Chandigarh

DF-I

CC/62/2019

Sat Paul Thapar - Complainant(s)

Versus

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

Navneet Jindal

12 Aug 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/62/2019
Date of Institution	:	07/02/2019
Date of Decision	:	12/08/2021

                 

Sat Paul Thapar S/o Sh.Late Chunni Lal aged about 61 years earlier resident of House No.1958, Sector 43-B, Chandigarh Now resident of 1005 –B-3 Kendriya Vihar Society Sector 125-Mohiali, Punjab.

… Complainant

V E R S U S

1.   Bajaj Allianz general Insurance Co. Ltd through      its Managing Director/Director

     Local Address:

          SCO 156, 157, 158, 159 2^nd Floor, Sector 9,                                Chandigarh 160009.

          Registered address:

          First Floor, A-Wing, Bajaj Finserv Building,    Behind Weikfield IT Park, Off Nagar Road, Viman    Nagar, Pune-411014.

2. The Director/Managing Director, Bajaj Allianz     General Insurance Co. Ltd. First Floor, A-Wing, Bajaj Finserv Building Behind Weikfield It     Park, Off Nagar Road, Viman Nagar, Pune-411014.
3. Synergy Institute of Medical Science, through     its Medical Superintendent Uddiwala, Canal Rd, Ballupur Chowk, Ballupur, Dehradun, Uttarakhand     248001.

… Opposite Parties

 

CORAM :	RAJAN DEWAN	PRESIDENT
	SURJEET KAUR	MEMBER
	SURESH KUMAR SARDANA	MEMBER

 

                                               

ARGUED BY	:	Sh.Navneet Jindal, Counsel for complainant
	:	Sh.Sachin Ohri, Counsel for OP No.1 & 2.
	:	None for OP No.3.

 

Per Suresh Kumar Sardana, Member

1.      The long and short of the allegations are that the complainant took an insurance policy for himself and his wife and the policy document was issued to him. The policy No.OG-17-999-9960 00000004(Annexure C-1) issued on 03.02.2018 which was valid till 02.02.2019 was issued to the complainant.

On 24.05.2018, the complainant felt pain in his left arm and numbness and he was rushed to the hospital of OP 3. The doctors admitted him in the hospital on 28.05.2018. The complainant was given treatment and was discharged on 31.05.2018. The discharge summary is annexed as Annexure C-3.

The complainant submitted the total claim of Rs1,04,455/- to Opposite Party No.1 & Opposite Party No.2 which includes Rs 54,525/- as expenses on hospitalization and 49,475/- on medication and injection. The medicines etc were taken from pharmacy shop at the premises of OP-3.

The complainant alleged that OP 1 and 2 kept on lingering on the claim and ultimately repudiated the same without any basis (Annexure C-6). Alleging that the act and conduct of Insurance Company in unnecessary delaying the claim and then rejecting the same without any basis is unfair trade practice and deficiency in service and the complainant suffered huge damages on account of mental, physical and financial agony.

2.     Opposite Party No.1 & Opposite Party No.2 contested the consumer complaint and filed its written reply and submitted that the liability of the answering respondent if any is strictly as per terms and conditions of the policy. Submitting that as per the documents submitted by the complainant himself, it is clear that the complainant had a history of hypertension, therefore, the claim of the complainant was rightly repudiated because policy does not extend coverage for any expenses incurred on the treatment of hypertension and its complication during the first two years of policy. Thus, there was no deficiency of service or unfair trade practice on their part.
3.     Opposite Party No.3 contested the consumer complaint & filed reply that it has nothing to do with the allegations leveled in the complaint and nothing has been claimed against it and prayed for the dismissal of the complaint against it.
4.     Complainant filed rejoinder controverting the stand of the Opposite Party and reiterating his own.
5.     Contesting parties led evidence by way of affidavits and documents.
6.     We have heard the learned counsel for the parties and gone through the record of the case. After appraisal of record, our findings are as under:-
7.     Per pleadings of the parties, we have perused the Annexure C-6 of the complainant which is the repudiation letter dated 09.10.2018. The claim has been repudiated with the following repudiation remarks.

          “verification of the claim document   reveals the aforesaid claimant was    hospitalized for the treatment of     Cerebrovascular Accident-Intracranial Haemorrhage Right thalamus and is claiming for expenses incurred of INR.104455/-. We     regret   to inform you that the claim   stands repudiated   as the policy does    not extend coverage for any     expenses     incurred on the treatment of   Hypertension & its complications during the first two years of policy.”

8.     On perusal of records we observe that there is no authentic evidence that the disease developed by the complainant had a nexus with the alleged hypertension. In the absence of the link of said disease with hypertension, it cannot be said that the alleged hypertension led to “Cerebrovascular accident-Intracranial Hemorrhage right thalamus”.
9.     Further we rely on case titled as LIC of India & Anr. Vs. Smt. Jaimanti Sharma & anr. Decided on 11.12.2009 by the Hon’ble HP State Commission and the relevant paragraph No.15 thereof reads as under:-

“15. At the risk of repetition, we may point out here again, that there is nothing on record even to remotely suggest that the deceased was aware on 30.03.1998 on his suffering from throat cancer, which plea is the sheet anchor of the appellants in this appeal. Once this conclusion is arrived at, we find no reason to interfere with the order passed by the District Forum below.”

10.      Further we bank upon case titled as Smt. Kalpana Rajendra Chavan Vs. Life Insurance Corporation of India decided on 11.12.2013 by the Hon’ble State Commission, Maharashtra in which under paragraph No.9 it was held as under:-

     “9. Therefore the non-disclosure of chronic Dyspepsia in the proposal form cannot be a ground for repudiation of the claim as rightly urged on behalf of the complainant and ruling of the Hon’ble National Commission relied by the complainant is applicable to the case on hand. In yet another order passed by the Himachal Pradesh State Consumer Disputes Redressal Commission, Simla in case of LIC of India & Anr. Vs. Jaimanti Sharma & Anr., reported in (2010) 4 CPR 126, it was held that, the life assured is supposed to give true and correct facts regarding state of health in the proposal form. However, it was held that it cannot be presumed that the deceased was well aware regarding his state of health (throat cancer) while filling the proposal form and the appeal of LIC was dismissed.”

    

This shows, as per precedents the life assured is supposed to give true and correct facts regarding state of health in the proposal form and not supposed to disclose the nature of disease which the life assured had suffered.

11.      Further relying on case titled as Religare Health Insurance Company Ltd. Vs. Subhash Chander Aggarwal decided on 26.04.2017 by the Hon’ble Punjab State Commission and the relevant paragraph No.10 thereof reads as under:-  

     “10. Whether Hypertension is a disease which is required to be referred in the proposal form. There is a judgment of Hon’ble National Commission reported as “Satish Chander Madan Vs. Bajaj Allianz General Insurance Co. Ltd”, I (2016) CPJ 613 (NC), in which it was observed by the Hon’ble National Commission that Hypertension is a common disease and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack and repudiation on account of pre-existing disease was not justified. Otherwise in the discharge summary of Smt. Paarvati Devi Hospital Ex. C-7 in which there is no reference of Hypertension. Discharge summary of Medanta Hospital Ex. C-14, in which there is a reference of Diabetes Mellitus but no reference of Hypertension. Then there is another referred document i.e. Ex. OP-21 dated 05.03.2015 i.e. after taking the policy in which the B.P. of the complainant is 140/180 which is quite normal at the age of complainant. Therefore, the ground that the complainant was suffering from hypertension is not corroborated on the basis of the evidence on the record.”

12.     In view of the above discussion, and the precedents relied upon, repudiation of the claim was not justified. The present consumer complaint succeeds and the same is accordingly partly allowed. Opposite Party No.1 & Opposite Party No.2 are directed as under :-

1. to pay ₹1,04,455/- to the complainant alongwith interest @ 9% per annum from the date of repudiation i.e. 09.10.2018 till realization.
2. to pay an amount of ₹20,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹10,000/- to the complainant as costs of litigation.

13.     Complaint qua Opposite Party No.3 is dismissed.
14.     This order be complied with by the Opposite Party No.1 & Opposite Party No.2 within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
15.     Certified copies of this order be sent to the parties free of charge. The file be consigned.

12/08/2021	[Suresh Kumar Sardana]	[Surjeet Kaur]	[Rajan Dewan]
Ls	Member	Member	President