Chandigarh

DF-II

CC/104/2016

Harbans Kaul - Complainant(s)

Versus

Bharti Axa Life Insurance Co.Ltd. - Opp.Party(s)

Adv.Jasjeet Singh Saini & Harpreet Saini

02 Dec 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	104 of 2016
Date  of  Institution	:	11.02.2016
Date   of   Decision	:	02.12.2016

 

 

 

 

Harbans Kaul s/o Chuni Lal Kaul, R/o SCO 82-83, Second Floor, Sector 8-C, Madhya Marg, Chandigarh.

             …..Complainant

Versus

1]  Bharti Axa Life Insurance Co. Ltd., RO: Unit 601 & 602, 6^th Floor, Raheja Titanium, Off Western Express Highway, Goregaon (E), Mumbai, through Sandeep Ghosh, Managing Director & CEO.

2]  Regional Manager, Bharti Axa Life Insurance, SCO 208-209, Sector 34, Chandigarh.  

….. Opposite Parties  

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER

 

 

For complainant(s)      : Sh.Jasjit Singh Saini, Advocate  

 

For Opposite Party(s)   : Sh.Gaurav Bhardwaj, Advocate

 

 

PER PRITI MALHOTRA, MEMBER

 

 

          As per the case, the complainant availed Bharti Axa ‘Life Triple Health Protect’, a health insurance policy from the OPs bearing NO.500-9403311, dated 10.1.2013 (Ann.C-1) by paying premium of Rs.20,824/- and under which upto three claims could be made for critical illness.  It is averred that the complainant fell ill on 8.7.2014 and as such, admitted in Maharaja Agrasen Hospital, Punjabi Bagh, New Delhi, which was also intimated to the OPs. The complainant was discharged on 14.7.2014 from the said hospital after having paid an amount of Rs.60,269/- incurred on the treatment. Thereafter, the complainant lodged claim with the OPs for reimbursement of medical expenses under the policy, but the same was rejected by the OPs through e-mail, after taking long time, alleging having past medical history and non-disclosure of the same in the proposal form (Ann.C-2).  It is stated that the complainant while taking the policy was hale and hearty and was not diagnosed with any medical problem and was not on any medication.  Hence, alleging the said repudiation/rejection of claim as illegal and claiming deficiency in service, this complaint has been filed.

 

2]       We have heard the ld.Counsel for the parties and have also perused the entire record as well as written arguments.

 

3]       At the outset of the discussion about the merits of the present complaint, it is pertinent to mention here that in the present complaint, the OPs defence was struck off vide separate detailed order dated 25.7.2016 and before passing of that order, the OPs have already placed on record the reply along with evidence while the  case was fixed for the reply to the application filed.

4]         Technically, the reply filed by the OPs need not to be taken into consideration while deciding the present complaint as their defence was struck off, as stated earlier, but in view of the judgment of the Hon’ble Supreme Court of India in Uma Nath Pandey and Ors. Vs. State of U.P. and Anr. – AIR 2009 SC 2375, we cannot ignore the material placed on record in toto.  The relevant part of the said judgment (Uma Nath Pandey), reads as under:-

“…….The administration of justice is to be freed from the narrow and restricted considerations which are usually associated with a formulated law involving linguistic technicalities and grammatical niceties. It is the substance of justice which has to determine its form.

………..Lord Buckmaster said, no form or procedure should ever be permitted to exclude the presentation of a litigants' defence”

 

                        In view of the above, the matter is undisputed to the extent that the complainant availed Bharti Axa ‘Life Triple Health Protect’, a health insurance policy from the OPs bearing NO.500-9403311, dated 10.1.2013 (Ann.C-1) by paying premium of Rs.20,824/- and under which upto three claims could be made for critical illness and the same was for a term of 15 years with annual premium of Rs.20,824/- to be paid upto 2027.

 

5]       During the currency of said insurance policy, the complainant fell ill on 8.7.2014, resultantly got admitted in Maharaja Agrasen Hospital, Punjabi Bagh, New Delhi, where he took treatment and was discharged on 14.7.2014. The claim lodged for reimbursement of expenses incurred on the abovesaid treatment was rejected by the OPs on account of past medical history and non-disclosure of the same in the proposal form filled-in by the complainant.  It is stated that the life assured i.e. complainant had answered in negative to the relevant questions pertaining to his health in the proposal form and deliberately concealed that he was suffering from Type-II Diabetes and Pulmonary Tuberculosis and was under treatment for the same since 5 years back and for such non-disclosure, the OPs repudiated the claim of the complainant.  Even if we sidelined the reply filed by the Opposite Parties, wherein the insurance company justified the repudiation on account of suppression of fact regarding non-disclosure of disease of Type-II Diabetes Mellitus and Pulmonary Tuberculosis suffered by the complainant since 5 years; this fact has also been recorded in the rejection e-mail dated Feb.7, 2015 on Page NO.35 placed on record by the complainant.  Since, it was clear to the complainant that the claim of the complainant was rejected on account of non-disclosure of previous ailment in the present complaint but the complainant has completely failed to negate the ground of rejection by any cogent and convincing evidence.   

 

6]       The medical record with regard to the treatment taken by the complainant during the currency of the present policy cogently establish that the complainant suffered from Type-II Diabetes Mellitus and Pulmonary Tuberculosis since 5 years back. We have also perused the proposal form filed-in by the complainant in order to obtain the present policy, wherein the complainant despite having knowledge of his previous ailment of Type-II Diabetes Mellitus and Pulmonary Tuberculosis, did not disclose the same and answered in negative to the specific questions relating the subject. Hence, the repudiation of claim by the OPs cannot be held unjustified.

         However, the arbitrariness of the OPs cannot be ignored for the reason that the OPs, without intimating to the complainant or issuing any notice to him and without putting any query to the complainant to explain the alleged concealment of previous ailment, straightway terminated the policy, which is highly unjustified on their part.  The OPs have totally ignored the first & foremost principle of natural justice known as audi alteram partem that no one should be condemned unheard.  In our considered opinion, one should be put on notice of the case before any adverse orders is passed against him, as it is one of the most important principle of natural justice, which has been laid down by the courts as being the minimum protection of the rights of an individual against any arbitrary procedure and that may be adopted by any authority while making an order affecting their rights. 

 

7]       Further, the original policy bond has also been retained by the OPs, which is reflected at Page NO.32 vide e-mail dated 26.2.2015 placed on record by the complainant.  As the Opposite Parties have failed to give prior notice to the complainant, before terminating his policy and acted in an arbitrary manner, hence we hold the same as unfair trade practice and deficient act of the OPs.  The OPs cannot forfeit the premium amount paid by the complainant and they are liable to refund the same to the complainant. 

          

8]       For the reasons recorded above, the present complaint of the Complainant deserves to partly succeed against the Opposite Parties.  Accordingly, the same is partly allowed against Opposite Parties. The Opposite Parties are jointly & severally directed as under:-

1. To refund the premium amount of Rs.41,327.13 paid by the complainant;
2. To pay an amount of Rs.10,000/- as compensation for the harassment suffered on account of unfair trade practice and deficient services of the Opposite Parties;
3. To pay litigation expenses to the tune of Rs.5000/-;

 

         This order shall be complied with by OPs within a period of 45 days from the date of receipt of copy of this order, failing which they shall be liable to pay interest @12% per annum on compensation amount as mentioned at sub-para (b) from the date of filing this complaint till realization, apart from complying with direction as at sub-para (a) & (c) above.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

2^nd December, 2016                                                                                                                                                                         Sd/-

 (RAJAN DEWAN)

PRESIDENT

 

                                                                                          Sd/-

          (PRITI MALHOTRA)

MEMBER