Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 280.
Instituted on : 18.05.2016.
Decided on : 13.11.2018.
Mrs. Sumitra Age 47 years, w/o Jai Bhagwan R/o H.No.883, Ward No.35, Janta Colony, Rohtak(Mob.No.9255124508).
………..Complainant.
Vs.
- The Branch Manager, Policy Servicing Branch Office Reliance General Insurance Co. Ltd. 2nd Floor SCO 400 to 402 HDFC BANK Building, Model Town, Delhi Road, Rohtak.
- The Manager, Claims Servicing R-Care, Reliance General Insurance Co. No.1-89/3/B/14 to 42/KS/301, 3rd Floor, Krishe Block, Krishe Sapphire, Madhapur, Hydereabad-500081.
- Naveen Goel, Agent Code No.28A07809 office of Sarvesh Kumar Perfect Insurance Solutions, G-5 and 6, H-3 Vardhman Plaza Tower, Near P.P.Jewellers, Netaji Subhash Palace, Pitampura, Delhi.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
SH. VED PAL, MEMBER.
SMT. SAROJ BALA BOHRA, MEMBER.
Present: Sh.V.K.Budhwar, Advocate for the complainant.
Sh.Gulshan Chawla, Advocate for the opposite party No.1 & 2.
Opposite party No.3 given up.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that complainant is customer of respondents from last two years and she had purchased family health insurance policy bearing no.201374-2828000019 for the period 27.05.2014 to 26.05.2015 in which she alongwith her family members were insured. Complainant again taken policy No.20132528000023 for the period 27.05.2015 to 26.05.2016. That on 20.03.2015 husband of the complainant suffered pain in abdomen and taken treatment in Siwach Hopsital, Rohtak where he got admitted from 20.03.2015 to 27.03.205 and thereafter in Sunflag Hospital for the period 11.04.2015 to 15.04.2015. That the husband of complainant did not get rid off the abdomen pain. So he had taken treatment from Jaipur Golden Hospital for the period from 17.04.2015 to 20.04.2015. That the complainant applied for above mentioned treatment expenditure from the respondents company and submitted all the required documents. That the opposite parties vide their letter dated 19.09.2015 had repudiated the claim of the complainant for non-disclosure of facts. That there is no concealment or suppression of facts on the part of the complainant and the husband of complainant was thoroughly checked by the respondent company’s doctor before issuing the policy to the complainant. That the act of opposite parties of repudiating the genuine claim of the complainant is illegal and amounts to deficiency in service. Hence this complaint and the complainant has prayed for directing the respondents to disburse the claim amount of Rs.330000/- alongwith interest, compensation and litigation expenses as explained in relief clause to the complainant.
2. After registration of complaint, notice was issued to the opposite parties. Opposite party No.1 & 2 in their reply has submitted that the complainant herself admitted in her complaint that the patient was diagnosed with chronic pancreatitis. That the meaning of chronic itself proves that disease was persisting for a long time or constantly recurring but complainant did not disclose the same at the time of proposal form which is violation of policy terms. That the claim of the complainant was rightly repudiated, as per the treating doctor/consultation of Dr. Manoj Goyal dated 13.04.2015 etiology of Pancreatitis is alcohol which is not covered under permanent exclusion clause 3.3.27. That there is no deficiency in service on the part of opposite parties and dismissal of complaint has been sought. Ld. counsel for the complainant as per his statement dated 30.05.2017 has given up opposite party No.3.
3. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C123 and has closed his evidence. On the other hand ld. counsel for the OP 1 & 2 has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R6 and closed his evidence.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. At the time of arguments, complainant has placed on record calculation sheet which is Annexure-A as well as the respondent also placed on record some documents which are Annexure RA to Annexure RD. Through this complaint, complainant has demanded an amount of Rs.144672/- on account of admission of her husband as explained in calculation sheet i.e. from 20.03.2015 to 27.03.2015 amounting to Rs.35285/-, for the period.11.04.2015 to 15.04.2015 Rs.27572/-, 17.04.2015 to 24.04.15 Rs.73514/- and 09.05.2015 to 11.05.2015 Rs.8301/-. But the claim of the complainant was denied by the respondent officials on the ground that the husband of complainant was suffering from chronic pancreatitis and the same was due to habit of consumption of alcohol. The respondents believed the report dated 13.04.2015 in which it has been mentioned that the patient Jai Bhagwan had consumed alcohol and due to this consumption, he was diagnosed with chronic pancreatitis. So the respondents refused the claim on the exclusion clause 3.3.27.
6. After perusal of the documents placed on record by both the parties we came to the conclusion that initially the patient was admitted on 20.03.2015 in Siwach Hospital Rohtak, thereafter in Sunflag Hospital Rohtak and Jaipur Golden Hospital, Sector 3, Rohini.. In fact the matter was minutely investigated by the respondent officials and they brought all the relevant record from these hospitals and minutely perused the same. Only one document was found on which it has been mentioned that Mr. Jai Bhagwan was diagnosed with chronic pancreatitis with chief complaint in pain abdomen. . It was also mentioned that the ailment is alcohol related. The respondent officials have not taken an expert opinion that the abdomen pain of Pancreatitis can be caused only due to alcohol. As per the medical jurisprudence there are several causes of chronic pancreatitis. No medical report has been placed on record by the respondent officials that Mr. Jai Bhagwan was consuming alcohol as per record. Initially on dated 20.03.2015 Mr. Jai bhagwan was admitted in Siwach Hospital and at the time of admission brief history regarding ailment was to be mentioned in the treatment record. If the complication was due to alcohol, in that situation this fact was to be mentioned by the treating doctor in the brief history of Siwach Hospital. But the respondent failed to provide the brief history of Jai Bhagwan before the Forum. Ld. counsel for the complainant has placed reliance upon the law II(2007)CPJ211(SC) titled as Life Insurance Corporation of India & Anr. Vs. Anand Kumar, 2002(1)CPC 314 titled as The SDM LIC and others Vs. Smt. Satya Devi , (1)2011CPJ209 titled as Tata AIG General Insurance Co. Ltd. Vs. Pooja Gupta and IV(2006)CPJ-379 titled as LIC of India Vs. Gurbaz Singh and the same are fully applicable on the facts of present case. In view of the above, OPs failed to prove that the cause of chronic pancreatitis was due to consumption of alcohol and as such repudiation of claim is not justified and the OPs are liable to pay the claim amount.
7. As per the respondents written statement the total amount payable comes to Rs.…………(left blank), but as per affidavit filed by Suryadeep Singh Thakur authorized signatory of Reliance General Insurance company, the total liability comes to Rs.88434/-. The perusal of Annexure A and Annexure RA to Annexure RD shows that the main difference of the bill is for the period from 17.04.2015 to 20.04.215. As per the complainant they have spent an amount of Rs.73514/- during this period. On the other hand respondent stated that admissible amount for this period is Rs.17136/-. But perusal of Annexure RD itself shows that complainant demanded an amount of Rs.61504/- against the admission period from 17.04.2015 to 20.04.2015. The perusal of Annexure A shows that an amount of Rs.15000/- has been wrongly mentioned twice in the calculation sheet. After deducting the same from 73415/- the same comes to Rs.58514/-. Now we come to the conclusion that Jai Bhagwan is entitled for an amount of Rs.35285/- against the bill for the period 20.05.2015 to 27.03.2015, Rs.27572/- against the period 11.04.2015 to 15.04.2015, Rs.58514/- against the period 17.04.2015 to 20.04.2015 and Rs.8301/- against the period 09.05.2015 to 11.05.2015. Hence the total amount comes to Rs.129672/-(Rupees one lac twenty nine thousand six hundred seventy two only) which shall be paid by the opposite party No.1 & 2 alongwith interest @9% p.a. from the date of filing the present complaint i.e. 18.05.2016 till its realization and a sum of Rs.5000/-(Rupees five thousand only) as litigation expenses and compensation on account of deficiency in service to the complainant within one month from the date of decision. Complaint is allowed accordingly.
8. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
13.11.2018.
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Nagender Singh Kadian, President
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Ved Pal Hooda, Member.
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Saroj Bala Bohra, Member.
