BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, PATIALA.

                                                Complaint No.CC/10/688 of 12.8.2010

                                                Decided on:          15.9.2011

Gurdeep Singh aged about 39 years, son of Dalwar Singh # 20, North Avenue, Bhadson Road, Patiala.

                                                                             -----------Complainant

                                      Versus

1.                 Bajaj Allianz  Life Insurance Co.Ltd. 1^st Floor, Navdeep Complex, Opp. Income Tax Office, Patiala through its Branch Manager.

2.                 Bajaj Allianz General Insurance Co. Ltd. Regd. Office GE Plaza,Airport Road, Yerwada,Pune-411006 through its Director/C.M.D.

                                                                             ----------Opposite parties.

                                      Complaint under Section 12 of the

                                      Consumer Protection Act.

                                      QUORUM

                                      Sh.D.R.Arora, President

                                      Smt.Neelam Gupta, Member

Present:

For the complainant:     Sh.K.S.Sidhu, Advocate

For opposite parties:     Sh.D.P.S.Anand, Advocate   

                                         ORDER

D.R.ARORA, PRESIDENT

          The complainant and the members of his family were got insured with the ops vide Generic Contingency policy No.0G-10-12146004-00000011. The policy had to commence w.e.f.8.7.2009 and expired on 7.7.2010. Before issuing the insurance policy, the complainant and members of his family were subjected to medical examination by a doctor of the ops who found them medically fit. The policy covered the medical expenses of hospitalization etc.

2.       In the month of August/2009 the complainant had suffered fever, uneasiness and bitter taste and he got himself examined from Gobind Hospital, Patiala, where he was diagnosed to be a case of chronic viral Hepatitis C with acute gastritis . He was admitted in the hospital for the period 11.8.2009 to 13.8.2009.Thereafter he was referred to gastroenterologist for further treatment and thereafter the complainant got himself treated from Dr.Mohnish Chhabra. The complainant spent an amount of Rs.2,94,385/- on his treatment.

3.       After the treatment the complainant visited the office of op no.1 and informed about his claim. As asked by the ops the complainant performed the formalities in the matter of submitting the documents. However, the complainant was shocked on receipt of letter dated 10.7.2010 from the ops when his claim was repudiated on the flimsy ground that the complainant was having Hepatitis –C and gastritis within 30 days of the insurance and therefore, the claim was not payable.

4.       At this the complainant visited the office of op no.1 and explained that he had suffered from the disease for the first time on 11.8.2009 whereas the policy had started w.e.f.8.7.2009 and therefore, the claim was not covered by the clause of the disease having been diagnosed within first 30 days of the insurance policy. Moreover, no such conditions were either supplied or explained to the complainant. The ops failed to listen to the complainant.

5.       The complainant describing the repudiation of the claim made by the ops to be arbitrary and illegal approached  this Forum through the present complaint brought under Section 12 of the Consumer Protection Act,1986 (for short the Act) for a direction to the ops to release the amount of Rs.2,94,385/- with interest @18% per annum from the date of loss;  further to pay him Rs.50,000/- on account of the harassment suffered by him and also to provide him Rs.22000/-as costs of the complaint.

6.       On notice, ops appeared and filed their written version. It is denied, if the complainant and the members of his family were insured with the ops. It is however, stated that the ops had issued a Generic Contingency policy in favour of the complainant for the period 8.7.2009 to 7.7.2010 in respect of the complainant, his wife and daughter. It is denied if the complainant had suffered from fever , uneasiness and bitter taste and he got himself treated from Gobind Hospital, Patiala having remained admitted there from 11.8.2009 to 13.8.2009 or that he spent Rs.2,94,385/- on his treatment.

7.       It is further averred that the claim of the complainant had been repudiated as the verification of the claim revealed that the complainant was diagnosed of having chronic viral hepatitis C with acute gastritis within 30 days from the inception of the policy and therefore, the claim was repudiated under exclusion clause. The complainant was suffering from chronic viral hepatitis C but he had not disclosed this fact at the time of obtaining the policy which amounts to the violation of the terms and conditions of the policy. After denouncing the other averments of the complaint, going against the ops, it was prayed to dismiss the complaint.

8.       In support of his complaint, the complainant produced in evidence his sworn affidavit,Ex.C1, alongwith the documents,Exs.C2 to C28 and his learned counsel closed the evidence.

9.       On the other hand, on behalf of the ops, their learned counsel produced in evidence,Ex.R1, the sworn affidavit of Sunil Kaur,Assistant Manager of the ops posted at Jalandhar  alongwith documents,Exs.R2 to R4 and  closed their evidence.

10.     The complainant filed the written arguments. We have examined the same, heard the learned counsel for the parties and gone through the evidence on record.

11.     Ex.C27 is the letter dated 10.7.2010, written by the authorized signatory of op no.2 to the complainant, whereby he was informed that the claim documents revealed that the complainant was diagnosed of having chronic viral hepatitis C with acute gastritis within first 30 days from the date of the inception ( 8.7.2009) of the policy. Hence claim was repudiated under exclusion clause.

12.     It was submitted by Sh.K.S.Sidhu, the learned counsel for the complainant that despite the complainant having provided the documents including Ex.C27, showing that he was diagnosed with viral Hepatitis C with acute gastritis only on 11.8.2009, in the Gobind Hospital Tripuri Chowk,Patiala ,where he remained admitted for the period 11.8.2009 to 13.8.2009,the claim of the complainant was repudiated arbitrarily by the ops. Admittedly the policy had started from 8.7.2009 and the complainant was diagnosed to be suffering from the aforesaid disease on11.8.2009 i.e. beyond a period of 30 days from the inception of the insurance policy. It was submitted by the learned counsel for the complainant that the claim of the complainant was repudiated without application of mind. It was submitted that there is nothing to show that the complainant was suffering from the disease of Viral Hepatitis C with acute gastritis prior to 11.8.2009.

13.     It was submitted by the learned counsel for the complainant that the Forum may settle the claim of the complainant with the help of  the documents produced by him.

14.     On the other hand, Sh.D.P.S.Anand, the learned counsel for the ops could not show us how the claim of the complainant could be repudiated despite the fact that the complainant had not been diagnosed to be suffering from the disease of Viral Hepatitis C with acute gastritis within a period of 30 days from the date of the commencement of the policy. Consequently we find that the repudiation of the claim of the complainant to have been made by the ops being without any basis and to be arbitrary can not be upheld.

15.     We are not in a position to settle the claim of the complainant because the complainant has simply produced,Ex.C2, the copy of the bill  showing the name of the patient, CR No., date of admission, date of discharge and the charges realized from the complainant by Gobind Hospital and Laboratory, Patiala.The complainant has not produced any bed head ticket or discharge summary to enable us to appreciate,Ex.C2 as also the medicines bills,Exs.C3 to C8, and other bills Exs.C9 to C13 obtained by the complainant from Fortis Hospital, Mohali and similarly the other receipt,Ex.C14 obtained from Dr.Mohnish Chhabra,Gastroentrolist, Chandigarh and the bills,Exs.C15 to C26 obtained from Taksal Pharma Pvt. Ltd.In view of the aforesaid position, we would like after accepting the complaint to give a direction to the ops to settle the claim  of the complainant within one month on receipt of the certified copy of the order on the basis of the documents already submitted by the complainant. Accordingly, we accept the complaint and give a direction to the ops to settle the claim of the complainant within 30 days from the receipt of the certified copy of the order. In case the claim is settled in favour of the complainant the ops shall disburse the amount to the complainant within 15 days with interest @9% per annum from the date of the repudiation that is 10.7.2010.The claim of the complainant having been repudiated arbitrarily and without any basis we accept the complaint with costs assessed at Rs.7500/- to be paid by the ops within one month of the receipt of the certified copy of the order.

Pronounced.

Dated:15.9.2011

                                       Neelam Gupta                  D.R.Arora

                                       Member                            President