DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/180/2021
Date of Institution: 23.08.2021
Date of Decision: 02.09.2024
Manpreet Singh son of S. Gurmail Singh Uppal, Patti Shaina, Barnala, Punjab.
…Complainant
Versus
1. M/s Bajaj Allianz General Insurance Co. Ltd. 2nd Floor, Satnam Complex, BMC Chowk, GT Road, Jalandhar through its Managing Director Mr. Tapan Singhel.
2. Mr. Tapan Singhel- Managing Director M/s Bajaj Allianz General Insurance Co. Ltd. 2nd Floor, Satnam Complex, BMC Chowk, GT Road, Jalandhar.
3. Mr. K.V. Dipu- Authorized Signatory M/s Bajaj Allianz General Insurance Co. Ltd. 2nd Floor, Satnam Complex, BMC Chowk, GT Road, Jalandhar.
…Opposite Parties
Complaint under Section 35 of the Consumer Protection Act, 2019
Present: Sh. S.D. Bansal Adv counsel for complainant.
Sh. Bhushan Kumar Garg Adv counsel for opposite parties.
Quorum.-
1. Sh. Ashish Kumar Grover : President
2. Smt. Urmila Kumari: Member
3. Sh. Navdeep Kumar Garg : Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant Manpreet Singh filed the present complaint under Section 35 of the Consumer Protection Act 2019 against M/s Bajaj Allianz General Insurance Co. Ltd. 2nd Floor, Satnam Complex, BMC Chowk, GT Road, Jalandhar through its Managing Director Mr. Tapan Singhel & others (in short the opposite parties).
2. The facts leading to the present complaint as stated by the complainant are that the complainant got his medical insurance done from the opposite parties along with the complainant the family members of the complainant was also covered under medical insurance policy. It is alleged that the opposite parties issued Health Guard (Floater) Policy Schedule on 19 July, 2019 and the period of policy was 25.06.2019 00:01 hrs to 24 June, 2020 Midnight and for the medical insurance the complainant paid a sum of Rs.10,975/- and the sum insured was Rs. 3,00,000/- (Rupees Three lacs) per member and the payment of Rs.10,975/- was duly received by opposite parties and the same reflects on page no. 3 of the policy book issued by opposite parties. It is alleged that before issuing insurance policy the opposite parties got the insurance forms signed from the complainant on 11.06.2019 and did not disclose any restrictions of coverage or special terms and conditions in the medical insurance policy and the policy was cashless policy and the policy book was delivered to the address of the complainant by post. After receiving of the policy book the complainant kept the same in his safe custody and did not read any terms and conditions of the policy as the complainant blindly trusted opposite parties opposite while getting medical insurance done on 11.06.2019. It is further alleged that the policy was done through agent of the opposite parties i.e. Capital Small Finance Bank Ltd. It is further alleged that on 16.02.2020 the complainant was admitted at Dayanand Medical college & Hospital at Ludhiana due to severe Gastro problem as the medical insurance done by the complainant cashless, as such the complainant informed the hospital staff that he is covered under medical insurance with opposite parties and the officials of the hospital got filled the request form for cashless hospitalization for medical insurance of the complainant and sent the same to the opposite parties. The complainant was shocked and surprised to know that the opposite parties have rejected the cashless claim of the complainant and clearly told the complainant that the medical problem for which the complainant is admitted in the hospital is not covered under insurance policy done by the opposite parties. The complainant was shocked to know that in the policy book in Customer Information Sheet in Clause No. 4 (2) it is mentioned that "We will also not pay for claims arising out of or howsoever connected to the following for the first 24 months of Health Guard Policy and in sub-clause (1) it is mentioned "Any types of Gastric or duodenal ulcers". It is alleged that due to the wrong acts and deeds of the opposite parties, the complainant was forced to pay a sum of Rs. 59,542/- for hospitalization and other charges to the hospital as the complainant remained admitted in the hospital from 16/02/2020 to 24/02/2020. The complainant also spent a sum of Rs. 23,317/- on medicines. The complainant was intentionally burdened by opposite parties to pay all medical bills totaling to Rs. 82,859/-. It is further alleged that if the opposite parties had disclosed all terms and conditions of the medical insurance then the complainant must not have got the insurance policy done which amounts to deficiency in service and unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.-
1) The opposite parties be directed to refund the amount of Rs. 10,075/- i.e. premium paid for medical insurance; Rs. 82,859/- i.e. medical expenses suffered by the complainant.
2) To pay Rs. 2,00,000/- on account of compensation for mental agony and harassment and Rs. 5,500/- as litigation expenses.
3. Upon notice of this complaint, opposite parties appeared and filed written reply by taking preliminary objections on the grounds that the present complaint filed by the complainant is gross abuse of process of law, and is absolutely false, frivolous and vexatious thereby making it illegal and not tenable thus as the said complaint is filed without any cause of action, the same is liable to be dismissed in limini. It is submitted that complainant has filed the captioned complaint with evil intention of harassing opposite parties as the facts put forth by the complainant are enormously misleading. It is further submitted that on considering and analyzing these documents, replying opposite parties found that insured was hospitalized with Diagnosis- Acute Pancreatitis with alcoholic etiology. Discharge Summary also mentions history off Pancreatitis 4 years back and insured is chronic alcoholic and the treatment of alcoholism, drug or substance abuse and its consequences are excluded from the purview of policy, therefore the claim of the complainant is not payable. Moreover the complainant has concealed his pre existing disease from the opposite parties while obtaining the health policy in hand. The complainant has not disclosed about the said disease in the proposal form submitted by complainant to opposite parties. As per policy, benefits will not be available for Any Pre-existing condition, ailment or injury, until 48 months of continuous coverage have elapsed, after the date of inception of the first Family floater health guard policy. It is further alleged that policy does not extend coverages for the said ailment and its complications as per exclusion clause No. 13 of the policy.
4. On merits, it is submitted that the complainant Manpreet Singh obtained Health Guard (Floater) Policy from answering opposite parties having No. OG-20-1202-8430-00000590 valid for the period from 25-JUN-2019 to 24-JUN-2020 vide which complainant Manpreet Singh had opted to get covered himself and his family members for Inpatient Hospitalization Treatment expenses upto Rs. 3,00,000/- and the total premium of Rs. 10,975/- has been paid by the complainant to answering opposite parties under this policy. This policy has been issued on the information provided to answering opposite parties and policy is not valid if the information provided is incorrect and this policy also does not cover any pre-existing medical condition /injury/illness/deformity and complications arising from them that are declared or undeclared. The policy coverage are as per the policy terms and conditions mentioned therein. It is submitted that the insured/complainant had not intimated about his admission and have not lodged any claim with the opposite parties. However, during the pendency of the present complaint the counsel for the complainant submitted some medical record of the complainant to the opposite parties. All other allegations are denied and prayed for the dismissal of complaint.
5. Ld. Counsel for the complainant has suffered the statement on 30.3.2022 that I do not want to file any rejoinder on behalf of complainant.
6. The complainant tendered into evidence, affidavit of Manpreet Singh as Ex.C-1, copies of medical bills Ex.C-2 to Ex.C-58, copy of policy Ex.C-59, copy of cashless form Ex.C-60, copy of health card Ex.C-61, copy of information-cum-undertaking for cashless medical claim patients Ex.C-62 and closed the evidence.
7. The opposite parties tendered into evidence affidavit of Saurav Khullar as Ex.OPs-1, copy of proposal form/declaration as Ex.Ops-2 (containing 2 pages), copy of discharge summary owth reports as Ex.OPs-3 (containing 9 pages), copy of policy as Ex.OPs-4 (containing 7 pages), copy of terms and conditions as Ex.OPs-5 (containing 16 pages) and close the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on the file.
9. It is admitted case of the opposite parties that the complainant Manpreet Singh obtained Health Guard (Floater) Policy from opposite parties having No. OG-20-1202-8430-00000590 valid for the period from 25-JUN-2019 to 24-JUN-2020 vide which complainant Manpreet Singh had opted to get covered himself and his family members for Inpatient Hospitalization Treatment expenses upto Rs. 3,00,000/- and the total premium of Rs. 10,975/- has been paid by the complainant to opposite parties under this policy (as per Ex.C-59 & Ex.O.Ps-4).
10. Ld. Counsel for the complainant argued that before issuing insurance policy the opposite parties got the insurance forms signed from the complainant on 11.06.2019 and did not disclose any restrictions of coverage or special terms and conditions in the medical insurance policy and the policy was cashless policy and the policy book was delivered to the address of the complainant by post. It is further argued that the policy was done through agent of the opposite parties i.e. Capital Small Finance Bank Ltd. It is further argued that on 16.02.2020 the complainant was admitted at Dayanand Medical College & Hospital at Ludhiana due to severe Gastro problem as the medical insurance done by the complainant cashless, as such the complainant informed the hospital staff that he is covered under medical insurance with opposite parties and the officials of the hospital got filled the request form for cashless hospitalization for medical insurance of the complainant and sent the same to the opposite parties. It is further argued that the complainant was shocked and surprised to know that the opposite parties have rejected the cashless claim of the complainant and clearly told the complainant that the medical problem for which the complainant is admitted in the hospital is not covered under insurance policy done by the opposite parties. It is further argued that due to the wrong acts of the opposite parties the complainant was forced to pay a sum of Rs. 59,542/- for hospitalization and other charges to the hospital as the complainant remained admitted in the hospital from 16/02/2020 to 24/02/2020 and the complainant also spent a sum of Rs. 23,317/- on medicines. It is further argued that the complainant was intentionally burdened by opposite parties to pay all medical bills totaling to Rs. 82,859/-.
11. On the other hand, Ld. Counsel for the opposite parties argued that on considering and analyzing the documents opposite parties found that insured was hospitalized with Diagnosis- Acute Pancreatitis with alcoholic etiology and Discharge Summary also mentions history off Pancreatitis 4 years back and insured is chronic alcoholic and the treatment of alcoholism, drug or substance abuse and its consequences are excluded from the purview of policy, therefore the claim of the complainant is not payable. It is further argued that the complainant has concealed his pre-existing disease from the opposite parties while obtaining the health policy in hand and the complainant has not disclosed about the said disease in the proposal form submitted by complainant to opposite parties. It is further argued that as per policy benefits will not be available for Any Pre-existing condition, ailment or injury, until 48 months of continuous coverage have elapsed, after the date of inception of the first Family floater health guard policy. It is further alleged that policy does not extend coverages for the said ailment and its complications as per exclusion clause No. 13 of the policy. It is further argued that this policy has been issued on the information provided to opposite parties and policy is not valid if the information provided is incorrect and this policy also does not cover any pre-existing medical condition /injury/illness/deformity and complications arising from them that are declared or undeclared.
12. In the present case the specific plea of the opposite parties (insurance company) is that on considering and analyzing the documents opposite parties found that insured was hospitalized with Diagnosis- Acute Pancreatitis with alcoholic etiology and Discharge Summary also mentions history off Pancreatitis 4 years back and insured is chronic alcoholic and the treatment of alcoholism, drug or substance abuse and its consequences are excluded from the purview of policy, therefore the claim of the complainant is not payable.
13. We have carefully gone through the entire facts and evidence produced by the parties. It is admitted fact that the complainant has purchased the above said mediclaim insurance policy from the opposite parties i.e. Bajaj Allianz General Insurance Company Limited. We have gone through the proposal form Ex.O.Ps-2 placed on record by the opposite parties which is to be related with information/investigation of any health complaint to the person insured the tick is mark “No”. But the opposite parties have failed to place on record any evidence to prove the fact that they have conducted any medical examination/investigation of the insured person at the time of filling the proposal form or at the time of issuing the insurance policy. It was in the hands of insurance company to see and not to issue the policy where person is not entitled to claim on account of treatment of Pre-existing disease. Therefore, we are of the view that at this stage the opposite parties cannot be escaped from their liabilities by raising these types of unreasonable and unjustified grounds. The learned counsel for the complainant also relied upon the judgment of the Hon'ble Punjab and Haryana High Court (DB) 2012 (1) RCR (Civil)-901 in which the Hon'ble High Court held that “Claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the policy. Single judge allowed the claim on the ground that it was for Insurance Company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. No interference called for in the order of Single Judge. Held the pre-existing condition existed in the year 2002 which was five years prior to acquiring Insurance Policy. Claim cannot be denied.
14. Ld. Counsel for the complainant further argued that the terms and conditions of the policy were not supplied to the complainant alongwith policy. On the other hand, the opposite parties have failed to place on record any cogent evidence to prove that they have supplied the terms and conditions to the complainant alongwith policy. We have also carefully gone through the insurance policy Ex.C-59 from which it established that the policy sent by the opposite parties is of only 1 page (printed from both sides) and the terms and conditions of the policy are not the part of the said insurance policy. Moreover, the opposite parties have also placed on record the copy of insurance policy Ex.O.Ps-4 which are containing 7 pages and the terms and conditions of the policy are not the part of the said insurance policy. Therefore, the terms and conditions on which the opposite parties relied upon are not part of the contract. The Hon'ble Supreme Court of India titled Modern Insulators Limited Versus Oriental Insurance Company Limited reported in 2000(1) CPC-596 in which Hon'ble Supreme Court held that “As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclose to the appellant, respondent cannot claim the benefit of the said exclusion clause.” The Hon’ble Supreme Court of India (2019) 6 SCC 212 in case titled Bharat Watch Company Through its Partner Vs National Insurance Company Limited held that “Conditions of exclusion under policy document not handed over to insured by insurer and in absence of insured being made aware of terms of exclusion, held, it is not open to insurer to rely upon exclusionary clauses”.
15. The opposite parties have failed to produce any cogent evidence to prove the pre-existing disease. The opposite parties can easily procure the affidavit of doctor who wrote the history in the Hospital. The Hon’ble Chandigarh State Consumer Disputes Redressal Commission, Union Territory in Complaint Case No. 234 of 2017 decided on 22.3.2018 in case titled Manish Goyal Vs Max Bupa Health Insurance Company Limited has held that “opposite parties failed to produce on record any document to show that the insured was still suffering from the said disease. Opposite parties further failed to get information from the hospital, as to whether the doctor who recorded the past history recorded such medical prescriptions were consulted. It was the duty of the opposite parties to prove who supplied this information to the hospital and also to conduct a thorough enquiry about the previous treatment of alleged epilepsy or tuberculosis obtained by complainant. However, no such enquiry was conducted. Even the affidavit of the doctor who recorded the said history had not been produced on record. So, merely on basis of past history mentioned in the Patient Admission Record, prepared by Hospital, it could not be held that insured was suffering from epilepsy or tuberculosis at the time of taking the policy and she had intentionally concealed the said material fact. Complaint partly allowed”.
16. From the above discussion, it is proved that the claim of the complainant/insured was repudiated by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties.
17. However, on the perusal of copies of Inpatient Final Bill/Detail Bill and Pharmacy Bills (i.e. Ex.C-2/Ex.C-3, Ex.C-5 to Ex.C-50) which shows that the total amount of Rs. 81,761/- has been spent on the treatment of complainant in the above said hospital. But in the present complaint the complainant has claimed an amount of Rs. 82,859/-. So, we are of the view that the complainant is entitled for the amount of Rs. 81,761/-.
18. In view of the above discussion, the present complaint is partly allowed and the opposite parties are directed to pay an amount of Rs. 81,761/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties are further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
2nd Day of September, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
(Navdeep Kumar Garg)
Member
