Haryana

Kurukshetra

240/2018

Harinder Kaur - Complainant(s)

Versus

Bajaj Allianz - Opp.Party(s)

Rohtash Jangam

16 Mar 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION KURUKSHETRA.

 

Consumer Complaint No.240 of 2018

Date of instt.:15.11.2018

                                                                        Date of Decision:16.03.2021

 

Harinder Kaur wife of Surender Pal Singh resident of house no.489, Sector -3, Urban Estate, near Sahara School, Kurukshetra, Tehsil Thanesar District Kurukshetra, Haryana.

                                                                                      …….Complainant.                                                 Versus

 

1.  Bajaj Allianz General Insurance Company Limited, GE Plaza Airport Road  Yerwada Pune- 411006.

 

2.  Bajaj Allianz General Insurance Company Limited, Kurukshetra Tehsil Thanesar, District Kurukshetra, through its Branch Manager.

         

….…Opposite parties.

 

                  Complaint under Section 12 of Consumer Protection Act.

 

Before        Smt. Neelam Kashyap, President.    

                   Ms. Neelam, Member. 

                   Shri Issam Singh Sagwal, Member.                                                       

 

Present:      Sh. Rohtash Jangam Advocate for the complainant.                 

Sh.Atul Mittal  Advocate for OPs.

ORDER

                                                                         

                    This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Harinder Kaur against Bajaj Allianz etc.-the opposite parties.

 

2.                The brief facts of the complaint are that the complainant went to Australia on 10.4.2018 and came back on 6.10.2018. During her aforesaid foreign stay, she obtained insurance policy from OPs vide policy No. OG-19-9906-9910-00001220  dated 7.4.2018 and paid a sum of Rs.17,534/- as premium. After going to Australia on 25.5.2018 she felt acute pain in her chest associated with diaphoresis and she was taken to Royal Perth Hospital, Australia in emergency by Ambulance where she remained indoor patient with effect from 25.5.2018 to 29.05.2018 and thereafter on 2.6.2018 to 4.06.2018 and during this treatment, she had to spent lot of money on her hospitalization, lab diagnostic, emergency ambulance etc. follow-up treatment and transportation and total amount spent by the complainant is Rs.32,856.51 Australia Do9ller i.e. Rs.17,23, 881.45P  and vide letter dated 17.09.2018 the OPs refused to pay the genuine  and bonafide claim of the complainant.  The said letter dated  17.09.2018 is illegal, void and without jurisdiction due to following reasons.

                   That the medical condition of Harinder Kaur was informed/emailed to Allianz Global Assistance at Australia and in India (insurer firm) the Allianz fax the release of informative authorization to the Royal Perth Hospital Australia. The hospital/treati NG Cardolialigt/Attending doctor reported on the same day i.e. 25.5.2018 that present illness is not due to any pre-existing condition. No illness when policy on 7.4.2018.

                   ii) That OPs have not heard the complainant prior to issuing the impugned letter.

                   iii)That no personal hearing has been given to the complainant prior to issuing the impugned letter.

                   iv) That the OPs being the insurer of the complainant are legally bound to pay the amount in question. Hence there is deficiency in services on the part of OPs.

 

                   Thus, alleging deficiency in services on the part of the OPs, the complainant has filed the present complaint and prayed that OPs be directed to pay Rs.17,23,881.45P alongwith interest, compensation for the mental harassment and agony caused to the complainant and the litigation expenses.

 

3.                Upon notice, OPs appeared and filed written statement disputing the claim of the complainant. It is submitted that the complainant consulted for the treatment of ST Elevation Myocardial infarction with Hypertension, Medical records received are suggestive  of history of hypertension and is on continuous medication for the same which is pre-existing to the policy and has  not been disclosed on proposal form at time  of purchase of policy and moreover current ailment is complication of pre existing medical conditions, policy does not extent coverage for pre existing ailment and is complications as per exclusion clause. It is submitted that there was evidence material suppression by non-disclosure of material fact i.e. pre existing ailment which in itself violation of principal of insurance as well as  terms and conditions of policy and declaration made thereof before the issuance of the policy.  It is further submitted that  this Commission has got no jurisdiction to  try and adjudicate the present complaint as the policy of insurance was issued from Chandigarh where the OP is  having its office and OP is having no branch office at Kurukshetra, so the present complaint before this Forum is not maintainable. Thus, it is submitted that there is deficiency in service on the part of the OP and has prayed for dismissal of the present complaint.

 

4.                The complainant in support of her complaint has filed her affidavit Ex.CW1/A and tendered documents Ex.C-1 to Ex.C-54 and closed her evidence.

 

5.                 On the other hand, OPs in support of their case have filed affidavit Ex.OW1/A and tendered documents Ex.O-1 to Ex.O-4 and closed their evidence.

 

6.                We have heard the learned counsel for the parties and gone through the material available on the case file.

 

7.                The learned counsel for the complainant while reiterating the averments made in the complaint has argued that complainant went to Australia on 10.4.2018 and  she came back on 6.10.2018. During her aforesaid foreign stay, she obtained insurance policy from OPs vide policy No. OG-19-9906-9910-00001220  dated 7.4.2018 and paid a sum of Rs.17,534/- as premium. After going to Australia on 25.5.2018 she felt acute pain in her chest associated with diaphoresis and she was taken to Royal Perth Hospital, Australia in emergency by Ambulance where she remained indoor patient with effect from 25.5.2018 to 29.05.2018 and thereafter on 2.6.2018 to 4.06.2018 and during this treatment, she had to spent lot of money on her hospitalization, lab diagnostic, emergency ambulance etc. follow-up treatment and transportation and total amount spent by the complainant is Rs.32,856.51 Australia Do9ller i.e. Rs.17,23, 881.45P  and vide letter dated 17.09.2018 the OPs refused to pay the genuine  and bonafide claim of the complainant.  The said letter dated  17.09.2018 is illegal, void and without jurisdiction and the complainant was not having any pre existing disease. It is further argued that hypertension and diabetes are not  pre-existing diseases.

 

8.                On the other hand, learned counsel for the OPs while reiterating the contentions made in the written statement has argued that the complainant consulted for the treatment of ST Elevation Myocardial infarction with Hypertension, Medical records received are suggestive  of history of hypertension and is on continuous medication for the same which is pre-existing to the policy and has  not been disclosed on proposal form at time  of purchase of policy and moreover current ailment is complication of pre existing medical conditions, policy does not extent coverage for pre existing ailment and is complications as per exclusion clause and as such the claim of the complainant has rightly been repudiated and there is no deficiency in services on the part of the OPs.

 

9.                After hearing the learned counsel for the parties and going through the record we are of the view that the claim of the complainant has wrongly been repudiated by the OPs.  It is not in dispute that the  complainant went to Australia on 10.4.2018 and came back on 6.10.2018. During her aforesaid foreign stay, she obtained insurance policy from OPs vide policy No. OG-19-9906-9910-00001220  dated 7.4.2018 and paid a sum of Rs.17,534/- as premium. After going to Australia on 25.5.2018 she felt acute pain in her chest associated with diaphoresis and she was taken to Royal Perth Hospital, Australia in emergency by Ambulance where she remained indoor patient with effect from 25.5.2018 to 29.05.2018 and thereafter on 2.6.2018 to 4.06.2018 and during this treatment, she had to spent lot of money on her hospitalization, lab diagnostic, emergency ambulance etc. follow-up treatment and transportation and total amount spent by the complainant is Rs.32,856.51 Australia Do9ller i.e. Rs.17,23, 881.45P  and vide letter dated 17.09.2018 the OPs refused to pay the genuine  and bonafide claim of the complainant.    The  OPs have stated that the complainant was already suffering from hypertension and it was a pre existing disease. She could not disclose this fact at the time of obtaining the present policy. The perusal document Ex.C-3, attending physician statement shows that the treating doctor has stated that the patient was not having any pre existing disease. The OPs have failed to adduce any cogent evidence to prove that the complainant was suffering from hypertension at the time of obtaining of the policy in question. Further as per law laid down in case Rajinder Singh Vs. The New India Assurance Co. Limited and others 2018(3) CLT 187, the Hon’ble State Commission, Haryana has held that “the treating doctor mentioned that the complainant was suffering from diabetes and hypertension for the last about three years without mentioning his source of knowledge in this regard and has not mentioned as to whether the patient had himself told him that he was suffering from the abovementioned ailments, repudiation of the claim was not justified.”

 

10.              As discussed above , it is clear that the OPs have failed to establish that the complainant was having pre existing disease like hypertension and if for the sake of arguments, it is admitted that the complainant was suffering from hypertension prior to taking of the policy in question, even then the claim of the complainant has wrongly been repudiated and the complainant is entitled to claim Rs. 17,23,881.45 P i.e. Rs.32,856.51 Australia Dollar which has not been paid by the OPs and as such deficiency in services on the part of OPs is made out.

 

11.              In view of our above discussion, we accept the present complaint and direct the OPs to make the payment of Rs.17,23,881.45P alongwith interest @ 6% per annum from the date of filing of the present complaint i.e. 15.11.2018 till its actual realization. The OPs are also directed to pay Rs.5000/- to the complainant as compensation for the mental harassment and agony caused to the complainant due to deficiency in services on the part of the OPs together with Rs.5000/- as litigation expenses.  The OPs are further directed to make the compliance of this order within a period of 45 days from the date of preparation of certified copy of this order, failing which the  complainant  will be at liberty  to initiate proceedings under Section 25/27 of the Act against the OPs. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the record-room, after due compliance.

 

Announced in open commission:

Dt.:16.03.2021.                                                       (Neelam Kashyap)                                                                                                  President.

 

 

(Issam Singh Sagwal),              (Neelam)         

 Member                                     Member.