Haryana

Kurukshetra

CC/212/2019

Meena Khurana - Complainant(s)

Versus

Cholamandlam Gen Ins - Opp.Party(s)

B.R.Bajaj

13 Dec 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL COMMISSION, KURUKSHETRA.

                                                     Complaint Case No.212 OF 2019

                                                     Date of institution: 29.05.2019

                                                     Date of decision: 13.12.2021.

 

Meena Khurana wife of Sh.Rajesh Kumar resident of house No.1441, Sector -7. Urban Estate, Kurukshetra District Kurukshetra

…Complainant.

                        Versus

1.Cholamandalam  General Insurance Company Limited  2^nd Floor, Dare House, 2 NSC Bose Road, Chennai – 600001, through its Managing Director/Authorized Signatory.

 

2.Cholamandalam General Insurance Co. Limited SCO 2463-2464, IInd Floor, Sector – 22C, Chandigarh through its Manager.

 

3.Central Bank of India, Jhansa District Kurukshetra through its Branch Manager.

….Opposite parties.

                Complaint u/s 12 of the Consumer Protection Act.

Before:      Smt. Neelam Kashyap, President.

                Ms. Neelam, Member.

                Sh. Issam Singh  Sagwal, Member.

       

Present:     Sh. B.R.Bajaj, Advocate for complainant.   

                Sh. Gaurav Gupta, Advocate for opposite parties. No.1 and 2.

                Sh.B.K.Sharma Advocate for OP No.3.

               

ORDER

                This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Meena Khurana against the  Cholamandalam General Insurance Company Limited etc.- the opposite parties.

 

2.             The brief facts of the present complaint are that Rajesh Kumar, husband of the complainant was partner in firm Khurana Agro Centre and Dharam Pal and having Account No.2354192149 with the OP No.3  and on the instructions of OP No.3 Rajesh Kumar obtained Health Insurance Policy Scheduled Chola Swasth Parivar Pearl from OP no.1 and 2 for himself and his family members including the complainant being wife of Rajesh Kumar bearing No.2856/00125150/000/00 vide  customer ID NO.1017406384540026 from Chandigarh Branch for a sum of Rs.2.00 lakh each, commenced from 3.10.2013 for one year and which was to be automatically renewed every year by the OP no.3 and  deducting the premium of Rs.3320/- every year from the account of husband of the complainant. The said policy continued to be renewed upto 2018 by the OP No.1 and 2 on receiving premium amount from the OP No.3 from the bank of account of husband of the complainant.  It is further submitted that for renewal of the said policy for the year 2019, the OP No.3 sent the premium amount late to OP No.1 and 2 and hence the said policy was not renewed by the OP No.1 and 2 from October 2018  and it was renewed from 3.2.2019 after receiving premium from OP No.3. It is submitted that unfortunately, the complainant suffered some problem of cyst in her stomach and  she received treatment from Max Super Speciality Hospital, Mohali and tests were conducted on 3 & 4-4-2019 and operation was conducted on 5.4.2019 and her left ovary was removed and the total sum of Rs.1,28,000/- was charged including expenses of tests vide bills dated 3.6.2019 and 6.4.2019 from the complainant by the Hospital. However, the complainant requested the hospital to charge the same amount from the OP No.1 and 2 under the cashless policy but the hospital stated that they demanded the amount from the OP no.1 and 2 but they refused to send the amount and the complainant has to deposit the said amount in cash with the hospital but it has not been done by the Ops despite repeated requests and legal notice. Thus, the complainant alleging deficiency in services on the part of the Ops has filed the present complaint and prayed for payment of Rs.1,28,000/- alongwith interest, compensation for the mental harassment caused to him and the litigation expenses.

 

3.             Upon notice OP No.1 and 2 appeared and filed written statement disputing the claim of the complainant. It is submitted that on perusal of documents, it is observed that the sign and symptoms of the present ailment were existing since two years which is prior to the inception of the policy (3 January 2019).Hence the present ailment is considered as pre existing disease  and the claim is inadmissible as per General Exclusion clause C-1 which reads as “ No indemnity is available for payable for claims directly or indirectly caused by, arising out of or connected to the following: C-1 Benefits will not be available for any pre-existing  condition(s)as defined in the policy until 48 months of continuous coverage have elapsed, since inception of the  first policy with insurer. Also  the cause of dysmenorrheal was found to be ovarian cyst for which there is two year waiting period applicable in the policy. Policy was in first year of its inception. Only cash request was made and the same was denied on the ground of PED vide letter date d 6.4.2019. However, in the letter, it is specifically mentioned  that a denial of cashless access is not to be considered in any way  as a denial of treatment. The insured can send a request for consideration through reimbursement within 30 days from the date of discharge but the complainant has not lodged the same, so claim of the complainant is not maintainable and deserves dismissal on this score alone. All other allegations made in the complaint have been denied specifically and it was submitted that there is no deficiency in services on the part of the Ops and prayed for dismissal of the present complaint.

 

4.             The OP no.3 appeared and filed written statement disputing the claim of the complainant. It is submitted that it is matter of record to the extent that   account of the firm of husband of the complainant and about the policy but rest of the contents are denied.  It is denied that the policy was renewed automatically as alleged. The policy was renewed as per instructions of the account holder. As per record of the OP the policy was 4renewed as per instructions/request of the account holder. A It is denied that the answering OP sent the premium late. The answering OP telephonically approached to the policy holder for renewal of the policy. Inspite of the telephonic calls and reminders the policy holder ignored the same and on 3.1.2019, they got renewed the policy. All other allegations made in the complaint have been denied and it is submitted that there  is no deficiency in services on the part of the OP and prayed for dismissal of the present complaint.

5.             The complainant in support of her case has filed affidavit Ex.CW1/A and tendered documents Ex.C-1 to Ex.C-19 and closed her evidence.

6.             On the other hand, OP No.1 and 2 filed affidavit Ex.RW1/A and tendered documents Ex.R-1 to Ex.R-3 and closed their evidence.

 

                The OP No.3 made a separate statement to the effect that he does not want to tender any evidence.

7.             We have heard the learned counsel for the parties and gone through the case file very carefully.

8.             The learned counsel for the complainant while reiterating the averments made in the complaint has argued that that Rajesh Kumar, husband of the complainant was partner in firm Khurana Agro Centre and Dharam Pal and having Account No.2354192149 with the OP No.3  and on the instructions of OP No.3 Rajesh Kumar obtained Health Insurance Policy Scheduled Chola Swasth Parivar Pearl from OP no.1 and 2 for himself and his family members including the complainant being wife of Rajesh Kumar obtained insurance policy Ex.C-5 No.2856/00125150/000/00 vide  customer ID NO.1017406384540026 from Chandigarh Branch for a sum of Rs.2.00 lakh each, commenced from 3.10.2013 for one year and which was to be automatically renewed every year by the OP no.3 and  deducting the premium of Rs.3320/- every year from the account of husband of the complainant. The said policy continued to be renewed upto 2018 by the OP No.1 and 2 on receiving premium amount from the OP No.3 from the bank of account of husband of the complainant.  It is further submitted that for renewal of the said policy for the year 2019, the OP No.3 sent the premium amount late to OP No.1 and 2 and hence the said policy Ex.C-6 was not renewed by the OP No.1 and 2 from October 2018 and it was renewed from 3.2.2019 after receiving premium from OP No.3. It is submitted that unfortunately, the complainant suffered some problem of cyst in her stomach and  she received treatment from Max Super Speciality Hospital, Mohali and tests were conducted on 3 & 4-4-2019 and operation was conducted on 5.4.2019 and her left ovary was removed and the total sum of Rs.1,28,000/- was charged including expenses of tests vide bills dated 3.6.2019 and 6.4.2019 from the complainant by the Hospital. It is further argued that the complainant requested the hospital to charge the same amount from the OP No.1 and 2 under the cashless policy but the hospital stated that they demanded the amount from the OP no.1 and 2 but they refused to send the amount and the complainant has to deposit the said amount in cash with the hospital  but it has not been done by the Ops despite repeated requests and legal notice. Thus, the complainant alleging deficiency in services on the part of the Ops has filed the present complaint and prayed for payment of Rs.1, 28,000/- alongwith interest, compensation for the mental harassment caused to him and the litigation expenses.

9.             The learned counsel for the Ops  No.1 and 2 while reiterating the averments made in the written statement has argued that on perusal of documents, it is observed that the sign and symptoms of the present ailment were existing since two years which is prior to the inception of the policy (3 January 2019).Hence the present ailment is considered as pre existing disease  and the claim is inadmissible as per General Exclusion clause C-1 which reads as “ No indemnity is available for payable for claims directly or indirectly caused by, arising out of or connected to the following: C-1 Benefits will not be available for any pre-existing  condition(s)as defined in the policy until 48 months of continuous coverage have elapsed, since inception of the  first policy with insurer. Also the cause of dysmenorrheal was found to be ovarian cyst for which there is two year waiting period applicable in the policy. Policy was in first year of its inception. Only cash request was made and the same was denied on the ground of PED vide letter date d 6.4.2019. However, in the letter, it is specifically mentioned  that a denial of cashless access is not to be considered in any way  as a denial of treatment. The insured can send a request for consideration through reimbursement within 30 days from the date of discharge but the complainant has not lodged the same, so claim of the complainant is not maintainable and deserves dismissal on this score alone.

10.            The learned counsel for the OP No.3 has argued that the policy was not to be renewed automatically and it was to be renewed on the request of the complainant. The counsel for OP No.3has further argued that the complainant was requested telephonically several times to get renewed the policy but he failed to  respondent to their request.

 

11.            After hearing the learned counsel for the parties, we are of the considered view that the policy Ex.C-5 was issued for the period from  3.10.2013 to 2.10.2014 but the policy for the year 2019-2020 Ex.C-6 was renewed  3.01.2019  to 2.01.2020.  The   current policy Ex.C-6 shows Customer ID No. 1017406384540026 and the same customer ID No. 1017406384540026 is  mentioned in the insurance policy Ex.C-5 which was issued on 3.10.2013 till 2.10.2014. Meaning thereby the policy is resumed without any break. The Ops were charging the amount of renewal premium through ECS and if the OP No.1 and 2 have not issued the ECS command for deducting the renewal premium in time, then the complainant cannot be said to be at fault, therefore,  it is held that the policy was continue since 3.10.2013 and the  treatment taken by the complainant on 5.4.2019 is well covered under the said policy and as such the condition C-1 is not applicable to the facts and circumstances of the present case. The contention of OP No.3 that the policy was not being renewed automatically is also devoid of any force because the perusal of statement of accounts Ex.C-10 shows that the amount of Rs.6640/- was transferred to OP no.1 and 2  on  9.10.2013  by way of INWD   then Rs.6740/- on 1.10.2015 as shown at page 3 of the said statement and then on 29.10.2016 Rs.3,398/- were transferred  to CLG and  as shown at page 5 Rs.6,974/- were transferred on 11.10.2017. It shows that the amount was being transferred and the policy was being renewed automatically and there was sufficient amount in the account of the husband of the complainant during this period. Therefore, non renewal of policy in time by OP no.1 and 2  is not justified because no prior notice or letter was issued by the Ops to the complainant regarding lapse of the policy and the policy in question shall be deemed to be continue, therefore, the  Ops have also wrongly denied the cashless facility to the complainant vide letter Ex.R-1. Therefore, complainant is entitled to the claim amount of Rs.1,28,000/- from OP No.1 and 2 and for non payment of this claim amount by the OP No.1 and 2 amounts to deficiency in services on the part of the OP No.1 and 2.

 

12.            In view of our above discussion and findings, we accept the present complaint and direct the Ops No.1 and 2  to make the payment  of sum assured i.e. Rs.1,28,000/- alongwith interest @ 6% per annum from the date of this order till its actual realization. The complainant shall also be entitled a compensation of Rs.10,000/- for the mental harassment caused to him and  Rs.5000/- towards litigation expenses. The Ops are further directed to make the compliance of this order within a period of 30 days from the date of this order, failing which the complainant shall be entitled to initiate proceedings u/s 25/27 of the Consumer Protection Act. The complaint qua Op No.3 stands dismissed. Certified copy of this order be supplied to the parties as per rules and the file be indexed and consigned to the record room after due compliance.

 

Announced in the open Commission.                         President.

Dated: 13.12.2021.

 

                                Member             Member,