Haryana

StateCommission

A/180/2016

TATA AIG GEN.INSURANCE CO. - Complainant(s)

Versus

JITENDER SIWACH - Opp.Party(s)

R.K.SHARMA

21 Oct 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

                                                 

First Appeal No  :      180 of 2016

Date of Institution:      29.02.2016

Date of Decision :       21.10.2016

 

TATA AIG General Insurance Company Limited, Joint Venture of TATA AIG and Apollo Munich through its Divisional Manager, SCO 232-234, 2^nd Floor, Sector 34-A, Chandigarh.

Through its authorized officer Shri Mohd. Azhar Wasi, Head North Zone Claims, TATA AIG General Insurance Company Limited, 2^nd Floor, SCO 232-234, Sector 34-A, Chandigarh.

                                      Appellant-Opposite Party

Versus

1.      Jitender Siwach son of Sh. Harkesh Siwach, Resident of VPO Bhaini, Tehsil Meham, Rohtak.

Respondent-Complainant

2.      Axis Bank, Channel Partner (Franchisee) TATA AIG General Insurance Company Limited, Shop No.1, Munjal Complex, Delhi Road, Rohtak through its Manager.

                                      Respondent-Opposite Party No.2

 

CORAM:             Hon’ble Mr. Justice Nawab Singh, President.

                             Shri B.M. Bedi, Judicial Member.

 

Argued by:          Shri Rajesh Kumar Sharma, Advocate for appellant.

Shri Abhineet Taneja, Advocate for respondent No.1.

None for respondent No.2.

 

                                                   O R D E R

 

B.M. BEDI, JUDICIAL MEMBER

 

          TATA AIG General Insurance Company Limited (for short ‘the Insurance Company’)-Opposite Party No.1, is in appeal against the order dated January 4^th, 2016 passed by District Consumer Disputes Redressal Forum, Rohtak (for short ‘the District Forum’), whereby complaint filed by complainant-respondent No.1, was accepted. For facilitation, the operative part of the order is reproduced as under:-

“….it is observed that opposite party No.2 shall pay the amount of Rs.472590/- (Rupees four lac seventy two thousand five hundred ninety only) under the policy No.0200142004 alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 13.11.2013 till its actual realization, other benefits under the policy, if any and shall also pay an amount of Rs.3000/- (Rupees three thousand only) as litigation expenses to the complainant maximum within one month from the date of decision failing which the awarded amount shall carry interest @ 12% p.a. from the date of decision. Complaint is allowed accordingly.”

2.                Jitender Siwach-complainant (respondent No.1 herein) purchased Health Insurance Policy (Exhibit P1/A) under “Family floater Plan”. The policy commenced with effect from 18^th January, 2013. The sum Insured was Rs.5.00 lacs. He fell ill and took treatment from Lilawati Hospital & Research Centre, Mumbai where he remained admitted from 19^th June, 2013 to 28^th June, 2013. According to the complainant he spent Rs.4,72,590/- on his treatment. The complainant filed claim with the Insurance Company but it did not pay the benefits of insurance. Hence, complaint under Section 12 of the Consumer Protection Act, 1986 was filed.

3.                The Insurance Company contested complaint by filing written version. It was stated that the complainant was suffering from Bilateral developmental Dysplasia of Hip. Since it was a congenital ailment, so the complainant was not entitled to the benefits of insurance as per Exclusions Clause. It was prayed that the complaint be dismissed.

4.                After evaluating the pleadings and evidence of the parties, the District Forum allowed complaint and directed the Insurance Company as detailed in paragraph No.1 of this order.

5.                The only question for consideration is whether or not the Developmental Dysplasia of Hip (DDH) falls under exclusions clause?

6.                To decide the issue, the relevant part of Section 3 of Exclusions reads as under:-

“(e)    We will not make any payment for any claim in respect of any insured Person directly or indirectly for, caused by, arising from or in any way attributable to any of the following unless expressly stated to the contrary in the Policy:

1. Xxx
2. Xxx
3. Xxx
4. Xxx
5. Xxx
6. Psychiatric, mental disorders (including mental health treatments); Parkinson and Alzheimer’s disease; general debility or exhaustion (“run-down condition”); congenital internal or external diseases, defects or anomalies; genetic disorders; stem cell implantation or surgery; or growth hormone therapy; sleep-apnoea”.

7.                To prove that the insured-complainant was suffering from Developmental Dysplasia of Hip (DDH), the Insurance Company has placed on record Discharge Card/Summary of the complainant issued from Lilavati Hospital & Research Centre, Mumbai where he remained admitted from 19^th June, 2013 to 28^th June, 2013 wherein the final diagnosis has been written as B/L DDH Neglected. The term DDH is used in referring to patients who are born with dislocation or instability of the hip and may then result in hip dysplasia, that is, it is abnormal growth of the hip.

8.                As per the medical literature, it is a Congenital disorder, also known as a congenital disease, deformity, birth defect, or anomaly. Thus, it is established from the record that the disease suffered by the complainant for which he was treated and sought claim, falls under exclusions clause and the Insurance Company is not liable to pay any compensation to the complainant. The District Forum fell in error in allowing the complaint and as such the impugned order cannot sustain.

9.                In view of the above, the appeal is accepted, the impugned order is set aside and the complaint is dismissed.

10.              The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the appellant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

Announced: 21.10.2016

(B.M. Bedi) Judicial Member

(Nawab Singh) President

 

CL