CONSUMER DISPUTES REDRESSAL FORUM – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110 016
Case No.531/2010
SH. JAGDISH SINGH,
M-II, E-7, SANGAM VIHAR,
NEW DELHI-110062
…………. COMPLAINANT
VS.
M/S BAJAJ ALLIANZ GENERAL INSURANE CO. LTD.,
6TH FLOOR, 93, ASHOKA BHAWAN,
NEHRU PLACE, NEW DELHI
………….. RESPONDENT
Date of Order:03.02.2016
O R D E R
A.S. Yadav – President
The case of the complainant is that he had taken a policy bearing No.OG-10-1104-6014-0000 1052 on 11.05.2009 under the name of SURAKSHA KAVACH from OP for the period from 11.05.2009 to 27.04.2011 and paid the premium amount of Rs.1500/-. As per the policy, in case of critical illness reimbursement to the extent of Rs.75,000/- was assured.
It is further stated that on 19.09.2009 due to chest pain, nausea, jaw back associated with profusely sweating etc., complainant had been rushed to Batra Hospital & Research Centre and was admitted there. Complainant was discharged from hospital on 25.9.2009. Complainant had applied for the Pre-Authorization for cashless facility with OP, but same has been denied by OP hence complainant had to pay Rs.2,15,111/- for the aforesaid treatment. Complainant informed OP about the said treatment and filed the claim in the month of October 2009 for the disbursement for the amount of Rs.75,000/-. Complainant supplied all the documents regarding his treatment to OP at the time of filing the claim. Complainant kept visiting the place of OP but they kept delaying the matter. Ultimately complainant received a letter on 26.10.2009 from OP regarding repudiation of the claim on flimsy ground that the “patient has non-ATEMI Coronary Syndrome with coronary artery disease undergone PTCA. Both fall under the exclusion as per policy clauses C1 & C2”. That being aggrieved with the conduct of OP, complainant left with no other option but to file this complaint. It is prayed that OP be directed to disburse the claim amount of Rs.75,000/- and also to pay Rs.4 lakhs for compensation and Rs.20,000/- for litigation expenses.
OP in the reply took the plea that complainant has filed all kinds of estimated expenses but has deliberately not filed copies of ‘Discharge Summary and Medical Procedure as given by the treating hospital as these documents clearly establish that the treatment taken by complainant was excluded from the insurance cover taken by him.
It is further stated that as the treatment taken by complainant was excluded as per policy clause C1 and C2 from purview of the insurance cover taken by the complainant hence the claim was inadmissible and therefore repudiated.
It is further stated that complainant submitted claim from on 22.10.09 and the claim was repudiated vide letter dated 26.10.09 as such there was no delay in dealing with claim of complainant. It is submitted that there is no deficiency in service on the part of OP hence the complaint be dismissed.
We have heard Ld. Counsel for the parties and carefully perused the record.
The only point for consideration is whether the ailment from which complainant suffered was covered under the policy or not. The policy is exhibit as CW-1 which provides that in case of critical illness, a sum of Rs.75,000/- was assured.
It is submitted by Ld. Counsel for OP that complainant suffered from angina and chest pain and he developed critical artery disease which was excluded from the coverage. He has referred to relevant clause of the policy that defines the exclusion is reproduced as under:-
“Section 1–Critical Illness Coverage – First Heart Attack(Myocardial infarction)
If the insured person named in the schedule is diagnosed as suffering from a critical illness which first occurs or manifests itself during the Policy Period, and if the insured survives for a minimum of 30 days from the date of diagnosis, the company shall pay the critical illness benefits as shown in the schedule. Diagnosis by a physician, of the death of a portion of heat muscle, as a result of inadequate blood supply to the relevant area. The diagnosis will be evidenced by all of the following criteria - History of typical chest pain, New and recent electrocardiographic changes indicating myocardial infarction, - Elevation of Infarction specific enzymes. Non-ST segment elevation myocardial Infarction (NSTEMI) with elevation of Troponin I or T is excluded, Specific Exclusion : Angina or chest pain.
Section1–Critical Illness Coverage–Coronary Artery Disease Requiring Surgery
If the insured person named in the schedule is diagnosed as suffering from a critical illness which first occurs or manifests itself during the Policy Period, and if the insured survives for a minimum of 30 days from the date of diagnosis, the company shall pay the critical illness benefits as shown in the schedule. The undergoing of open hest surgery for the treatment of a blockage of two or more coronary arteries with bypass grafts(CABG). Specific Exclusion : non-surgical techniques indulging but not limited to balloon angloplasty, laser relief of an obstruction or other forms of coronary artery clearing through catheters or similar devices.”
First of all, there is nothing to suggest that these clauses were brought to the notice of the complainant. Wherever a policy contained an exclusion clause, it is incumbent upon insurer to bring the same to the notice of the insured and also to get such terms and conditions duly signed by the insured. Complainant said that these terms and conditions were never brought to his knowledge. What has been told to him is that in case of critical illness a sum of Rs.75,000/- shall be paid to him. It is significant to note that in the policy it is nowhere defined what the insurer meant by critical illness. In ordinary paralence, critical disease includes heart disease also. In fact insurance companies are practicing a fraud. A man of an ordinary prudence whenever takes a policy and if he is told that in case of critical disease, he will be paid assured sum, then what he understands is that in case of serious illness he will be paid the amount assured in the policy. The persons taking policy are surprised when they are told by insurance companies that heart ailment is excluded from critical illness and more so when the same is not brought to his notice at the time of taking the policy.
It is a fact that complainant was admitted in the hospital on 09.02.2009 with complaint of nausea and chest pain, jaw back associated with profusely sweating etc. He underwent coronary angiography which revealed left anterior descending artery 80% tubular stenosis, left circumflex artery mild plaquing, right coronary artery was normal, his PTC with stent was done and he was discharged on 25.09.2009. Complainant paid total amount of Rs.2,15,111/- for his treatment in the hospital. He claimed a sum of Rs.75,000/- from OP as per the policy. Repudiation of the claim for the reasons stated above was wrong and the same amounts to deficiency in service on the part of OP.
OP is directed to pay a sum of Rs.75,000/- alongwith interest @ 10% p.a. from the date of filing of complaint and also to pay Rs.10,000/- towards compensation and Rs.5,000/- for litigation expenses.
Let the order be complied with within one month of the receipt thereof. The complaint stands disposed of accordingly.
Copy of order be sent to the parties, free of cost, and thereafter file be consigned to record room.
(D.R. TAMTA) (A.S. YADAV)
MEMBER PRESIDENT
