Before the District Consumer Disputes Redressal Forum, Room No. 208 2^nd Floor, District Administrative Complex, Tarn Taran

Consumer Complaint No  :   18 of 2017

Date of Institution                      : 03.04.2017

Date of Decision               : 25.06.2019

Davinder Kumar son of Tarlok Chand resident of Chownk Kazianwala, Ward No. 6 Patti, District Tarn Taran.

                                                ...Complainant

Versus

H.D.F.C. Standard Life Insurance Company Ltd., 13^th Floor, Apolo Mills Compound, NM Joshi Marg, Mahalakshmi, Mumbai, 400011, through its MD.

…Opposite Party.

Complaint Under Section 12 and 13 of the Consumer Protection Act, 1986.

Quorum:               Sh. Charanjit Singh, President

Smt. Jaswinder Kaur, Member

For Complainant                     Sh. H.s. Sandhu Advocate

For Opposite Party                           Expate.

ORDERS:

Charanjit Singh, President;

1        The complainant Davinder Kumar has filed the present complaint under Section 12 and 13 of the Consumer Protection Act (herein after called as 'the Act') against H.D.F.C. Standard Life Insurance Company Ltd., 13^th Floor, Apolo Mills Compound, NM Joshi Marg, Mahalakshmi, Mumbai, 400011, through its MD (Opposite Party) on the allegations of deficiency in service and negligence in service on the part of opposite party with prayer to make reimbursement of Rs. 1,43,455/- to the complainant being expenses paid by the complainant from his own pocket instead of bearing insurance policy of the opposite party having policy No. 90278184. The complainant has also prayed Rs. 20,000/- as compensation and Rs. 15,000/- as litigation expenses.

2        The case of the complainant in brief is that he is resident of above mentioned address and is a policy holder having policy Number 90278184 of opposite party having validity from 31.3.2016 for 3 years. The complainant has paid a premium of Rs. 8,364/- to the opposite party through the HDFC Bank Branch Patti. The complainant was having insurer cover of Rs. 3 Lacs in case of accidental injury. The complainant met with a road side accident on 17.5.2016 and he suffered serious injury on his hip and  regarding this, son of the complainant Mohit Kumar Sharma informed SHO P.S. Patti on the same day and the complaint was entered as number 102, Dasti Patti dated 17.5.2016 and after the accident the complainant was admitted at Guru Nanak Dev Superspeciality Hospital Tarn Taran immediately and was advised hip replacement surgery by the doctors of the Hospital. The complainant also informed the hospital authorities regarding his insurance cover by the opposite party up to Rs. 3 Lacs and also informed the agent of opposite party immediately regarding the accident and treatment of the complainant at the above mentioned hospital. Inspite of informing the hospital authorities and the agent of the opposite party, the complainant had to pay for the expenses of surgery amounting to Rs. 1,43,455/- from his own pocket. The complainant was discharged from the hospital on 24.5.2016 and after being discharged the complainant immediately approached the opposite party to get reimbursement of the expenses made by him from his own pocket from the opposite party and the agent of the opposite party informed the complainant that the reimbursement will be made in few days time. The complainant visited the agent of the opposite party number of times but he always told the complainant that the reimbursement will be made very soon. On 20.2.2017, the agent of the opposite party told the complainant that the claim case of the complainant has been closed by the opposite party and he can do nothing about it. The complainant asked from the agent of the opposite party for written order of closer of the case but he flatly refused to do so and told the complainant that the company had closed his case. The cause of action to the present complaint arose on 13.3.2017 when after the lapse of 15 days time given by the counsel for the complainant through a legal notice dated 25.2.2017 sent to opposite party for releasing the claim amount of Rs. 1,43,455/- being the reimbursement of expenses paid by the complainant from his own pocket but no reply of this legal notice as sent by the opposite party to his counsel nor the reimbursement has been made till date by the opposite party. This act of the opposite party constitutes deficiency in services, unfair trade practice. Feeling dissatisfied by the act and conduct of the opposite party, the complainant perforce has filed this complaint against the opposite party. 

3        Notice of this complaint was sent to the opposite party but no one appeared on behalf of opposite party and consequently, the opposite party was proceeded against exparte vide order dated 22.5.2017 of this Forum.

4        Ld. counsel for the complainant tendered in evidence his affidavit Ex. C-1 alognwith documents Ex. C-2 to Ex. C-14 and closed the evidence.

5        We have heard the Ld. counsel for complainant and have also carefully gone through the evidence and documents on the file.

6        The complainant has tendered in evidence his affidavit Ex. C-1 and in his affidavit he pleaded that the complainant is resident of above mentioned address and is a policy holder having policy Number 90278184 of opposite party having validity from 31.3.2016 for 3 years and Policy document is Ex. C-3. The complainant has paid a premium of Rs. 8,364/- to the opposite party through the HDFC Bank Branch Patti vide Ex. C-4. The complainant was having insurer cover of Rs. 3 Lacs in case of accidental injury as per policy documents Ex C-3. The complainant met with a road side accident on 17.5.2016 and he suffered serious injury on his hip and regarding this, son of the complainant Mohit Kumar Sharma informed and complained to SHO P.S. Patti on the same day and the same complaint was numbered 102, Dasti Patti dated 17.5.2016 and complaint is Ex. C-14. It is further pleaded that after the accident the complainant was admitted at Guru Nanak Dev Superspeciality Hospital Tarn Taran immediately and was advised hip replacement surgery by the doctors of the Hospital. The complainant also informed the hospital authorities regarding his insurance cover by the opposite party up to Rs. 3 Lacs and also informed the agent of opposite party immediately regarding the accident and treatment of the complainant at the above mentioned hospital. Inspite of informing the hospital authorities and the agent of the opposite party, the complainant had to pay for the expenses of surgery amounting to Rs. 1,43,455/- from his own pocket. The complainant was discharged from the hospital on 24.5.2016 and the discharge card is Ex. C-5 on the record. After being discharged the complainant immediately approached the opposite party to get reimbursement of the expenses made by him from his own pocket from the opposite party and the agent of the opposite party informed the complainant that the reimbursement will be made in few days time. The complainant visited the agent of the opposite party number of times but he always told the complainant that the reimbursement will be made very soon. On 20.2.2017, the agent of the opposite party told the complainant that the claim case of the complainant has been closed by the opposite party and he can do nothing about it. The complainant asked from the agent of the opposite party for written order of closer of the case but he flatly refused to do so and told the complainant that the company had closed his case. He further pleaded that the cause of action to the present complaint arose on 13.3.2017 when after the lapse of 15 days time given by the counsel for the complainant through a legal notice dated 25.2.2017 sent to opposite party for releasing the claim amount of Rs. 1,43,455/- being the reimbursement of expenses paid by the complainant from his own pocket but no reply of this legal notice as sent by the opposite party to his counsel nor the reimbursement has been made till date by the opposite party. He further pleaded that this act of the opposite party constitutes deficiency in services, unfair trade practice and prayer was made for allowing the complaint.

7        The evidence led by the complainant on the file goes unchallenged and unrebutted as Opposite Party is proceeded against exparte in the present complaint and there is no reason on the file as to why the evidence produced by the complainant be not believed. Otherwise also, due notice was issued to the Opposite Party and none has appeared on behalf of opposite party in order to contest the complaint which shows that the Opposite Party has nothing to say upon the allegations leveled against it by the complainant. As such, the complainant is entitled to the relief claimed in the complaint and it stands established on record that the complainant is approaching the opposite party several times but the opposite party did not care to resolve the matter, not only committed deficiency in service, but also indulged in an unfair trade practice.

8        There are letters dated 28^th August, 2016, 10^th March 2017 of the opposite party in which the opposite party has demanded some documents from the complainant. There is also another letter dated 26^th, May 2016 of the opposite party on record in which the opposite party has pleaded that as per available documents patient is K/c/ diabetes mellitus. The letter dated 26^th Mary 2016 is prior to the other letters dated 28^th August 2016, 10^th March 2017 in which the opposite party had refused to give the expenses of treatment and in the said letter dated 26^th Mary 2016 the opposite party has pleaded that ‘as per available documents’. This all shows that the opposite party is taking different pleas in delaying and rejecting the claim.  As per letter dated 26^th May, 2016 the claim of the complainant has been repudiated on the ground that the complainant was suffering from diabetic diseased i.e. prior to the issuance of the insurance policy.  But as per the numerous case law on the point, diabetic is not a disease. In such a situation, it is preposterous to presume that said disease was pre-existing or that non-disclosure thereof at the time of obtaining the insurance policy amount to concealment. Even otherwise,  diabetic is not a material disease, therefore, non disclosure thereof is not a concealment. We draw support from Life Insurance Corporation of India Vs. Sushma Sharma from II (2008) CPJ 213 wherein Hon'ble State Commission has held as under:-

“So far as hypertension is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.

9       We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease. Moreover, this case is not related to any disease, as this case relates to accident and there is no force in the stand taken by the opposite party in the latter dated 26^th, May 2016.

10       In such a situation the repudiation has not given the genuine claim of the complainant. It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.        The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

11      The accident of the complainant has occurred during the currency of the policy and the complainant has spent an amount of Rs. 1,43,455/- vide Bill Ex. C-11.  The risk of the complainant is covered up to the amount of Rs. 3,00,000/-. As such, the complainant is entitled to the amount of Rs. 1,43,455/- from the opposite party.

12      In view of the above discussion, the present complaint is allowed and the opposite party is directed to make the payment of Rs. 1,43,455/-  (Rs. One Lac forty three thousand and four hundred fifty five only) i.e. amount of treatment to the complainant. Complainant is also entitled to Rs.5,000/-  (Rs. Five Thousand only) as compensation on account of harassment and mental agony and Rs 3,500/- (Rupees Three Thousand and Five Hundred only) as litigation expenses. Opposite party is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room.