DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

Complaint Case No : CC/31/2023

Date of Institution : 20.03.2023

Date of Decision : 14.06.2024

Yog Raj son of Sh. Madho Ram, aged 69 years resident of #B-XI/1939, Street No. 9, K.C. Road, Barnala.      

                      …Complainant

Versus

1.Bajaj Allianz General Insurance Co. Ltd., through its Managing Directors registered address at 2nd floor, bajaj Finserv Building, Survey No. 208/B-1, Behind Weikfied IT Park, off Nagar Road, Viman Nagar, Pune, Maharashtra 411014.

2.Canara bank, intermediary Bajaj Allianz General Insurance Co. Ltd., having code 10045514, branch barnala district Barnala (Notice not issued to opposite party No. 2).    

                …Opposite Parties

Complaint under Section 35 of the Consumer Protection Act, 2019

Present: Sh. Nitin Bansal counsel for complainant.

Sh. B.K. Garg counsel for opposite party No. 1.

Quorum.-

1. Sh. Jot Naranjan Singh Gill : President

2.Smt. Urmila Kumari : Member

ORDER

 JOT NARANJAN SINGH GILL, PRESIDENT

1.    The complainant namely Yog Raj has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Bajaj Allianz General Insurance Co. Ltd & others (herein after referred as opposite parties). 

2. The facts leading to the present complaint are that the complainant purchased medical policy bearing No. OG-22-1203-6021-00000865 from opposite parties for himself and the medical coverage from 10.9.2020 to 9.9.2021. It is further alleged that on 1.9.2021 complainant Yog Raj complained about severe swelling in his knee and infection and he rushed to Dayanand Medical College & Hospital, Ludhiana for diagnose and there doctor admitted the complainant and the doctors conducted number of tests to diagnose the problem and detected the problem of arthirites of knee and MTP Joints and significantly positive ANA (Anti-Nuclear antibody). The complainant filed the claim for Rs. 1,49,691.74/- to opposite party No. 1 to issue Mediclaim bearing claim number OC-23-1002-6021-00018578 and the same was denied by opposite party No. 1 on 8.9.2021 on the ground that the treatment was related to Pre-existing CKD with 10 years Hypertension and the claim was rejected on 7.9.2021 on unjustified grounds and flatly refused to make payment. It is alleged that the complainant had hypertension from past 10 months instead of 10 years and the same was rectified by treating Dr. Vikas Gupta and also clarified that by mistake, it was wrongly written 10 years in evaluation report. After the complete diagnose and evaluation of complainant, doctors treated the complainant for Inflammatory Arthritis and Connective Tissue disorder with positive anti-nuclear antibodies and also stated that it was never the premedical condition. The presence and treatment for CKD is completely ruled out by doctors and the actual issue Inflammatory Arthritis and Connective Tissue disorder with positive anti-nuclear antibodies not related to hypertension and the same is also duly confirmed by doctors. The claim of the complainant has been re-lodged to the opposite parties but it is all in abyss and no further initiation of the process of claim has been made by the opposite parties. The opposite party No. 1 did not pay any heed to reply and to re institute the claim of the complainant even after reminders were sent by complainant to opposite parties. The above said act of the opposite parties comes within the definition of unfair trade practice as well as deficiency in services and unscrupulous exploitation of complainant. Hence, the present complaint is filed seeking the following reliefs.-

i)To release Rs. 1,49,691.74/- and directed the opposite party No. 1 to clear bill of medical treatment alongwith interest up to date @12% per annum.  

ii)To pay the amount of Rs. 1,00,000/- on account of physical and mental agony, harassment and Rs. 5,000/- on account of litigation expenses.  

3. It is important to mention here that the notice was sent to opposite party No. 1 only. 

4. Upon notice of this complaint, opposite party No. 1 appeared and filed written reply by taking preliminary objections that the present complaint is pre-mature as answering opposite party asked the documents from complainant but same was not supplied. It is submitted that as soon as the complainant reported its claim the opposite party initiated the process. It is further submitted that the complainant has conveniently concealed the letters dated 2.1.2023, 12.1.2023 and 23.1.2023 where answering opposite party after initial scrutiny, requisitioned for certain documents from the complainant for the proper assessment of the claim i.e. previous consultation papers of all known ailments from treating doctors, scan copy of PF and duly filled KYC form, however the answering opposite party has not received any reply from the complainant. It is submitted that on one hand the complainant refused to co-operate with the answering opposite party by failing to provide relevant documents/information and on the other hand it is wrongly claiming that his claim has not been settled. Further, the instant complaint as framed is devoid of any cause of action and as such merits rejection for failing to disclose the cause of action. 

5. On merits, it is submitted that the complainant's claim for cashless facility was denied because it was for the treatment of a pre-existing disease which was not disclosed in the proposal form. It is submitted that the complainant did not submit the requisite documents and therefore the opposite party No. 1 called the requisite documents vide letter dated 2.1.2023. The documents were necessary for the proper assessment of the subject claim. It is further submitted that the complainant conveniently concealed the letters dated 2.1.2023, 12.1.2023 and 23.1.2023 where opposite party No. 1 requisitioned for certain documents from the complainant and the claim of the complainant has been repudiated because the documents requisitioned by opposite party has not been submitted till date. All other allegations of the complaint are denied and prayed for the dismissal of complaint with costs. 

6. Ld. Counsel for complainant has suffered the statement that I do not want to file any rejoinder against the version of opposite party No. 1 and tendered into evidence his own affidavit Ex.C-1, copy of policy  Ex.C-2 (containing 3 pages), copy of discharge summary Ex.C-3 (containing 2 pages), copy of report Ex.C-4, copies of bills Ex.C-5 (containing 22 pages), copy of Denial letter Ex.C-6 (containing 2 pages), copy of re-evaluation report Ex.C-7, copy of emails Ex.C-8 (containing 3 pages), copy of claim status Ex.C-9 and closed the evidence. 

7. To rebut the case the opposite party No. 1 tendered into evidence copy of letter dated 2.1.2023 Ex.O.P1/1, copy of letter dated 12.1.2023 Ex.O.P1/2, copy of letter dated 23.1.2023 Ex.O.P1/3, copy of repudiation letter dated 1.2.2023 Ex.O.P1/4, copy of terms and conditions Ex.O.P1/5 (containing 23 pages), affidavit of Saurav Khullar Ex.O.P1/6 and closed the evidence. 

8. We have heard the learned counsel for the parties and have gone through the record on file. 

9. It is admitted fact that the complainant purchased medical policy from opposite party No. 1 for himself and the medical coverage from 10.9.2020 to 9.9.2021 (Ex.C-2). It is further admitted fact that the complainant admitted in Dayanand Medical College & Hospital, Ludhiana on 1.9.2021 for diagnose the problem of arthirites of knee and MTP Joints and significantly positive ANA (Anti-Nuclear antibody) and the complainant was discharged on 10.9.2021 (Ex.C-3).

10. Ld. Counsel for the complainant argued that on 1.9.2021 complainant Yog Raj complained about severe swelling in his knee and infection and he rushed to Dayanand Medical College & Hospital, Ludhiana for diagnose and there doctor admitted the complainant and the doctors conducted number of tests to diagnose the problem and detected the problem of arthirites of knee and MTP Joints and significantly positive ANA (Anti-Nuclear antibody). It is further argued that the complainant filed the claim for Rs. 1,49,691.74/- to opposite party No. 1 to issue Medical claim and the same was denied by opposite party No. 1 on 8.9.2021 (Ex.C-6) on the ground that treatment was related to Pre-existing CKD with 10 years Hypertension and the claim was rejected on 7.9.2021 (Ex.C-6) on unjustified grounds and flatly refused to make payment. It is argued that the complainant had hypertension from past 10 months instead of 10 years and the same was rectified by treating Dr. Vikas Gupta and also clarified that by mistake, it was wrongly written 10 years in evaluation report and after the complete diagnose and evaluation of complainant, doctors treated the complainant for Inflammatory Arthritis and Connective Tissue disorder with positive anti-nuclear antibodies and also stated that it was never the premedical condition and the presence and treatment for CKD is completely ruled out by doctors and the actual issue Inflammatory Arthritis and Connective Tissue disorder with positive anti-nuclear antibodies not related to hypertension and the same is also duly confirmed by doctors. It is argued that the claim of the complainant has been re-lodged to the opposite parties but it is all in abyss and no further initiation of the process of claim has been made by the opposite party No. 1 and the opposite party No. 1 did not pay any heed to reply and to re-institute the claim of the complainant even after reminders were sent by complainant to opposite parties. 

11. Ld. Counsel for the opposite party No. 1 argued that the present complaint is pre-mature as opposite party No. 1 asked the documents from complainant but same was not supplied. It is further argued that the complainant has conveniently concealed the letters dated 2.1.2023, 12.1.2023 and 23.1.2023 (Ex.OP1/1 to Ex.O.P1/3), where opposite party after initial scrutiny, requisitioned for certain documents from the complainant for the proper assessment of the claim i.e. previous consultation papers of all known ailments from treating doctors, scan copy of PF and duly filled KYC form, however the opposite party has not received any reply from the complainant. It is also argued that the complainant refused to co-operate with the opposite party by failing to provide relevant documents/information. It is argued that the complainant's claim for cashless facility was denied because it was for the treatment of a pre-existing disease which was not disclosed in the proposal form. It is further argued that the complainant did not submit the requisite documents and therefore the opposite party No. 1 called the requisite documents vide letter dated 2.1.2023 because the documents were necessary for the proper assessment of the subject claim and the claim of the complainant has been repudiated vide letter dated 1.2.2023 (Ex.O.P1/4) because the documents requisitioned by opposite party has not been submitted till date.

12. The allegation of the opposite party No. 1 is that the complainant's claim for cashless facility was denied because it was for the treatment of a pre-existing disease which was not disclosed in the proposal form and the complainant has failed to provide/submit the previous consultation papers of all known ailments from treating doctors. Further, we have perused copy of Denial of Cashless Facility dated 7.9.2021 Ex.C-6 vide which it is mentioned that the Pre-authorizations request mentions diagnosis CKD with known hypertension since 10 years with connective tissue disease the duration of hypertension since 10 years & CKD since august 2020 which is pre-existing to our policy hence cashless stand denied under exclusion clause 1. Pre-existing Disease waiting period (Exc101) a) Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 36 months of continuous coverage after the date of inception of the first policy with us. On the other hand, in order to rebut this allegation of the opposite party the complainant has placed on record copy of re-evaluation report dated 9.9.2021 Ex.C-7 vide which Dr. Vikas Gupta Assistant Professor, Department of Rheumatology, DMC & H Ludhiana has mentioned that Patient Yograj 68/M visited me first on 21.4.2021. Patient gave h/o hypertension for 10 months. However, by mistake it was mentioned as 10 years by me in the prescription. Patient presently has arthirites of knee & MTP joints. He has significantly positive ANA (Antinucler antibody) (2+ nucler pattern) & hence, possibility of connective tissues disease is considered which has no relation/link to hypertension. Further, in order to rebut the above said allegation of the opposite party No. 1 the complainant has also placed on record copy of report Ex.C-4 of Dayanand Medical College & Hospital, Ludhiana vide which it is mentioned as “so Based on investigation possibility of CKD is Completely ruled out”. Therefore, the presence and treatment for CKD is completely ruled out by doctors and the actual issue inflammatory Arthritis and Connective Tissue disorder with positive anti-nucler antibodies not related to hypertension and the same is also duly confirmed by doctors. Moreover, Dr. Vikas Gupta certified/clarified that complainant had hypertension from past 10 months. The complainant has placed on record the copy of bill Ex.C-5 of Dayanand Medical College & Hospital Ludhiana which shows the Total Bill of an amount of Rs. 1,49,691.74/- which was spent by the complainant on his treatment. 

13. The learned counsel for complainant referred the judgment Civil Appeal No.7437 of 2011 titled as P.Vankat Naidu Vs LIC of India. The Hon'ble Supreme Court of India held that Since the respondents had come out with the case that the deceased did not disclose correct facts relating to his illness, it was for them to produce cogent evidence to prove the allegation. The appeal is allowed. Ld. Counsel for complainant placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, 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 sort of excuses to deny the claim. 

14. Another case LPA No. 1537 of 2011 titled as Iffco Tokio General Insurance Company Ltd. Vs Permanent Lok Adalat Gurgaon and others 2012(1)R.C.R.(Civil) 901:2012(2)PLR 547 decided on 26.08.2011. The Hon'ble Punjab and Haryana High Court held that the law is well settled with regard to the standard form of contracts. When the bargaining powers of the parties is unequal and consumer has no real freedom to contract the Courts would strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power. It was also 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. 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. Claim cannot be denied. 

15. So, from the above discussion, it is established that the claim of the complainant was repudiated by the opposite party No. 1 on unreasonable and unjustified grounds and there is clear cut deficiency in service on the part of opposite party No. 1. Therefore, the present complaint is partly allowed against the opposite parties No. 1 and the opposite party No. 1 is directed to pay Rs. 1,49,691.74/- alongwith interest @ 7% per annum to the complainant from the date of filing the present complaint till realization. The opposite party No. 1 is further directed to pay Rs. 10,000/- on account of consolidated amount of compensation as well as litigation expenses to the complainant.

16. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order.

17. Copy of this order be supplied to the parties free of costs as per rules. File be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN COMMISSION:

       14h Day of June, 2024

 

            (Jot Naranjan Singh Gill)

            President

 

(Urmila Kumari)

Member