BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.500 of 2015
Date of Instt. 20.11.2015
Date of Decision :11.04.2017
S.Manjit Singh Chawla son of Sh.Amrik Singh, resident of House No.2222, Gali Lovely Sweets Wali, Rayya, Tehsil Baba Bakala, Distt. Amritsar.
..........Complainant
Versus
Branch Manager, Bajaj Allianz, General Insurance Co. Ltd 2nd Floor, Satnam Complex, G.T. Road, Jalandhar City .........Opposite party
Complaint Under Consumer Protection Act.
Before: Sh. Karnail Singh, (President),
Sh. Parminder Sharma (Member)
Present: Sh. SK Sharma, Adv. Counsel for complainant.
Sh. RK Sharma, Adv Counsel for OP.
Order
Karnail Singh (President)
1. The instant complaint filed by complainant Manjit Singh, wherein alleged that he obtained policy i.e. Overseas Travel Insurance Policy bearing No.OG-15-1202-9910-00001220 for the period from 29.07.2014 to 26.10.2014 from the opposite party against consideration under the plan Travelage and he paid the entire policy amount to the opposite party. He having hired the services of the opposite party for a consideration, is a, consumer, as defined the Consumer Protection Act.
2. The complainant went to Washington through the Flight from Delhi to Washington on 29.07.2014, there the complainant became sick/headache and he suffer uncontrolled Hypertension. He visited the doctor on 07.08.2014 consulted for his treatment and was accordingly treated the ailment and paid a sum of $73.92 to the consultant doctor. Again on 08.09.2014, the doctor received $82.93, then on 21.09.2014 the consultant doctor received $10. On 20.09.2014, the doctor charged $587 and on 21.09.2014, the doctor received $86 and further the consultant doctor on 26.09.2014 received $25 thus a total sum of Rs.$854.86 paid to the doctor in Washington. During this period even the complainant remained admitted in the Hospital for one and was discharged in the evening. The said amount becomes Rs.53,001.32p in Indian Currency.
3. That on arrival back to India, the complainant lodged his claim with the opposite party under the aforesaid policy for making payment to him to the tune of Rs.53,001.32 which was spent by him for his treatment in Washington and submitted all the requisite documents to the OP as per requirement but the opposite party put off the matter on one pretext or the other. He even personally visited the office of the OP number of times and requested them to make payment of his insurance claim covered under the said policy but the matter was lingered on. Ultimately, the OP illegally, malafide, arbitrarily repudiated the claim of the complainant through their repudiation letter dated 16.10.2014 on the flimsy grounds that as per attending physician statement, hypertension since 2009, which is pre-existing to the policy, hence claims stands repudiated. Such ground for repudiation of the claim of the complainant mentioned in the said letter is false, frivolous, baseless, malafide just to grab the huge amount of the complainant and to deprive him of his valuable right in the insurance claim. His policy is covered under the health plan of the complainant and on account of his ill-health/headache he had to take treatment from Washington Hospital. Hypertension is not a disease and it can occur at any time, as such, the same does not come under the definition of 'disease'. During his visit in Washington, the complainant had suddenly suffered uncontrolled hypertension and as such, he had to get himself medically treated after spending huge amount which he is entitled to claim. The aforesaid act of the OP amounts to a great negligence, carelessness, deficiency in service and unfair trade practice due to which, the complainant has suffered a great mental agony, inconvenience, harassment and financial loss and as such the complaint of the complainant may be accepted and OP be directed to pay insurance claim of $854.84 i.e. Rs.53001.32 along with interest on it @ 12% per annum and compensation of Rs.10,000/- and litigation expenses of Rs. 5000/-
4. Notice of the complaint was given to opposite party and accordingly OP filed reply and contested the same by taking preliminary objections that the complaint is not maintainable against the Bajaj Allianz General Insurance Co. Ltd./OP and it is clear from the Attending Physician's Statement of patient First- Manassas, 9715 Liberia Avenue, Manassas VA 20110 that the complainant was having a past history of hypertension and Cardiac Ailment since 2009. The said history has not been disclosed in the proposal form preventing the opposite party from making a clear assessment for the risk to be insured and taking decision on whether an insurance cover was to be given and if so, with relevant exclusions. There is a “Non Disclosure of material Information” by the complainant at the time of taking insurance policy and further referred the exclusion clause 2.4 as well as 2.4.12 and further alleged that in view of the aforesaid clause, claim of the complainant was repudiated. It is further averred that there is no deficiency in service or negligence or carelessness or delay or unfair trade practice on part of the opposite party, as repudiating the claim as per terms and conditions, exclusion clause of the insurance policy neither amount deficiency in service nor unfair trade practice. The claim of the complainant has been repudiated vide letter dated 16.10.2014 after due application of mind, as such the complaint is liable to be dismissed. On merits, purchase of policy by complainant and submitting the claim is admitted by the OP but the other allegations made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merit and same may be dismissed.
5. In order to prove his case, complainant himself tendered into evidence his duly sworn affidavit Ex.CW1/A alongwith some documents Ex.C1 to Ex.C22 and closed the evidence.
6. Similarly, Counsel for the OP tendered into evidence affidavit of Navjeet Singh as Ex.OA and some documents i.e. copy of Attending Physician Statement Ex.O1, Certified copy of Insurance Policy Ex.O2, Copy of terms and conditions of Insurance Policy Ex.O3, Copy of Overseas Travel Insurance Claim Form Ex.O4, Copy of Letter of Repudiation dated 16.10.2015 Ex.O5, thereafter evidence of the OP was closed by order vide order dated 22.08.2016.
7. We have heard the learned counsel for the respective party and also gone through the file very minutely.
8. It is admitted fact that the taking of Overseas Travel Insurance Policy, by the complainant is not denied by the OP. Even the OP has not denied that the complainant has submitted a insurance claim for his illness, copy of the insurance claim produced on the file by OP as Ex.O4 but the said claim of the complainant was repudiated by the OP vide letter dated 16.10.2014, the said letter is Ex.O5 on the ground that the complainant has not disclose the ailment which was prior to purchase of policy and this ground is challenged by the complainant through this complaint.
9. Now we have to decide whether the complainant has concealed any ailment from the OP prior to taking the insurance policy for that purpose the counsel for the OP has given much stress on the documents Ex.O1 and similar document produced on the file by the complainant as Ex.C11 which is the Attending Physician's Statement wherein the doctor who attended the complainant in Washington reported that the complainant is patient of hypertension since 2009 but simply writing by the doctor that the complainant is patient since 2009 is not sufficient because the complainant is not regular patient of the said doctor, if so then how the said doctor can assess that the complainant is patient of hypertension since 2009 and moreover the complainant himself stated that he is not taking any medicine of the hypertension till today. So, it means that the complainant is not within the knowledge of the disease of hypertension, if he is not aware about the said disease then how he can disclose the same to the Insurance Officials at the time of getting insurance policy. Apart from above, the plea has been taken by the OP that the complainant has concealed the pre-existing disease and then duty casted upon the OP to establish it by leading cogent and convincing evidence but the OP has not brought on the file any sufficient evidence to establish these factum. There was a liberty with the OP to bring on the file a proposal form which is apparently within the custody of the OP and the said proposal form has been filled at the time of purchase of a policy and the same must be signed by the Insured Person and all information has been filled in that proposal form and that proposal form is the important document to ascertain whether the complainant has concealed any material fact from the Insurance Official or not but for the best known reason the OP has themselves not brought on the file the said proposal form. So, from this angle, the OP has miserably failed to establish the pre-existing disease to the complainant. In support of above observation, we like to refer a pronouncement of Hon'ble National Consumer Disputes Redressal Commission cited 2009(4) CLT 718 Harjeet Kaur Vs. National Insurance Co. Ltd and Others, wherein held as under “ No evidence produced on record to prove that insured aware of disease at time of proposal”.
10. An upshot of our above detailed discussion, we find much force in the argument put forth by the learned counsel for the complainant and therefore the complaint of the complainant is partly accepted and OP is directed to pay the insurance claim of Rs.53001/- with interest @ 9% per annum from the date of repudiation of the claim i.e. 16.10.2014 till realization and further OP is directed to pay compensation for harassment to the complainant to the tune of Rs.5000/- and litigation expenses Rs.2000/-. The entire compliance of the order be made within 30 days from the date of receiving copy of order. Complaint could not be decided within stipulated time frame due to rush of work.
11. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Parminder Sharma Karnail Singh
11.04.2017 Member President
