District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 258/2021.
Date of Institution:20.04.2021.
Date of Order: 07.02.2023.
Rohan aged about 21 years Son of Shri Rajender Kumar R/o House No. 173, Jakhar Mohalla, Mujessar, Faridabad Adhar No. 7583 6912b 7278, Mobile No. 8800976687.
…….Complainant……..
Versus
M/s. Universal Sompo General Insurance Company Limited, Branch Office SCF-2,Ist floor, Sector-35, Ashoka Enclave-1, Faridabad (Haryana) through its Principal Officer/Authorized Signatory.
…Opposite party……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. N.S.Tanwar, counsel for the complainant.
Sh. Nitish Kumar, counsel for opposite party
ORDER:
The facts in brief of the complaint are that the complainant alongwith his father Shri Rajender Kumar and mother namely Smt. Darshan had taken the mediclaim policy No. 2825/57621194/01/00 which was valid from 19.09.2018 to midnight of 18.09.2019 for the total insured mediclaim benefit of Rs.8,00,000/-. The son was athletics of weight lifting and was taking training since January, 2018 from Mission Olympic Academy near Kheri Pul, Faridabad. During his practice on 27.08.2018 at about 7.00p.m. his right knee of Mr. Rohan Jakhar was twisted and he got injured. The complainant’s father taken the complainant to Royal Multispecialty Hospital, Faridabad on 28.08.2018 and Dr. Sunl Dhingra of the said hospital conducted MRI of right knee on 30.08.2018 and medicines of 10 days were given. On 15.11.2018 the complainant was admitted in Vardaan Hospital, 3-E/1, NIT, Faridabad and the right leg of the complainant was operated there by the Medical Officer and Inpatient bill No. 298 dated 17.11.2018 for Rs.44,916/- was raised by the medical officer. The intimation regarding the treatment and operation was given to the opposite party but the opposite party refused to provide cashless facility to the complainant. This fact was disclosed to the complainant by the said hospital and the opposite party also wrote in denial cashless facility letter to tender/sent all treatment records to the opposite party. The complainant was discharged from Vardaan Hospital 3-E/1, NIT, Faridabad on 17.11.2018. the complainant paid bill amount of Rs.44,916/- to the said hospital. The opposite parties refused to make the payment of the treatment expenses to the complainant so the complainant hardly arranged the said amount from his friends and relatives and thereafter the complainant was discharged from the hospital. After discharge from the hospital the complainant sent all the original documents of treatment i.e. discharge summary, medicine bills, policy papers alongwith the bank account detail and I.D.card as required by the opposite party to the opposite party through their agent and the opposite party allotted the claim No, 156284 dated 21.11.2018. Thereafter the complainant visited to the office of the opposite party from time to time but the opposite party avoided to reimburse the amount of Rs.44,916/- & Rs.10,000/- approximately spent on medicines to the complainant. Thereafter the complainant requested to the opposite party thereby requesting to make the payment of treatment charges of Rs.44,916/- and also requested the opposite party to reimburse the claim of the complainant to the tune of Rs.44,916/- but the opposite party did not give any satisfactory reply to the complainant. Despite going through all the document son record, facts and circumstances of the case, the opposite party sent the letter dated 22.12.2018 to the complainant according to which the opposite party remarked “Adventure sports/professional sports, defence operation we do not cover treatment of an injury sustained whistly you were paid or founded by sponsorship or grand unless, you received travel post only, involved in Naval, Military, Air Force operations or any adventure spots. While the complainant had never taken any claim prior to this injury. At the time of taking the policy the opposite party had not disclosed this fact to the complainant and it was the hidden condition of the opposite party. The complainant sent legal notice dated 15.05.2019 to the opposite party but all in vain. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) make the payment of the claimed amount of Rs.44,916/- plus Rs.20,000/- approximately spent on medicines to the complainant alongwith interest @ 24$ p.a. since the date of the complainant form the date of due to the date of realization of the amount.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that that the insurance policy mentioned about treatment of first attempt of any disease, however, the complainant suffered a sports injury while training for weight lifting and the same was excluded as per Section 7 of the Term policy and the same was provided to the complainant at the time of them taking policy. It was submitted that cashless facility as not provided to the complainant because Vardaan Hospital, NIT, Faridabad was not on the Panel list of opposite party. It was admitted to the extent that the complainant sent his claim to the opposite party and claim NO. 156284 dated 21.11.2018 was allotted to the complainant. It was submitted that the opposite party had properly disposed off the claim of the complainant in time and had sent a repudiation letter dated 22.12.2018 to the complainant as the complainant suffered injury while training for weight lifting and the same was excluded from the policy. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party– Universal Sompo General Insurance Company Ltd. with the prayer to: a) make the payment of the claimed amount of Rs.44,916/- plus Rs.20,000/- approximately spent on medicines to the complainant alongwith interest @ 24$ p.a. since the date of the complainant form the date of due to the date of realization of the amount. b) pay Rs. 50,000/- as compensation for causing mental agony and harassment . c) pay Rs. 11,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Shri Rohan, Ex.C-1 – insurance policy, Ex.C2 – History Sheet, Ex.C-3 – Discharge Ticket, Ex.C-3 – Inpatient Bill, Ex.C-4 – Receipt, Ex.C-5 to 9 – Bill/cash Memo,
On the other hand counsel for the opposite party strongly agitated and
opposed. As per the evidence of the opposite party Ex.RW1/A - Prashant V.Shukla, S/o Shri Vinod Shukla, Office at Mumbai, Ex.RW1/1 – Claim repudiation letter.
6. In this case, the complainant alongwith his father Shri Rajender Kumar and mother namely Smt. Darshan had taken the mediclaim policy No. 2825/57621194/01/00 which was valid from 19.09.2018 to midnight of 18.09.2019 for the total insured mediclaim benefit of Rs.8,00,000/- vide Ex.CW1/A. The complainant was athletics of weight lifting and is taking training since January, 2018 from Mission Olympic Academy near Kheri Pul, Faridabad. During his practice on 27.08.2018 at about 7.00p.m. the right knee of the complainant was twisted and the complainant got injured. On 15.11.2018 the complainant was admitted in Vardaan Hospital, 3-E/1, NIT, Faridabad and the right leg of the complainant was operated there by the Medical Officer and Inpatient Bill No. 298 dated 17.11.2018 for Rs.44,916/- was raised by the medical officer. Opposite party has repudiated the claim of the complainant vide letter dated 22.12.2018 (Ex.RW1/1) on the ground that Insued had C/o injury with a Lat. Meniscus tear with parameniscal cyst sustained after having twist of injury whilst weightlifting training. By considering all mentioned facts and finding ssubmitted in claim papers this claim falls under excusion as per scope & coverage of policy. The claim is not admissible as per folowing policy clause:
“What we exclude : Adventure Sports/Professional sports/Defence operation we do not cover tratment of an injury sustained whilst you are: Training for, or taking part in sport for which you are paid or funded by sponsorship or grant (unless you receive travel costs only). Involved in naval, military, air force operation or any adventure sports.”
7. After going through the evidence led by the parties, the Commission is of the opinion that the opposite party has rightly repudiated claim of the complainant as the complainant was involved in Professional Sports and suffered injury during the training and the same is excluded by the opposite party’s term policy and is mentioned in Section 7(Exclusions) of their term policy. Hence, the complaint is dismissed. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 07.02.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
