DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.
Complaint No. 40
Instituted on: 30.01.2017
Decided on: 18.05.2017
Rajbir Singh son of Jaswant Singh C/o New Style Tailor, Sadar Bazar, Sangrur.
…Complainant
Versus
1. Max Bupa Health Insurance Company, Plot No.88, 2nd Floor, Kunal Tower, Mall Road, Ludhiana through its Manager.
2. Anoop Kumar, Agent Code No.Lud0116600, resident of H.No.61, New Grain Market, Sangrur.
..Opposite parties.
For the complainant : Shri G.S.Chahal, Adv.
For Opp.party No.1 : Exparte.
For Opp.Party No.2 : Shri Sanjeev Kansal, Adv.
Quorum: Sukhpal Singh Gill, President
Sarita Garg, Member
Vinod Kumar Gulati, Member
Order by : Sukhpal Singh Gill, President.
1. Shri Rajbir Singh, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant got a health insurance policy for himself and his family members bearing number 30476978201500 for the period from 24.11.2015 to 23.11.2016 and according to the policy, the complainant and his family members were entitled to get treatment anywhere in India and the OPs had to pay the claim.
2. The case of the complainant is that during the subsistence of the insurance policy, the wife of the complainant suffered from uterine bleeding problem in the month of August, 2016 and got medically checked from Grewal Health Care Hospital, Sangrur, where she had to undergo an operation where the uterus of the wife of the complainant was removed on 12.10.2016 and spent an amount of Rs.35,000/- on the treatment/operation. That after discharge from the hospital, the complainant approached OP number 2 and submitted all the relevant documents, but the Ops did not settle the claim of the complainant. Thereafter the complainant got renewed the said policy vide number 30476978201601 for the period from 24.11.2016 to 23.11.2017 and paid an amount of Rs.23,332/- for renewal of the policy. But, the grievance of the complainant is that the OP number 1 repudiated the claim of the complainant vide letter dated 26.12.2016 on the ground that the wife of the complainant was suffering from the said disease before getting the insurance policy, which is totally illegal. The complainant also got served a legal notice upon the OP number 1 on 16.1.2017, but no clam was paid. Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant the insurance claim of Rs.35,000/- along with interest @ 18% per annum from the date of operation i.e. 12.10.2016 till realisation and further claimed compensation and litigation expenses.
3. Record shows that the OP number 1 did not appear on 10.04.2017 nor filed any reply, as such the right to file the written reply by OP number 1 was closed by the order of this Forum and the OP number 1 was also proceeded exparte.
4. In reply of the complaint filed by OP number 2, legal objections have been taken up on the grounds that the complainant has not come to the Forum with clean hands, that the complainant has concealed the material facts from this Forum, that the complainant has illegally dragged the OP into unwanted litigation. On merits, it is admitted that the complainant took the insurance policy from OP number 1. It has been admitted that the complainant supplied the documents to OP number 2 which were accordingly submitted to OP number 1, but it has been stated that the claim has to be settled by OP number 1 and nothing was to be done on his part. Thus, alleging no deficiency in service on the part of the OP number 2, the OP number 2 has prayed for dismissal of the complaint with special costs.
5. The learned counsel for the complainant has produced Ex.C-1 affidavit, Ex.C-2 to Ex.C-16 copies of documents and closed evidence. On the other hand, the learned counsel for the OP number 2 has produced Ex.OP-2/1 affidavit and closed evidence.
6. We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.
7. It is an admitted fact between the parties that the complainant got family health insurance policy for the period from 24.11.2015 to 23.11.2016 from the OP number 1 for Rs.9,00,000/- on floater basis after paying the requisite premium, as is evident from the copy of insurance policy document Ex.C-4 on record. It is also not in dispute that wife of the complainant Smt. Harwinder Kaur suffered from the problem of uterus, which was accordingly removed by operation conducted by Dr. Sumandeep Kaur Grewal on 12.10.2016, as is evident from the copy of bill issued by Dr. Sumandeep Grewal, Ex.C-6 and Ex.C-7 to Ex.C-14 are the copies of the bills of medicine and tests etc. It is not in dispute that the complainant had already lodged the claim with the Ops. But, in the present case, the OP number 1 though earlier appeared, but later on it chose to remain exparte on 10.4.2017 and also did not file the written reply to the complaint. There is no explanation from the side of the Ops that why the Op number 1 did not file any written reply to the complaint, more so when it is proved on record that Smt. Harwinder Kaur wife of the complainant remained admitted in the Hospital of Dr. Sumandeep Grewal for removal of uterus. The complainant also got served a legal notice upon the OP number 1 on 16.1.2017, a copy of which on record is Ex.C-2, but the OP number 1 did not chose to give even the reply of the complaint. Under the circumstances, we feel that the complainant is entitled to get the claim under the policy as his wife suffered operation for removal of her uterus on 12.10.2016. The complainant has produced on record the receipt of Rs.22500/- as Ex.C-9 issued by Grewalz Health Care Clinic and Ex.C-7, Ex.C-8, Ex.C-10 to Ex.C-14 the copies of the bills/receipts of medicine and tests for the claimed amount of Rs.35,000/-. In the circumstances of the case, we feel that the OP number 1 has wrongly repudiated the claim of the complainant, which is a clear cut deficiency in service on the part of OP number 1. As such, we feel that the ends of justice would be met if the OP number 1 is directed to pay to the complainant the claim amount of Rs.35,000/-.
8. The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.
9. Accordingly, in view of our above discussion, we allow the complaint and direct the OP number 1 to pay to the complainant an amount of Rs.35,000/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 30.01.2017 till realisation. We further order the OP number 1 to pay to the complainant an amount of Rs.5000/- in lieu of consolidated amount of compensation and litigation expenses.
10. This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.
Pronounced.
May 18, 2017.
(Sukhpal Singh Gill)
President
(Sarita Garg)
Member
(Vinod Kumar Gulati)
Member
