Delhi

New Delhi

CC/247/2022

Raja Gautam - Complainant(s)

Versus

m/s. Bajaj Allianz General Insurance Company Ltd. - Opp.Party(s)

01 May 2023

ORDER

 

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-VI

(NEW DELHI), ‘M’ BLOCK, 1STFLOOR, VIKAS BHAWAN,

I.P.ESTATE, NEW DELHI-110002.

Case No.247 /2022       

IN THE MATTER OF:

 

 

Mr Raja Gautam

A-481, J.J. Colony, Sector-15,

Bharat Vihar, Kakrola,

New Delhi -110078                                                       ....Complainant

 

                                      VERSUS

      Bajaj Allianz General Insurance Company Limited.

      12^th Floor, Dr. Gopaldass Bhawan,

      28, Barakhamba Road,

      Connaught Place, New Delhi-110001.                                   ....Opposite Party

 

Quorum:

Ms. Poonam Chaudhry, President

Sh. Bariq Ahmad, Member

Sh. Shekhar Chandra, Member

                                                                                                                              Date of Institution:-06.10.2022                                                                                                                                                                          Date of Order   : -    01.05.2023

ORDER

 

POONAM CHAUDHRY, PRESIDENT

 

 

1. The present complaint has been filed under Section 12 and 35 of Consumer Protection Act, 1986 (in short CP Act) against Opposite Party ( in short OP) alleging deficiency of services.
2. Briefly stated the facts of the case are that the complainant had taken an online health insurance policy bearing no. 0G-22-1101-8441-00001933 on 18.01.2022 from opposite party. It is further submitted that said policy was from 18.01.2022 to 17.01.2023 for the sum insured of Rs.4,00,000/- (Rupees Four Lakh).
3. The complainant got admitted in the Shree hospital for his treatment on 03.04.2022 and remained hospitalized till 08.04.2022. The said hospital generated the final bills of Rs.68,066/- (Rupees Sixty Eight Thousand Sixty Six) which was paid by complainant. Complainant claimed the aforesaid bill amount from the opposite party, but Claim No. 0C-23-1002-8441-00000932 was rejected by the opposite party vide letter dated 11.08.2022 stating as under:

“Verification of claim documents reveal aforesaid claimed was hospitalization and treatment of Urinary Tract Infection and is claiming for expense incurred of INR 68,066/- (Rupees Sixty Eight Thousand Sixty Six). As per received documents we have notice certain discrepancies and lapses in your hospitalization. As per insured’s statement, patient did not submit claim documents. Hence claim stands repudiated as fraudulent claim in view of misrepresentation of facts.”

 

4. It is alleged that the complainant sent a letter with all required documents and original documents on 20.09.2022 to the OP but no response was received from the insurance company. Hence the present complaint. It is alleged that the present case has been filed within the period of limitation.
5. The cause of action arose to file present case when the claim of the complainant repudiated by opposite party on 11.08.2022. The residence of the complainant is situated at “Kakrola” New Delhi, hence, this Court has jurisdiction to entertain the present complaint.
6. It is prayed that OP be directed to pay a sum of Rs.68,066/- (Rupees Sixty Eight Thousand Sixty Six) to the complainant with pendent elite and future interest @ 18% p.a. since the date of repudiation of claim i.e. 11.08.2022 till its realization.  OP be also directed to verify and produce the medical treatment record and bills of treatment of complainant from 03.04.2022 to 08.04.2022.   Cost of litigation be also awarded.
7. Notice of the complaint was issued to OP, pursuant to which OP entered appearance and filed reply/written statement contesting the complaint  stating inter alia that all averments/allegations/assertions/submissions made by the complainant were denied unless having been specifically admitted. It was alleged the complainant has not filed all the relevant records along with his complaint and in the absence of the same, it is very difficult for the OP to effectively address the issues raised by the complainant.
8. The present complaint has been filed wrongly asserting that there is a “deficiency of service” on the part of the respondent,it is the complainant who has not come to this Commission with clean hands and has concealed various material facts. It was submitted that while the claim of the complainant was being processed certain glaring discrepancies were noticed and there were lapses in the period of alleged hospitalization. It was also alleged that complainant failed to provide claim documents despite repeated request as such the claim of the complainant was repudiated on 11.08.2022 being fraudulent and misrepresentation of facts. It was also alleged that an insurance policy is a legal contract and its formation is subject to fulfillment of the requisition of a contract as denied under the India Contract Act, 1872.
9. Complainant thereafter filed rejoinder reiterating therein the averments made in the complaint and denying all the allegation made in the written statement. Both parties therafter filed their evidence by way of affidavits.
10. We have heard the AR of complainant and Ld. Counsel for  OP and perused the evidence and material on record as well as their written arguments.
11. It is admitted case that complainant had obtained the policy in question from OP which was valid with effect from 18.01.2022 to 17.01.2023. It is the case of OP the claim of complainant was repudiated for violation of the terms and conditions of the policy being fraudulent and filed on misrepresentation of facts.

 

12. It is to be noted that complainant stated in the rejoinder that complainant had filed all medical bills, purchase vouchers, laboratory reports attested by the hospital authority. The repudiation letter states that the claim was repudiated for discrepancies and lapses in the hospitalization of complainant. The insured did not submit the claim documents.
13. It is to be noted that it is not the case of OP that Shree Hospital was not in its panel hospital. Moreover all the bills and treatment record duly attested by hospital were submitted by the complainant to OP. We thus hold that OP has failed to prove that claim did not fall within the purview of the policy. OP failed to show that complainant violated the terms and conditions of the policy. It was the duty of OP to verify the treatment record from its panel hospital, but it failed to do so. Thus the claim could not be repudiated under the exclusion clause as alleged.
14. It is also to be noted that OP has not filed any document to show that the terms and conditions of the policy were communicated or served on the insured/complainant. Moreover, OP had accepted the premium from complainant for the policy in question.
15. As regard the liability of Insurance Company in case the terms and conditions of the policy were not communicated or served on the insured, it has been held by the Hon’ble Supreme Court in M/s Modern Insulators  Ltd. Vs. The Oriental Insurance Company 2000 (2) SCC 734 as under :
    •      It is the fundamental principle of insurance law that utmost good faith must be observed by the contracting parties and good faith forbids either party from non-disclosure of the lads which the parties known. The insured has a duty to disclose and similarly it is the duty of the insurance company and its agents to disclose ill material facts in their knowledge since obligation of good faith applies to both equally.

In view of the settled position of law we are of the opinion that the view expressed by the National Commission is not correct. 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 disclosed to the appellant respondent cannot claim the benefit of the said exclusion clause.Therefore, the finding of the National Commission is untenable in law.”

 

16. We accordingly hold that OP was deficient in providing services and direct OP i.e. Bajaj Allianz General Insurance Company Limited to pay Rs.68,066/- (Rupees Sixty Eight Thousand Sixty Six) to the complainant with interest @ 9% per annum from date of repudiation of claim within four weeks of date of receipt of order failing which OP will be liable to pay interest @ 12% per annum till realization. We also direct OP to pay compensation of Rs.25,000/- (Rupees Twenty Five Thousand only) for mental agony and Rs.10,000/- (Rupees Ten Thousand only) toward litigation expenses to the complainant.

A copy of order be sent to all the parties free of cost. The order be also uploaded on the website of the Commission (www.confonet.nic.in).

File be consigned to the record room along with a copy of the order.

 

 

Poonam Chaudhry

(President)

 Bariq Ahmad                                                                                                                                                  Shekhar Chandra

  (Member)                                                                                                                                                        (Member)