Haryana

Ambala

CC/301/2022

JATINDER KUMAR. - Complainant(s)

Versus

M/S TATA AIG GENERAL INSURANCE CO.LTD. - Opp.Party(s)

JASVEER CHAND,ADV

16 Aug 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	301 of 2022
Date of Institution	:	29.07.2022
Date of decision	:	16.08.2024

 Jatinder Kumar, aged 43 years, son of Sh. Vinod Kumar, resident of House No. 144, Luxmi Vihar, Village and P.O. Kanwla, Ambala City, Tehsil and District Ambala.

          ……. Complainant

                                                Versus

1. M/s Tata AIG General Insurance Co. Ltd., through its General Manager, Registered Office: Peninsula Business Park, Tower A, 15th Floor, GK Marg, Lower Parel, Mumbai-100013.
2. Tata AIG General Insurance Co. Ltd. (TAGIC Health Claims), 5th and 6th floor, Imperial Towers, H.No.7-1-6-617/A, GHMC No.- 615, 616, Ameerpet, Hydrabad-500016, Telangana.
3. Tata AIG General Insurance Co. Ltd. (Policy Serving Office), 3rd Floor, Shanti Complex, Opp. Civil Hospital, Jagadhri Road, Ambala Cantt., District Ambala, Haryana-133001.
4. AXIS Bank Ltd., (Policy Holder of Master Policy No. 0237868334), through its Branch Manager, Jandli Kanwla Main Road, Village and P.O. Kanwla, Ambala City, Tehsil and District Ambala.

                                                                                   ….…. Opposite Parties.

Before:        Smt. Neena Sandhu, President.

                      Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

 

Present:       Shri Vineet Kumar, Advocate, counsel for the complainant.

                     Shri Mohinder Bindal, Advocate, counsel for OPs No.1 to 3.

                     Shri Rahul Vig, Advocate, counsel for OP No.4.

Order:        Smt. Neena Sandhu, President.

                   Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

i) To pay Rs.1,66,425/- i.e. the amount spent by the complainant on his treatment for injury.

ii) To pay Rs.2,00,000/- to the complainant on account of mental agony, harassment and torture.

iii) To pay Rs.30,000/-, as conveyance charges.

iv) To pay Rs.22,000/- as litigation expenses.

v) To pay the aforesaid amount alongwith interest @ 18% per annum from the date of injury i.e 25.06.2021, till its realization.

                                                 Or

                   Grant any other relief which this Hon'ble Commission may deems fit. 

2.             Brief facts of the case are that the complainant has a Bank Account with OP No.4. OP No.4 the representatives of the insurance company allured him for taking health insurance policy.  It was declared by OP No.4 that it is the policy holder with Intermediary name AXIS Bank Ltd., Intermediary Code: CA0069 and Intermediary Contact No. 1800 209 2001. The OPs took the complainant in their confidence and convinced him that if he had the health insurance policy from them, it will meet all medical expenses in case of any eventuality. As such, the complainant purchased policy bearing no.0237868334/013661 valid from 31.08.2021 to 30.08.2022. The aforesaid policy covered the complainant, his wife Simran Kaur, minor daughter Arshmeet Kaur, minor son Akshdeep Singh. The nominee of the said policy was Smt. Paramjeet Kaur, mother of the complainant. The date of 1^st policy inception was 31.08.2019 which expired on 30.08.2020 and was renewed on the very day to take effect from 31.08.2020 and valid upto 30.08.2021 and for the 3^rd time, the said policy was again renewed with effect from 31.08.2021 and is valid upto 23:59 Hrs on 30.08.2022. The complainant had a fall from the stairs at his home at 08:00 A.M. on 25.06.2021, with injury to left knee. The complainant is a non smoker and non alcoholic. On sustenance of the said injury, to avail the medical benefits covered under the said health insurance policy, the complainant was admitted in ARV Orthopaedic Hospital, Sector 21-C, Chandigarh on 25.06.2021, itself, where he was medically examined for the injuries sustained by him. The complainant was advised for MRI of his left knee and was also prescribed medicine for 5 days. The complainant got the MRI of his left knee done and showed to the doctor Atul Malhotra of said ARV Orthopaedic Hospital, Sector 21-C, Chandigarh. A sum of Rs.5,500/- was spent  by the complainant on the said MRI test. Since the injury was of serious nature, the complainant was admitted in the said hospital on 02.07.2021 in the evening and was operated upon for his left knee injury. The complainant remained admitted in the said hospital from 2.07.2021 to 05.07.2021 and was discharged with prescribed medicines and instructions and advised to come back for follow up treatment after 5 days. All the expenses on the medical treatment i.e. hospital expenses and medicine expenses etc., were borne by the complainant which were to be disbursed by the OPs in accordance with the said health insurance policy. The UH id no. of the complainant in the said hospital was UD 202107025, IP No. IP-202107024. All the payments were made in cash. The complainant was asked to deposit advance payment of Rs. 25000/-, in the said hospital, which he did against a receipt no. 202107023 dated 02.07.2021. On discharge from the said hospital on 05.07.2021, the total hospital expenses of Rs.1,02,032/- were paid by the complainant. Apart from it the complainant paid Rs. 5,550/-, Rs. 450/-, Rs. 49,987/-, Rs. 3,697/-, Rs. 2,244/-, Rs. 1,639/-, Rs. 826/- totaling Rs. 64,393/-. In this manner, the complainant spent a total sum of Rs. 1,66,425/-, on his treatment. The complainant also spent more amounts on his treatment in shape of follow up treatment and other medicines, conveyance charges from his home to Chandigarh and back which is 110 KM for which he had to hire ambulance and sometimes private car to go to said hospital. All the necessary documents alongwith claim form was submitted by the complainant to the OPs.  However, vide letter dated 03.09.2021, the OPs repudiated the claim of the complainant on a very frivolous plea that the submitted claim is for the illness which have a specific two years waiting period as per the policy. By not reimbursing the claim amount, the OPs have committed deficiency in service. Hence, the present complaint.
3.           Upon notice, the OPs No.1 to 3 appeared and filed written version wherein they raised preliminary objections with regard to maintainability, not come with clean hands and suppressed the material facts and cause of action  etc. On merits, while admitting factual matrix of the case with regard to the fact that the complainant purchased the insurance policy in question from the OPs No.1 to 3, it has been stated that the claim of the complainant, was not payable because the complainant has tried to manipulate the facts for initiating this false and frivolous case. As a matter of fact a claim no. 2021082500292 was lodged by the complainant and related documents were also submitted by the complainant for the reimbursement of treatment expenses against the treatment in ARV Orthopaedic Hospital, Chandigarh from 02.07.2021 to 05.07.2021 for his treatment/procedure of ACL Reconstruction with partial medial menisectomy, which was pursued by the expert medical team of the complainant. From the enclosed treatment papers including MRI, it was observed that it was a case of degenerative changes involving the tibiofemoral joint with mildly reduced medial joint space with thinning of the articular cartlilages, Anterior cruciate ligament complete tear in its mild segment and retracted fibres.. Since the hospitalization of the complainant was for partial medial menisectomy which has arisen within two years of the inception of the present insurance policy, hence the claim amount was not payable being excluded for initial two years of the commencement of the first Insurance policy as mentioned in 3 (1) j of the policy. The complainant was apprised about the fate of his claim and the legal position vide letter dated 03.09.2021 but inspite of all these facts and even very much aware about the fate of his claim he has filed this false complaint by exploiting the process of law in order to put undue pressure on the answering respondent; hence the present complaint deserves dismissal. Moreover, it is clearly stated in the policy schedule that "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES, WARRANTIES, EXCLUSIONS ETC. ATTACHED." Rest of the averments of the complainant were denied by the OPs No.1 to 3 and prayed for dismissal of the present complaint with special costs.
4.           Upon notice, OP No.4 appeared and filed written version wherein it raised preliminary objections with regard to maintainability, bad for mis-joinder of unnecessary party and no locus standi etc. On merits, it has been stated that OP No.4 being bank has no concern whatsoever with issuance of the policy in question and also rejection of claim of the complainant for the treatment taken by him. The complainant has purchased the policy in question from OPs No.1 to 3 out of his own free will. Rest of the averments of the complainant were denied by the OP No.4  and prayed for dismissal of the present complaint with costs. 
5.           Learned counsel for the complainant tendered affidavit of complainant as Annexure CW1/A alongwith documents as Annexure C-1 to C-22 and closed the evidence on behalf of complainant. On the other hand, learned counsel for the OPs No.1 to 3 tendered affidavit of Amit Chawla, Authorized Signatory of OPs No.1 to 3-company Tata AIG General Insurance Company Ltd., Regional Office, Noida as Annexure OP-A, alongwith documents as Annexure OP-1 to OP-4 and closed the evidence on behalf of OPs No.1 to 3  Learned counsel for the OP No.4  tendered affidavit of Neeru, Operations Head/Officer of OP No.4-Axis Bank Jandli Kanwla Main Road, Tehsil and District Ambala as Annexure OP-W4/A and closed the evidence on behalf of OP No.4.
6.           We have heard the learned counsel for the parties and have also carefully gone through the case file.
7.           Learned counsel for the complainant submitted that since the complainant has taken medical cover under the policy in question therefore he was entitled to get the amount, which was spent by him on his treatment of injury caused as he fell down from stairs, yet, his genuine claim has been repudiated by the OPs No.1 to 3, which act amounts to deficiency in providing service. 
8.           On the contrary, the learned counsel for the OPs No.1 to 3 submitted that the treatment of complete tear of ligament i.e. ALL RECONSTRUCTION MEDIAL PARTIAL MENISECTOMY taken by the complainant, was  covered only after waiting period of 24 months, from the date of inception of the policy in question, as such, the claim of the complainant was rightly repudiated by the OPs No.1 to 3, strictly as per terms and conditions of the insurance policy, as he took treatment thereof, in the very first year of inception thereof.
9.           Learned counsel for OP No.4 submitted that OP No.4 being bank has no concern whatsoever with issuance of the policy in question and also rejection of claim of the complainant for the treatment taken by him. He further submitted that the complainant has purchased the policy in question from OPs No.1 to 3 out of his own free will.
10.           Admittedly, the policy in question was purchased by the complainant from the OPs No.1 to 3, which was valid for the period from 31.08.2020 to 30.08.2021. It is also not in dispute that the complainant was hospitalized in ARV Orthopaedic Hospital from 02.07.2021 to 05.07.2021 and underwent treatment for injury of complete tear of anterior cruciate ligament (ACL) in its mid segment with retracted fibres i.e. ALL RECONSTRUCTION MEDIAL PARTIAL MENISECTOMY.  This fact is clearly found mentioned in the MRI Report of the complainant, dated 26.06.2021, Annexure C-2. The claim of the complainant was rejected by the OPs No.1 to 3, on the ground that the said procedure/treatment, fell under waiting period of 24 months from the date of inception of the policy in question.  Under these circumstances, the question which falls for consideration is, as to whether, the claim of the complainant was rightly rejected by the insurance company or not. For coming to any conclusion, we need to refer relevant clause no.3 (1) (ii) (j) of the policy, Annexure OP-4, pertaining to the waiting period for some specified diseases/illness/procedures, as under:- 

“….3 (1) (ii) Exclusions with waiting periods- (ii) A waiting period of 24 months from the first policy commencement date will be applicable to the medical and surgical treatment of illness, disease or surgical procedure mentioned below, unless necessitated due to cancer:-

1. To (i) …………….

(j)  Ligament, Tendon or Miniscal tear (due to injury or otherwise) …”

11.           From the afore-extracted condition no. 3 (1) (ii) (j) of the policy, Annexure OP-4, it is evident that the aforesaid treatment for Ligament, Tendon or Miniscal tear (due to injury or otherwise) was covered after a waiting period of 24 months, as specified in the policy schedule/Certificate of Insurance. Since in the present case, the complainant took the first policy from the OPs valid for the period from 31.08.2019 to 30.08.2020 and thereafter renewed the policy for the period from 31.08.2020 to 30.08.2021. Complainant took treatment for injury of complete tear of anterior cruciate ligament in its mid segment with retracted fibres i.e. ALL RECONSTRUCTION MEDIAL PARTIAL MENISECTOMY, during the period 02.07.2021 to 05.07.2021 in the ARV Hospital therefore, the expenses incurred by the complainant for the said treatment was not payable being excluded for initial 24 months, and as such, his claim was rightly repudiated by the OPs No.1 to 3.  It is significant to mention here that the insurance policy between the insurer and the insured represents a contract between the parties and the insured cannot claim anything more than what is covered by the insurance policy. Our this view is supported by the ratio of law laid down by the Hon’ble Supreme Court of India in Oriental Insurance Co. Ltd Vs Sony Cherian (II 1999 CPJ 13 SC) wherein it was held that- ― “..The insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy. That being so, the insured has also to act strictly in accordance with the statutory limitations or terms of the policy expressly set out therein…”.
12.           In view of peculiar facts and circumstances of this case, it is held that because the complainant has failed to prove his case, therefore, no relief can be given to him. Resultantly, this complaint stands dismissed with no order as to cost. Certified copies of the order be sent to the parties concerned as per rules.  File be annexed and consigned to the record room.

  Announced:- 16.08.2024

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President