BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 177 of 2016
Date of Institution : 20.07.2016
Date of Decision : 13.07.2017
Lalit Mohan Jain aged 48 years s/o Sh. A.N. Jain, resident of Shop No.77, Anaj Mandi, Sirsa, Tehsil and District Sirsa.
…Complainant.
Versus.
1. Bajaj Allianz Life Insurance Company Ltd., 1st Floor, Kar House Building, Opposite Hotel Aroma, Dabwali Road, Sirsa through its Branch Manager/ Divisional Manager/ Authorized person.
2. Bajaj Allianz Life Insurance Company Ltd., West Hub, IInd. Floor, Bajaj Finserv, Survey # 208/1-B, Behind Wiekfield it building, Viman Nagar, Pune, (Maharashtra)- 410014.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: Sh. Raghbir Singh …………………President
Smt. Rajni Goyat ………………….Member.
Sh. Mohinder Paul Rathee……….. Member.
Present: Sh. N.K. Daroliya, Advocate for the complainant.
Sh. Sanjay Goyal, Advocate for the opposite parties.
ORDER
In brief, the case of the complainant is that being the eligible person he purchased the insurance policy bearing No.0306109092 namely Bajaj Allianz Family Care First, covering the medical risk to his life from ops and its date of commencement was 27.09.2013 and was valid up to 26.9.2016 on payment of premium amount of Rs.14207/- plus service tax and the mode of payment of premium was yearly. The said policy was purchased by complainant from op no.1 having their office at Sirsa and all the requisite forms were duly got filled up by the complainant through their agent/ authorized person and after thorough enquiry by the ops qua the health of the insured through their Medical Officer/ doctor and as the insured was found as medically fit, the ops supplied the insurance policy. It is further averred that complainant was/is regular customer of the insurance company and for the betterment of himself as well as for his family purchased first medi claim policy on 14.7.2011 vide policy No.0226748544 and which policy was followed by next policy for year 2012 and 2013 vide same policy number. Thereafter on 14.8.2013, the complainant could not deposit the premium in time due to which further policy had not been renewed by continued policy by the ops but later on it had been renewed by the ops by accepting the premium of Rs.10504/- for year 2014 vide receipt dated 2.9.2014 and this medi claim policy was effective from 28.9.2013 and the premium of Rs.10504/- was paid vide receipt dated 28.9.2013 and 2.9.2014. It is further averred that complainant never committed any default in making the payment of premium and this policy was duly ported in the ops’ company and it was assured by the ops that last two years during which the complainant purchased same medi claim policy from same insurance company will be treated and counted in the waiting period for the policy issued by their office and it will be deemed to be continue policy from the date of 14.7.2011 till date and also assured that the complainant is entitled for all the benefits under their policy being treated as continue from year 2011 as mentioned above. It is further averred that however to the bad luck of the complainant on 3.6.2014, the condition of the complainant became serious and he had to admit to Dr. Shergill, Sher Gill Hospital, Dabwali road, Sirsa from where he was referred and was advised to go to some multi specialty hospital, so he was taken to Sri Balaji Action Medical Institute, New Delhi on 4.6.2014 and he was admitted and undergone medical checkup and tests by Dr. Amar Singhal of said hospital. His angiography was done and stent was inserted to cure his single vessel disease because he was suffering from acute coronary syndrome and remained admitted in the said hospital uptill 6.6.2014. It is further averred that complainant informed the concerned officer of the local office of the ops and submitted his medical bills of Rs.2,12,843/- before the ops. However, the ops acting in a gross unfair manner and in a monopolistic way refused to admit the claim of the complainant on the ground that as the policy in question did not mature because of lack of time i.e. as per reply policy in question would be deemed to be matured after completion of three years from the date of the policy which amounts to gross deficiency in services, negligence and mal-trade practice on the part of ops. It is further averred that before repudiating the claim of the complainant, the ops remained on giving false assurances to the complainant. The complainant filed an application before the Permanent Lok Adalat (PUS) Sirsa which has been dismissed by the Hon’ble Lok Adalat, hence the complainant preferred the CWP No.27529 of 2015 titled as “Lalit Mohan Jain Versus President Officer PLA, Sirsa” in which it was explained by the complainant that the respondent misled the facts and given false assurance by asserting false facts and the Hon’ble High Court passed an order dated 19.2.2016 vide which the Hon’ble Court granted liberty to avail the appropriate remedy against the ops. Hence, this complaint.
2. On notice, opposite parties appeared through counsel but did not file written statement despite availing various opportunities including last opportunity and as such their opportunity to file written statement was closed.
3. The complainant produced his affidavit Ex.CW1/A and copies of documents Ex.C1 to Ex.C28.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. The commencement date of medi claim policy number 0306109092 is 27.9.2013 and same was valid up to 26.9.2016. Admittedly, the complainant was treated for acute coronary syndrome on 4.6.2014 in Sri Bala Ji Action Medical Institute, New Delhi and was discharged there from on 6.6.2014. The claim submitted by the complainant has been repudiated by the opposite parties vide repudiation letter dated 22.7.2014 on the ground that patient is diagnosed of acute coronary syndrome and has undergone for angioplasty for the same. Medical expenses incurred towards treatment related to any heart disease has a waiting period of three years in the policy, hence the claim is not payable. The repudiation letter is based on Exclusions clause 6b and 8 of the terms and conditions of the policy as mentioned in the repudiation letter which are reproduced hereunder:-
“6b The Company shall not be liable to make any payment if Hospitalization or Medical Expenses or claims are attributable to, or based on, or arise out of, or are directly or indirectly connected to any of the following: Hospitalization and/ or treatment within the Waiting Period and Hospitalization and/or treatment following the diagnosis within the Waiting Period.
“Illness covered only after first Renewal:
The Company shall be liable to make payment for the following illnesses only from the first Renewal Date or date of Revival whichever is later, provided these illnesses are diagnosed or Hospitalization or Medical Expenses incurred after the first Renewal Date or date of Revival, whichever is later: Any heart related disease, Tympanoplasty, Valve Replacement, Valvotomy, Cerebral Hemorrhage, Angriographies, Angioplasty (with or without stent), Coronary Artery Bypass Graft unless post Accident. The first Renewal will be due after three years from the Policy Commencement Date.”
So, in view of above clauses of the policy in question, we are of the considered view that complainant is not entitled to the claim amount. There is no document on file to show that opposite parties assured the complainant that the policy in question will be in continuation of earlier policy obtained by the complainant. It is pertinent to mention here that petition of complainant filed before Permanent Lok Adalat on similar facts was dismissed on 30.7.2015 and complainant filed a civil writ petition before the Hon’ble High Court, Chandigarh. In the CWP No.27529 of 2015 before the Hon’ble Punjab and Haryana High Court, learned counsel for petitioner/ complainant submitted that the conditions mentioned in the policy were not disclosed to the petitioner when he purchased the same. In fact, he was misled. Learned counsel submitted that he may be permitted to withdraw the present petition with liberty to avail of appropriate remedy for the action of respondent no.2 for misleading the petitioner and as such permission was granted by the Hon’ble High Court vide order dated 19.2.2016 and copy of the same is placed on file as Ex.C28. However, there is nothing on file to show that how the complainant was misled by the opposite parties. The complainant himself has placed on file copy of letter dated 28.9.2013 Ex.C1, from which it is evident that documents of the policy in question were supplied to the complainant vide letter dated 28.9.2013 and a free look in period of 15/30 days was provided to the complainant to cancel the policy in question but the complainant did not get the policy in question cancelled from the opposite parties within above said free look in period. In these circumstances, the complainant has failed to prove his case and is not entitled to any claim amount.
6. Thus, as a sequel to our above discussion, we find no merit in the present complaint and as such the present complaint is hereby dismissed. No order as to costs. A copy of the order be supplied to the parties free of costs. File be consigned to the record room after due compliance.
Announced in open Forum. President,
Dated:13.7.2017. District Consumer Disputes
Redressal Forum, Sirsa.
Member Member
