Haryana

Yamunanagar

CC/1223/2011

Devendera Kumar s/o Sh.Gunanand, - Complainant(s)

Versus

Bajaj Allianze Life Insurance - Opp.Party(s)

Bhanwar Singh

01 May 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

                                                                       Complaint No. 1223  of 2011.
                                                                       Date of institution: 13.12.2011
                                                                       Date of decision:  01.05.2017

 

Devendera Kumar aged about 43 years son of Sh. Gunanand resident of House No. 1262, Jain Evnew Colony, Jagadhri, Tehsil Jagadhri, district Yamuna Nagar.                                                             

                                                                                                           …Complainant.
                Versus
1.    Bajaj Allianz Life Insurance Company Limited Opp. Madhu Petrol Pump, Yamuna Nagar through its Branch Manager.
2.    Bajaj Allianz Life Insurance Company Limited, Head Office GE Plaza, Airport Road, Yerawada, Pune-411006 through its Director.                                                                              

                                                                                                           …Respondents

 

BEFORE:  SH. ASHOK KUMAR GARG…………………… PRESIDENT
                   SH. S.C.SHARMA……………………………….. MEMBER
                   SMT. VEENA RANI SHEOKAND……………….MEMBER    

 

Present: Sh. Bhanwar Singh, Advocate, counsel for complainant.    
               Sh. Rajiv Gupta, Advocate, counsel for respondents.
    
ORDER (ASHOK KUMAR GARG PRESIDENT)

1.        The present complaint has been filed under section 12 of the Consumer Protection Act 1986 amended upto date.

2        Brief facts of the present complaint, as alleged by the complainant, are that complainant purchased a mediclaim policy bearing No. 0046349693 on 28.03.2007 for a sum insured of Rs. 1,95,000/- from the respondents (hereinafter respondents will be referred as Ops). On 05.09.2011, the complainant suffered chest problem and for this reason he got himself admitted in Kapil Hospital, Jagadhri where the complainant suffered heart attack. On this, doctor of the Kapil Hospital referred the complainant to Fortis Hospital SAS Mohali where the complainant  was treated by Dr. Ramesh K. Jaswal and the angioplasty of the complainant was done and an amount of Rs. 2,91,110/- was charged by the Fortis Hospital vide bill No. FHM/11-12/I/Cs/00006023. The complainant remained admitted there from 05.09.2011 to 09.09.2011 after discharge from the Fortis Hospital, Mohali, the complainant lodged the claim with the Ops Insurance Company and visited there office so many times and also sent e-mails on dated 10.10.2011, 19.10.2011, 17.10.2011, 02.11.2011 and 17.11.2011 but every time the officials of the Ops Insurance Company put off the matter on one pretext or the other. However, ultimately the Ops Insurance Company repudiated the claim of the complainant vide letter dated 09.11.2011 mentioning therein that "illness suffered by him is not covered under 11 Critical Illnesses mentioned in policy terms and conditions" which is absolutely wrong, illegal and arbitrary which constitute the deficiency in service and unfair trade practice on the part of OPs Insurance Company and lastly prayed for directing the Ops Insurance Company to pay the claim amount and also to pay compensation as well as litigation expenses.

3.        Upon notice, OPs appeared and filed its written statement by taking some preliminary objections such as complainant has no locus standi to file the present complaint as critical illness rider claim lodged by the complainant was not covered under any of critical illnesses as defined under the terms and conditions of the Insurance policy; the complainant life assured was suffering from CAD ( Coronary Artery Disease) and Post PTCA ( Percutaneous Transluminal Coronary Angioplasty) plus Stent to RCA (Right Coronary Artery Stent) and reportedly remained admitted for the treatment in the Fortis Hospital from 05.09.2011 to 09.09.2011 vide UHID No. 320139. The illness suffered by the complainant was not covered under any category of 11 Critical Illness mentioned under the head "Critical Illnesses rider Benefits" expressly and specifically mentioned in the terms and conditions of the policy. As per terms and conditions of the policy the critical illness cover, which may be considered for adjudication to the dispute in this case are  

     9.Critical illness to be covered.
(a)    First Heart Attack.
The death of a portion of heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis should be based on all of the following:
(i)    A history of typical chest pain, if any.
(ii)    New and recent electrocardiographic changes indicating myocardial infarction
(iii)    Elevation of cardiac enzymes
(iv)    Diagnosis based on the elevation of Troponin Test, alone shall not be considered diagnostic of a heart attack. Angina and chest pain are especially excluded.
(b)    Coronary Artery Disease Requiring Surgery.
The undergoing of heart surgery to correct narrowing of blockage of left main coronary artery or three or more coronary arteries with bypass grafts in persons with limiting anginal symptoms and compromise of blood supply supported by investigation but excluding nonsurgical techniques such as balloon angioplasty, laser relief of an obstruction or other forms or Coronary artery clearing through catheters or similar devices. Narrowing of the affected artery should be more than 75% (seventy five percent).
     That since the claim lodged by the respondent was for reimbursement of expenses towards CAD (coronary Artery Disease) and Post PTCA (Percutaneous Transluminal Coronary Angioplasty) plus Stent to RCA (right Coronary Artery Stent), the same amount to non-surgical techniques which is not covered under the terms and conditions of the Insurance policy and therefore, the claim of the respondent was not payable and was rightly repudiated vide letter dated 09.11.2011.

     Rest contents of the complaint were denied and on merit controverted the plea taken in the complaint and reiterated the stand taken in the preliminary objections. Lastly, prayed for dismissal of complaint.

4.        In support of his case, complainant tendered into evidence his affidavit as Annexure CW/A and documents such as Photo copy of Insurance policy schedule as Annexure C-1, Photo copy of discharge slip of Kapil Hospital dated 05.09.2011 as Annexure C-2, Photo copy of certificate issued by Kapil Hospital as Annexure C-3, Photo copy of certificate issued by Fortis Hospital dated 09.11.2011 as Annexure C-4, Photo copy of bill as Annexure C-5, Photo copy of repudiation letter dated 09.11.2011 as Annexure C-6 and closed his evidence.

5.        On the other hand, counsel for the OPs tendered into evidence affidavit of Shalini D.O.H. Bajaj Allianz Life Ins. as annexure RA and documents such as Photo copy of repudiation letter as Annexure R-1, Photo copy of certificate dated 09.09.2011 alongwith treatment file of Fortis Hospital as Annexure R-2, Photo copy of proposal form as Annexure R-3, Photo copy of regular premium receipt alongwith terms and conditions as Annexure R-4  and closed the evidence on behalf of Ops.

6.         We have heard learned counsel for both the parties and have gone through the pleadings as well as documents carefully and minutely placed on the file.

7.        The only version of the OPs Insurance Company is that the illness suffered by the Life Assured/complainant is not covered under any category of 11 Critical Illness mentioned under the Head " Critical Illness Rider Benefits" as per the terms and conditions was of the Insurance Policy. Since, the claim lodged by the complainant was for reimbursement of expenses towards CAD ( Coronary Artery Disease) and Post PTCA (Percutaneous Transluminal Coronary Angioplasty) plus Stent to RCA (right Coronary Artery Stent), the same amount to non-surgical techniques which is not covered under the terms and conditions of the Insurance policy and draw our attention towards the terms and conditions of the insurance policy Annexure R-4. Learned counsel for the OPs Insurance Company further argued that the policy in question is not a medical insurance policy rather it is a unit link insurance policy and Extra Rider Benefits are only covered subject to rider covered as per terms and conditions of the Insurance Policy. Lastly, prayed for dismissal of complaint as the claim of the complainant was rightly repudiated by the OPs Insurance Company.

8.        On the other hand, learned counsel for the complainant argued at length that genuine claim of the complainant has been wrongly and illegally repudiated by the OPs Insurance Company whereas from the perusal of certificate issued by Fortis Hospital Annexure C-4 it is clear that the disease of the complainant was Chronic Disease and requires continuous domiciliary treatment. Learned counsel for the complainant further draw our attention towards the bill of expenses issued by the Fortis Hospital Annexure C-5 and argued that complainant is entitled to get the reimbursement of the expenses. Learned counsel for the complainant referred the case law titled as Bajaj Allianz General Insurance Company Ltd. Versus Valsa Jose, IV (2012) CPJ page 839 National Commission and argued that in this case also the claim of the complainant was repudiated by the same company whereas the complainant was suffering from the same disease i.e. Angiogram and Angioplasty of right coronary artery, however,  the appeal was accepted by the Hon'ble National Commission and the OPs Insurance Company was directed to reimburse the medical expenses to the complainant.

9         After hearing both the parties and going through the contents of complaint, we are of the considered view that  the claim of the complainant has been rightly repudiated by the OPs Insurance Company. We have perused the terms and conditions of the insurance policy (Annexure R-4) under the Head Rider Benefits wherein it has been mentioned that the Additional Rider Benefits, if any, specified in the schedule shall be subject to the terms and conditions of the respective riders. Learned counsel for the OPs draw our attention towards the respective riders mentioned under clause 9 under the Head Critical Illness to be covered and referred clause 9 b wherein it has been mentioned that Coronary Artery Disease requiring by post grafting surgery- The undergoing of heart surgery to correct narrowing of blockage of left main coronary artery or three or more coronary arteries with bypass grafts in persons with limiting anginal symptoms and compromise of blood supply supported by investigation but excluding nonsurgical techniques such as balloon angioplasty, laser relief of an obstruction or other forms or Coronary artery clearing through catheters or similar devices. Narrowing of the affected artery should be more than 75% (seventy five percent).

10.        After going through the above noted terms and conditions mentioned in the policy, it is clear that the illness suffered by the life assured is not covered under the head of critical illness. It is not the case of the complainant that OPs Insurance Company has not supplied the terms and conditions of the insurance policy to him as the complainant is paying the installments regularly since the purchase of insurance policy in question on 28.03.2007. Learned counsel for the complainant has totally failed to controvert the version of the OPs Insurance Company and also has failed to point out any terms and conditions of the Insurance Policy vide which the illness of the complainant was covered. The case law referred by the counsel for the complainant is not disputed but in that case the claim was repudiated on the ground of hypertension etc. whereas in the instant case the claim of the complainant has been repudiated by the OPs Insurance Company on the ground that illness suffered by the complainant is not covered under the insurance policy in question. It is a settled proposition of law that the insurance policy is a contract between the parties and both the parties are bound by its terms and conditions.  

11        Resultantly, in the circumstances noted above, we are of the considered view that there is no merit in the present complaint and the same is hereby dismissed with no order as to costs. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.
Announced: 01.05.2017
                                

 

                                                                                            (ASHOK KUMAR GARG)
                                                                                             PRESIDENT

 

            (VEENA RANI SHEOKAND)                             (S.C.SHARMA)
             MEMBER                                                             MEMBER