Haryana

Karnal

CC/21/2019

Sham Lal - Complainant(s)

Versus

DHFL Pramerica Life Insurance Company Limited - Opp.Party(s)

11 Sep 2019

ORDER

 BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                          Complaint No.21 of 2019

                                                         Date of instt. 11.01.2019

                                                         Date of decision:11.09.2019

Shyam Lal son of Shri Gaje Singh resident of village and post office Sheikhpura Sohna, tehsil and district Karnal. Mobile no.9467734541.

                                                                       …….Complainant

                                                  Versus

1. D.H.F.L. Pramaerica 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

                Dr. Rekha Chaudhary……Member

 

 Present:  Complainant in person.

                   Shri Abhishek Chaudhary 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 opposite parties(OPs) are a life insurance company which does insurance policies. In July, 2017 one agent of the insurance company met the complainant and allured him for getting insured by explaining many policies to him and also informed the complainant a new policy named as Dengue Shield and this policy covers the insured for a period of five years from the disease of Dengue by paying the premium only once a time. Agent also told the complainant about all terms and conditions of the insurance company by saying that claim of Rs.50,000/- is to be paid by company to insured person suffering from Dengue disease. On believing the agent the complainant took one policy in his name and another for his wife. Complainant paid Rs.2920/- for his policy to agent and agent gave a print out of insurance policy bearing no.00512345. On December, 2017 complainant got viral and Dengue was diagnosed and complainant got his treatment at S.S. Hospital Sector-14, Karnal. After that complainant filed his claim with the OPs for the amount of Rs.50,000/- that has been paid by the OPs and the abovesaid policy shall remain as it is for further period of 5 years.

2.             Further, thereafter on 9.10.2018 complainant went to Ishwar Kirpa Hospital due to his fever where he came to know that he has got Dengue fever and should be admitted in hospital for treatment but due to more expensive treatment complainant went to another hospital named Singla Children and Maternity Hospital and on the same day 09.10.2018 doctors got admitted the complainant in their hospital where Rs.10,000/- was spent by the complainant on his treatment and complainant was discharged on 13.10.2018 after getting well and was asked to take further bed rest. After getting well the complainant contacted the OPs with relating to his case history and told the company about his disease and showed all reports etc. upon which OPs assured for passing his claim. The complainant sent his claim file to OPs through courier on 13.10.2018 and contacted the insurance company many times. Then insurance company asked the complainant to sent the claim file again upon this the complainant sent again his claim file to OPs on 08.11.2018. The complainant received a phone call from company and they enquired about the Dengue disease. Thereafter, complainant received another phone call from a person from the company who was claiming himself as surveyor of the company and he also collected some information and photocopies of some documents from the complainant. Thereafter, complainant received a letter dated 19.11.2018 regarding the rejection of this claim. After knowing the rejection of his claim, complainant contacted the OPs and enquired in this regard but the officials of the OPs did not give the satisfactory reply to the complainant. Due to this act and conduct of OPs complainant suffered mental pain, mental harassment apart from financial loss. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

3.             Notice of the complaint was given to the OPs, who appeared and filed written version raising preliminary objections with regard to mis-joinder and non-joinder of necessary parties; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the said agent has not been made a party to the present complaint. It is further pleaded that complainant was clearly explained regarding the terms and conditions of the policy named as DHFL Pramerica Dengue Shield and the payment schedule at the time of signing of the policy documents. The complainant was duly informed regarding the Freelook period and the detailed terms and conditions of the policy in question, vide letter dated 26.07.2017 and complainant was duly supplied the Welcome Kit comprising of Forwarding Letter, Policy Schedule, Premium Receipt and the terms and conditions of the policy. The complainant never applied before the OPs for cancellation of the said Policies within the stipulated Freelook period. It is further pleaded that the complainant filed a claim of the policy benefit against the policy bearing no.512345 and the OPs responded to the same, vide letter dated 16.10.2018. It is further pleaded that in order to verify the authenticity of the claim raised by the LA against the treatment of Dengue Fever taken by the LA, got a verification regarding the same done and the medical records of the LA pertaining to the said treatment was procured by the OPs. It is further pleaded that under part C:Specific Terms and conditions of the said policy claim of the LA did not meet all the conditions laid down under Section one: Policy Benefits of the terms and conditions of the said policy. The terms and conditions of the policy in question is reproduced as under:-

PARTC-Specific Terms and Conditions

Section one: Policy Benefits.

The benefit equal t the Sum Insured shall be payable on the diagnosis of the Dengue Fever (as defined above) on meeting all of the following conditions:

a) Decreasing platelet level-less than 100,000 cells/mm3 and

b) Increasing in hematocrit more than 20% of the highestnormal value and

c) Immunoglobulins/PCR test showing positive results for Dengue and

d) Attending physician’s certification for diagnosis of Dengue Haemorrhagic fever and/or Dengue Shock Syndrome and

e) Minimum 48 In-patient care consecutive hours of hospitalization in a Hospital for Medically Necessary Treatment of Dengue

 

During each Policy Year, a maximum of one claims shall be payable to each life assured and no carry forward to the next Policy year shall be allowed. However, the cover will continue for each life insured after a claim is made till the end of the policy term or the date on which a claim is made in the last policy year, whichever is earlier, subject to payment of all due premiums by the policyholder.”

From the perusal of the medical report of the LA it is evident that the claim of the LA is not as per clause b,d and e of the terms of the Part C-Section One, policy benefits i.e. “Attending Physician certification for diagnose for Dengue Haemorrhagic fever and/or Dengue Shock Syndrome.” Due to this very fact, the OP has rejected the claim of the complainant after due verification and investigation and even it has been found that the hospital is not registered with any authority since prior to the date of hospitalization of the complainant. It is further pleaded that as required under the IRDA Regulations 2017, the policy terms and conditions specifically provides for a freelook period of 15 days, during which period the policy owner is entitled to review the policy terms and conditions and request for a cancellation if dissatisfied with the terms and conditions of the policy. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

4.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C9 and closed the evidence on 17.07.2019.

5.             On the other hand, OPs tendered into evidence affidavit of Mr. Parmal Singh Ex.OP1/A and documents Ex.OP1 to Ex.OP5 and closed the evidence on 21.08.2019.

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

7.             The case of the complainant, in brief, is that in July, 2017 complainant took one policy  in his name and another for his wife named as Dengue Shield and this policy covers the insured for a period of five years from the disease of Dengue by paying the premium only once a time. On December, 2017 complainant got viral and Dengue was diagnose and complainant got his treatment at S.S. Hospital Sector-14, Karnal. After that complainant filed his claim with the OPs for the amount of Rs.50,000/- that has been paid by the OPs and the abovesaid policy shall remain as it is for further period of 5 years. Thereafter on 9.10.2018 complainant went to Ishwar Kirpa Hospital due to his fever where he came to know that he has got Dengue fever and should be admitted in hospital for treatment but due to more expensive treatment complainant went to another hospital named Singla Children and Maternity Hospital and on the same day 09.10.2019 doctors got admitted the complainant in their hospital where Rs.10,000/- was spent by the complainant on his treatment. The complainant sent his claim file to OPs through courier on 13.10.2018 and contacted the insurance company many times. Then insurance company asked the complainant to sent the claim file again upon this the complainant sent again his claim file to OPs on 08.11.2018. The complainant received a phone call from a person from the company who was claiming himself as surveyor of the company and he also collected some information and photocopies of some documents from the complainant. Thereafter, complainant received a letter dated 19.11.2018 regarding the rejection of this claim. After knowing the rejection of his claim, complainant contacted the OPs and enquired in this regard but the officials of the OPs did not give the satisfactory reply to the complainant.

8.             The case of the OPs, in brief, is that complainant was clearly explained regarding the terms and conditions of the policy named as DHFL Pramerica Dengue Shield and the payment schedule at the time of signing of the policy documents. The complainant was duly informed regarding the Freelook period and the detailed terms and conditions of the policy in question, vide letter dated 26.07.2017 and complainant was duly supplied the Welcome Kit comprising of Forwarding Letter, Policy Schedule, Premium Receipt and the terms and conditions of the policy. The complainant never applied before the OPs for cancellation of the said Policies within the stipulated Freelook period. The complainant filed a claim of the policy benefit against the policy bearing no.512345 and the OPs responded to the same, vide letter dated 16.10.2018. In order to verify the authenticity of the claim raised by the LA against the treatment of Dengue Fever taken by the LA, got a verification regarding the same done and the medical records of the LA pertaining to the said treatment was procured by the OPs. During each Policy Year, a maximum of one claims shall be payable to each life assured and no carry forward to the next Policy year shall be allowed. However, the cover will continue for each life insured after a claim is made till the end of the policy term or the date on which a claim is made in the last policy year, whichever is earlier, subject to payment of all due premiums by the policyholder. From the perusal of the medical report of the LA it is evident that the claim of the LA is not as per clause b,d and e of the terms of the Part C-Section One, policy benefits i.e. “Attending Physician certification for diagnose for Dengue Haemorrhagic fever and/or Dengue Shock Syndrome.” Due to this very fact, the OP has rejected the claim of the complainant after due verification and investigation and even it has been found that the hospital is not registered with any authority since prior to the date of hospitalization of the complainant.

9.             Admittedly, the complainant purchased Dengue Shield policy from the OP. It is also admitted that the complainant got admitted in the hospital due to fever. As per version of the complainant, he was suffering/diagnosed of Dengue. The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.OP5 on the grounds maintained in that letter which reproduced as under:-

“Increasing in hematocrit more than 20% of the highestnormal value and

 Attending physician’s certification for diagnosis of Dengue Haemorrhagic fever and/or Dengue Shock Syndrome and Minimum 48 In-patient care consecutive hours of hospitalization in a Hospital for Medically Necessary Treatment of Dengue.”

10.            OP relied upon the investigation report Ex.OP4 but here is nothing mentioned in the report that LA did not meet the condition laid down under part C of the policy. The OP has only tendered the report of investigator as Ex.OP4. As per condition no.b of the policy, increasing in hematocrit more than 20% of the highest normal value, but OPs failed to produce the medical report to prove his version. Second ground for rejection of the claim is not physician’s certification for diagnosis of Dengue Haemorrhagic fever. In this regard OP did not produce any record with regard that attending doctor was not having any physician’s certification. Lastly, the ground for rejection the claim is that patient must be hospitalization minimum 48 hours for treatment of Dengue. In this regard the complainant got admitted in the hospital on 9.10.2018 and discharged on 13.10.2018 and period for hospitalization in the hospital by the complainant comes more than 48 hours. It has been proved from the report Ex.1, Ex.C6 to Ex.C9 and treatment record Ex.C2 & C3 that the complainant was suffering from Dengue Fever. Thus, in view of above discussion, the acts of the OPs amounts to deficiency in service and unfair trade practice. Vide bills Ex.C3 and Ex.C4 the complainant spent Rs.9044/- on his treatment hence he is entitled for the said amount.

11.            Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.9044/- to the complainant with interest @ 9% per annum from the date of repudiation of claim till its realization. We further direct the OPs to pay Rs.5,000/- to the complainant on account of mental agony and harassment suffered by him and Rs.2200/-for the litigation expenses. This order shall be complied within 30 days from the 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:11.09.2019                                                                       

                                                                      President,

                                                              District Consumer Disputes

                                                               Redressal Forum, Karnal.      

 

        (Vineet Kaushik)          (Dr. Rekha Chaudhary)

            Member                           Member