BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.375 of 2019
Date of Instt. 02.09.2019
Date of Decision: 29.03.2023
Manohar Lal S/o Roshan Lal, aged 62 years, resident of House No.8-A, Vasant Vihar, Kapurthala.
..........Complainant
Versus
Bajaj Allianz General Insurance Co. Ltd., through its Branch Manager, at 2nd Floor, Satnam Complex, BMC Chowk, GT Road, Jalandhar-144001.
….….. Opposite Party
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Amritpal Singh, Adv. Counsel for the Complainant.
Sh. R. K. Sharma, Adv. Counsel for OP.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the complainant has purchased a Mediclaim Insurance Policy from the OP vide policy no.OG-20-3710-6021-00000002 for the period from 23.04.2019 to 22.04.2020, by porting his previous continues PNB-Oriental Royal Medical Policy issued by the Oriental Insurance Co. Ltd. The complainant has originally purchased said medi-claim insurance policy from the OP in the year 2012. At the time of issuing/porting the present insurance policy no.OG- 20-3710-6021-00000002 by the OP, the official of the OP has assured the complainant that all the benefits shall be continued, as if the insurance policy has regularly been issued by the OP. The complainant accordingly agreed for the same and made the payment of the insurance premium of Rs.16546/- as asked by OP. The OP duly issued the insurance policy after getting his previous insurance ported from his previous insurance company i.e. Oriental Insurance Co. Ltd at Kapurthala. The OP has provided medical cover for all ailments or diseases etc. vide above mentioned mediclaim insurance policy. On 27.07.2019 the complainant suffering from right eye partial rhegmatogenous retinal detachment problem, so he had to admit in SB Dr. Sohan Singh Eye Hospital Pvt. Ltd. at Amritsar under such critical condition. The complainant was advised to undergo surgery/operation of his right eye, accordingly the complainant did so and after 3 days, he was discharged upon his stable condition by concerned doctor. The complainant after attaining good health lodged insurance claim with the opposite party in the month of July, 2019. The complainant has also provided all necessary documents/bill/diagnose summary etc. for reimbursement of his medical treatment expenses for an amount of Rs.53,000/- along with claim form. But the OP arbitrary not provided any cashless facilities to the complainant, rather it denied the claim too. The OP astonishingly not only failed to provide cashless facilities for claim settlement, but also till date not paid/reimbursed the insurance claim amount to the complainant. Even though all the formalities have duly been done by him. The OP vide its denial letter dated 29.07.2019 malafidely and arbitrarily denied insurance claim, on the pretext that the preauthorization request mentions the duration of Diabetes Mellitus since 10 years and HTN since 7 years, which is pre-existing to our policy & is not being disclosed in the proposal form, hence cashless stands denied under exclusion clause C-1 and B-16.
Exclusion clause C-1 i.e. ‘We shall not be liable to make any payment for the any claim directly or indirectly caused by, based on, arising out of or attributable to any of the following: benefits will not be available for any pre-existing condition, ailment or injury until 36 months if continues coverage have elapsed, after the date of inception of the first mediclaim insurance policy, provided the pre-existing disease/ailment/injury is disclosed on the proposal form. The above exclusion 1 shall cease to apply if you have maintained a mediclaim insurance policy with us for a continues period of full 36 month without break from the date of your first mediclaim insurance policy with us for continues period of a full 36 months without break from the date of your first mediclaim insurance policy. In case of enhancement of sum insured, this exclusion shall apply afresh only to the extent of the amount by which the limit of indemnity has been increased (i.e. enhance sum insured) and if the policy is renewal of mediclaim insurance policy.
Definition clause B-16 is ‘Disclosure to information norm- the policy shall be void and all premium paid hereon shall be forfeited to the company, in the event of misrepresentation, mis- description o non-disclosure of any material fact.’
Whereas above said ailments had not been related or arisen or resulted from any such alleged pre-existing health condition, as illegally been considered by the OP for denying his genuine insurance claim. Because the diabetes and Hypertension are lifestyle related problems/deceases, which cannot be taken as pre-existing health condition for denial of genuine claim, hence the ground taken by the OP is not maintainable, as such pre-existing health condition not falls within the exclusion clause of the policy. The OP till dated has not settled said insurance claim lodged by the complainant. Even though more than two month period has been elapsed. Further the Exclusion clause C-1 does not apply in this claim, because the complainant has got ported his previous Health Insurance Policy from the Oriental Insurance Co. Ltd with the Opposite Party. Hence as per IRDA (Protection of policy holders' interest) Regulations, 2002 after accepting the proposal of policy holder for switching from one insurer to other, the insurance company shall allow for credit gained by the policy holder. The complainant has been continuing his health insurance policy since 2012, hence the pre-existing clause C-1 dose not bar the claim settlement, because after 36 months the policy issued by the opposite party does cover all the ailment etc. whether it is pre-existing or not. The complainant's claim is genuine and he has not concealed anything nor mis-represented nor did any mis-description with the opposite party. Hence such denial of insurance claim on the pre- existing by the opposite party is illegal, arbitrary and unjustified that too against their own rules and regulations. The insurance claims is genuine and legal, hence it has to be reimbursed as per the terms & conditions of the insurance policy by the opposite party. The grounds taken for the denying or repudiating or non-settlement of claim are arbitrary and illegal. As neither the ailment or disease for which treatment taken by the complainant fall under pre- existing health condition or disease or ailment/injuries etc. nor there was any policy break, as it has been ported from previous insurer, where it was continued since 2012. The OP has malafidely denied the insurance claim lodged with it by their Letter dated 29.07.2019 on the ground of pre-existing health conditions. Further the OP has not made the payment of insurance claim till date, after the expiry of two months, hence said claim would deemed to be repudiated by the OP. The act, conduct, non-settlement and denial or repudiation of insurance claim by the OPs has caused a great mental agony, tension, harassment and hardship to the complainant and failure on the part of the OP to pay the insurance claim as per the insurance policy, not only it amounts to deficiency of services on part of OP but it also amount to an unfair trade practice done by the OP 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 pay the insurance claims for medical treatments for an amount of Rs.53000/- along with 12% interest till realization or decision of complaint, as per the terms of the Mediclaim Policy, issued vide no. no. OG-20-3710-6021-00000002 by the OP and further OPs be directed to pay a compensation of Rs.2,00,000/- for causing mental tension and harassment to the complainant.
2. Notice of the complaint was given to the OP, who filed reply and contested the complaint by taking preliminary objections that the petition is not maintainable in law on facts and the same is liable to be dismissed in limine. This Commission has no jurisdiction to entertain the present case. There is no deficiency of service or unfair trade practice on the part of the Insurance Company, hence the petition is liable to be dismissed at the outset for want of cause of action. It is further averred that the case at hand involves intricate questions of facts and law which require voluminous evidence, oral as well as documentary, to be lead for proper adjudication of the matter. This is not possible in summary procedure followed by this Forum. Hence the Petition may be returned to the competent Court. It is further averred 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 the strict sense of the words written therein. As the terms and conditions of the Policy are sacrosanct, the claim arrived is also processed within the precincts of the Policy only. The Policy bearing No.OG-20-3710-6021-00000002 for the period 23-04-2019 to 22-04-2020 was ported to
OP from Oriental Insurance Co. Ltd. On request of pre-authorization for cashless treatment of the complainant from the S.B. Dr. Sohan Singh Eye Hospital Pvt. Ltd., Amritsar, it was mentioned in the Cashless Form submitted by the Hospital that the complainant is a patient of Diabetes Mellitus and Hypertension and duration of History of Diabetes Mellitus is since 10 years and Hypertension is since 7 years, which is pre-existed to the policy issued by the OP and also not disclosed in the Proposal form. Hence, the cashless request was denied in terms of violation of terms and conditions of the insurance policy and Dr. Rajvir Singh of S B Dr. Sohan Singh Eye Hospital. Pvt. Ltd., Amritsar was informed vide communication dated 29-07-2019 about denial of cashless facility. It is further averred that the claim of the petitioner is inadmissible due to coming under clause B13 and exclusion clause 1 of the terms and conditions of the insurance policy. It is further averred that there is neither any deficiency in service nor negligence nor unfair trade practice on the part of the OP. Denying the cashless treatment to which the complainant was not entitled to is as per terms and conditions of the insurance policy. On merits, the factum with regard to issuance of Mediclaim Insurance Policy bearing No.OG-20-3710-6021-00000002 for the period 23-04-2019 to 22-04-2020 in the name of complainant is admitted, 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.
3. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file as well as written arguments submitted by counsel for both the parties very minutely.
6. The case of the complainant is that the complainant had purchased a Mediclaim Insurance Policy from the OP vide policy no.OG-20-3710-6021-00000002 for the period from 23.04.2019 to 22.04.2020, by porting his previous continuous PNB-Oriental Royal Medical Policy issued by the Oriental Insurance Co. Ltd, which is evident from Ex.C-1 and Ex.C-2. The OP has provided medical cover for all ailments or diseases etc. vide this insurance policy. The complainant suffering from right eye partial rhegmatogenous retinal detachment problem and he was admitted in S. B. Dr. Sohan Singh Eye Hospital Pvt. Ltd. at Amritsar on 27.07.2019 under such critical condition and the operation was conducted on 27.07.2019 and he was discharged on 29.07.2019 as per discharge summary Ex.C-3. The complainant has produced on record bill of Rs.51,000/-, vide Ex.C-5 and lodged the claim, but the OP denied his insurance claim vide letter dated 29.07.2019 Ex.C-6 on the ground that ‘the preauthorization request mentions the duration of diabetes Mellitus since 10 years and HTN since 7 years, which is pre-existing disease.’ Request has been made to allow the complaint.
7. The contention of the OP is that the complainant is a patient of Diabetes Mellitus and Hypertension and duration of history of Diabetes Mellitus is since 10 years and Hypertension is since 7 years, which is pre-existing disease, which existed prior to the policy issued by the OP and this fact was not disclosed in the proposal form and the claim of the complainant is inadmissible due to coming under clause B13 and Exclusion Clause-1 of the terms and conditions of the OP, which reads as under:-
B13 Disclosure to information norm- the policy shall be void and all the premium stated herein shall be forfeited to the company, in the event of misrepresentation, mis-description or non-disclosure of any material fact.
Exclusion clause 1- the company shall not be liable to make any payment for any claim directly or indirectly caused by, based on arising out of or attributable to any of the following: benefits will not be available to any pre-existing condition, ailment or injury, until 36 months of continuous coverage have elapsed, after the date of inception of first mediclaim insurance policy, provided the preexisting disease/ailment/injury is disclosed in the proposal form.
8. It is not disputed that the complainant has purchased a mediclaim insurance policy from the OP and it is also not disputed that the complainant got operated himself from the doctor. It is proved that the complainant lodged claim for availing cashless facility but the same was declined vide Ex.C-6. It is proved that no claim for reimbursement was lodged by the complainant himself as he was asked to claim reimbursement, vide Ex.C-6. In such circumstances, the complainant is directed to lodge the claim for reimbursement alongwith necessary required information/documents to the OP, within 15 days from the date of receipt of the copy of the order and then the OP will settle the claim of the complainant within 15 days from the date of receipt of the claim form, failing which the OPs will be liable to pay compensation of Rs.20,000/- to the complainant. It is further ordered that if the complainant is not satisfied with the settlement of the claim made by the OPs, then he is at liberty to file a fresh complaint. Original documents submitted alongwith the complaint be returned to the complainant for onward submission of the same to OP for the settlement of the claim. Thus, this complaint is disposed of. This complaint could not be decided within stipulated time frame due to rush of work.
9. 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 Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
29.03.2023 Member Member President
