Haryana

Yamunanagar

CC/616/2012

Suresh Kumar S/o Jai Parkash - Complainant(s)

Versus

Bajaj Allianz Life Insurance Company Ltd. - Opp.Party(s)

D.S Kamboj

07 Jun 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

                                                                                          Complaint  No.616  of 2012.

                                                                                          Date of institution: 11.06.2012

                                                                                          Date of decision: 07.06.2017

 

Suresh Kumar aged about 40 years son of Sh. Jai Parkash, resident of village & Post Office Bubka, Sub Tehsil Radaur, Tehsil Jagadhri, District Yamuna Nagar.                                                                                                                                                                                                                                                                                              

                                                                                                                              …Complainant.

                                        Versus

Bajaj Allianz Life Insurance Company Ltd. 1^st Floor, Ganpati Building, Opp. Madhu Hotel, Yamuna Nagar through its Branch Manager.                                                                                                                                                                                              

                                                                                                                              …Respondent.  

BEFORE:       SH. ASHOK KUMAR GARG, PRESIDENT, 

                        SH. S.C.SHARMA, MEMBER

                        SMT. VEENA RANI SHEOKAND, MEMBER.

                       

 

Present: Sh. D.S.Kamboj, Advocate, counsel for complainant.   

              Sh. Rajiv Gupta,  Advocate, counsel for respondent.

 

ORDER( ASHOK KUMAR GARG PRESIDENT)

 

1.                     Complainant Suresh Kumar has filed the present complaint under section 12 of the Consumer Protection Act, 1986 as amended upto date.

2.                     Brief facts of the present complaint, as alleged by the complainant, are that complainant purchased a life mediclaim policy bearing No.0079376511 dated 07.01.2008 for a sum insured of Rs. 2,00,000/- from the respondent (hereinafter respondent will be referred as OP Insurance Company). After that, complainant diagnosed with heart ailment i.e. PSVT-CAG and during his illness he got treatment from Rameshwar Dass Memorial Hospital, near Bus Stand, Jagadhri and remained admitted there from 05.03.2010 to 10.03.2010 and after that he remained admitted in Prime Heart, Shivalik Hospital, Mohali where he was operated and undergone to angiography and remained admitted there from 26.03.2010 to 26.03.2010 and complainant spent more than Rs. 60,000/- at Shivalik Hospital, Mohali and Rameshwar Dass Memorial Hospital, Jagadhri on his treatment and also spent Rs. 20,000/- on conveyance charges. After that, complainant submitted all the bills and lodged the claim with the OP Insurance Company vide claim No. AZBJ/00039619 but the same was repudiated by the OP Insurance Company vide its repudiation letter dated 22.06.2010 stating therein that “ Verification of the claim documents reveal that patient has undergone angiography for PSVT and as per the policy terms and conditions there is a waiting period of 3 years for angiography”. The repudiation done by the OP Insurance Company is totally illegal and liable to be set aside. Lastly, prayed for directing the OP Insurance Company to pay Rs. 80,000/- alongwith interest and also to pay compensation as well as litigation expenses.

3.                     Upon notice, OP Insurance Company appeared and filed its written statement by taking some preliminary objections such as complaint is hopelessly time barred by limitation under section 24(A) of the C.P.Act as the claim of the complainant was legally and rightly repudiated by the OP Insurance Company on 22.06.2010 strictly in accordance with the terms and conditions of the insurance policy and the present complaint has been filed after 2 years; complainant has no locus standi to file the present complaint; no cause of action arise in favour of the complainant as the complainant underwent angiography for PSVT on 26.03.2010 i.e. within 26 months i.e. 2 years 2 months of commencement of policy ( i.e. 07.01.2008) and lodged the claim for reimbursement for medical expenses incurred by him for treatment of said disease but as per terms and conditions of the contract of insurance, the angiography has a waiting period of 3 years from the date of commencement of policy. Thus, the claim lodged by the complainant for  having underwent angiography within 3 years from the commencement of the policy is neither payable nor admissible and has been rightly rejected by the OP Insurance Company; the complainant is estopped to file the present complaint by his own act and conduct as the complainant was offered 15 days free look cancellation period from the date of receipt of the policy bonds but the complainant failed to do so; the complainant has enjoyed the benefits of the policy in question and has also taken the risk of investment and concocted a false story after a period of more than 4- 4 ½ years just to mislead the Forum and on merit it has been admitted that complainant purchased a mediclaim policy bearing No. 0079376511 on 07.01.2008 with the maturity date of 07.01.2011 subject to its terms and conditions. Since the contract of insurance terminated upon completion of the policy term of 3 years, the complainant does not fall under the definition as defined under section 2(1)(d) of the C.P.Act. It has been further admitted that a claim for reimbursement of medical expenses was lodged by the complainant for an amount of Rs. 31,994/- and the same was expeditiously considered by the OP Insurance Company and after going through the hospital record submitted by the complainant it was confirmed that complainant underwent angiography for PSVT on 26.03.2010 within a period of 2 years and 2 months of the commencement of the policy but the angiography has a waiting period of 3 years from the date of commencement. Rest contents of the complaint were denied being wrong and manipulated and lastly prayed for dismissal of complaint.

4.                     In support of his case, counsel for the complainant tendered into evidence short affidavit of complainant as Annexure CX and documents such as forwarding letter regarding issue of policy in question dated 07.01.2008 as Annexure C-1, Receipt of first premium as Annexure C-2, Photo copy of repudiation letter dated 22.06.2010 as Annexure C-3, OPD treatment slips, medical expenses bills as Annexure C-4 to C-19 and closed the evidence on behalf of complainant.

5                      On the other hand, counsel for the OP Insurance Company tendered into evidence affidavit of Daljit Singh, Customer Support Executive, Bajaj Allianz as Annexure RW/A and documents such as Photo copy of repudiation letter dated 22.06.2010 as Annexure R-1, Photo copy of proposal form as Annexure R-2, Photo copy of insurance policy with schedule as Annexure R-3 and closed the evidence on behalf of OP Insurance Company.

6.                     We have heard the learned counsel for both the parties and have gone through the pleadings as well as documents placed on file very minutely and carefully. Counsel for the complainant reiterated the averments made in the complaint and prayed for its acceptance whereas the counsel for the OP Insurance Company reiterated the averments made in the reply and prayed for its dismissal.

7.                     It is not disputed that the complainant purchased a life mediclaim policy bearing No.0079376511 dated 07.01.2008 from the OP Insurance Company for a sum of Rs. 2,00,000/-. It is also not disputed that complainant lodged the claim for reimbursement of medical expenses with the OP Insurance Company for a sum of Rs. 31994/- as this fact has been admitted by the OP Insurance Company in para No.3 of the written statement on merit.

8.                     The only ground of the OP Insurance Company in repudiating the claim of the complainant is that the complainant underwent angiography for PSVT on 26.03.2010 within a period of 2 years and 2 months from the commencement of the policy but as per terms and conditions of the insurance policy there is a waiting period of 3 years for the treatment of angiography but this plea of the OP Insurance Company is not tenable as the OP Insurance Company has totally failed to prove that the complainant was having any pre existing history of disease in question. Furthermore, Section 45 of the Insurance Act 1938 is reproduced here as under:-

“ No policy of life insurance effected after coming into the force of this act shall, after the expiry of 2 years from the date on which it was effected, be called in question by an insurer on the ground that a statement made in the proposal for insurance or in any report of a medical officer, or referee, or friend of the insured or in any other document leading to the issue of policy, was inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policy holder and that the policy holder knew at the time of making it that the statement was false or that it suppressed facts which it was material to disclose”  

Meaning thereby that no policy of life insurance after a period of expiry of two (2) years from the date on which it was affected be called in question and in the present case the complainant has obtained the treatment of angiography after a period of two (2) years and 2 months from the commencement of the policy in question. Further, it is also not the case of the OP Insurance Company that the complainant was having any problem regarding heart disease prior to taking the insurance policy in question as no such record of any hospital or any doctor has been placed on file. On the other angle also, OP Insurance Company failed to prove by cogent evidence that they had supplied any terms and conditions to the complainant alongwith policy certificate. The OP Insurance Company has neither mentioned in the written statement to whom these terms and conditions were supplied nor there is any proof of sending the same to the complainant. As per case law laid down by the Hon’ble State Consumer Disputes Redressal Commission,Haryana, Panchkula in case titled as Oriental Insurance Company Limited Versus Vivek Rekhan, 2014(3) CLT page 202 it has been held that “Insurance Claim (Medi-claim)- Pre existing disease- Exclusion Clause- Held-Unless the terms and conditions have been supplied to the complainant before taking the policy, the same cannot be enforced- Exclusion clause not binding- Oral version cannot take the place of proof unless supported with some documentary evidence”

            And the same view has been held in another case law titled as M/s Modern Insulators Ltd Vs. Oriental Insurance Company Ltd. 1(2000) CPJ page 1 Supreme Court of India and the same view has been held in another case titled as Oriental Insurance Company vs. Satpal Singh 2014(2) CLT page 305 (National Commission) wherein it has been held that “ when the terms and conditions have not been supplied/ communicated to the consumer, it cannot be invoked against the consumer. When the exclusion clause was never disclosed to the insured, the insurance company cannot take the benefit of the said clause. Insured/consumer cannot be affected by such exclusionary clause”.

            Further, the same view has also been held in case titled as Start Health and Allied Insurance Co. ltd. Versus Asha & Others, 2015(1) CLT page 591 wherein it has been held that insurance policy- Exclusion clause-Not explained to insured when cover note was issued- Insurance Company cannot derive any benefits from exclusion clause.

9.                     On the other hand, counsel for the OP Insurance Company referred the case law titled as Parkash P.N. Versus Manager New India Insurance Company Ltd. and another 2013(3) CLT page 443, New India Insurance Company Ltd. Versus Nanak Singla and others 2015(1) CPJ page 599 National Commission are not disputed but not helpful in the present case.

10.                   So, in view of the detailed facts narrated above, we are of the confirmed view that the OP Insurance Company is admittedly deficient in providing proper services to the complainant and is also guilty of committing unfair trade practice by wrongly repudiating the genuine claim of the complainant. Hence, in the circumstances noted above we have no option except to partly allow the present complaint.

11.                   Now, the next question arisen what amount should be given to the complainant. The complainant has claimed in his complaint Rs.80,000/- on account of his treatment whereas on the other hand, Ops Insurance Company has stated in para No.3 of his written statement that a claim for Rs. 31994/- was lodged by the complainant. Accordingly, the complainant is entitled to get the same from the OP Insurance Company.

Although some bills of Rameshwar Dass Hospital has been placed on file but from these bills it is duly evident that these bills were not submitted by the complainant to the OP Insurance Company as original bills are attached with this File. Hence, the same are declined.

12                    Resultantly, we partly allow the complaint of complainant and direct the OP Insurance Company to pay Rs. 31,994/- to the complainant alongwith interest at the rate of 6% per annum from the date of filing of complaint till its realization. Order be complied within a period of 30 days after preparation of copy of this order failing which complainant shall be entitled to invoke the jurisdiction of this Forum as per law.  Copies of this order be sent to the parties concerned as per rules. File be consigned to the record room after due compliance.

Announced in open court. 07.06.2017.

                                                                                    (ASHOK KUMAR GARG )

                                                                                    PRESIDENT,

                                                                                    DCDRF, YAMUNANAGAR

 

 

                 (VEENA RANI SHEOKAND)                 (S.C.SHARMA)

                     MEMBER.                                             MEMBER