Chandigarh

DF-II

CC/312/2020

Gurkirpal Singh Mann - Complainant(s)

Versus

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

Abhishek Gupta

03 Sep 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	CC/312/2020
Date of Institution	:	23/07/2020
Date of Decision	:	03/09/2024

       

                                       

                       

 

 

Gurkirpal Singh Mann, Kothi No.1, Phase 2, SAS Nagar, Near Bassi Cinema Hall, Mohali, Punjab 160055.

                                ...  Complainant

Versus

Bajaj Allianz General Insurance Co. Ltd., SCO 156 & 159, 2^nd Floor, Sector 9-C, Chandigarh 160009.

…. Opposite Party

BEFORE:
	SHRI AMRINDER SINGH SIDHU	PRESIDENT
	SHRI S.K. SARDANA	MEMBER
ARGUED BY:-
	Sh. Abhishek Gupta, Counsel for complainant
	Sh. Rajesh Verma, Counsel for OP (through VC)

       

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

1.        The complainant has filed the present consumer complaint alleging that he had purchased a Medi-claim Insurance Policy (Ex.C-1) from the OP and the same was valid w.e.f. 5.12.2018 to 4.12.2019.  On 12.10.2019, the complainant felt pain in his chest and approached Fortis Hospital, Mohali where he was admitted and on 13.10.2019 he was operated in the Department of Cardiovasular and Thoracic Surgery of the said hospital.  Thereafter on 8.11.2019, complainant intimated the document recovery department of the OP regarding claim and vide letter dated 27.11.2019, he was asked to send further necessary documents. On 2.12.2019, the complainant sent the required documents through reply. Though the complainant had spent an amount of Rs.8,08,563/- on his treatment but as the sum insured under the policy was Rs.5,00,000/-, therefore, he claimed the said amount only.  However, vide letter dated 31.1.2020 (Ex.C-4), the OP repudiated the claim of the complainant on the ground of pre-existing illness despite the fact that the diagnosis report made at Fortis Hospital clearly stated that the complainant had been recently diagnosed with systemic hypertension and there was no prior history of diabetes mellitus/systemic hypertension & Aortic Dissection.  Alleging that the aforesaid acts of omission and commission on the part of OP amounts to deficiency in service and unfair trade practice, complainant has filed the instant consumer complaint.
2.        In its written version OP, inter alia, admitted that the complainant had purchased the insurance policy in question and the same was valid at the relevant time with sum insured of Rs.5.00 lacs.  The answering OP did not dispute the facts with regard to admission of the complainant at the Fortis Hospital, procedure adopted there and discharge etc.  However, it is alleged that after perusal of documents, claim of the complainant was rightly repudiated vide letter dated 31.1.2010 (Annexure R-2) under the terms of the policy.  The remaining allegations have been denied, being false. Pleading that there is no deficiency in service or unfair trade practice on its part, OP prayed for dismissal of the complaint.
3.        The parties filed their respective affidavits and documents in support of their case.
4.        The complainant chose not to file replication.
5.        We have heard the learned Counsel for the parties and have gone through the documents on record, including written arguments.
6.        The main objection taken by the OP/insurer is that it had repudiated the claim of the complainant vide letter dated 31.1.2020 (Annexure R-2) on the basis of pre-existing disease which was not disclosed by the complainant/insured at the time of obtaining the insurance policy in question. 
7.        To rebut this plea of the OP, complainant has placed on record the diagnosis report (Ex.C-3(e)/page 40) of Dr. Jagjit Singh of the treating hospital i.e. Fortis Hospital, Mohali wherein the complainant was got treated, which clearly states that the complainant has been recently diagnosed with systemic hypertension and there is no prior history of diabetes mellitus/systemic hypertension and Aortic Dissection.  On the other hand, except for its self serving bald averments in the written version, OP has not placed on record any documentary evidence in support of its defence.
8.        Thus, on the basis of the findings duly given by the doctor of the treating hospital that the complainant has been recently diagnosed with systemic hypertension which can cause aortic dissection and there is no prior history of diabetes mellitus, systemic hypertension and Aortic dissection, it is safe to conclude that the complainant/ insured was not suffering from any pre-existing disease.
9.         It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sorts of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims.
10.        In similar set of facts the Hon’ble Punjab & Haryana High Court, Chandigarh in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others, 2008(3) RCR (Civil) Page 111 went on to hold as under:-

       “It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.  The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

 

11.        In view of the above discussion, it can be safely concluded that the act of the OP/insurer in rejecting the genuine claim of the complainant is not only wrong and arbitrary but the same certainly amounts to deficiency in service on its part.
12.        Consequently, the present consumer complaint deserves to succeed and the same is accordingly partly allowed. The OP is directed to pay the sum insured i.e. Rupees Five Lacs Only (Rs.5,00,000/-) alongwith interest @6% per annum from the date of order till the date of its actual realization to the complainant. 
13.        This order be complied with by the OP within 60 days from the date of receipt of its certified copy.
14.        The pending application(s), if any, stands disposed of accordingly.
15.        Certified copy of this order be sent to the parties, as per rules. After compliance file be consigned to record room.

Announced 03/09/2024 hg	(AMRINDER SINGH SIDHU) PRESIDENT
	(S.K. SARDANA) MEMBER