vexatious thereby making it illegal and not tenable thus as the said complaint is filed without any cause of action. The complainant has not come with clean hands. It is admitted that complainant has opted portability in his wish with agreeing all terms applicable regarding portability and non-disclosure. It is further submitted that the complainant Subash Kumar Goyal obtained Mediclaim Insurance Policy from answering opposite party having No OG-21-1203-6021- 00001524 for the period from 22-JAN-2021 to 21-JAN-2022 vide which complainant Subash Kumar Goyal had opted to get covered himself for medical expenses upto Rs. 5,00,000/- and the total premium of Rs. 15,471/- has been paid by the complainant to answering opposite party under this policy. This policy has been issued on the information provided to answering opposite party/representative and policy is not valid if the information provided is incorrect. This policy also does not cover any pre-existing medical condition/injury/illness/deformity and complications arising from them that are declared or undeclared. It is further submitted that the policy coverage is as per the policy terms and conditions mentioned in the Group Mediclaim For Canara Bank provided with policy schedule.
4. On merits, it is admitted that the insured/complainant had intimated a claim with the answering opposite parties by submitting claim documents in support with the claim form on account of medical expense incurred by the complainant on his treatment of disease and the same was registered by the answering opposite parties. It is further alleged that the alleged claim of the complainant was duly processed by the answering opposite parties. It is further alleged that as per the medical record of the complainant the complainant has history of Hypertension and Diabetes Mellitus since 1 year, which is prior to the inception of policy and current ailment is pre-existing medical condition and the policy does not extend coverage for pre-existing ailment and its complications as per exclusion clause of the policy and there is evidence of material suppression by non-disclosure of material fact i.e. pre existing ailment which in itself is a violation of principle of insurance as well as terms and condition of policy. It is further alleged that this policy has been issued based on the information provided to the insurance company or their representative and the policy is not valid if any information provided is incorrect and this policy does not cover any Pre-existing medical condition/injury/deformity and complications arising from them that are declared and undeclared and Coronary artery Disease is most commonly caused by Hypertension and Diabetes Mellitus. All other allegations are denied and prayed for the dismissal of complaint.
5. The opposite party No. 3 filed written version by taking legal objections on the ground that the opposite party No. 3 is not in the business of insurance nor under law can it carry on the business of insurance and opposite party No. 3 is only doing the business of Banking and the actual insurance policy issued by the Bajaj Allianz General Insurance Company Limited, i.e. opposite party No. 1 and 2. Therefore, no cause of action arose against the opposite party No. 3 and the opposite party No. 3 is not liable to pay any amount to the complainant.
6. On merits, it is submitted that the complainant himself purchased the Group Insurance Health Plan Insurance Policy with Appolo Munich Insurance Company and the opposite party No. 3 paid the premium amount as directed by the complainant. It is denied that opposite party No. 3 i.e. Canara Bank assured the complainant that they will continue the previous policy only and get it renewed with the new company namely Bajaj Allianz General Insurance Company Limited i.e. opposite party No.1 and 2. It is further submitted that the opposite party No. 3 is only service provider to the complainant and to the utmost satisfaction of the complainant the answering opposite party give services to the complainant. All other allegations of the complaint are denied and prayed for the dismissal of complaint.
7. The complainant filed rejoinder to the written version of opposite parties.
8. The complainant tendered into evidence, affidavit of Subhash Kumar Goyal as Ex.C-1, copies of policies are Ex.C-2 to C-4, copies of Labs report are Ex.C-5 & C- 6, copies of bills are Ex.C-7 to C-22, copy of Cancelled cheque as Ex.C-23, copy of repudiation letter as Ex.C-24 (containing 2 pages), copy of Adhaar Card as Ex.C-25, copy of Discharge summary as Ex.C-26 (containing 2 pages) and close the evidence.
9. The opposite parties No. 1 & 3 tendered into evidence affidavit of Saurav Khullar as Ex.OP1.2/1, copy of proposal form as Ex.OP1.2/2 (containing 3 pages), copy of insurance policy as Ex.OP1.2/3 (containing 5 pages), copy of insurance policy wording (terms and conditions of policy) as Ex.OP1.2/4 (containing 36 pages), copy of IRDA guidelines as Ex.OP1.2/5 (containing 17 pages), copy of medical literature as Ex.OP1.2/6 (containing 2 pages), copy of repudiation letter as Ex.OP1.2/7 (containing 2 pages) and closed the evidence.
10. The opposite party No. 3 tendered into evidence affidavit of Rahul Singla as Ex.OP3/1, copy of Voucher as Ex.OP3/2, copy of statement of account as Ex.OP3/3 and closed the evidence.
11. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments filed by the complainant and opposite party No. 3.
12. It is admitted case of the opposite parties No. 1 & 2 that the complainant Subash Kumar Goyal obtained Mediclaim Insurance Policy from opposite party No. 1 & 2 having No OG-21-1203-6021-00001524 for the period from 22.1.2021 to 21.1.2022 vide which complainant Subash Kumar Goyal had opted to get covered himself for medical expenses upto Rs. 5,00,000/- and the total premium of Rs. 15,471/- has been paid by the complainant to opposite party No. 1 & 2 under this policy (as per Ex.O.P1.2/3). It is also not disputed between the parties that the complainant initially purchased the "Group Assurance Health Plan" insurance policy with Apollo Munich Insurance Co. bearing number 120100/12586/2019/A012586/PE01342393 having group policy holder name as Canara Bank by paying the gross premium of Rs. 15,176/- dated 22.1.2019 which was valid upto 21.1.2020 and the said policy insured Subhash Kumar Goyal and her wife namely Sunita Rani and the complainant was issued policy bearing number 120100/22001/2019/A012596/PE01342394 in the name of Subhash Kumar Goyal by paying gross premium of Rs. 295/- (as per Ex.C-2 & Ex.C-3). It is also not disputed that the complainant continued the said policy regularly without any discrimination and paid the premium amount for year 2020-2021 and issued Renewal policy No. 120100/22001/2020/A017525/PE01977244 in the name of Subhash Kumar Goyal which was valid till 21.1.2021. It is also not disputed that thereafter the Apollo Munich Insurance Company left and therefore the Canara Bank i.e. opposite party No. 3 assured the complainant that they will continue the previous policy only and get it renewed with the new company namely Bajaj Allianz General Insurance Company Limited and the complainant paid the premium amount of Rs. 15,471/- and get it renewed for the sum insured of Rs. 5,00,000/- which was valid from 22.1.2021 to 21.1.2022 midnight issued on 3.2.2021 (as per Ex.C-4).
13. Ld. Counsel for the complainant argued that during the subsistence of the said policy the complainant started suffering from some chest pain and also pain in both the arms and due to this health issues the complainant was taken to Pragma Hospital, A Super Specialist Hospital, Bhatti Road, Bathinda for consultation on 12.3.2021 (as per Ex.C-5), where an expenditure of Rs.1,390/- occurred and the doctor said that there is blockage in the heart and the treatment is required as early as possible and then the next day the complainant was taken to Dayanand Medical College and Hospital, Ludhiana for further treatment where the complainant was got admitted on 13.03.2021 and was discharged on 19.03.2021 (as per Ex.C-26) and an amount of about Rs. 2,42,920/- has been spent on the treatment of the complainant till now. It is further argued that thereafter the complainant approached opposite parties for the medical claim which is covered under the policy and the complainant submitted the claim form with all the required details and all the documents with opposite parties as said by them along with a copy of cancelled cheque bearing number 095995 of State Bank Of India having account number 38858947668 (as per Ex.C-23) and opposite parties assured the complainant that they will incur all the expenses of treatment as per the policy bought and will give the claim amount within a week. But the opposite parties repudiated the claim and sent claim denial letter dated 3.6.2021 (Ex.C-24) to the complainant where the reason for rejection was that the complainant was suffering from Diabetes and Hypertension since 1 year which is pre-existing to the policy and didn't pay even a single penny of claim as assured to the complainant till today which is withheld by the opposite parties without any justified cause which amounts to deficiency in service and unfair trade practice.
14. On the other hand, Ld. Counsel for opposite parties No. 1 & 2 argued that as per the medical record of the complainant the complainant has history of Hypertension and Diabetes Mellitus since 1 year, which is prior to the inception of policy and current ailment is pre-existing medical condition and the policy does not extend coverage for pre-existing ailment and its complications as per exclusion clause of the policy and there is evidence of material suppression by non-disclosure of material fact i.e. pre existing ailment which in itself is a violation of principle of insurance as well as terms and condition of policy. It is further argued that this policy has been issued based on the information provided to the insurance company or their representative and the policy is not valid if any information provided is incorrect and this policy does not cover any Pre-existing medical condition/injury/deformity and complications arising from them that are declared and undeclared and Coronary artery Disease is most commonly caused by Hypertension and Diabetes Mellitus. Ld. Counsel for the opposite parties further argued that the complainant has not disclosed regarding his above said ailment in the proposal form.
15. Ld. Counsel for the opposite party No. 3 argued that the opposite party No. 3 is not in the business of insurance nor under law can it carry on the business of insurance and opposite party No. 3 is only doing the business of Banking and the actual insurance policy issued by the Bajaj Allianz General Insurance Company Limited, i.e. opposite party No. 1 and 2. It is further argued that the complainant himself purchased the Group Insurance Health Plan Insurance Policy with Apollo Munich Insurance Company and the opposite party No. 3 paid the premium amount as directed by the complainant. It is further argued that the opposite party No. 3 is only service provider to the complainant and to the utmost satisfaction of the complainant.
16. In the present case the specific plea of the opposite parties No. 1 & 2 (insurance company) is that as per the medical record of the complainant the complainant has history of Hypertension and Diabetes Mellitus since 1 year, which is prior to the inception of policy and current ailment is pre-existing medical condition and the policy does not extend coverage for pre-existing ailment and its complications as per exclusion clause of the policy and there is evidence of material suppression by non-disclosure of material fact i.e. pre-existing ailment which in itself is a violation of principle of insurance as well as terms and condition of policy and the policy is not valid if any information provided is incorrect and this policy does not cover any Pre-existing medical condition/injury/deformity and complications arising from them that are declared and undeclared and Coronary artery Disease is most commonly caused by Hypertension and Diabetes Mellitus, therefore the opposite parties No. 1 & 2 repudiated the claim of the complainant vide repudiation letter dated 3.6.2021 Ex.O.P1.2/7.
17. We have gone through the entire facts and evidence produced by the parties. It is admitted fact that the complainant has purchased the above said mediclaim insurance policy initially from the Apollo Munich Health Insurance Company and later on purchased/renewed the above said policy for the period 22.1.2021 to 21.1.2022 from the opposite parties No. 1 & 2 i.e. Bajaj Allianz General Insurance Company Limited under portability benefit. We have gone through the proposal form Ex.O.P1.2/2 placed on record by the opposite parties No. 1 & 2 and in the column No. 25 which is to be related with information/investigation of any health complaint to the person insured the tick is mark “No”. The above said proposal form filled up on 31.1.2021 but the opposite parties No. 1 & 2 have failed to place on record any evidence to prove the fact that they have conducted any medical examination/investigation of the insured person at the time of filling the proposal form or issuing/renewing the insurance policy. On the other hand, Ld. Counsel for the complainant argued that the complainant started suffering from some chest pain and also pain in both the arms on 12.3.2021 and for the treatment the complainant got admitted in Dayanand Medical College and Hospital, Ludhiana on 13.3.2021 and discharged on 19.3.2021. We have also gone through the copy of discharge summary Ex.C-26 vide which it is mentioned in the column of Procedure Done: PTCA WITH STENTING TO MID LAD (XIENCE XPEDITION 3.0 X 28 mm) & PROXIMAL OM (XIENCE XPEDITION 2.5 X 23mm) and it is further mentioned in the column of HISTORY OF ILLNESS: 63 years male known case of CAD- double vessel disease (12.03.21, outside) was admitted for further management. H/o chest pain present. Ld. Counsel for the complainant further argued that the terms and conditions of the policy were not supplied to the complainant alongwith policy. On the other hand, the opposite parties No. 1 & 2 have failed to place on record any cogent evidence to prove that they have supplied the terms and conditions to the complainant alongwith policy. Further, from the file it shows that the complainant has purchased the above said policy in the year 2019 (as mentioned in Ex.C-2) and after that the said policy was renewed regularly, so at this stage how the opposite parties could have raised the objection that the insured has pre-existing disease prior to the policy inception date. It was in the hands of insurance company to see and not to port or issue or renew the policy where person is not entitled to claim on account of treatment of Pre-existing disease. Therefore, we are of the view that at this stage the opposite parties cannot be escaped from their liabilities by raising these types of unreasonable and unjustified grounds. The learned counsel for the complainant also relied upon the judgment of the Hon'ble Punjab and Haryana High Court (DB) 2012 (1) RCR (Civil)-901 in which the Hon'ble High Court held that “Claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the policy. Single judge allowed the claim on the ground that it was for Insurance Company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. No interference called for in the order of Single Judge. Held the pre-existing condition existed in the year 2002 which was five years prior to acquiring Insurance Policy. Claim cannot be denied.
18. We have carefully gone through the insurance policy Ex.C-4 from which it established that the policy sent by the opposite parties No. 1 & 2 are containing 3 pages and the terms and conditions of the policy are not the part of the said insurance policy. Moreover, the opposite parties No. 1 & 2 have placed on record the copy of insurance policy Ex.O.P1.2/3 are also containing 3 pages and the terms and conditions of the policy are not the part of the said insurance policy. Therefore, the terms and conditions on which the opposite parties relied upon are not part of the contract. The Hon'ble Supreme Court of India titled Modern Insulators Limited Versus Oriental Insurance Company Limited reported in 2000(1) CPC-596 in which Hon'ble Supreme Court held that “As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclose to the appellant, respondent cannot claim the benefit of the said exclusion clause.” The Hon’ble Supreme Court of India (2019) 6 SCC 212 in case titled Bharat Watch Company Through its Partner Vs National Insurance Company Limited held that “Conditions of exclusion under policy document not handed over to insured by insurer and in absence of insured being made aware of terms of exclusion, held, it is not open to insurer to rely upon exclusionary clauses”.
19. From the above discussion, it is proved that the claim of the complainant/insured was repudiated by the opposite parties No. 1 & 2 vide letter dated 3.6.2021 Ex.O.P1.2/7 on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties No. 1 & 2.
20. However, on the perusal of copies of Inpatient Final Bill and Pharmacy Bills (i.e. Ex.C-7, Ex.C-8, Ex.C-10 (containing 3 pages), Ex.C-19 to Ex.C-22) which shows that the total amount of Rs. 2,15,852/- has been spent on the treatment of complainant in the above said hospital. But in the present complaint the complainant has claimed an amount of Rs. 2,42,920/-. So, we are of the view that the complainant is entitled for the amount of Rs. 2,15,852/-.
21. In view of the above discussion, the present complaint is partly allowed against the opposite parties No. 1 & 2 and the opposite parties No. 1 & 2 are directed to pay an amount of Rs. 2,15,852/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties No. 1 & 2 are further directed to pay Rs. 10,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
13th Day of August, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
(Navdeep Kumar Garg)
Member
