Haryana

Karnal

241/2014

Mehar Singh S/o Chandan Ram - Complainant(s)

Versus

Indusing Bank Ltd - Opp.Party(s)

Jai Pal Singh

11 Nov 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                              Complaint No. 241 of 2014

                                                             Date of instt.  28.04.2014

                                                               Date of decision:11.11.2016

 

1. Mehar Singh son of Shri Chandan Ram.

2. Krish minor son of Shri Mehar Singh son of Sh. Chandan Ram. The minor is residing under the care and custody of his father Sh.Mehar Singh being the natural guardian and next friend who has got no adverse to that of minor resident of village Majra Roran, District Karnal.

                                                                         ……..Complainants.

                                                Versus

1. Indusind Bank Ltd. Nigdhu, District Karnal through its Branch Manager.

2. Religare Health Insurance Company Limited GYS Global, plot no.A-3, A-4 and A5 Sector 125, Noida (U.P.) through its Manager.

 

                                                                                …………Opposite Parties.

 

                     Complaint u/s 12  of the Consumer Protection Act.

 

Before                   Sh.K.C.Sharma……….President.

                   Sh.Anil Sharma…….Member.

 

Present:-      Shri Jaipal Singh Advocate for complainants.

                    Shri Gurmeet Singh Advocate for opposite party no.1.

                    Shri Rohit Gupta Advocate for opposite party no.2

                                     

 ORDER:

 

                        This complaint has been filed by the complainants u/s 12 of the Consumer protection Act, 1986, on the averments that the complainant was having account no.100028320297 dated 06.03.2014 with opposite party no.1. There was a scheme for insurance and he obtained the health insurance policy from the opposite parties. Premium amount of Rs.6598/- was deducted by opposite party no.1 from his account and paid to opposite party no.2. Thereafter, opposite party no.2 issued policy no.10095423 commencing from 30.03.2014. As per policy the complainants were insured for an amount of Rs.3,00,000/-. On 2.6.2014 complainant no.2 fell ill, he was admitted in Karnal Medical Centre Private Limited Karnal on 2.6.2014, where he was operated upon and discharged on 3.6.2014. An amount of Rs.40,000/- was spent on the treatment. Thereafter, the complainant no.1 contacted the opposite parties and submitted all the relevant documents for releasing the amount spent on the treatment. Initially, the officials of the opposite parties postponed the matter on one pretext or the other and ultimately refused to accept the genuine claim. Such acts and conduct of the opposite parties amounted to deficiency in service, due to which complainants suffered mental pain, agony and harassment apart from financial loss.

2.                Notice of the complaint was given to the opposite parties. Opposite party no.1 put into appearance and filed written statement controverting the claim of the complainant. Objections have been raised that the complainants are estopped from filing the complaint by their own acts and conduct; that complicated questions of law are involved, which cannot be decided by this forum under summary jurisdiction and that the complaint is bad for mis-joinder of opposite party no.1.

                   On merits, it has been admitted that the complainants purchased health insurance policy issued by opposite party no.2 through opposite party no.1. The terms and conditions of the policy were explained to the complainant and thereafter the copy of the insurance policy was sent by opposite party no.2 to the complainants, to which the complainant no.1 agreed and did not opt for return of policy within 15 days period of freelook. It has been denied that the complainant no.1 approached opposite party no.1, lodged claimed there and submitted documents.

3.                Opposite party no.2 also filed written statement disputing the claim of the complainant. Objections have been raised that this Forum has got no territorial jurisdiction to entertain and adjudicate the present complaint; that the complainant have no locus standi to file the complaint; that complicated questions of law and facts are involved, which cannot be adjudicated in summary manner and that there was no deficiency in service or unfair trade practice on the part of the opposite party no.2.

                   On merits, it has been pleaded that the claim was duly processed and it was repudiated, vide letter dated 18.7.2014. The verification of the claim documents and discharge summary revealed that the complainant no.2 was hospitalized for the treatment of Tonsillectomy and Adenoidectomy, which falls under the exclusion clause 4.1(b)(i)(ii), as the policy does not extend coverage for any expenses incurred on treatment of Tonsilitis during the first 24 consecutive months. The claim of the complainants does not fall within the purview of the policy terms and conditions, therefore, no benefit of the said policy could be granted. It has also been averred that the claim for reimbursement for Rs.21,352/-was only submitted and not for Rs.40,000/- as alleged in the complaint.

4.                In evidence of the complainants, affidavit of complainant no.1 Ex.CW1/A and documents Ex.C1 and C13 have been tendered.

5.                On the other hand, in evidence of the opposite parties, affidavit of Sunny Dhamija Ex.OP1/A and documents Ex.OP1/1 to Ex.OP1/3, affidavit of Ramnique Sachar Manager Legal Ex.OP2/A and documents Ex.OP2/B to Ex.OP2/F have been tendered.

6.                We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

7.                The complainant no.1 had obtained the policy from opposite party no.1, which commenced from 30.3.2014. The copy of the insurance policy is Ex.OP2/B. Copy of the terms and conditions of the policy is Ex.OP2/C. Condition no.4 is with regard to the exclusions. The relevant portion of exclusion clause 4.1(b)(i)(ii) is reproduced as under:-

4.1 Waiting Period:

b. Specific waiting period:

          (i.) Any claim for or arising out of any of the following illnesses or Surgical Procedures shall not be admissible during the first 24 (twenty four) consecutive months of coverage of the insured Person by the Company from the first policy period Start Date.

          (ii) Benign ear, nose and throat (ENT) disorders and surgeries (including but not limited to Adenoidectomy. Mastoidectomy, Tonsillectomy and Tympanoplasty), Nasal Septum Deviation, Sinusitis and related disorders.

                  

                   A bare reading of the said condition makes it quite clear that any claim for or arising out of illness or Surgical Procedures regarding Benign ear, nose and throat (ENT) disorders and surgeries (including but not limited to Adenoidectomy, Mastoidectomy, Tonsillectomy and Tympanoplasty), Nasal Septum Deviation, Sinusitis and related disorders shall not be admissible during the 24 consecutive months of coverage of the insured person. As per the case of the complainants and evidence on record complainant no.2 was admitted in the Karnal Medical Centre Private Limited Karnal on 2.6.2014. Operation was performed and he was discharged on 3.6.2014. As per discharge certificate, the copy of which is Ex.C6 B/l, Tonsillectomy and Adenoidectomy were done under general Anesthesia on 3.6.2014. Thus, the case of the complainant was fully covered under the aforesaid exclusion clause and the insurance company was not liable to pay the claim.

8.                Learned counsel for the complainant vehemently argued that the terms and conditions of the insurance policy were not readover and explained to complainant no.1 before obtaining his signatures on the proposal form, therefore, complainant no.1 was having no knowledge about the said exclusion clause and as such the opposite party no.2 illegally repudiated the claim of the complainant.

9.                The argument advanced by learned counsel for the complainant is not tenable. Firstly, no such plea has been raised by the complainant in the complaint. Moreover, the policy documents must have been sent to complainant no.1. If, he had any objection regarding any term or condition of the policy, he could return the policy and claim refund of the premium within 15 days i.e. freelook period, of receipt of the policy document, but neither there is any such plea nor any evidence on record. Under, such circumstances, the terms and conditions of the policy were binding upon the complainants as well as insurance company and the complainants cannot wriggle out of the same. Under such facts and circumstances, we do no find any illegality in the order of repudiation of the claim of the complainants passed by the opposite parties. Consequently, there was no deficiency in service on the part of the opposite parties.

10.              As a sequel to the foregoing reasons, we do not find any merit in the present complaint. Therefore, the same is hereby dismissed. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 11.11.2016

                                                                                      (K.C.Sharma)

                                                                                         President,

                                                                             District Consumer Disputes

                                                                             Redressal Forum, Karnal.

                             (Anil Sharma)

                               Member