Punjab

StateCommission

FA/1080/2013

Oriental Insurance Compay Ltd. and another - Complainant(s)

Versus

Dharamvir Sareen - Opp.Party(s)

Brig. B.S. Taunque, Retd.

16 Feb 2015

ORDER

2^nd  ADDITIONAL BENCH

 

PUNJAB STATE CONSUMER DISPUTES REDRESSAL

COMMISSION,

DAKSHIN MARG, SECTOR 37-A, CHANDIGARH

 

First Appeal No. 1080 of 2013

 

                                                           Date of institution: 10.10.2013

                                                           Date of Decision  : 16 .02.2015

 

1. Oriental Insurance Company Limited Regd &Head Office, A-25/27m Asaf Ali Road, New Delhi, through its Manager Legal, Regional Office SCO No.109-111, Sector 17-D, Chandigarh.
2. Senior Divisional Manager/Senior Branch Manager, The Oriental Insurance Company Limited, Vishwakarma Chowk, G.T. Road, Miller Ganj Ludhiana.

…..Appellants/Opposite Parties

 

Versus

 

Dharamvir Sareen aged 50 years, s/o Sh. Hira Lal Sareen, r/o House No. B-36-117/5, Vikas Nagar, Pakhowal Road, Ludhiana.

....Respondent/Complainant

 

First Appeal against the order dated 12.08.2013 passed by the District Consumer Disputes Redressal Forum, Ludhiana.

 

Before:-

 

Sh. Gurcharan Singh Saran, Presiding Judicial Member

Sh. Jasbir Singh Gill, Member

Sh. Harcharan Singh Guram, Member

 

Present:-

 

For the appellant                   : Sh. B.S. Taunque, Advocate

For the respondent               : Sh. J.S. Lalli, Advocate

 

Sh. Harcharan Singh Guram, Member

   ORDER

                  This appeal has been preferred by appellant/Opposite Parties(hereinafter as the Ops) under section 15 of the Consumer Protection Act, 1986 (hereinafter referred to as the “Act”) against the order dated 12.08.2013 in C.C. No. 67 of 22.01.2013 passed by the learned District Consumer Disputes Redressal Forum, Ludhiana (in short the ‘District Forum’) vide which the complaint filed by the Respondent/ complainant ( hereinafter referred as “Complainant”) under section 12 of the Act,  was allowed and directed to pay the claim as per policy terms;  to pay Rs. 6000/- as compensation and to pay Rs. 3000/- as litigation  expenses within 30 days from the receipt of the copy of the order.

3.                The complainant alleged in his complaint that he was having current account no. 13541131000094 in Oriental Bank of Commerce, Shaheed Bhagat Singh Nagar, Pakhowal Road, Ludhiana. He was already having medi-claim policy vide policy No.2001702825001705 from Reliance General Insurance, the said policy was to mature on 16.02.2012. He further alleged that One Mr. Ashok, an agent of the OPs company, working in OBC bank, pressurized him to purchase policy No. 233902/48/20/12/2154 as he was creating hindrances in his current account operations in the bank. The OPs had admitted vide their letter dated 25.10.2012 that their employee Mr. Ashok had allured the complainant to purchase the aforesaid Mediclaim policy. At the time of purchasing the present policy from the OPs he was duly examined by their Doctor and was found, not sufferings from the heart disease. He was admitted in Daya Nand Medical College and hospital, Unit-Hero (DMC) Heart Institute Ludhiana on 18.08.2012.  He was operated for Heart disease on 22.08.2012 for single vessel and PTCA with stent (Bio-mime 3.5 ×24mm) & MID RCA (Bio-mime 3.5×13mm). After his discharge he lodged his medi-claim bill of Rs. 2,05,551/-with OPs and who repudiated his claim vide their letter dated 20.09.2012. The complainant requested the OPs several time to reimburse the amounts spent by him on his treatment and also served a legal notice on 12.10.2012 through his Counsel to pay up his medical treatment charges, but to no avail. On failure to get any relief he was forced to file his complaint in the District Forum.

4.                The complaint was contested by the OPs by filing detailed written reply before the District Forum. In the written reply they took certain preliminary objections, that the present complaint was not maintainable. It was admitted that after the receipt of the claim, the same was sent to their TPA M/s .Medi Assist, Shilpa Vidya, 3^rd Floor, 49, 1st Main Road, Bangalore, who had repudiated the claim of the complainant vide letter dated 19.09.2012, on the grounds, as per policy terms and conditions during the period of Insurance, the expenses on treatment of ailment/surgeries for diabetic disease for specified periods of 2 years was not payable if contracted or manifested during the currency of the policy. CAD was directly related to the presence of ailment of diabetes and as such the claim was repudiated as no claim in terms of exclusion clause 4.2 of the policy. As per the discharge summary given by the Hospital on the ground that the complainant was admitted in DMC for treatment of TYPE-II Diabetic with CAD, AC inferior valve; M1 on 18.08.2012 and discharged on 28.08.2012.

5.                In support of his allegations, the complainant had tendered into evidence his affidavit as Ex-CW1/A alongwith documents Ex-C1 to C-26. Whereas, Learned Counsel for OPs had tendered into evidence affidavit of Shri. Jagmohan Singh, Senior Divisional Manager, Oriental Insurance Company Limited Ludhiana, as Ex-R/A and affidavit of Dr. H.S. Sandhu, of Medi Assist, TPA as Ex-R/B along with documents Ex-R/1 to R/12.

6.                The District Forum, after going through the record and hearing Learned Counsels on their behalf allowed the complaint, vide aforesaid order.

7.                The Ops have contested the order of the District Forum on the ground that the order is based upon complete mis-reading of the documents, and evidence brought on record. As the complainant did not disclose his illness of diabetes at the time of taking medi-claim policy. The complainant had not revealed before  the District Forum that the TPA was approached by him through DMC Hospital for availing cashless facility but the TPA declined pre authorization request vide their letter dated 21.08.2012. Wherein it was stated “claim is denied under the policy clause 4.2 xv-iii 1.2”. It has been submitted that the complainant was in the knowledge that his treatment taken by him was not payable under the medi-claim policy. However, the complainant after his discharge from the Hospital submitted his medical claim, and the same was rejected by the TPA vide its letter dated 19.09.2012(Ex-R/5)

 8.               It has been submitted that the complainant obtained Oriental Bank Medi claim policy scheduled for a sum of Rs.2,00000/- for the period 19.12.2011 to 18.12.2012. It has been further stated that as per the discharged summary given by the Daya Nand Medical Hospital patient was diagnosed with having Type-II meelitus diabetes which was not covered under 4.1 conditions,  as pre-existing disease and for treatment of said disease, there was a waiting period of 2years from the date of availing policy. Order of District Forum is not justified according to the terms and conditions of the policy. It be set aside and consequently compliant be dismissed.   

9.                During the course of arguments a specific question was raised to the Counsel of Ops whether any other medical record was available with them wherein it was specifically mentioned that the complainant was taking medical treatment for diabetes earlier to the period when the policy was  taken by him from them. The Counsel was stressing the sole point that the disease mentioned in the discharge summary which was submitted by the complainant himself to them, was being relied upon by them, which proves that the OPs did not have any records to prove that complainant was suffering from the said disease and no other record of taking any treatment for this disease before taking the policy.

10.              Moreover, the Supreme Court in its judgment dated 10.10.1995 recorded in Biman Krishan Bose V/s United India Insurance Company, in Civil Appeal number 3438 of 1995 had stated: “that if a person is suffering from hypertension, the insurance claim of the legal heirs of such a person cannot be repudiated on the ground that the life assured had suppressed this information from the Insurance company. Moreover hypertension is not a material disease which is fatal in itself.

11.              Similarly the Hon’ble Delhi State Consumer Disputes Redressal Commission, in case of Life Insurance Corporation of India versus Sudha Jain” 2007 (2) CLT 423, had drawn the conclusions in para 9 and had stated as under.

        “Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day to day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.

  12.           In case of “Birla Sun Life Insurance Co. Ltd. Versus Keshav Lal”, 2008(3) R.C.R. (Civil) 637, the Hon’ble Punjab & Haryana High Court in para 5 observed that the disease of bronchitis had no nexus with the cause of death and further observed as follows:-

“The death of the insured is not related to any such disease which he was expected to disclose in response to questions addressed and that being the position, the Insurance Company is totally unreasonable and unjustified in repudiating the claim. This is only a farce on the part of the Insurance Company to deny a genuine claim and is aimed at escaping the liability, which would arise on account of having sold this policy to deceased.”

13.    However the Punjab and Haryana High Court has expressed its  anguish in the case of “New India Assurance Company Limited versus Smt. Usha Yadav and others”, 2008(3) R.C.R. (Civil) 111, and observed as follows:-

“It seems that the Insurance Companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. A large number of cases, the Insurance Companies make the effected people to fight for genuine claims. Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus, pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.

14.              Moreover, treatment was taken for CAD and not for diabetes and no waiting period for CAD was mentioned in terms and conditions of the policy.

15.              From our above discussion, we conclude that the Ops were not justified in repudiating the claim of the complainant on the ground of pre-existing disease. Correct findings were recorded by the District Forum, and we do not find any ground to upset those findings.

16.              There is no merit in the appeal and the same is dismissed.

 

17.              The appellant had deposited an amount of Rs. 25,000/- at the time of filing this appeal and another sum of Rs. 75,000/-, as per directions of this Commissions. This amount of Rs.25,000/- plus 75,000/- with interest accrued thereon, if any, be remitted by the registry to the complainant by way of a crossed cheque/demand draft after the expiry of 45 days from the date of this order, under intimation to the District Fora/court and to the appellant subject to any stay order from any higher Fora /court. The remaining amount of the claim shall be paid by the appellant to the respondent within 30 days from the receipt of the copy of the order as per the directions of the District Forum.

18.              The arguments in this appeal were heard on 2.02.2015 and the orders were reserved. Now the order be communicated to the parties as per rules.

19.              The appeal could not be decided within the statutory period due to heavy pendency of court cases.

 

                                                (GURCHARAN SINGH SARAN)

                                                PRESIDING JUDICIAL MEMBER

(JASBIR SINGH GILL)

MEMBER

(HARCHARAN SINGH GURAM)

  MEMBER

 

 

February 16 , 2015                                                    

Surinder