Delhi

New Delhi

CC/248/2022

Rakhi - 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.248 /2022       

IN THE MATTER OF:

 

 

Mrs. Mrs. Rakhi

RZ-65, Nand 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

Shri 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-22-1101-8441-00000620 on 17.07.2021 from OP, valid from 17.07.2021 to 16.07.2022 for the sum insured of Rs.3,00,000/- (Rupees Three Lakh).
3. It is further alleged that the complainant got admitted in the Mahavir Multispeciality hospital for treatment on 08.07.2022 and remained hospitalized till 14.07.2022. The hospital generated final bills of Rs.68,902/- (Rupees Sixty Eight Thousand Nine Hundred Two) and the same was paid.
4. The complainant claimed the aforesaid bill amount from the OP vide Claim No. 0C-23-1501-8441-00000161 but the same was rejected by OP vide letter dated 26.08.2022 stating as under:

“Verification of claim documents revealed that claimant was hospitalization and treatment of Urinary Tract Infection. As per verification of claim by our field investigator we have notice non cooperation from hospital as hospital authoritydid not provideICP and other treatment records of patient and visited hospital multiple time but all the time we noted non corporation from hospital side. Both treating doctor and pathologist were not available in the hospital at the time of visit and hospital did not provide contact details of both treating doctor and pathologist. We regret to inform you that the claim stands repudiated. Disclosure to information norm: The policy shall be void and all premiums paid thereon shall be forfeited to the company in the event of misrepresentation, mis-description or non-disclosure of any material fact by the policyholder.”

 

5. Hence, this present complaint, it is also alleged that the present case  has been being filed within the period of limitation, the cause of  when the claim of the complainant was rejected by opposite party vide letter dated 26.08.2022. It is further alleged that 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.68,902/- (Rupees Sixty Eight Thousand Nine Hundred Two)  to complainant with pendent elite and future interest @ 18% p.a. p.a. with effect from the date of repudiation of claim 26.08.2022 till its realization. Opposite party be also  directed to verify and produce the medical treatment record and bills of complainant.  OP be also directed to pay litigation charges.
7. Notice of the complaint was issued to OP, pursuant to which OP entered appearance  and filed written statement contesting the complaint on various grounds inter alia that all averments/allegations/assertions/submissions made by the complainant  are denied unless having been specifically admitted.
8. It was alleged the complainant has not filed all the relevant records and in the absence of the same, it is very difficult for the respondent to effectively address the issues raised by the complainant.
9. It was also alleged there was no “deficiency of service” on the part of the respondent and the complainant has not come to this Commission with clean hands and  she has concealed material facts. It was further alleged that Mahavir Multispecialty hospital refused to co-operate and failed to provide treatment records of the Patient/complainant. The Doctor and the Pathologist were not available at the Hospital. The Hospital authorities also refused to show any bill or receipts to the field investigator of OP. As such the claim of the complainant was repudiated vide letter dated 14.09.2022 being fraudulent and misrepresentation of facts.
10. It was submitted that an insurance policy is a legal contract and its formation is subject to fulfillment of the requisite of a contract as defined under the Indian Contract Act, 1872, its performance is also directly proportional to the performance by both the parties, especially the insured.
11. It was denied that there is any cause of action in favour of the complainant and against the respondent. It is denied that the complainant is entitled for any relief(s). It was prayed complaint be dismissed with heavy costs.
12. Complainant thereafter filed rejoinder reiterating therein the averments made in the complaint and denying all the allegation made in the written statement. Both Parties filed their evidence by affidavits.
13. 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.
14. It is admitted case that complainant had obtained the policy in question from OP which was valid with effect from 17.07.2021 to 16.07.2022 and complainant was hospitalized during the continuance of the policy. It is the case of OP that the terms and conditions of the policy were explained to the complainant and served on the complainant. It is also the case of OP the claim of complainant was repudiated for violation of the terms and conditions of the policy.
15. It is to be noted that complainant stated in the rejoinder that complainant had filed the certificate of treating doctor, Dr. P. Kalra and certificate of Delhi Medical Council. The repudiation letter states that the claim was repudiated for violation of terms and conditions of the policy regarding the disclosure of information clause which provides that policy shall be void and all premiums paid thereon forfeited in the event of misrepresentation, mis-description or non-disclosure of material fact by the policy holder.
16. It is to be noted that it is not the case of OP that Mahavir Multispecialty hospital was not in its panel hospital. Moreover all the bills and treatment record were submitted by the complainant to OP. Therefore, we find that OP has failed to prove that complainant violated the terms and conditions of the policy regarding the disclosure clause. It was the duty of OP to verify the treatment record from its penal hospital, but it failed to do so.
17. 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.
18. 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.”

 

19. We accordingly hold that OP was deficient in providing services and direct OP i.e. Bajaj Allianz General Insurance Company Limited to pay Rs.68,902/- (Rupees Sixty Eight Thousand Nine Hundred Two) 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)