Chandigarh

DF-II

CC/102/2015

Sumesh Chander Khazanchi - Complainant(s)

Versus

M/s Future Generali India Insurance Company Ltd. - Opp.Party(s)

Sh.Ravinder Rana Adv.

29 Mar 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	102 of 2015
Date  of  Institution	:	26.02.2015
Date   of   Decision	:	29.03.2016

 

 

 

 

 

Sh. Sumesh Chander Khazanchi aged about 66 years s/o Sh. Madan Gopal Khazanchi r/o H. No.465, First floor, Sector 20A, Chandigarh.

                …..Complainant

Versus

 

1]  M/s Future Generali India Insurance Company Ltd. Policy Servicing office SCO No. 78-79, 2^nd floor & 3^rd floor, Sector 17-C, Chandigarh 160017  through its Branch Head.

2]  M/s Future Generali India Insurance Company Ltd. Corporate & registered office 6^th floor, Tower-3, Indiabulls finance centre, Senapati Bapat Marg, Elphinstone Road, Mumbai (Maharashtra) 400013 through its Managing Director.

3]  Europe Assistance Exclusion India Pvt. Ltd. C/o 301, ‘C’ Wing Business Square, Andheri Kurla Road, Chakala, Andheri (East) Mumbai 400 093 through its Managing Director.

 

….. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         SH.JASWINDER SINGH SIDHU       MEMBER

         MRS.PRITI MALHOTRA             MEMBER

 

 

For complainant(s)      :     Sh. Raj Karan, Adv.  

For OP No.1&2           :     Sh. Puneet Jain, Adv.

For OP No.3             :     Exparte.     

 

PER PRITI MALHOTRA, MEMBER

 

 

1.      As per the case, the complainant obtained an insurance policy called ‘Travel Surksha’ Individual vide Policy No. 2014-T0319506-FTIdated 9.4.2014 from Opposite Party No.1&2 for the period from 28.5.2014 to 23.11.2014. During the visit of the complainant to USA on 17.7.2014   he rushed to the Elliot Health System Hospital due to blood vomiting where he was diagnosed stomach ulcer (gastric ulcer). It is pleaded that the policy purchased by the complainant is cashless and the said hospital is duly empanelled hospital. It is alleged that the hospital raised bill of 10,239$ 880$ and 374$ and the complainant also raised separate claim of 50.55$ but the Opposite Parties arbitrarily and illegally repudiated the same vide letter dated 4.11.2014 on the ground that the complainant was using aspirin medicine due to which problem of ulcer developed.  It is further pleaded that the complainant requested the Opposite Parties to reconsider his claim but it again rejected the same on 11.11.2014. Alleging the said act of OPs as deficiency in service, this compliant has been filed.

 

2.     Notice of the complaint was sent to Opposite Parties seeking their version of the case. However, since nobody appeared on behalf of Opposite Party No. 3 despite service, therefore, it was proceeded ex-parte on 3.8.2015.

 

3.     Opposite Parties No.1& 2 have filed joint reply and stated that the present complaint is pre mature and not maintainable at this stage as the complainant had requested for grant of cashless facility for his treatment during his trip to USA and the answering Opposite Parties had only denied the cashless facility. It was also clarified that the denial of cashless facility does not imply denial of treatment and does not in any way prevent the present complainant from claiming reimbursement but till date no such reimbursement claim has been applied by the complainant nor any medical record ever been provided by him.  The Opposite Parties never refused to process the claim of the complainant.  It is further asserted that the complainant suppressed the material fact with regard to his health and did not disclose the complete facts of his previous medical history of arthritis, migrane and treatment with anti platelet agent aspirin in the proposal form. As such the complainant is not entitled to get any relief as the policy clearly provides that any claim arising or related to consequence of the pre-existing disease is excluded from the scope of policy cover. Pleading no deficiency in service and denying rest of the allegations, it is prayed that the complaint be dismissed.

 

4. The Complainant also filed rejoinder thereby reiterating the averments as made in complaint and controverting that of the Opposite Parties No.1&2 made in the reply.

 

5.     The contesting parties led evidence in support of their contentions.

 

6.     We have heard the ld. Counsel for the contesting parties and have also perused the record.

 

7.     It is well proved that the complainant purchased an insurance policy called ‘Travel Surksha Individual’ vide Policy No. 2014-T0319506-FTI dated 9.4.2014 from Opposite Party No.1&2 for the period from 28.5.2014 to 23.11.2014. It is not disputed  that the complainant while his visit to USA on 17.7.2014  (during the subsistence of the policy) was rushed to the Elliot Health System Hospital due to blood vomiting where  he was diagnosed as a case of stomach ulcer (gastric ulcer). It is also not disputed that the treatment for the same was undergone in the said hospital which is duly empanelled hospital.

 

         As per the complainant the hospital raised bills of 10,239$ 880$ and 374$ and the complainant also raised separate claim of 50.55$ but the Opposite Parties arbitrarily repudiated the same vide letter dated 4.11.2014 on the ground that the complainant was using aspirin medicine due to which problem of ulcer developed. It is further claimed that the complainant requested the Opposite Parties to reconsider his claim but it again rejected the same on 11.11.2014.

 

8.     On the contrary the counsel for the OPs No.1&2 contended that the present complaint is not maintainable for the reason that it is premature complaint as the complainant has not lodged any reimbursement claim with the OPs under the given policy and the letter dated 4.11.2014 as referred by the complainant as repudiation letter is in actual a denial for cashless facility only and the same has no effect of repudiation as claimed by the complainant. The OPs No.1&2 during the pendency of the complaint also filed an application for return of the complaint being pre-mature.

 

9.     The perusal of record before us reveals that the present complaint is premature as the complainant admittedly not lodged claim for reimbursement with OPs after taking the treatment from the hospital and the complainant was only denied for cashless treatment.

 

10.     The contents of letter of cashless denial dated 4.11.2014 (Annexure C-7) itself states that denial for authorization for cashless does not in any way prevent the complainant from seeking necessary medical attention or hospitalization claiming or reimbursement. As the complainant has failed to show any record pertaining to the lodging of the claim with Opposite Parties so its repudiation cannot be presumed before hand.

 

11.     In our opinion OPs should be given an opportunity to process the claim of the complainant within reasonable time which we assess as 30 days from the date of lodging of the claim by the complainant.

 

12.     It is observed that the OPs No.1&2 had took contradictory stand in their defence as on the one side they claimed that the present complaint is pre-mature and are ready to process the claim of the complainant; AT the same time the written statement filed by Opposite Party No.1&2 reveals that the OPs have unilaterally decided the fate of the forthcoming claim of the complainant and had expressed their intention to repudiate the claim of the complainant by leveling the allegations of suppression of material facts by the complainant and that too without giving an opportunity to the complainant to justify himself. This act of the OPs certainly is a glaring example of unfair trade practice. To curb this practice we hold that the complainant be compensated for the overt act shown by the Opposite Parties. Hence we are of the view that the complaint deserves to be partly allowed with a direction to the OPs to settle the claim of the complainant within 30 days from the date of formal lodging of the claim by the complainant, which shall be filed by the complainant alongwith requisite documents within 15 days from the date of passing of this order and the Opposite Party is also liable to pay compensation and litigation cost.   

        

13.     In view of the above, the complaint is partly allowed and the Opposite Parties are jointly & severally directed as under:-

        

a]  To settle the claim of the complainant within 30 days from the date of formal lodging of the claim by the complainant;

 

b]  To pay Rs.15,000/- as compensation to the complainant.

 

C]  To pay Rs.5,000/- towards litigation expenses.

 

14.     The Opposite Parties shall comply with the above said order within 30 days from the date of filing the claim by the complainant, failing which they shall be liable to pay interest on the compensation amount at (b) @18% p.a. from the date of this order till the claim is settled and the other directions are complied with.

 

15.     The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

29.3.2016                                                                                sd/-

                                                                                      

 (RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (JASWINDER SINGH SIDHU)

MEMBER

 

Sd/-

 

(PRITI MALHOTRA)

MEMBER