BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.403 of 2017
Date of Instt. 23.10.2017
Date of Decision: 30.07.2019
Navneet Mahay wife of Sh. Gurdev Mahay, resident of H. No.476- G.T.B. Nagar, Jalandhar City.
..........Complainant
Versus
1. Bajaj Allianz General Insurance Company Ltd., Satnam Complex, 2nd Floor, B. M. C. Chowk, G. T. Road, Jalandhar. Through its Branch Manager.
2. Bajaj Allianz General Insurance Company Ltd. G. E. Plaza, Airport Road, Yerwada, Pune-06, through its Chairman.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Sh. Naveen Chhabra, Adv Counsel for the Complainant.
Sh. R. K. Sharma, Adv Counsel for the OPs No.1 & 2.
Order
Karnail Singh (President)
1. The instant complaint has been filed by the complainant, wherein alleged that the OPs are providing General Insurance Services to the General Public for consideration throughout India and more particularly at Jalandhar. The complainant purchased a Health Guard Individual Policy from OPs and paid a sum of Rs.9595/- by cheque and the OPs issued a cover note No.OG-17-120-2-8401-00000026, Security No.55566843 dated 07.05.2016. The period of the insurance is from 06.05.2016 to 05.05.2017 Midnight.
2. That the sum insured under the policy was Rs.3,00,000/- as per insurance policy cover note. The complainant got treatment of Carcinoma Vault on 13.07.2016 from Max Super Speciality Hospital, Phase-IV, Mohali, Punjab and spent a sum of Rs.2,80,000/- on her treatment. The complainant submitted the requisite medical bills along with other documents to the OPs for reimbursement of the medical expenses incurred, but the complainant was shocked when she received a letter dated 13.12.2016 from the OPs, wherein the claim of the complainant is repudiated, illegally and unlawfully, whereas no such clause which is given in the letter dated 13.12.2016 was ever told to the complainant at the time of covering of the insurance nor the policy contained the details of the terms and conditions is received by the complainant. Thereafter, the complainant got served a legal notice upon the OPs through her counsel, but all in vain. The act and conduct of the OP is tantamount to deficiency in service and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse a sum of Rs.2,80,000/- to the complainant being the medical expenses incurred and further OPs be directed to pay Rs.1,00,000/- as compensation for mental tension, harassment, inconvenience and financial loss caused to the complainant and further, OPs be directed to pay litigation expenses of Rs.26,000/-.
3. Notice of the complaint was given to the OPs and accordingly, both the OPs served and appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that there is no deficiency in service or unfair trade practice on the part of the insurance company to invoke the jurisdiction of this Forum. Hence, the complaint is liable to be dismissed. It is further alleged that the insurance policy is a contract and both the parties are under obligation to obey/fulfill all the terms and conditions of the same in strict sense of words written therein. It is further alleged that the verification of the claim documents revealed that the complainant was hospitalized for the treatment of Carcinoma Vault on 13.07.2016. The complainant had consulted the Max Hospital on 13.07.2016, which is post 6 weeks of chemotherapy i.e. started with chemotherapy on 01.06.2016. The policy incepts on 06.05.2016. As per Condition No.4 of the terms of the policy, the policy does not cover expenses incurred on the treatment of any illness, which is diagnosed during the first 30 days of the first year policy and further submitted that the claim of the complainant was inadmissible as per terms and conditions of the insurance policy, which was rightly repudiated, vide letter dated 13.12.2016. On merits, the factum in regard to purchase of insurance policy as well as submitting of insurance claim are admitted and the same was legally and rightly repudiated, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
4. In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA alongwith some documents Ex.C-1 Copy of the Policy, Ex.C-2 Medical Bill, Ex.C-3 Copy of Repudiation Letter, Ex.C-4 Copy of Legal Notice and Ex.C-5 & Ex.C-6 Postal Receipts and closed the evidence.
5. Similarly, counsel for the OPs tendered into evidence affidavit of Navjeet Singh as Ex.OA and some documents Ex.O-1 Hospital Papers of Max Health Care dated 13.07.2016, Ex.O-2 Copy of Insurance Policy, Ex.O-3 Terms and Conditions of the Insurance Policy and Ex.O-4 Letter of Repudiation dated 13.12.2016 and closed the evidence.
6. We bestowed our thoughtful consideration to the arguments put forth by learned counsel for the respective parties and also scanned the case file very minutely.
7. Precisely, the case put forth by the complainant to the effect that he purchased Health Guard Individual Policy after making payment of premium of Rs.9595/- for an insurance period 06.05.2016 to 05.05.2017 for insured amount of Rs.3,00,000/-, is not in dispute, rather these facts have been admitted by the OP. Further, the OP also admitted that the complainant got treatment from Max Super Speciality Hospital, Mohali and thereafter submitted a medical claim alongwith all relevant documents, but after considering the same, the claim of the complainant repudiated and to that extent, there is no dispute between the parties.
8. Now, we have to analyze and consider, whether the repudiation of the insurance claim of the complainant is legal and valid or not, for that purpose, we required to go through the repudiation letter Ex.C-3 dated 13.12.2016, wherein the OP has invoked Section-4 Exclusion Clause of the terms and conditions of the policy and repudiated the claim of the complainant by incorporating these words:-
“Verification of the claim documents reveals the aforesaid claimant was hospitalized for the treatment of Carcinoma Vault on 13.07.2016. The claimant had consulted Max Hospital on 13.07.2016, which is post 6 weeks of Chemotherapy, i.e. started with Chemotherapy on 01.06.2016. The policy incepts on 06.05.2016. We regret to inform you that the claim stands repudiated as the policy does not extend coverage for expenses incurred on the treatment of any illness which is diagnosed or was diagnosable during the first 30 days of the first year policy.”
9. In order to give strength of the above observation, the OP has brought on the file one related document, issued by the Max Hospital dated 13.07.2016, wherein the word ‘Post RT-6 Week’ has been referred by the learned counsel for the OP. The entire case of the OP depends upon these words i.e. ‘Post RT-6 Weeks’. The OP alleged that the complainant started taking Chemotherapy 6 weeks prior to date of admission in the Max Hospital i.e. 13.07.2016, if we go that 6 weeks, then it means the Chemotherapy was started by the OP on 01.06.2016, whereas the policy was obtained by the complainant on 06.05.2016 and the OP alleged that the complainant got diagnosed within 30 days from the commencement of the policy and as such, the complainant is not entitled.
10. We have thoroughly scanned the all documents including Ex.O-1 issued by Max Hospital dated 13.07.2016 and find that there is no documentary evidence except the aforesaid document Ex.O-1, that the complainant had started taking Chemotherapy since 01.06.2016. Further, from this document Ex.O-1, it is not clear from which date Post 6 weeks will start, it may start from 13.07.2016, when first time the complainant got treatment from the Max Hospital. So, the story propounded by the OP is based on surmises and conjectures, not having any documentary evidence rather made a story just to reject the insurance claim of the complainant and as such, we find that the OP has illegally and arbitrarily repudiated the claim of the complainant because the case of the complainant is not covered under the alleged clause-4 of the terms and conditions and as such, we hold that the complainant is entitled for the relief claimed.
11. In the light of above detailed discussion, the complaint of the complainant is partly accepted and OPs are directed to reimburse a sum of Rs.2,80,000/- being the medical expenses incurred and further, OPs are directed to pay compensation to the complainant for causing mental tension and harassment, to the tune of Rs.25,000/- and further, OPs are directed to pay litigation expenses of Rs.10,000/-. The entire payment be made within one month from the date of receipt of the copy of order, failing which the OPs are further liable to pay the entire amount alongwith interest @ 9% from the date of filing complaint i.e. 23.10.2017, till realization. This complaint could not be decided within stipulated time frame due to rush of work.
12. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Karnail Singh
30.07.2019 Member President
