Haryana

Karnal

CC/155/2018

Yashpal Singh - Complainant(s)

Versus

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

Balwan Singh

11 Sep 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                          Complaint No.155 of 2018

                                                         Date of instt. 25.06.2018

                                                         Date of decision:11.09.2019

Yashpal Singh son of Shri Madho Ram resident of house no.324/130, Gali no.2, Suraj Nagar, Rampura Katabag, Tehsil & District Karnal-132001. Mobile no.7988768166.

                                                                       …….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 December, 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 the policy in his name. Complainant paid Rs.2475/- for his policy to agent and agent gave a print out of insurance policy bearing no.00553653. On 19.03.2018 complainant got viral and Dengue was diagnose and complainant got his treatment at Tagore Hospital Sector-14, Karnal. Complainant admitted in the hospital from 21.03.2018 to 25.03.2018.  After that complainant filed his claim with the OPs and the official of the OPs assured the complainant that the claim of the complainant has been released within 15-30 days. Thereafter, 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 namely Rakesh, who was claiming himself as surveyor, and he asked the complainant to give some money(kharcha Pani) and then they will pass his claim then complainant asked the agent that his claim is genuine and complainant refused to pay any bribe. Thereafter, complainant received a letter dated 11.04.2018 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.

2.             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. 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 1 of the policy terms and conditions of the said policy wherein it has been stipulated that the benefit equal to the sum insured shall be payable on the diagnostics of Dengue Fever. The terms and conditions of the policy in question is reproduced as under:-

PARTC-Specific Terms and Conditions

Section one: Policy Benefits.

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

 

The claim of the complainant stood reject as the claim did not meet all the conditions stipulated in Part C: Section 1 of the policy terms and conditions. The complainant did not produce Physician’s certificate for diagnosis of Dengue Hemorrhagic fever and/or Dengue Shock Syndrome.  It is further pleaded that after fully understanding the terms and conditions of the policy the complainant applied for the said policy. It is further pleaded that neither the complainant is entitled to the policy benefit nor the said claim is bonafide. The said report states that even the Hospital official did not provide any registration certificate or provide any other information of the complainant to the investigator. It is further pleaded that the credibility of Tagore Hospital, Sector-14, Karnal is also questionable as per the report of the investigation. This is 2^nd claim from Tagore Hospital and earlier 1^st claim also rejected as hospital infrastructure is not upto mark and hospital did not have registration certificate. The concerned investigator further recorded the finding that the Tagore Hospital did not have registration nor it has any drug licenses. Hence, on account of the same the claim of the complainant does not meet the conditions under Part C: Section 1 of the policy terms and conditions. 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.CW1/A, Ex.CW2/B and documents Ex.C1 to Ex.C7 and closed the evidence on 25.01.2019.

4.             On the other hand, OPs tendered into evidence affidavit of Mr. Parmal Singh Ex.OP1/A and documents Ex.OP1 to Ex.OP4 and closed the evidence on 21.08.2019.

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, in brief, is that in the month of December, 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. On believing the agent the complainant took the policy in his name. On 19.03.2018 complainant got viral and Dengue was diagnose and complainant got his treatment at Tagore Hospital Sector-14, Karnal. Complainant admitted in the hospital from 21.03.2018 to 25.03.2018.  After that complainant filed his claim with the OPs. The complainant received a letter dated 11.04.2018 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.

7.             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. 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 1 of the policy terms and conditions of the said policy wherein it has been stipulated that the benefit equal to the sum insured shall be payable on the diagnostics of Dengue Fever. The claim of the complainant stood reject as the claim did not meet all the conditions stipulated in Part C: Section 1 of the policy terms and conditions. The complainant did not produce Physician’s certificate for diagnosis of Dengue Hemorrhagic fever and/or Dengue Shock Syndrome. The investigator further recorded the finding that the Tagore Hospital did not have registration nor it has any drug licenses. Hence, on account of the same the claim of the complainant does not meet the conditions under Part C: Section 1 of the policy terms and conditions.

8.             Admittedly, on dated 26.12.2017 the complainant purchased Dengue Shield Policy for the sum assured Rs.50,000/-. On 19.03.2018, The complainant was diagnosed for Dengue Fever and admitted in Tagore Hospital Karnal. The claim of the complainant was repudiated, vide repudiation letter Ex.OP4 on the ground that the claim did not meet all the conditions stipulated in para C: Section 1 of the policy terms and conditions, that complainant did not produce Physician’s certification for diagnosis of Dengue Hemorrhagic fever and/or Dengue Shock Syndrome.

9.             The claim of the complainant has been repudiated by the OPs only on the ground that the complainant failed to produce the Physician’s certification for diagnosis of Dengue Hemorrhagic Fever. As per the version of the OP that the credibility of Tagore Hospital Karnal is also questionable, as per report of the investigation as the hospital does not have any registration and also does not have a drug licences. The onus upon the OP to prove that said hospital does not have any registration and also does not have a drug licence. But OPs failed to prove his version. Thus, we are of the confirmed view that act of the OPs amounts to deficiency in service. The complainant have claimed the assured amount i.e. Rs.50,000/-. The complainant has also failed to produce the medical bills with regard to his treatment and without medical bill no claim is awarded in favour of the complainant. Moreover, the complainant had authorized Shri Sunil Kumar for contested the case on his behalf. In the present case, said Sunil Kumar had tendered the evidence on behalf of the complainant, who is not competent as per law.

10.            Thus, as a sequel to abovesaid discussion, we dismiss the present complaint on the ground mentioned above. No order as to costs. 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