Final Order / Judgement

( Delivered on 3/8/2018)

Per Smt. Jayshree Yengal, Hon’ble Member

1. The original complainant Shri Deelipkumar J. Agrawal being dissatisfied by an order dated 27/6/2016, passed by the Addl. District Consumer Forum, Nagpur dismissing the consumer complaint bearing No. RBT/CC/12/152,  has preferred this appeal.
2. Appellant Mr. Dilipkumar J. Agrawal  and respondent No. 1/Manager, the Oriental Insurance Company, Nagpur and respondent No. 2, Manager Punjab National Bank, Nagpur are referred as per in their original status of  the complainant as complainant & opposite party  ( for short OP)  and OP Nos. 1 and 2 respectively, for the sake of convenience.
3. Facts in brief as set out by the complainant in his complaint are as under.

1. The Complainant had purchased a mediclaim policy bearing No. 19100/48/2610/851 in the joint name of his wife and son for the period from 23/6/2009 to 27/6/2010, for the total sum covered  of Rs. 1,25,000/-
2. The complainant had issued a cheque  dated 22/06/2010 drawn on the OP No. 2 Punjab National Bank for the sum of Rs. 12,287/- towards the premium for renewal of the aforesaid policy. The OP No. 2 without putting the said cheque for clearance returned the same to the complainant. As a result of which the mediclaim policy of the complainant was cancelled due to non-payment of renewal premium.
3. The OP No. 2 informed the complainant that it is in tie up with OP No. 1 bank  and the complainant can avail  another insurance policy namely PNB Oriental Royal Mediclaim. The complainant therefore purchased another policy by aforesaid name for the period from 11/10/2010 to 10/10/2011 by paying the premium of Rs. 6,705/-. The said policy was bearing No. 181100/48/11/2185 in the joint name of his wife and son and the risk covered under the said policy  was Rs. 5,00,000/-
4. During the subsistence of the said policy, the complainant developed pain in the lower back. The complainant  took the medical treatment of said ailment at Sujoy Hospital Mumbai. The complainant was admitted in that hospital on 22/4/2011 for treatment and he was discharged after treatment from that hospital on 23/4/2011. The complainant incurred the total expenses of Rs. 53,096/- for the medical treatment for that ailment.
5. The complainant filed his claim under the mediclaim policy supported by all the documents in respect of the medical treatment being availed.
6. The insurance company, however did not pay the claim. Therefore the complainant issued a legal notice on 3/11/2011 calling upon it to pay the claim of Rs. 53,096/- under the policy and Rs. 10,000/-, 25,000/- and 10,000/- be paid more as expenses, compensation for physical and mental harassment and litigation charges respectively.
7. The complainant further requested the insurance company to review the previous mediclaim policy for the period from 28/6/2010 to 27/6/2011 by accepting  the premium towards its renewal and allow him all the benefits under the said policy.
8. As the insurance company  took no cognizance of the legal notice issued by the complainant, he alleging deficiency in service filed a consumer complaint seeking  the same relief which he had sought in the legal notice issued to the insurance company.

4. The OP No. 1 Manager Oriental Insurance Company, Nagpur and OP No. 2 Manager Punjab National Bank, Nagpur resisted the complaint by filing their written version and denied all the adverse allegations of the complainant.
5.  The OP No.1 /Oriental Insurance Company in its written version  admitted  both the mediclaim policies. The first being  for the period from 28/06/2009 to 27/06/2010. The said policy  is accepted  on receipt of premium from the bank with condition that if the amount of premium is not received from the bank, the mediclaim policy stands automatically cancelled as per terms and conditions of the policy. In this case, the cheque issued by the complainant was dishonored for the reason “Account Blocked.”The OP No. 1 therefore had cancelled the first mediclaim policy on 13/6/2010. The insurance company again admitted that if the issued PNB Royal Mediclaim Policy bearing No. 181100/48/11/2185 for the period from 11/10/2010 to 10/10/2011. The OP No. 1 further specifically submitted that the claim of the complainant was towards the medical treatment availed at  Sujoy Hospital, Mumbai from  22/4/2011 to 23/04/2011.  The complainant was suffering from that disease since almost one and half year prior to the taking of the mediclaim policy. The claim therefore was rightly repudiated as per terms and conditions of the said policy. The OP No. 1 therefore denied to have rendered any deficiency in service and sought for dismissal of the complaint.
6. The OP No.2, Manager Punjab National Bank in its written version has specifically submitted that the account of the complainant was blocked as he had not submitted the KYC details in spite of it being repeatedly demanded from the complainant. OP No. 2 have returned the cheque issued by the complainant to him on 24/6/2010. Had the complainant been diligent, he would have reissued the cheque by providing the KYC. The complainant is liable for his own wrong and therefore the complaint deserves to be dismissed as against it.
7. The Forum below after hearing both the sides and perusing the documents on record, dismissed the complaint as aforesaid. The Forum in its order has specifically held that the insurance company has not rendered any deficiency in service as the first insurance policy stood cancelled  as the premium towards its renewal was not received by it. It had informed the complainant that the said policy can be revived by paying delay charges etc. The complainant instead purchased another policy for the period from 11/10/2010 to 10/10/2011. The Forum below has accepted that the insurance company has not committed any mistake in repudiating the claim of the complainant. The clinical report  which is filed on record has mentioned that the complainant is suffering from that ailment of “Lumber Disk” since last 10 years. The said ailment has enhanced since one and half year. The discharge summary of hospital  filed by the complainant also mentioned that the complainant has been suffering from this back pain since quite some time. The Forum has accepted these documents as evidence and found  no reason for any further evidence.
8. As already mentioned the complainant feeling  dissatisfied has preferred this appeal. The impugned order is challenged mainly on the ground  that the Forum below has not considered the documents filed by the complainant in support of the medical treatment being taken by him at Sujoy Hospital at Bombay on 22/4/2011 and incurred expenses of Rs. 53,096/- especially when the PNB Oriental Royal Mediclaim Policy bearing No. 181100/48/11/2185 for the period from 11/10/2010 to 10/10/2011 is not disputed.
9. We heard counsel for the appellant and respondent Nos. 1 and 2 orally and perused the written notes of arguments filed by them. We also perused copies  copy of the complaint, written version and documents filed on record by both the parties.
10. The mediclaim policy bearing No. 19100/48/2610/851 in the joint name of his wife and son for the period from 23/6/2009 to 27/6/2010 and another policy bearing No. 181100/48/11/2185 for the period from 11/10/2010 to 10/10/2011 under PNB Oriental Royal Mediclaim Policy are not disputed. The First/previous policy  has stood cancelled due to non-payment of renewal premium is also not disputed. There is no other evidence on record in respect of the KYC being not provided by the complainant, the account being blocked as per banking norms etc. The complainant has sought one of the relief for renewal of said policy by issuing directions to the insurance company to accept the amount of renewal premium. The only inference that can be drawn is that the policy has stood cancelled for non- payment of renewal premium and therefore we are of the reasoned view by not allowing the aforesaid prayer of the complainant, the Forum has not adopted any illegality or infirmity in the impugned order.
11. The second issue that survives in respect of the mediclaim under second PNB Oriental Royal Mediclaim Policy  and its repudiation.  The letter dated 18/11/2011 which the repudiation letter issued by respondent No. 1/insurance company  has specifically mentioned as:-

“ On scrutiny of claim documents, it is observed that Policy is in first year and current illness is since 1 & ½years, i.e. pre-existing to the policy. Hence stand of repudiation remain unaltered under clause 1.2”

12. We also perused the discharge card issued by Sujoy Hospital, Bombay. Under the heading “Clinical Notes” it is recorded as  case of (C/o) lower backache ( Since) many years &  arrow increased  SED since four months. Although it is recorded as case of (C/o) lower backache (Since) many years. The said observation is approximate and in abstract form and  there is no other supportive evidence in respect of the complainant suffering from the ailment of backache since so many years. The other observations as “arrow SED since four months” even if  accepted as it is then also the clinical note has specifically recorded the period of said  ailment for four months then it falls within the subsistence of the mediclaim policy as the treatment taken on 23/4/2011 and the period of insurance is 11/10/2010 to 10/10/2011. The insurance company has not proved by cogent evidence that the complainant was suffering from pre-existing disease and therefore not entitled to the insurance claim. Thus, repudiation of claim on the ground of pre-existing disease is not supported by cogent evidence & thus it constitutes deficiency in service on the part of appellant.
13. For the foregoing reason we are of the considered view that the appeal deserves to be partly allowed and impugned order cannot be sustained in law in view of the observations  recorded above. In the result, the appeal deserves to be partly allowed and the impugned order is modified as under.

ORDER

1.  The appeal is partly allowed. The impugned order is set aside. The complaint is partly allowed.
2. The respondent No. 1/OP No. 1  to pay the complainant Rs. 53,096/- towards the mediclaim under the PNB Oriental Royal Mediclaim  Policy  with 9 percent per annum interest from the date of repudiation from 18/11/2011 till its realization by him. The OP No. 1/respondent No. 1 to pay Rs. 5,000/- as compensation for mental and physical harassment and Rs. 5,000/- towards cost of proceedings to the complainant.
3. Copy of order be furnished to both the parties, free of cost.