BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 213 of 2018
Date of Institution : 13.08.2018
Date of Decision : 25.04.2019.
Priyanka Malhotra aged about 35 years wife of Shri Sandeep Kumar son of Shri Laxmi Narayan resident of Laxmi Complex, Masharan Partap Chowk, Hisar Road Thief & District Sirsa.
……Complainant.
Versus
- Bajaj Allianz Life Insurance Co. (Family Care 1st Health Policy) 1st floor, KAR House Building, Opposite Hotel Jai villas, Dabwali road, Sirsa through its authorized person.
- Bajaj Allianz Life Insurance Co.Ltd. West Hub, 2nd Floor, Bajaj Finserv, Survey # 208/1-B, Behind Fwikfield it Building Viman Nagar, Nagar Road, Pune, Maharashtra-411014.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA………………. ……PRESIDENT.
SH. ISSAM SINGH SAGWAL ………MEMBER.
MRS. SUKHDEEP KAUR……………..MEMBER.
Present: Sh. S.K.Dhandhal, Advocate for the complainant.
Sh. J.B.L.Garg, Advocate for opposite parties.
ORDER
The case of the complainant, in brief, is that husband of the complainant namely Sandeep Kumar had purchased a cashless Family Care 1st Health Policy bearing No.287048583 on 06.12.2012 from Ops and he had to pay a sum of Rs.5029/- per year as premium. All the accidental risks were covered under the said policy for sum assured of Rs.3,75,000/-. At the time of purchasing the policy, husband of the complainant was unmarried and lateron he was got married and in the year 2016 name of the complainant was got added and the annual premium was extended to Rs.8280/-. The premium of the policy was paid regularly. On 09.06.2018, when the complainant was pregnant, she met with an accident and got miscarriage and there was severe bleeding and acute pain. She was taken to the penal hospital of insurance i.e. Bansal Nursing Home, Sirsa but the insurance company denied the cashless policy and the hospital had declined to treat the complainant under cashless policy. The hospital had charged Rs.5,000/- from the husband of the complainant and besides this sufficient amount was also incurred on the medicines and diet etc. The husband of the complainant requested the OP to indemnify the claim and also sent emails on 11.06.2018, 13.06.2018, 17.06.2018, 27.06.2018 and 30.06.2018 by lodging the claim and also got served legal notice upon the Ops but to no avail. The act and conduct of the Ops clearly amounts to deficiency in service on their part. Hence, this complaint.
2. On notice Ops appeared and filed their joint reply, wherein it has been submitted that in fact the complainant has suppressed the material facts from this Forum, therefore, he has no cause of action and locus standi to file the present complaint. There is no deficiency in service on the part of Ops and the present complaint has been filed in order to cause under harassment to the reply Ops. The complainant was at liberty to go through the terms and conditions of the policy. After receiving the proposal form and going through the entire contents of the same, the underwriters of the policy reached to such a conclusion that there is no risk to issue the policy to the complainant and accordingly the present policy was issued and sent to the complainant alongwith its all terms and conditions. The complainant cannot get the claim under the policy as per terms and conditions of the policy. The policy holder was admitted in Bansal Hospital Sirsa for retained product and undergone for treatment. Cashless claim documents received from the hospital and consultation paper dated 9, June received stating that insured is having period problem with gestational history. LSCS was done 6th months back and suggested for D&C. There is no history of any accident mentioned in the documents. As per exclusion Clause 6h, the company shall not be liable to make any payment, if hospitalization or medical expenses or claims are attributable to, or based on, or arise out of, or are directly or indirectly connected to any of the following: Treatment arising from pregnancy which shall include childbirth or miscarriage (except as a result of an Accident) excepting ectopic pregnancy and further the complainant till date did not send the documents for reimbursement of the claim under the policy with the replying Ops. The complainant is not entitled for any claim under the policy terms and conditions. Other contentions have been controverted and prayer for dismissal of the complaint has been made.
3. Thereafter, both the parties have led their respective evidence.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. The perusal of the case file reveals that in order to prove her case the complainant has furnished her affidavit Ex.CW1/A wherein she has deposed all the averments made in his complaint. The complainant has also furnished affidavit of her husband Sandeep Kumar Ex.CW2/A, who has corroborated the version of the complainant. The complainant has tendered document legal notice Ex.C1, postal receipt Ex.C2, acknowledgment Ex.C3, denial of cashless policy Ex.C4, receipts of Ex.C7 to Ex.C8, hospital bill Ex.C9, prescription slip Ex.C10, USG report Ex.C11, premium receipt Ex.C12 and insurance policy Ex.C13, health card Ex.C14, email regarding denial of cashless Ex.C15 and postal receipt Ex.C16. On the other hand the Ops have tendered affidavit of Sh. Rajiv Kumar, as Ex.RW1, in which, he has reiterated the averments of the written statement. The OPs have also furnished copies of documents such as proposal form Ex.R1, personal details Ex.R2 to Ex.R4, prescription slip Ex.R5, test report Ex.R6, cashless form Ex.R6, ultrasound report Ex.R7 and health card Ex.R8.
6. The evidence of the complainant reveals that at the time of inception of the policy, the complainant was unmarried lady and thereafter she was married to Sandeep Kumar and her name was got added in the policy by her husband and the annual amount was extended to Rs.8280/-. It is proved fact on record that on 09.06.2018, the complainant met with an accident and she was pregnant at that time and she got miscarriage and the complainant was taken to the Bansal Hospital and she remained there to take treatment and spent Rs.6500/- her treatment. The claim was lodged with the Ops but the claim was rejected on the ground that the insured was having period problem with gestational history. LSCS was done 6 months back and suggested for D&C. There is no history has been any accident mentioned in the documents submitted. The perusal of the evidence of the Ops reveals that the Ops have not placed on record any opinion of the expert by whom the documents were inspected and formed opinion that there was only a period problem. So, it appears from the evidence of the Ops that the Ops have failed to lead any cogent and convincing evidence in order to prove their pleas taken in defence and the claim has been repudiated wrongly and in arbitrarily manner.
7. In view of the above discussion, we hereby allow the present complaint with a direction to the Ops to settle and pay the claim of the complainant within 30 days of the receipt of the copy of this order. The Ops are further directed to pay Rs.3,000/- as composite compensation on account of harassment and litigation expenses to the complainant. A copy of this order be sent to both the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:25.04.2019. District Consumer Disputes
Redressal Forum, Sirsa.
Member Member
DCDRF, Sirsa DCDRF, Sirsa
