The complainant Ashok Kumar (here-in-after referred to as complainants) has filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against Life Insurance Corporation of India and anther (here-in-after referred to as opposite parties).
Briefly stated, the case of the complainant is that insurance advisor of the opposite parties, obtained the signatures of the complainant on various forms and documents including Proposal Form No.1043 dated 4.12.2009 and also got deposited the premium of Rs.19,500/- and the opposite parties issued policy No,301870066 dated 31.12.2009 in favour of the complainant for the period of 27 years w.e.f. 31.12.2009 to 31.12.2036 having a Basic sum assured of Rs.3,00,000/-. The complainant has been regularly depositing the premium of Rs.19,500/-per annum with the opposite parties since the date of the purchase of policy.
It is alleged that Ritu wife of the complainant fell seriously ill on 28.8.2019 due to the excessive bleeding P/V during periods and she was got admitted in Sidhu Hospital Pvt. Ltd. On 28.8.2019. After clinical tests, she was diagnosed to be a case of Multiple Fibromyoma Uterus and was advised for the Operation of salpingectomy left side, Total LAPAROSCOPIC HYSTERECTOMY (TLH) & SALPINGOOPHORECTOMY RIGHT SIDE which was done on 29.8.2019. The wife of the complainant remained admitted in the said hospital w.e.f. 28.8.2019 to 31.8.2019 and was discharged on 31.8.2019. The complainant spent total Rs.63,100.00 for the treatment of his wife as per the final bill issued by the hospital besides other misc. expenses
It is further alleged that the complainant then lodged the insurance claim with the opposite parties and requested for reimbursement of the amount of Rs.63,100/- and furnished all the requisite documents but despite lapse of period of more than four months, opposite parties failed to reimburse the said amount of insurance claim without any reasonable cause and the claim of the complainant has been wrongly and illegally withheld by the opposite parties although the complainant has furnished all the requisite formalities and has submitted all the relevant documents to honour the said claim of the complainant. Due to the illegal acts of the opposite parties, the complainant has suffered from great mental tension, agony, botheration, harassment and humiliation and huge financial losses for which he claims compensation to the tune of Rs.50,000/-.
On this backdrop of facts, the complainant has prayed for directions to opposite parties to pay claim of Rs.63,100/- in addition to compensation to the tune of Rs.50,000/- and litigation expenses amounting to Rs.11,000/-.
Upon notice, opposite parties appeared through counsel and contested the complaint by filing joint written version raising legal objections that the complaint is premature as the claim is still pending due to non furnishing the consent letter by the complainant as per letter dated 08.01.2020. The intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure under the Act and appropriate remedy, if any, lies only in the Civil Court. That the complainant has concealed material facts and documents from this Commission as well as the opposite parties.
It has been pleaded that the complainant has concealed the fact that the opposite parties on receipt of claim papers of Smt. Ritu Bala (Member) under the policy was referred to TPA for payment but the TPA with the remarks that previous claim was rejected under PED (Pre-Existing Disease); hence the claim is recommended for repudiation under PED and further the opposite parties put the case before DODRC for reconsideration and the DODRC decided to make payment of this case on the life of Smt. Ritu Bala wife of complainant, subject to consent from side of complainant for not claiming any claim on his own life as earlier claim was rejected under PED and the opposite parties vide letter dated 08.01.2020 requested the complainant to send consent and on receipt of consent, the case will be sent to TPA for payment of claim of Smt. Ritu Bala but the complainant failed to give any reply. Further the claim of Ritu Bala wife of the complainant was sent to TPA and the TPA has rejected the case under PED (Pre-existing illness irrespective of prior medical treatment or advice), but the opposite parties have taken this case in DODRC where decision to pay the claim of Rs.3625/- only as HCB was decided subject to consent of complainant regarding omission of his name as PI and making Smt. Ritu Bala as new (PI). Surgery was not considered as it was not covered under the listed 49 surgeries of this plan as mentioned in Annexure-II as per terms and conditions of the policy.
Further legal objections are that the complainant is not consumer of the opposite parties and that the complainant has no locus standi or cause-of-action to file the present complaint.
On merits, the opposite parties have pleaded that the complaint regarding purchase of policy No.301870066 with date of commencement from 31.12.2009 to T-901-27 is matter of record. However, the said policy is strictly as per terms and conditions thereof. The opposite parties received the claim of treatment of Ritu Bala on 20.9.2019 and referred the claim to TPA on 23.9.2019 but the TPA has rejected the case under PEd (Pre-existing illness irrespective of prior medical treatment or advice), but the opposite parties further referred the case to DODRC where decision to pay the claim of Rs.3625/- only as HCB was decided subject to consent of complainant regarding omission of his name as PI and making Smt. Ritu Bala as new (PI). Further surgery was not considered as it was not covered under the listed 49 surgeries of this plan as mentioned in Annexure II. Hence, the allegations leveled by the complainant against the opposite parties are totally false and baseless. It is denied that the claim of the complainant has been wrongly or illegally withheld by the opposite parties.
It has also been pleaded that opposite parties sent registered letter dated 08.01.2020 to the complainant but he failed to give any reply or to submit the consent letter as demanded by opposite parties. After controverting all other averments of the complainant, the opposite parties prayed for dismissal of complaint.
In support of his complaint, the complainant has tendered into evidence his affidavit dated 22.1.2020 (Ex.C-1) and other documents (Ex. C-2 to Ex. C-20).
In order to rebut the evidence of the complainant, opposite party No.1 tendered into evidence affidavit of Sanjay Kumar Sharma dated 26.10.2018 (Ex.OP1/1).
Opposite parties tendered into evidence of Affidavit of K.K. Arora dated 18.3.2020 (Ex. OP-1/3) and other documents (Ex.OP-1/2 & Ex.OP-1/2).
We have heard learned counsel for the parties and gone through the record.
Learned counsel for parties have reiterated their stand as taken in their respective pleadings and detailed above.
We have given careful consideration to these submissions.
There is no dispute regarding Insurance and filing of claim by complainant regarding his wife Ritu Bala. The opposite parties have not paid the claim to complainant and the pleading in written version of the opposite parties regarding this is that claim papers of Smt. Ritu Bala (Member) under the policy was referred to TPA for payment but the TPA with the remarks that previous claim was rejected under PED (pre-existing disease), hence the claim was recommended for repudiation.
Ex. C-2 is the insurance policy in question which shows date of commencement of policy in question vide which complainant and his wife Ritu Bala are insured is 31-12-2009 and date of expiry is 31-12-2035.
A perusal of file reveals that opposite parties placed on file a letter dated 8-1-2020 (Ex. OP-1/1), this letter reads as under :-
“We would like to inform you that earlier claim on your life was rejected on 16-02-2013 under PED rejection code H01, L-99 & M02, date of injury/disease 21-10-2012 (Pre-existing illness irrespective of prior medical treatment or advice).
On the receipt of claim papers of Smt. Ritu Bala (Member) under this policy, case was referred to TPA for payment. TPA sent us letter with remarks that previous claim was rejected under PED (Pre-existing disease); hence this claim is also recommended for repudiation under PED. So, we have put up your case before DODRC for reconsideration.
DODRC decided to make payment of this case on the file of Smt. Rtu Bala, subject to consent from your side for not claiming any claim on your own life (as earlier claim on your life was rejected under PED). Also your name will be replaced by your wife as PI (Principal Insured). So, you are requested to send your consent. On receipt of consent, case will be send to TPA for payment of claim of Smt. Ritu Bala.”
The opposite parties have not placed on file any terms and conditions of the policy under which previous claim of complainant, if any, was rejected, and so, claim of Smt. Ritu Bala is also to be rejected under PED (pre-existing disease). The opposite parties have also not placed on file any document to prove that Smt. Ritu Bala was suffering from PED or she took any treatment before 31-12-2009 (commencement of policy).
The opposite parties have also pleaded that surgery performed upon Smt. Ritu Bala is not covered under the listed 49 surgeries of this plan as mentioned in Annexure II. Ex. OP-1/2 is the Annexure-II. This document is incomplete. There is nothing mentioned regarding policy or schedule of policy in question. Therefore, this incomplete document cannot be relied upon and on the basis of it, it cannot be said that this Annexure II is the part of the policy under which complainant and his wife Smt. Ritu Bala are covered.
Thus, keeping in view the facts and circumstances and the evidence placed on file by the parties, this Commission is of the considered view that opposite parties have rejected the genuine claim of the complainant without any basis.
Hon'ble State Commission, Haryana, in the case titled Star Health and Alied Insurance Co. Ltd., Vs. Asha and others 2015 (1) CLT 590 has held that :
“It is well settled that the company, who is taking specific plea about repudiation of any claim, has to prove that the exclusion clause was explained to the consumer – Once the insurer failed to prove this fact, it cannot take any benefit from such an exclusion clause.”
Hon'ble National Commission in the case titled National Insurance Co. Ltd., Vs. Radhey Shyam Balwada and another 2014(2) CPJ 201 held :
“Insurer is under obligation to act in good faith, which obliges him to enter into contract without concealing material fact like exclusion clause.”
Hon'ble National Commission in Revision Petition No. 2939 of 2011 decided on 15-11-2017 case titled Vipin Grover & anothers Vs. New India Assurance Co. observed :-
“If Insurance companies co-relate each and every disease with pre-existing condition, under such circumstances, insured i.e. helpless consumers will never succeed to get his genuine claim from Insurance Company.”
Therefore, there is deficiency in service on the part of the opposite parties in rejecting the genuine claim of the complainant on flimsly grounds. Hence, the complainant is entitled to the medical expenses incurred on the treatment of Smt. Ritu Bala with interest from the date of rejection of claim.
In view of what has been discussed above, this complaint is partly allowed with Rs.10,000/- as cost and compensation. The opposite parties are directed to pay Rs. 63,100/- to complainant with interest @ 6% p.a. w.e.f 8-1-2020 (date of Rejection of Claim) till realization.
The compliance of this order be made by the opposite parties jointly and severally within 45 days from the date of receipt of copy of this order.
The complaint could not be decided within the statutory period due to heavy pendency of cases.
Copy of order be sent to the parties concerned free of cost and file be consigned to the record room.
Announced :
25-01-2023
