BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.433 of 2016
Date of Instt. 14.10.2016
Date of Decision: 03.01.2018
Arvinder Singh aged about 63 years S/o Sh. Mohan Singh R/o 716, Model Town, Jalandhar
..........Complainant
Versus
1. M/s National Insurance Co. Ltd., Head Office:3, Middleton Street, Kolkatta, West Bengal, PIN 700071, Through its Chairman/Mg.Director.
M/s National Insurance Co. Ltd., Divisional Office I, BMC Chowk, G.T. Road, Jalandhar Through its Senior Divisional Manager.
3. M/s National Insurance Co. Ltd., Divisional Office I, Branch Office 93, District Shopping Complex, First Floor, Near Passport Office, Ranjit Avenue, Amritsar, Punjab Through its Senior Branch Manager.
..….…Opposite parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Harvimal Dogra (Member)
Present: Sh. Rohan Bhalla, Adv Counsel for the Complainant.
Sh. Darshan Singh, Adv Counsel for the OP No.1 to 3.
Order
Karnail Singh (President)
1. This complaint is filed by the complainant, wherein alleged that he purchased one Medi claim Policy bearing Policy Note No.401200/48/16/8500000205 dated 10.05.2016 valid from 11.05.2016 to 10.05.2017 from the OPs and the said policy include the coverage of all kinds of risk of medical expenses of medical treatment including major surgeries of the complainant and his wife namely Jatinder Kaur as mentioned in the policy. The yearly premium of the policy was Rs.23,578/- and the complainant has paid the said premium to the OPs and the said policy is to cover the risk of medical treatment upto the tune of Rs.2,50,000/- of each insured member. The complainant has purchased this policy on 07.05.2004 and thereafter, the complainant is regularly getting the renewal of the same from the OPs without any default. The complainant is regularly paying the annual premium and getting the renewal of the same. At the time of purchase of the policy, the concerned agent assured the complainant that during the validity of the policy, if the complainant will suffer any kind of medical problem including any kind of surgery, the OPs are liable to pay all the hospital expenses, medicine expenses as well as other connected expenses to the complainant. Moreover, at the time of purchase of the policy, medical check-up as well as blood test was done by the empaneled doctor of the OP and after the complete check up, the OP issued the policy in question to the complainant. That during the validity of the said policy, the complainant was having problem of breathing and doziness. Due to that reason, the complainant was admitted in Doaba Hospital, Jalandhar on 17.05.2016, where he was provided medical treatment by hospital authority and the said doctors referred the complainant to DMC Hospital, Ludhiana, where he was admitted on 19.05.2016 and diagnosed as Sleep Apinia and the complainant was given treatment by the hospital authorities and the complainant was put on CPAP. The complainant was discharged from the hospital on 25.05.2016. The complainant has paid a sum of Rs.89,955/- to the DMC Hospital, Jalandhar. At the time of discharge, the complainant was advised to purchase a respiratory machine namely BPAP and the complainant purchased the same from M/s Nevikare Technomed Solutions, Ludhiana vide invoice dated 24.05.2016 for Rs.73,000/- and also purchased a pulse meter vide invoice dated 21.05.2016 for Rs.2138/-. These machines are the part of medical treatment and without these machines the treatment of the complainant cannot be completed.
2. That thereafter, the complainant contacted the agent of the OPs and supplied all the medical bills to the said agent and who got the signatures of the complainant on one claim form, which was blank at that time. The complainant asked the said agent to complete the said form and explained all the medical expenses and the said agent assured the complainant that he will do the same at his own level. Inspite of completion of all the necessary formalities, the OPs repudiated the claim of the complainant, vide letter dated 05.09.2016, by which the OPs declined the claim of the complainant on the ground “Convalescence, general debility, rest cure, congenital external disease or defects or anomalies, sterility, venereal disease, intentional self injury and use of intoxicating drugs/alcohol under Clause 4.8. As per the OP, the claim of the complainant is not payable under Clause 4.8 of the policy. In fact, the clause 4.8 is shown as refractive error and that clause is not applicable in the present case. Moreover, the policy was firstly purchased in the year 2004 and thereafter, the said policy was regularly being renewed by the OP and even after the passage of 12 years now the excuse under which the present claim is being repudiated is totally false and frivolous, whereby the complainant is suffering from mental tension, harassment and agony due to non-payment of claim amount, which is clear cut deficiency in service on the part of the OPs and as such, the present complaint filed with the prayer that the complaint of the complainant may be accepted and OPs may kindly be directed to pay the amount of claim i.e. Rs.1,66,000/- and further be directed to pay a compensation to the tune of Rs.1,00,000/- for mental tension and harassment, suffered by the complainant and further OPs be directed to pay litigation expenses of Rs.22,000/-.
3. Notice of the complaint was given to the OPs and accordingly, all the OPs appeared through their counsel and filed their joint written reply and contested the complaint by taking preliminary objections that the complainant has suppressed material facts and as such, the complaint of the complainant is not maintainable and even the complaint has not been filed in a proper form and therefore, the complaint is not maintainable and is liable to be dismissed and further averred that the complainant is estopped by his own act and conduct from filing the present complaint and further submitted that there is no deficiency in service on the part of the OP and even the complaint of the complainant is bad for non-joinder of necessary parties i.e. the hospitals, where from the complainant got his treatment. On merits, it is admitted that the complainant purchased medi-claim policy valid from 11.05.2016 to 10.05.2017 and also admitted that the complainant remained admitted in Doaba Hospital, Jalandhar as well as DMC Hospital, Ludhiana and diagnose as Sleep Apinia and discharged from the hospital on 25.05.2016 and further submitted that the claim of the complainant is legally repudiated by the OP because as per the discharge summary, the complainant was having some medical problems prior to purchase of the policy, which has not been disclosed by the complainant at the time of filling the proposal form and as such, the claim of the complainant is repudiated under Clause 4.8 and the other averments as made in the complaint are categorically denied and lastly prayed that the complaint of the complainant is without merits and the same may be dismissed.
4. In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA alongwith some documents i.e. Original certificate issued by DMC Hospital as Ex.C-1, Insurance Policy Ex.C-2, Ex.C-3 to Ex.C-21 Copies of Cover Notes of the insurance, Ex.C-22 Medi Claim Policy, Ex.C-23 Discharge Summary, Ex.C-24 to Ex.C-65 Copies of Medicine and Medical Bills, Ex.C-66 Copy of Repudiation Letter and then closed the evidence.
5. Similarly, counsel for the OP No.1 to 3 tendered into evidence affidavit Ex.OP/A alongwith some documents Ex.OP/1 to Ex.OP/4 and closed the evidence.
6. We have heard the learned counsel for the respective parties and also considered the written arguments, submitted by learned counsel for the OP No.1 to 3 and also gone through the case file very minutely.
7. From the submission put forth by both the counsel for the parties, itself shows that the complainant has admittedly purchased medi claim policy valid for 11.05.2016 to 10.05.2017 and it is also admitted that the complainant has initially purchased the said policy on 07.05.2004 and thereafter, the complainant is regularly getting the renewal of the same from the OP and it is also not disputed by the OP that the complainant got treatment from Doaba Hospital, Jalandhar as well as from DMC Hospital, Ludhiana and where he remained admitted from 19.05.2016 to 25.05.2016. The OP has repudiated the claim of the complainant, vide letter Ex.C-66 under Clause 4.8 on the ground that the complainant was having serious disease at the time of inception of the insurance policy, but the said disease has not been disclosed by the complainant at the time of inception of the policy and whenever the insured concealed any material facts, then he is not entitled for the insurance claim and accordingly, the learned counsel for the OP submitted that the claim of the complainant is rightly repudiated and in support of the above submission, the learned counsel for the OP made a reliance upon a judgment of the Hon'ble National Commission, cited in 2016 CPJ 480 NC, title “R. Venkata Krishna Vs. United India Insurance Co. Ltd and Others” and on the same point, he further made a reliance upon a pronouncement of Rajasthan State Commission, cited in 2016 CPJ 57 Rajasthan, title “Kailash Chand Jain Vs. National Insurance Co. Ltd and Others” and further referred a pronouncement of the Hon'ble Supreme Court, cited in 2009(9) JT 82, title “Satwant Kaur Sandhu Vs. New India Assurance Company Ltd” and in view of the above submission, the learned counsel for the OP submitted that the complaint of the complainant is without merit and the same may be dismissed.
8. We have gone through the entire documents produced on the file by the complainant as well as OP and find that the term and condition as alleged by the OP i.e. Clause 4.8 itself explanatory to decline the claim of the complainant because the complainant has concealed the material facts and the said term and condition has been brought on the file by the OP as Ex.OP/2, wherein the reference of the Clause 4.8 is very well mentioned, but we find that the OP/Insurance Company is under liability to establish on the file that the said term and condition as placed on the file Ex.OP/2, had been supplied to the complainant at the time of purchase of the policy, but no such type of evidence has been brought on the file by the OP, if so then, how the complainant is bound by the said term and condition, which were never supplied to the complainant nor ever brought to the notice of the complainant since the first inception of the policy in the year 2004 till the filing of the medical claim in the year 2016. The OPs are blindly renewing the insurance policy of the complainant on every year just for getting a premium of each year and they never bother to get a medical check of the complainant and moreover, the complainant himself alleged in the complaint in para No.1 that at the time of purchase of the policy, medical check up as well as blood test was done by the impaneled doctor of the OP, but this factum of the complaint has not been categorically denied by the OP nor rebutted. So, it presume that a medical check up of the complainant was done by the OP at the time of inception of the policy, if so then, the question for concealment of any previous illness does not arise.
9. Further more, it is bounded duty of the OP to produce on the file the proposal form just for checking the date on each it was filled whether it was filled in the year 2004 or in the year 2016, when the last insurance policy was purchased by the complainant, but for the best known reason, the OP has not brought on the file any proposal form, where from this Forum can ascertain whether the complainant has virtually concealed any material fact from the insurance company or not that can be adjudged only after going through the proposal form, which is apparently not brought on the file by the OP and this factor also goes against the OP, showing that the OP has illegally and arbitrarily rejected the claim of the complainant.
10. Further more, the learned counsel for the OP also alleged that the instrument, respiratory machine namely BPAP and a pulse meter having total value of Rs.89,955/-, but the said respiratory machine namely BPAP and Pulse Meter are not part and parcel of the medicine and also not covered under the treatment. Therefore, the complainant is not entitled for the said amount. We have considered this aspect of the OP and find that the doctor has recommended the complainant to get treatment through respiratory machine as well as pulse meter. So, how we can say that these instruments are not part of the treatment of the complainant rather according to our opinion, these instruments are part of the treatment of the complainant. So, with these observations, we are of the considered opinion that the ruling referred by the learned counsel for the OPs are not applicable in the present case being reason the facts of the instant case are not identical to the facts of the said judgments of the National Commission, Apex Court and Rajasthan Forum and therefore, we reach to the conclusion that the complainant has able to establish his case and accordingly, we find that the complainant is entitled for the claim and thus, the complaint of the complainant is partly accepted and OPs are directed to pay the claim amount of Rs.1,66,000/- to the complainant with interest @ 9% per annum from the date of repudiation of the claim i.e. 05.09.2016, till realization and further OPs are directed to pay compensation to the complainant to the tune of Rs.20,000/- for mental tension and harassment and also directed to pay litigation expenses of Rs.7000/-. The entire compliance be made within one month from the date of receipt of the copy of order. The complaint could not be decided within stipulated time frame due to rush of work.
11. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Harvimal Dogra Karnail Singh
03.01.2018 Member President
