| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION PATIALA. Consumer Complaint No. 245 of 22.6.2017 Decided on: 1.9.2021 Bir Devinder Singh, Advocate, resident of H.No.14-A, Factory Area, Patiala. …………...Complainant Versus - Bajaj Allianz General Insurance Company Limited, GE Plaza Ist Floor, Airport Road, Yerawada, Pune through its M.D./Chairman/Director.
- Bajaj Allianz General Insurance Company Limited, Feroze Gandhi Market, branch Office, Ludhiana through its Branch Manager.
- Bajaj Allianz General Insurance Company Limited,SCO-12-13, 2nd Floor, Gurudwara Dukhniwaran Sahib Market, Patiala, Punjab through its Manager.
…………Opposite Parties Complaint under the Consumer Protection Act, QUORUM Sh. Jasjit Singh Bhinder, President Dr.Harman Shergill Sullar, Member ARGUED BY Sh.Surjit Rai, counsel for the complainant. Sh.Amit Gupta, counsel for OPs. ORDER JASJIT SINGH BHINDER,PRESIDENT - This is the complaint filed by Bir Devinder Singh (hereinafter referred to as the complainant) against Bajaj Allianz General Insurance Company Limited and others (hereinafter referred to as the OP/s) under the Consumer Protection Act, 2019 (hereinafter referred to as the Act).
- Briefly the case of the complainant is that he purchased health insurance policy bearing No.OG-17-1214-8417-00000034. It is averred that the complainant has been purchasing family floater medical policy from the OPs in his own name, in the names of Gurjinder Kaur and Agamjot Singh and has been regularly paying the premium. It is further averred that he had also availed the facility of free medical claim on account of any family member got admitted in hospital. It is averred that since the date of inception of medical policy, number of times Master Agamjot Singh availed cashless medical policy by submitting the medical record and discharge summary of Agamjot Singh with the insurance company. It is further averred that the policy was renewed on 6.1.2017. It is further averred that as per settled law if the proposer did not disclose (though the whole record of medical condition being with the OP) any disease after the lapse of 48 months the claim cannot be repudiated nor the policy can be cancelled. It is further averred that the last lodged claim was not for seizer disorder of Master Agamjot Singh but he was suffering from abdominal pain and the OPs are liable to pay the claim. It is further averred that the photocopy of claim form sent with the letter dated 6.5.2017 is not real form and is bogus and fabricated one. It is further averred that the complainant received letter dated 9.5.2017 vide which the claim has been repudiated on flimsy grounds. After receipt of this letter the complainant sent reply-cum-legal notice dated 26.5.2017 to the OPs through registered post with the request to not to cancel the policy and also to make the payment of the claim lodged for the treatment of Agamjot Singh but to no effect. Thus, the act and conduct of the OPs shows mal practice and deficiency of service on their part, which caused mental agony, pain and harassment to the complainant. On this back ground of the facts, the complainant has filed the complaint with the prayer to accept the same by giving direction to the OPs to make the payment of claim of Rs.25000/- towards hospital charges for treatment of Agamjot Singh; to further renew the policy after its expiry on receipt of premium and not to stop the policy in future; not to cancel the policy till its expiry date; to pay Rs.1100/-as costs of legal notice; to pay Rs.60,000/-as compensation; Rs.3000/-as postoperative charges; to pay Rs.10,000/- as litigation expenses with any other relief which this Forum may deem fit.
- Upon notice, OPs appeared through counsel and contested the complaint by filing written reply having raised preliminary objections that the complainant has taken one medi claim policy No.OG-17-1214-8417-00000034 for the period from 6.1.2017 to 5.1.2018. It is submitted that the complainant intimated on 9.3.2017 with regard to the treatment of his son on 24.1.2017 at CMC, Ludhiana, the claim of the complainant was duly processed, which was found not tenable on the ground that son of the complainant was hospitalized for pain in abdomen in a k/c/o seizures, for which he was suffering from 2011, which is pre existing to the policy and has not been disclosed on the proposal form. As such the claim was repudiated as there was no such treatment being administered (active line of treatment) or any such investigative procedure being performed which support the need for hospitalization.
- On merits, purchase of insurance policy in question is admitted. It is pleaded that the complainant has concealed the material illness of the child at the time of inception of the policy in the proposal form. It is admitted to be correct that as per the discharge summary: “ Course in the hospital: A 6 year 10 months old made child K/C/O seizure disorder admitted with abdominal pain was started on oral antibiotics (metronidazole) and drotin was given for pain relief. Currently pain was relieved and his general condition is stable and is being discharged to be followed up from OPD.Discharge weight:20Kg”. It is further pleaded that the insurance is a contract of good faith and the insured is liable to disclose each and every fact prior to the purchase of the policy and the non disclosure of the ailment at the time of inception of the policy is not covered. The claim of the complainant was not found tenable and has been rightly repudiated. There is no mal practice or deficiency of service on the part of the OPs. After denying all other averments, the OPs have prayed for the dismissal of the complaint.
- In support of the complaint, the complainant has tendered in evidence his own affidavit, Ex.CA alongwith documents Exs.C1 to C54 and his counsel closed the evidence.
- On the other hand, the ld. counsel for the OPs has tendered in evidence Ex.OPA affidavit of Saurav Khullar alongwith documents Exs.OP1 to OP9 and closed the evidence.
- We have heard the ld. counsel for the parties and have also gone through the record of the case, carefully.
- The ld. counsel for the complainant has argued that the complainant purchased medical policy in his name and in the name of his family and full premium was paid. The ld. counsel further argued that Master Agamjot Singh was also covered under the policy. The ld. counsel further argued that he became ill and the bill was submitted to the insurance company but the same was rejected. So the complaint be allowed.
- On the other hand, the ld. counsel for the OPs has argued that minor Agamjot Singh was admitted in the hospital for pain in abdomen and is suffering from seizure from 2011 and seizure is not covered under the policy. So the complaint be dismissed.
- To prove this case, the ld. counsel for the complainant has tendered in evidence Ex.CA affidavit of the complainant who has deposed as per his complaint, Ex.C1 is the letter written by Bajaj Allianz to Sh.Bir Devinder Singh regarding non disclosure of material facts.Ex.C2 is policy of Bajaj Allianz commenced from 6.1.2017 till 5.1.2018 in which alongwith Bir Devinder Singh, his wife Gurjinder Kaur and child Agamjot Singh were also covered,Ex.C4 is proposal form,Ex.C5 is renewal of health guard family floater option, Ex.C7 is discharge summary of CMC, Ludhiana of Agamjot Singh when his age was 3 years 3 months and he was suffering from acute gastritis, acute upper respiratory tract infection, acute seizure disorder and treated case of pulmonary T.B. So from this record of hospital CMC, Ludhiana which is popular/biggest hospital of that area, it is proved that master Agamjot Singh was suffering from acute gastritis, acute upper respiratory tract infection, acute lungs disorder and the insurance company has no right to reject the claim. Ex.C8 is the letter written by Bajaj Allianz to Sh.Bir Devinder Singh vide which the claim was repudiated .It is mentioned that he was suffering from abdomen pain in a k/c/o seizures and there was no such treatment being administered. This ground is totally illegal and is just to defeat the right of the complainant. They have no right to reject the claim because master Agamjot Singh was also suffering from other disease and he was 3 years and 3 months of age, Ex.C9 to Ex.C14 legal notices and postal receipts,Ex.C15 to C42 are the documents of Bajaj Allianz, Ex.C43 is the receipt of pharmacy of CMC, Ludhiana,Ex.C44 to C52 are also receipts, and Ex.C53 is final bill of Rs.25941/-.
- On the other hand Sh.Saurav Khullar has tendered his affidavit, Ex.OPA and he has deposed as per the written statement. Ex.OP1 is policy, Ex.OP5 is proposal form, Ex.OP6 is document of CMC, Ludhiana.
- So by taking into consideration, it is clear that vide policy Ex.C2 Bir Devinder Singh was insured alongwith his wife Gurjinder Kaur and child Agamjot Singh. Agamjot Singh fell ill and all the record of CMC, Ludhiana is also filed and as per the record of CMC, Ludhiana,Ex.C7, he was suffering from acute gastritis, acute upper respiratory tract infection, acute lungs disorder and he was admitted in the hospital. After that Ex.C53 bill of Rs.25941/- was submitted but the claim was rejected by the OPs on 9.5.2017 vide Ex.C8. The claim was wrongly rejected as Agamjot Singh was suffering from acute gastritis, acute upper respiratory tract infection, acute seizure disorder at the age of 3 years 3 months which are not pre existing disease.
- So due to our above discussion, the complaint is allowed and the OPs are directed to pay the claim amount of Rs.25941/- to the complainant alongwith interest @6% per annum from the date of repudiation till realization .The OPs are further directed to pay Rs.5000/-as compensation and another amount of Rs.5000/- as costs of litigation.
- Compliance of the order be made by the OPs within a period of 45 days from the date of the receipt of the certified copy of this order.
ANNOUNCED DATED:1.9.2021 Dr.Harman Shergill Sullar Jasjit Singh Bhinder Member President | |
