Punjab

Sangrur

CC/12/2018

Bhagwan Dass - Complainant(s)

Versus

IFFCO TOKIO General Insurance Company Limited - Opp.Party(s)

Sh.Anil Aggarwal

03 May 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

 

                                                               

                                                Complaint No.    12

                                                Instituted on:      08.01.2018

                                                Decided on:       03.05.2018

 

Bhagwan Dass son of Sh. Des Raj, resident of H.No.87/C, Arora Colony, Sunam, Tehsil Sunam, District Sangrur.

                                                        …Complainant

                                Versus

1.             IFFCO TOKIO General Insurance Co. Ltd. Iffco Tower, Plot No.3, Sector 29, Gurugram (Haryana) through its Manager.

2.             IFFCO TOKIO General Insurance Co. Ltd. Above Hotel Hot Chop Building, Kaula Park, Sangrur through its Branch Manager.

                                                        ..Opposite parties.

 

 

For the complainant    :       Shri Anil Aggarwal, Adv.

For Opp. Parties :       Shri Darshan Gupta, Adv.

 

 

Quorum:    Sarita Garg, Presiding Member

                Vinod Kumar Gulati, Member

       

 

Order by : Sarita Garg, Presiding Member.

 

1.             Shri Bhagwan Dass, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant availed the services of the OPs by getting a medical health insurance policy number 28/FHP/17/52774140  for Rs.3,00,000/- for the period from 13.4.2017 to 12.4.2018 by paying the requisite premium.  It is further averred that during the subsistence of the insurance policy, the complainant on 2.8.2017 met with an accident and suffered accidental injuries and after taking the first aid from Sunam, he was admitted to Dayanand Medical College and Hospital, Ludhiana due to close fracture distat end of radius and closed fracture iliac blade and soft tissue injury and remained admitted in the hospital  from 2.8.2017 to 19.8.2017, where he spent more than Rs.5,00,000/-.  Further case of the complainant is that the complainant had also taken another accidental insurance  policy number 51817730 for the period from 12.4.2017 to 11.4.2018 covering the risk of Rs.80,000/- against accidental injuries.  Further case of the complainant is that though the policy in question was cash less one, but the treatment under cashless policy was denied by the OPs vide letter dated 5.8.2017.  Thereafter the complainant submitted all the bills to the OPs for reimbursement, but the claim of the complainant was not settled nor paid despite his best efforts. Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.3,00,000/- under policy number 52774140 and Rs.80,000/- under policy number 51817730 along with interest @ 15% per annum from the date of accident till realisation and further claimed compensation and litigation expenses.

 

2.             In reply filed by the OPs, legal objections are taken up on the grounds that the present complaint is totally misconceived, groundless and unsustainable in law, that the complaint is baseless and flagrant abuse of process of law, that the complainant has not come to the Forum with clean hands and that present complaint involves intricate questions of law and facts which require extensive evidence.  On merits, it is admitted that the complainant had obtained the policy in question bearing number 52774140 for the period from 13.4.2017 to 12.4.2018 for Rs.3,00,000/-, which is subject to the terms and conditions of the policy.  It is admitted that a cashless request was received by the OPs from the hospital, whereas the said request was denied via cashless denial letter dated 5.8.2017 as on scrutiny of the documents, it was observed that during the taking of FHP policy from the OP, the proposer did not reveal the past history of AD and HTN since 7/8 years, so liability of the cashless claim cannot be ascertained at this time, hence cashless was denied.  It is further averred that it was a case of close fracture distal end of radius, closed fractured lilac blade, soft tissue injury left high and the complainant was also suffering from hypertension and coronary artery disease, which is evident from indoor case record, where under the pre anesthesia assessment, column system review/history, it is mentioned that the patient is having hypertension from 7-8 years. It is stated that the claim under the policy has rightly been repudiated as the complainant was asked to submit various documents such as original receipt, test reports, x-ray reports with file, original fitness certificate issued by doctor/self declaration from, original leave certificate issued by employer, copy of attendance register, NEFT details, aadhar card and PAN card, but the complainant did not submit the same. It is stated further that the claim under policy number 5187730 is pending. However, the other allegations levelled in the complaint have been denied in toto.

 

3.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-14 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OPs/1 affidavit and closed evidence.

 

4.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

5.             It is an admitted fact between the parties that the complainant  along with his family members was  insured with the OPs under medi claim insurance policy for Rs.3,00,000/- by paying the requisite premium for the period from 13.4.2017 to 12.4.2018, as is evident from the copy of the insurance policy on record as Annexure-A.  It is further an admitted fact that the complainant on 2.8.2017 suffered accidental injuries and after taking the first aid from Sunam, he was admitted to Dayanand Medical College and Hospital, Ludhiana due to close fracture distat end of radius and closed fracture iliac blade and soft tissue injury and remained admitted in the hospital  from 2.8.2017 to 19.8.2017, where he spent sufficient amount on his treatment. To support this contention, the complainant has produced on record various documents as well as medical bills as Ex.C-8 to Ex.C-9, which clearly reveals that the complainant remained admitted in the hospital and spent the huge amount on his treatment.  On the other hand, the learned counsel for OPs has contended vehemently that no claim amount is payable to the complainant and the claim is said to has been rightly repudiated on the ground that the complainant concealed material information such as he was suffering from hypertension and coronary artery disease.  It is further contended that if the complainant had disclosed the above said diseases at the time of insurance policy, then the Ops would not have issued the policy to the complainant. But, we are unable to go with this contention of the learned counsel for the OPs because the Ops have not produced any such documentary evidence that the complainant was suffering from any pre existing disease and more over in the present case, the complainant had suffered accidental injuries and that the complainant took treatment for curing the injuries from the Dayanand Medical College and Hospital, Ludhiana and the hypertension etc. has no concern with the present accident. To support such a contention, the learned counsel for the complainant has cited Bajaj Allianz General Insurance co. Ltd. versus Valsa Jose 2012(4) CPJ 839 (NC). Further to support this contention of the complainant, reliance can also be made on the decision of the Hon’ble National Commission in Abedin S. Baldiwala versus United India Insurance co. Ltd. 2016(3) CLT 584 (NC). Further the learned counsel for the complainant has contended vehemently that no terms and conditions were ever supplied to the complainant, as such, the terms and conditions are not binding upon the complainant as the same were never brought to the knowledge of the complainant since the year of taking the policy in question. To support this contention, the learned counsel for the complainant has cited Dr. J.R.Banik Ad versus Managing Director National Insurance Co. Ltd. 2017(2) CLT 376 (NC), wherein the Commission has held that when the insurance company has not supplied the terms and conditions, then the claim is payable.  Further same view has been taken by the Hon’ble Apex Court of India in  United India Insurance Co. Ltd. versus M.K.J. Corporation 1996(8) SCC 428 and in Modern Insulators versus Oriental Insurance Co. Ltd. 2000(2) SCC 734.  Further the Hon’ble Punjab State Commission in The Oriental Insurance Co. Ltd. versus Dr. Ram Kumar in FA No. 947 of 2016 decided on 18.9.2017 has also taken the same view as taken by the Hon’ble Supreme Court of India.

 

6.             On the other hand, the learned counsel for the OPs has cited Jagdeep Arora versus Life Insurance Corporation of India and others 2015(3) CPR 513 (NC), wherein the claim was repudiated on the ground of suppression of pre existing disease. But, this judgment is not at all applicable as in the present case the claim has arose from the accidental injuries and not from the hypertension etc.  As such, we are of the considered opinion that this judgment is not at all helpful to the case of the OPs.

 

7.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

 

8.             Accordingly, in view of our above discussion, we allow the complaint and direct OPs to pay to the complainant the claim amount of Rs.3,80,000/- (under both the policies) along with interest @ 9% per annum from the date of filing of the present complaint i.e. 08.01.2018 till realisation.  We further order the OPs to pay to the complainant an amount of Rs.5000/- in lieu of consolidated amount of compensation and litigation expenses.

 

9.             This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        May 3, 2018.

                                                             (Sarita Garg)

                                                           Presiding Member

 

                                                             

                                       

                                                                (V.K.Gulati)

                                                                    Member