Delhi

East Delhi

CC/386/2017

AJAY KOCHER - Complainant(s)

Versus

BAJAJ ALLIANZ - Opp.Party(s)

05 Mar 2022

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO. 386/2017

 

 

	Shri Ajay Kachru R/o A-604, New Cosmopolitan Society Sector 10, Plot No. 33, Dwarka New Delhi 110075	….Complainant
Versus
	M/s Bajaj General Insurance Co. Ltd. 1st Floor, Rishab Corporate Tower, Karkardooma, Community Centre Delhi 110095	……OP

 

                                                   

Date of Institution: 12.09.2017

Judgment Reserved on: 08.02.2022

Judgment Passed on: 05.03.2022

            

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Ms. Ritu Garodia (Member)

 

Order By: Shri S.S. Malhotra, President

 

JUDGEMENT

1. By this order I shall dispose off the present complaint filed by the complainant against OP, inter-alia claiming deficiency in service by the OP, in not indemnifying the claim w.r.t. the ailment despite there being a valid Health Shield Insurnace Policy issued by OP.
2. Brief facts stated by the complainant in nutshell are that the complainant had purchased a Health Shield Insurance Policy for self and his wife vide insurance policy no. OG-17-9906-8408-00000450 for the period 27.08.2016 to 26.08.2017 for an insurance value of Rs. 2,00,000/-. Prior to issue once of policy OP has conducted all health check up of the complainant. The complainant further alleged that OP had never supplied `terms & conditions’ of the said policy  and only provided a soft copy of the same. 

Complainant further stated that on 06.02.2017, he felt some uneasiness and acute pain in the chest for which he was immediately taken to Medanta Hospital. After carrying out the required test and further discussion of doctors and on their opinion, an operation was conducted by a team of cardiologist/surgeons from Medanta Hospital. Complainant remained in the hospital till 14.02.2017. On intimating about the hospitalization, the OP deputed his panel doctor to verify bills and medicines prescribed by the doctors. The complainant also submitted all the necessary paper viz. claim form duly completed, admission and discharge summaries and medical bills worth Rs. 3,29,846/-, testing reports and prescription slips etc, but the OP sent a rejection letter of claim to the complainant without any valid reason.   Complainant further alleged that non-settlement of the claim of the complainant within three months is a clear case of deficiency in service and he has prayed that OP be directed to pay settlement of the claim alongwith a sum of Rs. 2,00,000/- alongwith interest 24% p.a., Rs. 1,50,000/- as compensation for mental agony, pain and suffering and also Rs. 25,000/- cost of the present litigation. Complainant annexed copy of policy documents, medical related documents, hospital bill, emails exchanged with OP regarding his claim in the support of his complaint.

3. In response to the Notice served upon the OP, the OP filed its written statement wherein it supported the repudiation of the claim OP categorically stated that the said claim of the complainant is inadmissible and stands repudiated for the reason that the complainant was known case of suffering from hypertension since one year and the ailment for which the complainant is seeking reimbursement was a complication arising out of the aforementioned pre existing hypertension. It further submitted that the claim was not maintainable as the complainant failed to disclose the abovementioned facts on the proposal form. It is further stated that the policy does not cover liability for any pre-existing ailment or any complications arising thereon until 12 consecutive months have elapsed from the first policy or if the policy is of the subsequent renewal, without break of an earlier Silver Health Policy which is held for a continuous period of one year. Therefore, the OP prayed for dismissal of the present frivolous complaint.
4. Complainant has filed rejoinder to the written statement of OP wherein all facts mentioned in complaint were reiterated and the facts of written statement were denied. The complainant in his evidence by way of affidavit has affirmed the contents of the complaint are true.  OP has also supported their reply by their evidence as filed by way of affidavit. In its evidence OP states that complainant was suffering from the Hypertension  which was confirmed by the declaration of Dr. Madhukar Shahi which was duly acknowledged by the complainant too. True copy of insurance policy bearing no. OG-17-9906-8408-000000450 commencing from 27.08.2016 to 26.08.2017 and proposal filed by the complainant exhibited as Ex OPW1/1 (Colly), True copy of claim form exhibited as Ex OPW1/2 (Colly), true copy of repudiation letter dated 05.04.2017 exhibited as Ex OPW1/3. Rests of the contents of the written statement are reiterated in its evidence.
5. Both the parties have filed their respective written arguments.
6. The OP has relied upon the judgment of the Hon’ble NCDRC in case titled M/s Aviva Life Insurance Co. India Pvt Ltd Vs Phool Kanwar bearing Revision Petition No. 2877 of 2013 wherein Hon’ble NCDRC upholding the repudiation of the insurance claim by the insurance company opined in relation to non-disclosure of pre-existing disease, and held ;

It is settled principle of law that the contract of insurance is a contract uberrima fides and there must be complete good faith on the part of the life assured at the time of submitting proposal form and obtaining the policy and the assured is under a solemn obligation to make full disclosure  of material facts with regard to his state of health because the same was relevant for the insurer to decide as to whether the insurance policy is to be issued to the proposer or not.

Mellitus and Hypertension for over two years but he did not disclose these facts while making the proposal statement and has violated the terms and conditions of the insurance policy, therefore, respondent-wife of life insured, is not entitled for any insurable benefit….”

7. The Ld. Counsel for complainant on the other hand has relied upon the judgment of the Hon’ble NCDRC in case titled Neelam Chopra vs Life Insurance Corporation of India bearing Petition No. 4461 of 2012 wherein Hon’ble NCDRC upholding that the disease like Hypertension and Diabetes etc, have been classified as a daily life disease and it is held that even if the life style have not been disclosed, the insurance company cannot repudiate the claim on the sole ground. Para 11 of the said Judgment which relates to present matter is reproduced as under:

Para 11 “From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases. The person insured may suffer consequences in terms of the reduced claims.”

This was the case where the petition was suffering from diabetes and which was not disclosed by the consumer while taking insurance policy and the court ultimately given their findings as mentioned here.

8. Coming to the facts to present case and by applying the law laid in the Judgment Neelam Chopra vs Life Insurance Corporation of India bearing Petition No. 4461 of 2012 by Hon’ble NCDRC, this court has opined that petitioner in the present case was not suffering any serious disease except hypertension which otherwise was in control at the time of taking the insurance policy. Further, no document has been filed by OP that after taking the policy the insured has ever been treated with any disease arising due to hypertension i.e. disease pertaining to high or low blood pressure. In the considered opinion of this Court mere suffering with hypertension coupled with the facts that insured has not suffered with any such disease of such nature so far, this Court is of opinion that repudiation of the claim by insurance company in toto merely on the ground of hypertension which is common life style disease and very common in nature, cannot repudiate the claim, Accordingly, the contention of OP cannot be accepted and contention of complainant is well found and petition is allowed in terms of the Judgment Neelam Chopra vs Life Insurance Corporation of India bearing Petition No. 4461 of 2012 particularly Para 11 of the Judgment, the Commission is of the opinion that rejection of the claim in totality by the OP amounts to deficiency in service and as such complainant is entitled to get compensation but keeping in view the observation made by Hon’ble NCDRC in para 11 he is entitled to reduced claim, Accordingly, the Commission has granted following reliefs to the complainant:

1. OP is directed to pay 75% of total claim amount to complainant alongwith 6% interest p.a. on the reduced amount i.e. 75%.
2. Further in view of these facts where there is some fault on part of complainant too, hence, he is not entitled for any compensation on account of harassment mental pain and agony suffering or any other head.
3. OP is directed to pay Rs. 7500/- towards legal expenses to complainant

9. This order be complied with within 30 days from the date of the order.
10. Copy of the order be supplied / sent to the parties free of cost as per rules.
11. File be consigned to Record Room.
12. Announced on 05.03.2022

DELHI

 

(Ravi Kumar) Member

(Ritu Garodia) Member

(S.S. Malhotra) President