Chandigarh

DF-I

CC/187/2020

Sahil Sood - Complainant(s)

Versus

M/s Bajaj Allianz General Insurance Co. Ltd. - Opp.Party(s)

Amarbir Dhaliwal & Sunit Kumarr Chauhann

16 Feb 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/187/2020
Date of Institution	:	26.6.2020
Date of Decision	:	16/2/2024

 

Sahil Sood, s/o Sh. Rakesh Sood, House No. 891, Sector 49-A, Chandigarh.

 

...Complainant

 

Versus

 

M/s Bajaj Allianz General Insurance Company Limited, through its Managing Directors/ Directors/ Manager/ Authorized Person/ Authorized Signatory

 

Regd. Office: GE Plaza, Airport Road, Yerwada, Pune 411006. Branch Office: SCO 156 to 159, 2nd Floor, Sector-9 C, Chandigarh.600091.

 

  … Opposite Party

 

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR SURESH KUMAR SARDANA	MEMBER MEMBER

                       

ARGUED BY	:	Ms. Keerti Sandhu, Advocate proxy for Sh. Amarbir Dhaliwal, Advocate for complainant.
	:	Sh. Rajesh Verma, Advocate for OP.

Per surjeet kaur, Member

     Briefly stated the complainant allured with the promises and assurances made by the OP purchased Travel Prime Student Gold policy from OP by paying premium amount of Rs.9964/- which was valid w.e.f.20.8.2018 to 20.8.2019 and the complainant was covered for mediclaim upto $200,000 i.e. Rs.15 lakh approximately. The complainant travelled to Costa Rica to pursue his studies, however, unfortunately he fell ill there and visited the hospital and the surgeon advised him surgery.  The complainant accordingly filed overseas travel insurance claim form and requested the OP to process his cashless medical insurance claim to the tune of Rs.$3800 and also sent all the required documents as required by the OP from time to time. However, the OP kept delaying the matter on one pretext or the other and asked the complainant to pay  directly and later submit the documents for reimbursement. Ultimately the complainant underwent surgery on 6.6.2019 and paid US $3800 i.e. Rs.2,75,000/- to the hospital and after returning to India requested the OP to reimburse the claim but to the utter shock of the complainant the OPs repudiated the claim of the complainant vide letter dated 29.11.2019 on the ground that the surgery performed on the complainant is not covered in the policy as the same attributed to HIV(AIDS), which is totally wrong. Alleging the aforesaid act of Opposite Parties deficiency in service and unfair trade practice on their part, this complaint has been filed.

2. The Opposite Party in its reply stated that the claim of the complainant was rightly repudiated under the terms and conditions of the policy as the same was not payable, as mentioned in the repudiation letter. It is averred that On receipt of the claim documents pertaining to the claim for which the complainant was admitted in the hospital on 17.05.2019 and on detailed scrutiny of documents, the OP found that the claim does not fall under the purview of the policy as the complainant was admitted for treatment of surgery for Anogenital (Venereal) Warts Secondary to Human Papilloma Virus (HPV). Thus, the claim stands repudiated as any expenses or other liability attributable to Venereal disease and/or any mutant derivative or variation thereof however, caused is not covered under the policy on Clause Standard Policy Exclusion Section 3. Thus, there is no deficiency on the part of the OP insurance company.  All other allegations made in the complaint has been  denied being wrong.
3. Rejoinder was filed and averments made in the consumer complaint were reiterated.
4. Contesting parties led evidence by way of affidavits and documents.
5. We have heard the learned counsel for the contesting parties and gone through the record of the case.
6. It is evident from Annexure C-2 that the complainant bought insurance policy Travel Prime Student Gold valid w.e.f. 23.8.2018 to 31.7.2019 which included  medical coverage  with cashless facility upto US $2,00,000.  When the complainant was in Costa Rica to pursue study, he  began to feel discomfort and pain in his anal region  in the month of May 2019 and accordingly visited  the concerned doctor who advised him to undergo surgery. Annexure C-3 is the copy of medical record of the hospital. Thereafter vide Annexure C-4 the complainant requested the OP to process/ approve his medical insurance  claim to the tune of US $3800 but despite repeated requests  the OP did not pay any heed and after prolonged follow up,  the OP refused cashless facility  and for this inactive approach of the OP the treatment of the complainant got delayed and ultimately the complainant had to pay from his own pocket US $3800 for the surgery  to the hospital on 6.6.2019
7.  As per the case of the complainant  the OP never responded to the calls and follow up of the complainant regarding his medical claim  but when the complainant issued legal notice the OP finally vide email Annexure A-33 dated 25.11.2019, rejected the insurance claim of the complainant without any relevant reason. The OP  vide Exhibit C-7 informed the complainant that his insurance claim has been repudiated on the reason that  HPV illness attributable to  HIV  is not covered under the policy.
8. Now first of all we have to consider the terms and conditions of the disputed policy  in question. Exclusion Clause 5 of the terms and conditions annexed as Annexure R-1  with the repudiation letter reproduced as under:-

“5. Any injury, illness, death, loss, expenses or other liability attributable to HIV (Human Immunodeficiency Virus) and/or any HIV related Miss including AIDS (Acquired Immune Deficiency Syndrome), venereal disease and/or any mutant derivative or variation thereof however caused.”   

 

 

9. Now as per the medical record and admitted fact of the OP the complainant had undergone surgery for  treating the disease of HPV and not of HIV. As per policy terms and conditions undoubtedly the patients with HIV related illness including AIDS,  are not covered  under the policy in question. As per medical literature annexed by the complainant, the definition of HPV  is as below:-

“HPV is the human papillomavirus. Evan Goldstein, M.D., an anal surgeon, sexual health and wellness expert, and founder of Bespoke Surgical, tells The Body that HPV is the most common sexually transmitted infection, with up to 14 million people infected in the U.S. each year. "Most people get exposed to HPV at some point in their lives but don't know it," he explains.HPV is spread by skin-to-skin contact and can affect the infected site differently, depending on the specific HPV strain and site of infection. "For example." Cerreta says, "HPV is responsible for the common warts that people can develop on their hands and feet, and it is also the cause of anogenital warts. Certain strains are considered high risk and can cause an increased risk in cervical, anal, and oropharyngeal cancer."

10. On the other hand as per the same medical literature the definition of HIV is as under:-

“HIV stands for human immunodeficiency virus. It is a lifelong infection that affects the CD4 cells (white blood cells). This weakens the immune system and the body's ability to fight infection. "If not treated, it can lead to acquired immunodeficiency syndrome (AIDS)," Khera explains. "It can make a person more vulnerable to other infections and diseases."

 

11. It is clear from the above medical literature that HIV is  spread  when bodily fluid that contains live HIV enters a person’s bloodstream. But this is not the case of the complainant as there is no mention of HPV specifically under the exclusion clause , therefore, we are of the opinion that the OP  for not providing cashless facility despite being the complainant duly covered under the policy in question illegally repudiated the genuine claim of the complainant under the garb of its terms and conditions. Hence, there is deficiency on the part of the OP. Pertinently the complainant is a student and was in foreign land and he went with complete care and caution by taking the instant medical policy but due to  the inactive attitude of the OP he had to undergo mental agony and physical harassment and thus, the  complaint is entitled to be compensated. Thus, the act of OP for non- providing cashless facility, delaying  the matter, finally repudiating the genuine claim of the complainant and forcing the complainant for present unnecessary litigation  proves deficiency in service and its indulgence in unfair trade practice.   
12. In view of the above discussion, the present consumer complaint succeeds and the same is accordingly allowed. OP is  directed as under:-

1. to pay Rs.2,75,000/- with interest @9% P.A. from the date of claim till onwards.
2. to pay Rs.20,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay Rs.10,000/- to the complainant as costs of litigation.

13.      This order be complied with by the OPs within 45 days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
14. Pending miscellaneous application(s), if any, also stands disposed off.
15.      Certified copies of this order be sent to the parties free of charge. The file be consigned.

			sd/- [Pawanjit Singh]
			President
			Sd/-
			[Surjeet Kaur] Member Sd/-
16/2/2024			[Suresh Kumar Sardana]
mp			Member