Haryana

Yamunanagar

CC/688/2010

Manmohan S/o Brij pal - Complainant(s)

Versus

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

Vikas aggarwal

12 Oct 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, YAMUNA NAGAR

 

                                                                                             Complaint No. 688 of 2010.

                                                                                             Date of institution: 27.7.2010.

                                                                                             Date of decision: 12.10.2015

Manmohan son of Brij Pal, age 47 years, r/o Jai Nagar Khera Rolling Mills, Near Police Station, Jagadhri, Tehsil Jagadhri, District Yamuna Nagar. 

                                                                                                                                                         …Complainant.

1. IFFCO TOKIO General Insurance Company Ltd. 6330, 2^nd floor above Dena Bank, Punjabi Mohalla Ambala Cantt. through its Manager/Authorized Signatory (insurer of the medi claim policy of the complainant).
2. Paramount Health Services (TPA) Ltd. D-39, Okhla Industrial Area Phase-I, Near D.D.Motors, New Delhi-110020, through its Manager/Authorized Signatory Dr. Suman S.Tilak, General Manager.
3. Parveen Goyal son of Sh. Trilok Chand Goyal r/o # 431, Krishna Building, Jagadhri Road, Yamuna Nagar, Tehsil Jagadhri, Disttt. Yamuna Nagar (Agent of respondent No.1 & 2.).                                                                                                                                                                                                       …opposite parties. 

 

Before:             SH. ASHOK KUMAR GARG…………….. PRESIDENT.

                        SH. S.C.SHARMA………………………….MEMBER.

 

Present:  Sh. Vikas Aggarwal Advocate, counsel for complainant.  

               Sh. Rajiv Gupta, Advocate, counsel for OP No.1.

               OP No.2 already ex-parte.

               Sh. Saurabh Bansal, Advocate, counsel for OP No.3. 

 

             

ORDER

 

1.                     Complainant Manmohan has filed the present complaint under section 12 of the Consumer Protection Act. 1986, praying therein that respondents (hereinafter referred as OPs) be directed to make the payment of claim amount of Rs. 15,247/- on accoeunt of medical expenses and also to pay a sum of Rs. 50,000/- as compensation on account of suffering, mental agony as well as physical harassment and also to pay litigation expenses to the tune of Rs. 11,000/-.

2.                     Brief facts of the complaint, as alleged by the complainant, are that he and his wife jointly obtained a Medi-claim policy bearing No. 52100275 for a sum assured of Rs. 2,00,000/- w.e.f 22.9.2008 to 21.9.2009 and as per policy in case of any illness the complainant is entitled to claim up to Rs. 2,00,000/-. During the existence of said policy, the complainant fell ill with the complaint of high fever and he was admitted in Santosh Hospital, Near Govt. School, Kanhaiya Sahib Chowk, Gobindpuri, Yamuna Nagar on 14.5.2009 and he was examined by Dr. Lokesh Garg who after thorough investigation found that there was low platelet count  and he was treated for the same. The complainant remained admitted in Santosh Hospital till 18.5.2009 and in these five days lots of test were conducted and medicines were administered but on 18.5.2009 complainant developed spots all over his body and due to his critical condition he was referred to PGI Chandigarh and admitted on 19.5.2009 and discharged on 22.5.2010 and complainant spent a sum of Rs. 13247/- on his treatment besides this Rs. 2000/- has been spent on transportation and he lodged his claim alongwith original bills on 28.1.2010 with OPs No.1 & 2. The complainant was astonished to know about the repudiation of his claim by OPs No.1 & 2 on false and flimsy ground. As such there is a great deficiency in service on the part of OPs No.1 & 2. Hence, this complaint.  

3.                     Upon notice, OPs No.1 & 3 appeared and filed their written statement separately whereas OP No.2 failed to appear despite service, hence, he was proceeded ex-parte vide order dated 29.9.2010. OP No.1 filed its written statement by taking some preliminary objections such as complaint is not maintainable,  no negligence or deficiency in service on the part of OP and on merit it has been mentioned that the complainant had obtained a mediclaim insurance policy from the OP No.1 i.e. Iffco Tokio Gen. Ins. Co w.e.f. 22.9.2008 to 21.9.2009 for a sum of Rs. 2,00,000/-.  A claim was lodged by complainant with the OP No.2 i.e. TPA  on 3.3.2010 and on the perusal of the claim documents it was observed that complainant was hospitalized at Santosh Hospital, Yamuna Nagar on 14.5.2009 and was diagnosed to be suffering from chronic alcoholism with pancytopenia. Further on scrutiny of medical documents it was found that patient was discharged on 18.5.2009 but the claim documents were submitted on 3.3.2010. From the perusal of documents it was found that the expenses incurred on the treatment of ailment arising from or complication related to use of intoxicating drugs/alcohol is not payable as per exclusion clause No.8 of the policy. Further as per the policy condition No.6 the claim must be filed with the company within 30 days from the date of discharge from the hospital or completion of treatment but the complainant did not file the claim with the OP company within the stipulated period which again amounts to violation of the policy conditions and keeping in view the abovesaid facts, the claim of the complainant was legally and justiciably repudiated vide letter dated 6.3.2010. As such, there is no deficiency in service on the part of OP No.1. The complainant is not entitled to any compensation from the OP Company and the complaint is without any merit and the same is liable to be dismissed.

4.                     OP No.3 filed his written statement by taking some preliminary objections such as complaint is not legally maintainable in the present Forum, no locus standi or cause of action to file and maintain the present complaint, legally stopped by his own act and conduct and on merit it has been mentioned that the OP No.3 had only advised the complainant for taking Insurance policy just at the requests of the complainant and except that advice the OP No.3 has no role of any kind between the OP No.1 & 2 and the complainant. The present complaint is afterthought story of the complainant and has filed the same against the OP No.3 only in order to harass him and prayed for dismissal of complaint with costs.

5.                     To prove the case, counsel for complainant tendered into evidence affidavit of complainant as Annexure CX and documents such as Annexure C-1 Cover Note, C-2 Claim letter dated 28.1.2010, C-3 Repudiation Letter dated 6.3.2010, Annexure C-4 to C-22 Photo copies of prescription slip and medicine bills etc. of Santosh Hospital, C-23 to C-29 Photo copies of bills of PGI, Chandigarh, C-30 Photo copy of receipt of medicos centre, C-31 to C-51 Photo copy of discharge & follow up card and bills,  C-52 Photo copy of Fluid report, C-53 Insurance cover note, C-54 Photo copy of personal detail of Manmohan  and closed the evidence on behalf of complainant.

6.                     On the other hand, counsel for the OP Company tendered into evidence affidavit of Sh. Saikat Sarkar, IFFCO TOKIO General Insurance as Annexure R1/X and documents such as Photo copy of repudiation letter dated 6.3.2010 as Annexure R1/1,  Photo copy of insurance cover note alongwith terms and conditions as Annexure R1/2,  Photo copy of prescription slip of Santosh Hospital as Annexure R1/3 and closed the evidence on behalf of OP No.1.

7.                     Counsel of OP No.3 tendered into evidence affidavit of OP No.3 as Annexure R3/X and closed the evidence on behalf of OP No.3.  

8.                     We have heard the learned counsels of both the parties and have gone through the pleadings as well as documents placed on the file carefully and minutely.

9.                      It is admitted fact that the complainant and his wife was insured under the medical benefits/ health risk policy bearing No. 52100275 valid from 22.9.2008 to 21.9.2009 for the sum insured of Rs. 2,00,000/-. It is also admitted fact that complainant got his treatment from Santosh Hospital, Kanhiya Sahib Chowk as well as from PGI Chandigarh for fever and spots all over his body and submitted his medical and hospital bills which was to the tune of Rs. 13247/-.

10                    Learned counsel for the complainant hotly argued that insurance company i.e. OP Company has illegally repudiated the genuine claim of the complainant and draw our attention towards Annexure C-7 case summary issued by Dr. Lokesh Garg of Santosh Hospital wherein it is nowhere mentioned that the complainant/Manmohan has been hospitalized as a case of chronic alcoholism with pancytopinia whereas it has been specifically mentioned by Dr. Lokesh Garg that complainant was suffering from fever and on investigation it was found that platelet counts was low and there was also blood infection. Learned counsel for the complainant further argued that OP No.2 was duly informed in time and regarding this a letter (Annexure C-2) was sent to  OP No.2 i.e. TPA. Learned counsel for the complainant further argued that the complainant has spent an amount of Rs. 13247/- on account of medical investigations treatment and medicine which is evident from Annexure C-4 to C-52 and referred the case law titled as Jasbir Kaur Vs. Oriental Insurance Company Ltd. and others, 2012(5) RCR (Civil) page 123, Oriental Insurance Company Ltd. Vs.  Khandha Nayak 2010 )1) CLT page 189 an also referred guidelines issued by IRDA vide its circular No. IRDA/HLT/CIR/036/02/2013 dated 20.2.2013. Learned counsel for the complainant further referred the case law titled as Santaven Rati Lal Patel Versus LIC 1996(2) CPJ page 92, LIC of India Vs. Prameshwari 1994(1) CPJ page 319 and lastly prayed for acceptance of complaint.

11.                   On the other hand, counsel for the OP Sh. Rajiv Gupta Advocate, argued at length that the complainant was suffering from chronic alcoholism with pancytopenia which is evident from the prescription slip issued by Dr. Lokesh Garg of Santosh Hospital, Yamuna Nagar Annexure C-4/R-3. Hence the claim of the complainant has been rightly repudiated by the OP company vide its letter dated 6.3.2010 as the claim of the complainant was not payable as per exclusion clause 8 of the policy in question. Learned counsel for the OP further argued that the complainant had submitted the documents on 3.3.2010 whereas he remained under treatment of the doctor from 14.5.2009 to 18.5.2009 at Yamuna Nagar and from 19.5.2009 to 22.5.2009 at PGI Chandigarh i.e. claim has not been lodged within a period of 30 days as per general condition No.6 of the policy in question and lastly prayed for dismissal of complaint.

12.                   After going through the above noted arguments advanced by both the parties at length and case law referred by both the parties and material available on the case file, it transpires that the insurance company has wrongly and illegally repudiated the claim of the complainant. The fact that the complainant Manmohan had obtained the policy in question from OP No.1 is not disputed. It has also not been disputed that he had taken treatment during the subsistence of the policy in question. The main objection on behalf of OPs is that complainant Manmohan had intentionally withheld the information regarding state of health from the insurance company at the time of taking the insurance policy. The insurance company has come with a plea that the complainant was suffering due to chronic alcoholism. The plea taken by OP is not sustainable because in Annexure C-7 it has been mentioned that the complainant was suffering from fever and on investigation it was found that platelet count in the blood was low and there was also infection in the blood, therefore, insurance company at this stage cannot raise a plea that complainant has withheld the information from it because the insurance company has failed to prove any nexus between the illness and alcoholism. On this point reliance can be taken from case law titled as Shantaven Rati Lal Patel Vs. LIC of India 1996(2) CPJ page 92 and LIC of India Vs. Prameshwari 1994(1) CPJ page 319 wherein the Hon’ble Apex Commissions have held that “ Deficiency in service”- Insurance- Life Insurance-Material facts- Suppression of -Diabetes- Non disclosure of -Heart attack- Death- OP failed to established nexus between the diabetes and heart attack- Claim repudiated-Whether amounts to deficiency in service? (Yes) and suppression- Complainant filed insurance claim of her disease husband- Repudiated as complainant was suffering from bronchial asthma-Deceased died of cardiac Arrest- Complaint allowed by the District Forum-Appeal- No nexus between ailment and death- Whether reason given by LIC to reject the claim is erroneous? Yes.

13.                   Moreover, the insurance company has not filed any affidavit of the doctor to prove the fact that complainant was a case of chronic alcoholism and the blood infection and that the fever and low count of platelets was due to alcoholism. On this point also reliance can be taken from the case law titled as Life Insurance Corptoion of India vs. Badri Nageshwaramma and others 2005 (2) CPJ page 9 National Commission wherein Hon’ble National Commission has held that section21- Life Insurance- Repudiation of claim- Disease on old TB patient, having a diabetes, not known on the date of proposal- Burden to prove false representation and suppression of facts- On insurer, Doctors certificate without affidavit in support no basis for repudiation the claim- No conclusive evidence produced to suggest suppression on the part of deceased- Company liable under policy. Further learned counsel for the OP Insurance company has failed to explain whether any preliminary investigation has been made by the insurance company at the time of insurance of the policy to the complainant. The insurance company is not supposed to get only premium but it is also liable to act fairly without taking the benefits of weakness of the assured and it is also liable to indemnify all the responsibility for which the premium has been received. The act and conduct of the insurance company reveals that instead of acting fairly the insurance company is trying to befool its customers.

14.                   Further as a matter of fact in the reality, insurance companies in India are functioning arbitrarily with a view to escape and avoiding its legal and factual liabilities to make the payment of sum assured and doing fake acting in dramatically, opposite of the principle of fair play and decency and in that series it is not even caring that their wrong actions are causing wrongful losses to their customers.

15.                   In the present case instead of acting fairly the insurance company is trying to escape from its liability by making one pretext or the other, which cannot be allowed to do so.

16                    Keeping in view the facts and circumstances mentioned above we are of the considered view that there is a deficiency in service on the part of OP No.1. Hence the complaint is partly allowed with a direction to OP No.1 to pay the claim amount of Rs. 13247/- to the complainant alongwith interest at the rate of 9% per annum from the date of filing of complaint till its realization and further directed to pay Rs. 5000/- on account of compensation as well as litigation expenses. Order be complied within 30 days on receipt of copy of this order failing which complainant shall be entitled to invoke the jurisdiction of this Forum as per law.  Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced in open court.  12.10.2015.

                       

                                                                                    (ASHOK KUMAR GARG )

                                                                                    PRESIDENT,

 

                                                                                     

                                                                                    (S.C.SHARMA )

                                                                                     MEMBER.