DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Ajay Saini son of Shri Biswanath Saini, R/o H.No.2208, First Floor, Sector 37-C, Chandigarh.

              ---Complainant

Vs

[1]  Bajaj Allianz Insurance Co. Limited, SCO No. 139-140, Sector 8-C, Chandigarh.

[2]  Parveen Kumar Sharma (Agent), R/o H.No. 3279, Sector 23-D, Chandigarh.

---- Opposite Parties

BEFORE:    SH. LAKSHMAN SHARMA             PRESIDENT

MRS.MADHU MUTNEJA               MEMBER

           SH.JASWINDER SINGH SIDHU        MEMBER

Argued By:    Sh. N.S. Jagdeva, Counsel for Complainant.

Sh. Varun Chawla, Counsel for Opposite Party No.1.

Opposite Party No.2 Ex-parte.

PER MADHU MUTNEJA, MEMBER

1.        The instant complaint relates to denial by the Opposite Parties of a medical insurance claim issued in the name of the Complainant and his dependent nominee Mrs. Victoria Saini (wife).

          This complaint had earlier been allowed by this Forum vide order dated 22.07.2011 and the Opposite Parties had been directed to pay, jointly and severally, Rs.32,205/- (being 95% of Rs.33,900/-) i.e. the expenditure incurred on the treatment, along with compensation and cost of litigation. As the Opposite Parties had failed to put in appearance to contest the claim, the complaint had been decided ex-parte on merits.

          Opposite Party No.1 had gone in appeal to the Hon’ble State Consumer Disputes Redressal Commission, U.T. Chandigarh. The Hon’ble State Commission was pleased to remand back this complaint vide orders dated 24.01.2012, with a direction to afford an opportunity to Opposite Party No.1 to file its written version and evidence and the case be decided on merits thereafter.

          An opportunity thereafter was accorded to the Opposite Parties to give their version of the complaint. 

2.        The facts of the case are briefly narrated as under:

          The Complainant had availed Health Insurance Policy from the Opposite Parties, valid from 15.11.2008 to 15.11.2011. The wife of the Complainant Mrs. Victoria Saini (nominee) suffered severe lower abdomen pain in February, 2010 and was taken to Dr. Mangla Hospital, for treatment. After surgery the wife of the Complainant was discharged from the hospital and a claim for payment of the amount spent on the treatment was lodged with the Opposite Party. However, the Opposite Party repudiated the claim, due to which reason the Complainant had approached this Forum for redressal of his grievance. 

          It has been mentioned in the complaint that the terms and conditions of the policy were not supplied to the Complainant at the time of issuance of policy or even thereafter. The Agent (Opposite Party No.2) had collected the premium and issued the cover note only. The form had been filled by the Agent and signatures of the Complainant had been obtained. The Complainant was hence not aware either of the terms and conditions or about the free look period of the policy. The claim had been repudiated by the Opposite Party on the basis of an exclusion clause in the Policy, which according to the insured were not explained to him and hence, not binding. 

3.        The Opposite Party No.1 in reply has taken certain vague preliminary objections. Opposite Party No.1 has stated that the complaint is time barred as the policy was issued in the year 2008. Also, on acceptance of the proposal form a policy bearing no. 0112630725 valid for 03 years commencing from 15.11.2008 had been issued to the Complainant. The Complainant never disputed receipt of policy documents or the terms and conditions contained therein within the free look period of 15 days and continued to pay the monthly premium @Rs.188/- (excluding service tax) till 15.5.2010. The wife of the Complainant was operated upon for Fibroid Uterus and Endometriosis and remained hospitalized from 3.2.2010 to 4.2.2010 incurring an expenditure of Rs.33,900/-. As this is a Gynecological ailment and treatment for the same required a waiting period of two years, as per terms and conditions of the policy, the claim was repudiated being inadmissible.

          On merits, Opposite Party No.1 made similar submissions as made in the preliminary objections. All other material contentions of the complaint were controverted. Pleading that there was no deficiency in service on their part, a prayer has been made for dismissal of the complaint.

4.        As none had appeared on behalf of Opposite Party No. 2 either during the earlier proceedings or during the currency of proceedings when the case was remanded back, he was proceeded against exparte on 16.3.2012.

5.        During the course of proceedings, the Opposite Party No.1 in an attempt to prove the factual position of delivery of the policy documents to the Complainant made an application for summoning Parveen Kumar Sharma (Opposite Party No.2) as a witness. The said Parveen Kumar Sharma was summoned by the orders of this Forum and his statement was recorded on 20.09.2012.

          As per the version of said Sh. Parveen Kumar Sharma, he was an Agent of Opposite Party No.1 from October 2006 to May/ June, 2009. He had filled the original proposal form bearing No. 0601597702 on the instructions of the Complainant. He also admitted that the proposal form bore his signatures. Annexure R-5 placed on record by the Opposite Party No.1 was also shown to Parveen Kumar Sharma which is a receipt by hand of the policy bond on 19.12.2008 by Parveen Kumar Sharma from the Opposite Party No.1. The said Parveen Kumar Sharma denied receipt of Annexure R-5 or the signatures borne therein. He also categorically stated that he did not deliver the policy to the Complainant, as the same had not been given to him/ received by him by the insurance company. The terms and conditions mentioned in the policy were also not in his possession at the time of filling the proposal form.    

6.        Parties led evidence in support of their contentions.

7.        We have heard the learned counsel for the parties and have perused the record, along with written arguments filed by the parties.

8.        The version of the Complainant is that though the proposal form was signed by him, the actual policy documents containing terms and conditions therein were not supplied to him. Hence, he was surprised to receive a denial/ repudiation of the insurance claim when need for reimbursement arose. The version/ statement of Sh. Parveen Kumar Sharma (Opposite Party No.2) called as witness by Opposite Party No.1 is also a clear pointer in favour of the version given by the Complainant. The Opposite Party No.1 has placed reliance on the policy document to state that as the treatment undergone by the wife of the Complainant was a Gynecological ailment, it was a part of the exclusion clause of the policy for a period of two years from the date of inception and hence, claim was not payable.

9.        Admittedly, the treatment has been taken within two years of issuance of policy. However, as the Complainant has not received the terms and conditions of the policy, which fact has also been proved by the version of Sh. Parveen Kumar Sharma, Agent (Witness) brought in the Forum by the Opposite Party No.1, the stand of the Complainant has to be accepted and payment for the expenditure incurred on the medical treatment should not be denied to him. 

10.       As per the earlier order dated 22.07.2011, 95% of Rs.33,900/- had been allowed along with compensation and cost of litigation. We also pass orders to the same effect and allow the complaint with a direction to the Opposite Party No.1 as under:-

i)   To pay Rs.32,205/- (being 95% of Rs.33,900/-) to the Complainant to indemnify him for the expenditure incurred on the treatment of his wife as per terms of the Policy.        

ii)  To pay Rs.10,000/- to the Complainant as compensation for causing mental agony and harassment.

iii) To pay Rs.7,000/- to the Complainant as cost of earlier litigation + Rs.7,000/- for additional litigation.

11.       The above said order shall be complied within 45 days from the date of its receipt, failing which Opposite Party No.1 will be liable for an interest @12% per annum on the awarded amount of Rs.42,205/-, from the date of filing the present complaint i.e. 27.05.2010, till it is paid, besides paying Rs.14,000/- as cost of litigation.  However, as there is no specific averment against Opposite Party No.2, who is only the Agent, the complaint against him is dismissed.

12.       Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

01^st October, 2012.                                             

Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

Sd/-

(MADHU MUTNEJA)

 MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER