BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 159 of 2013
Date of Institution : 10.9.2013
Date of Decision : 18.11.2015
Subhash Chander, aged 51 years son of Shri Karam Chand, r/o 153, Bansal Colony, Sirsa District Sirsa.
….Complainant.
Versus.
- Birla Sun Life Insurance, Regd. Office: One Indiabulls Centre, Tower 1, 15th and 16th Floor, Jupiter Mill Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai-400 013 through its General Manager.
- Birla Sun Life Insurance, Branch Office, Opp. State Bank of India, ADB Branch, Dabwali Road, Sirsa through its Branch Manager.
- MD India Healthcare Services (TPA) Pvt. Ltd., S.No.46/1, E-Space, A2 Building, 3rd Floor, Pune Nagar Road, Vedgaon Sheri, Pune-411 014, through its Manager.
..…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SMT.GURPREET KAUR GILL ………PRESIDING MEMBER.
SHRI RAJIV MEHTA ……MEMBER.
Present: Sh.JBL Garg, Advocate for the complainant.
Sh.M.K.Singla Advocate for the opposite parties no.1&2.
Opposite party no.3 exparte vide order dt. 8.11.2013.
ORDER
In brief, one Ashok Kumar, Insurance Agent of opposite parties no.1 and
2, visited the complainant in February, 2012 and on his allurements, the complainant made the proposal for medi-claim of opposite parties no.1 and 2 on 17.2.2012. On such proposal made by the complainant, the opposite parties no.1 and 2 got him medically examined from their approved doctor and on 28.3.2012, the opposite parties no.1 and 2 by accepting the said proposal, issued policy no. 005389754 to the complainant on receipt of insurance premium of Rs.13,768.75. In the said policy, it was acknowledged and recited that “your application for Health Insurance has been accepted and we have adjusted the initial deposit amount towards first premium as stated above on 28.3.2012”. Earlier the service provider for said policy was TPA, but on 12.2.2013, opposite parties no.1 and 2 made contract with addressee no.3 for providing the service under the said policy.
2. On 11.4.2013, the complainant fell ill and he developed pain in his chest
and he was got medically checked-up from Poonia Hospital, Sirsa, but due to his critical condition, he was referred to AIIMS for further treatment. However, the complainant was shifted to Medanta, the Medicity Hospital, Gurgaon. Information to this effect was given by the complainant to opposite parties no.1 and 2, whereupon, he was told that now MD India-opposite party no.3 is the service provider and, therefore, the complainant gave information to opposite party no.3. As the complainant could not afford the charges of Medanta Hospital, therefore, he was shifted to Action Medical Institute, Paschim Vihar, New Delhi, where he was treated and remained admitted as an indoor patient from 21.4.2013 to 29.4.2013 and was operated upon. A sum of Rs.1,75,280/- was incurred by the complainant on his treatment. Another sum of Rs.36,716/- was also incurred on his treatment. Thereafter, the complainant lodged his claim with opposite parties no.1 and 2, which was forwarded to addressee no.3 for settlement on 17.4.2013. opposite party no.3 raised the main query about the disease of complainant. The complainant got conducted a test for the same from Medanta Hospital and it was reported that patient has not been on any diabetic medicines and his sugars are within normal range. But, till today, the case of the complainant has not been settled, despite repeated requests and legal notice sent through registered post on 19.6.2013. Ultimately, they have refused to admit the claim. Hence, the complaint for direction to opposite parties to make payment of claim amount Rs.2,11,996/- alongwith interest and compensation for harassment, mental tension, pain etc. and litigation expenses.
3. Opposite parties no.1 and 2, in their joint reply, have pleaded that while submitting proposal form, the complainant had intentionally concealed about his pre-existing disease. The opposite party came to know about the fraudulant act of the life assured after the claim form was submitted. The false declaration has vitiated the contract of life insurance. As per the documents submitted by the life assured at the time of purchase of policy, it is manifestly clear that the claim submitted by the complainant does not stand on the pillar of truth and hence, on account of concealment of material fact, the claim on this policy was rightly repudiated by the opposite party. Other averments have also been denied by the opposite parties.
4. We have gone through the pleadings and documents of the parties very carefully. There is no dispute between the parties that complainant namely Subhash Chander had obtained a medi-claim insurance policy No.005389754 on dated 28th March, 2012 and paid first installment Rs. 13767.75 (Ex. C2) . It is not disputed by the OPs in the written statement that complainant fell ill on 11th April, 2013 and remained admitted in Action Medical Institute Paschim Vihar, New Delhi, from 21th April, 2013 to 29th April, 2013 and prior to that complainant consulted with other doctors also.
5. Respondent have taken a specifically plea in written statement that complainant have pre- existing disease, while submitting the proposal form concealed the disease.
6. We have to decide that whether OPs have repudiated the claim of the complainant , is legal manner or not? Before deciding the case on merit, we have to glance on the documents produced by the parties. Complainant has produced documents Ex. C1-hiw own affidavit , supported to his complaint ; Ex.C2 and Ex. C3 installment receipts; Ex.C4 letter of OPs for change of TPA Ex.C5 legal notice Ex.C6 to Ex.C8 receipt registered letter, sent the legal notice to OPs Ex.C9 to Ex.C11 copies of postal acknowledgment Ex.C13 quarries through e-mail from MDI (TPA) Ex.C14 reply of quarries sent by the complainant through e-mail C15 again reply Ex.C16 to Ex.C25 documents in support of quarries Ex.C26 claim form submitted to TTK(TPA) Ex.C27 e-mail to TTK (TPA) Ex.C28 to Ex.C31 reply of quarries to MDI (TPA) Ex.C32 rejection letter Ex.C33 to Ex.C45 cash memo amount paid to various hospitals Ex.C46 insurance policy. But the OPs have tendered the affidavit Ex. R1 of Prasun Partik Zonal Legal Manager of the OPs.
7. It is imaginary version of OPs that complainant have pre-existing disease. But the OPs have tendered the self serving affidavit of their manager Ex. R1 only. There is no document on the file to prove the version of the OPs, stated in written statement as well as in their self serving affidavit Ex. R1. There is no evidenciary value of the written statement without any supporting documents/investigation. Complainant has submitted before this Forum various valuable documents connected to each other to establish his case with all aspect.
8. Insurance company is large entity there are so many officials/investigator and penal advocates under their control. It was duty of OPs to investigate the previous medical history of the complainant and procured the record of the same to prove their case. As per record produced before this Forum, there is no previous medical history of the complainant. Even no person came to witness box or tendered the affidavit to that effect that complainant was earlier suffering from any disease.
9. At the time of insurance OPs introduced with complainant TTK(TPA) later-on OPs changed the suo- motto TPA as a MDI without any notice to complainant . First of all complainant has submitted his claim with documents to TTK(TPA) and further submitted his claim to MDI(TPA) and Ops put the complainant with hardship.
10. Third Party Administrator(MDI) is under the control of respondent. Insurance company has authorized to TPA for investigation and verification of the claim cases of clients MDI has repudiated the claim of the claimant on alleged ground that complainant has not replied the quarries raised by agency, hence the claim has been rejected vide Ex.C31. The insurance company i.e. OPs no. 1 and 2 has taken a specifically plea that complainant has pre -existing disease. There is no clarity from any document as to which agency is competent to investigate the said matter and finalized the claim case? On what norms OPs have declared to complainant having pre -existing disease, when the statement of both the OPs are hostile with each other.
11. OPs has categorically stated that complainant has not given true facts in the proposal form, the false declaration has vitiated the contract of insurance. A person for taken the insurance policy moved with a procedure, first of all consumer submitted his proposal form, after that a Board of Penal Doctors examined the proposer and gave undertaking for his health then the official of company passed/verified the proposal form and permit him to deposit the installment. It is clearly mentioned in the document Ex.C2 on first premium receipt “ your application for Health Insurance has been accept and we have adjusted the initial deposit amount towards first premium as stated above on 28.3.2012”. When the complainant has gone through all the procedure for taking the policy launched by the Ops, so now the question of pre- existing disease cannot be prevailed.
12. The MDI has stated in Ex.C32 that complainant has not reply the quarries of the company. It is general practice that a person has submitted all the original documents to the Government agency and kept the copies with him. All the copies of relevant documents required by the OPs even copies of e-mail which are sent the replies of quarries to the MDI are on the file. On the ground of above mentioned the version of MDI seems to be false.
13. Complainant has served a legal notice to the respondents through registered post through his counsel Shri Jai Bharat Lal Garg Advocate Sirsa on 19.06.2013. But the Ops have not replied the same. All the Ops kept mum for long time and not replied the legal notice of complainant. Silent on the part of Ops is a admission. The consumer and insurance company are supplement to each other. IRDA issue the license to insurance companies for welfare and financial support to the consumers in hardship.
14. When the illness of complainant is genuine, fact of documents submitted by complainant to Ops is true one. So there is no room in this case to hold the claim of the complainant by the OPs, when all the facts are speaking against their version. 15. IRDA in their circular and instructions advised to insurance companies time to time to behave with consumer in soft and sober manner. But the Ops imposed them unnecessary conditions/ tactics.
16, OP no. 3 served with registered letter Ex. C8 but they have not come to this forum to put up their version and proceeded ex-parte vide order dated 8.11.2013. It means they have nothing to explain in this case and admitted the case of complainant.
17. It is true fact that at the time of policy the official/ agent of Ops motivate the people and assure them for better service and return but at the time of settlement of the claim they imposed unnecessary condition to prolonging the matter to one pretext or to other. In view of factual position the complainant is entitled for relief. It would also not be out place to say that the insurance companies have been adopting double standard. When they are in need of business they showed a rosy picture to the clients but when they have to pay claim they try hard to avoid the claim even on flimsy grounds. Even in the present case same thing has happened with the complainant. A person obtains a medi-claim policy for the simple reason to avail help and pays the premium from his hard earnings in hard days. The insurance companies are not meant simply but to collect premium but they have also to discharge duty honestly in making the payment of the genuine claims. The fact that the complainant had informed the Ops about his illness/treatment and replied quarries of agencies with documents two times, but still OPs did not bother to settle the claim of the complainant, it speaks high decree of negligence and deficiency in service on the part of the Ops and the complaint of the complainant is liable to be accepted and the complainant is even entitled to avail the interest on the claim amount suitably for delay caused by the Ops.
18. Now we have to decide the quantum of amount, complainant claimed Rs.175280/-+Rs. 36716/- = Rs. 211996/- incurred by him. Complainant submitted the copies of all above mentioned bill which are exhibited on the file. The OPs has not raised any objection on the quantum of amount. Without any objection or re-buttle we have no reason to discard the quantum of amount, as prayed in complaint.
19. For the reasons and findings recorded above we accept the complaint of the complainant with cost of Rs. 2000/- and direct the Ops to pay the claim amount to the tune of Rs. 211996/- to the complainant with interest @ 9 % from the date of filling of this complaint in this forum i.e. 10.9.2013 till its realization. Compliance of this order be made within a period of one month. A copy of this order be supplied to the parties free of costs. File be consigned to record room after due compliance.
Announced in open Forum. Presiding Member,
Dated:18.11.2015. Member. District Consumer Disputes
Redressal Forum, Sirsa.
Subhash Chander Vs. Birla Sun Life Insurance
Present: Sh.JBL Garg, Advocate for the complainant.
Sh.M.K.Singla Advocate for the opposite parties no.1&2.
Opposite party no.3 exparte vide order dt. 8.11.2013.
Arguments heard. For order to come up on 18.11.2015.
Presiding Member,
Dt.13.11.2015. D.C.D.R.F,Sirsa.
Member.
Present: Sh.JBL Garg, Advocate for the complainant.
Sh.M.K.Singla Advocate for the opposite parties no.1&2.
Opposite party no.3 exparte vide order dt. 8.11.2013.
Order announced. Vide separate order of even date, complaint has been allowed with costs. File be consigned to record room after due compliance.
Announced in open Forum. Presiding Member,
Dated:18.11.2015. Member. District Consumer Disputes
Redressal Forum, Sirsa.
