Haryana

Karnal

CC/112/2018

Bansi Lal - Complainant(s)

Versus

D.H.F.L. Pramerica Life Insurance Company Limited - Opp.Party(s)

20 Dec 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                          Complaint No.112 of 2018

                                                         Date of instt. 09.05.2018

                                                         Date of decision:20.12.2018

 

Bansi Lal son of Shri Kora Ram resident of village Dabraki Khurd, tehsil and District Karnal. Mobile no.9991078467.                                                                                           …….Complainant

                                        Versus

 

1. D.H.F.L.Pramerica Life Insurance Company Ltd., SCO 227, Second floor, Sector-12, Urban Estate, Karnal, Haryana-132001 through its Manager/Authorized Signatory. Phone no.0184-4022101.

2. D.H.F.L. Pramerica Life Insurance Company Ltd. at registered Head office, 4^th floor, Building no.9, Tower-B, Cyber City, DLF City Phase II, Gurgaon-122002 through its Manager/Authorized Signatory. Phone no.0124-4697100/7200.

                                                                      …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act.            

Before   Sh. Jaswant Singh……President.       

              Sh. Vineet Kaushik………Member

 

 Present: Complainant in person.

                Shri Akshat Sharma Advocate for opposite parties.

               

                (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant and his wife jointly purchased a Dengu Shield Policy bearing no.005535556 by paying premium of Rs.5724/- from the OPs. The sum assured of the policy is Rs.50,000/- for a term of 5 years. On 29.1.2018 complainant suffered from viral and after testing by the doctor, he was diagnosed as suffering from Dengu. On 31.1.2018 complainant got admitted in S.S.Hospital, Sector-14 Karnal and he was discharged o n 2.2.2018. After few days from the discharge from the hospital complainant approached the OPs and filed his claim. Thereafter, complainant visited the office of OPs so many times and requested to release his claim but OPs did not pay any claim and repudiated the same without any reason. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written version raising preliminary objections with regard to maintainability; cause of action; locus standi and concealment of true and material facts. The true facts are that as per the terms and conditions of the policy, the benefits equal to the sum insured shall be payable on the diagnose of Dengue fever (means a fever which is diagnosed as Dengue Haemorrhagic fever and/or Dengue shock Syndrome). But in the present case the complainant claims did not meet the criteria as per specific terms and conditions of the policy document, which created lawful reasons/cause led to cancel the claim of the complainant, which was rightly and legally cancelled. Hence there is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence his affidavit Ex.C1 and documents Ex.C2 to Ex.C6 and closed the evidence on 25.09.2018.

4.             On the other hand, OP tendered into evidence affidavit of Parmal Singh Ex.RW1/A and documents Ex.R1 to Ex.R7 and closed the evidence on 03.12.2018.

5.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

6.             The case of the complainant is that on 22.12.2017 the complainant purchased a “Dengu Shield Policy” of the sum assured Rs.50,000/- for a term of five years after paying Rs.5724/- as premium from the OPs. On 29.01.2018, complainant suffered from viral and after testing by the doctor, he was diagnosed as suffering from Dengue. On 31.1.2018, complainant got admitted in S.S. Hospital, Sector-14, Karnal and was discharged on 2.2.2018. The complainant submitted his claim with the OPs but his claim was repudiated by the OPs without any reason.

7.             On the other hand, the case of OPs is that complainant and his wife jointly purchased the policy in question. OPs dispatched the policy documents with terms and conditions alongwith the forwarding letter dated 25.12.2017. The investigation of the case was carried out by the OPs as per procedure. The claims and investigation findings are:-

. Complainant purchased single premium family coverage offline on 22.12.2017 for sum assured Rs.50,000/- each.

.  The family coverage and claimed received for the coverage.

.  Call was made to the complainant on 9991078467 to know about his illness, as per prior admission, he had fever so he took medicine from the local pharmacy, however due to non-improvement, he consulted doctor who advised Dengue profile and blood screening test.

. Dengue NSI tested positive on 29.1.2018

. Complainant’s lowest platelet count recorded was 64000 per cmm as on 2.2.2018

. As per the documents received, complainant was admitted in S.S. Hospital on 31.01.2018 and post treatment was discharge on 2.2.2018.

 Diagnosis as per discharge summary Acute Febrile illness with thrombocytopenia.

Investigation agency also suspected the claim to be suspicious and pre-planned claim and recommended to be rejected the claim as DHF/DSS was not diagnosed. The claim of the complainant was rightly repudiated.

8.             Admittedly, the complainant purchased the “Dengue Shield Policy” of sum assured Rs.50,000/-. Complainant paid the premium of Rs.5724/- at that time to the OPs. It is also admitted, the complainant got admitted in S.S. Hospital from 31.1.2018 to 2.2.2018. As per the report (Ex.C5) of Dr. Lal Path labs, the Dengue was diagnosed. The claim of the complainant was repudiated on the ground that the complainant’s claim did not meet the terms and conditions of the policy. We are not satisfied with the argument advanced by the counsel of the OPs that, which condition of the policy was not meet, when the Dengue was confirmed by the laboratory. Thus, we are of the considered view that the acts of the OPs amounted to deficiency in service.

9.             In view of the above observations, we allow the present complaint and direct the OPs to pay the sum assured amount of Rs.50,000/- to the complainant with interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OPs to pay Rs.5500/- to the complainant on account of mental agony, harassment and towards litigation expenses. This order shall be complied with within 30 days from the date of receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:20.12.2018

                                                                        President,

                                                            District Consumer Disputes

                                                            Redressal Forum, Karnal.

 

                          (Vineet Kaushik)

                                 Member