Delhi

North

CC/54/2021

PREM LATA BANSAL - Complainant(s)

Versus

M/S. BAJAJ ALLIANZ GIC LTD. & OTHER - Opp.Party(s)

P L BANSAL & ASSOCIATES

07 Dec 2023

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

Consumer Complaint No.:54/2021

 

In the matter of

 

Prem Lata Bansal,

G-1, Vishwa Appartment,

3, Shankaracharya Marg,

Civil Lines, Delhi-110054                                                 …… Complainant No. 1

 

Ram Avtar Bansal,

G-1, Vishwa Appartment,

3, Shankaracharya Marg,

Civil Lines, Delhi-110054                                            …… Complainant No. 2

 

Versus

Bajaj Allianz General Insurance Company Limited,

7th Floor, Block No.4,

DLF Tower, 15, Shivaji Marg,

New Delhi-110015

 

Also at :-

 Bajaj Allianz House, Airport Road, Yerwada, Pune-411006

 

Also at:-

3rd Floor, Minerva Complex, Ambala Cantt-133001

      ….    Opposite Party

ORDER/

07/12/2023

 

Ashwani Kumar Mehta, Member:

 

1.       The present complaint has been filed under Section 35 of the Consumer Protection Act, 2019. The brief details of facts, as alleged by the Complainant in the Complaint in hand, are that the Complainants had purchased a Mediclaim Insurance Policy bearing No. OG-19-1155-6021-00002045 with Master Policy No. OG-18-9999-9960-00000006 and Customer ID-125851013 on 06.09.2018 for a sum assured at 10 lakh on family floater basis at a premium of ₹16,546/- through OPs. A true copy of Mediclaim Policy issued by OP No.1 have been filed  as Annexure-"A". The said policy was also renewed on payment of premium of 16,546/- on 04.09.2019 to OP No.1 and the policy was renewed by the OP-1 w.e.f. 06.09.2019 with a new number bearing OG-20-1207-6021-00000114. True copy of the policy issued by OP No.1 for the 2nd year has also been filed with complaint as Annexure-"B".

 2.      It has been alleged that in the month of November 2019, Complainant No.2, was  got admitted in Sir Ganga Ram Hospital and got the Pace Maker installed in his body on 26.11.2019. On account of this Hospitalisation, complainant filed a claim of ₹3,90,273/- with the OP No.1 on 12 Dec 2019 and the said claim was processed for ₹3,88,353/- and the complainants received the reimbursed amount on 24.03.2020. Since the 2nd year Mediclaim policy was going to be expired on 05.09.2020, the complainants, before the expiry of the policy, paid a premium of ₹16,546/- to OP No.1 on 25.08.2020 for renewal. The credit card statement showing the payment has also been filed as Annexure-"C". In the meanwhile, Complainant No.1, Smt Prem Lata Bansal, got affected with COVID and was admitted in Max Super Speciality Hospital at Shalimar Bagh, Delhi on 06.08.2020 and was discharged on 13.08.2020 and lodged a claim of ₹1,34,688/- with OP No.1 on 09.09.2020. The true copy of the claim filed by the complainant have been filed as Annexure-"D".

3.       It has further been alleged by the complainants that thereafter,   complainant received a message on here mobile, from her banker i.e. ICICI Bank Ltd. on 13.09.2020 that Bajaj Allianz General Insurance Company Ltd. has given a refund of 16,546/- which has been credited to her credit card on 11.09.2020. The true copy of credit card statement reflecting the credit has been filed annexure-"E" with the complaint. On inquiry in this regard, the representative Ms Sneha Mishra of OP No.2 informed that the Mediclaim policy of the complainants is blocked but there was no message whatsoever from OP No.1 as to why the policy has been blocked and why the premium amount has been returned? Even the representative of OP-2 did not inform as to why policy is blocked? The complainant then visited the office of OP1 at Moti Nagar, New Delhi on 23.09.2020 but nobody gave proper reply except one Mr. Kasim, informed telephonically that Mediclaim Policy has been blocked due to non-disclosure in the application form filed at the time of getting the policy issued in the year 2018 that Mr. Ram Avtar Bansal i.e. Complainant No.2, had blood pressure.

4.       It has further been alleged that nothing has been turned out on filing various complaints before OP except for the information from one of OP employee that policy cannot be given to Mr. Bansal/complainant no.2 but can be given to Complainant No.1 if the premium is paid before 05.10.2020. Accordingly, premium was paid but the same was also returned due to the reason that Complainant No.1 had suffered from COVID-19. It is also stated by the complainants that despite various efforts neither policy was renewed nor claim for COVID was processed. Hence, the present Complaint has been filed with following prayer alleging deficiency in service on the part of OP on account of (i) not renewing the policy for the 3rd year and (ii) not processing the claim of Complainant No.1 for COVID hospitalization:-

a) OP-1 be directed to issue the Mediclaim policy to the complainants for the 3rd year i.e. from 06.09.2020 to 05.09.2021;

 b) OP-1 be directed to process and allow the claim of the Complainant No.1 for ₹1,34,688/- which had arose during the subsistence of the Mediclaim Policy;

c) OP-1 be directed to allow interest @ 18% per annum from 09.09.2020 till the date of filing of complaint, to allow pendente lite interest @ 18% from the date of complaint till the date of order and also to allow award interest @ 18% from the date of order till the date of payment;

d) award cost of litigation at ₹50,000/- in favour of         complainants;

                   e) award damages of ₹2 lakh in favour of complainants; and

f) pass any other order/s that may deem fit and proper in favour of the complainants.

 

5.       Accordingly, notice was issued to the OP and in response, the OP has filed its reply admitting that a Mediclaim Insurance Policy under the Plan of "Family Floater Basis" bearing no.0G-19-1155-6021-00002045 was issued for the period 6.9.2018 to 5.9.2019 in the name of Complainant no.1  for sum insured  Rs.10 lakh only and  was covering the risk of the Complainant no.1 & 2. The policy was renewed for the second year on the same terms for the period 6.9.2019 to 5.9.2020 vide policy bearing no.0G-20-1207-6021- 00000014.

6.       It has also been stated by the OP that during the continuation of the second year of the  policy, a claim was lodged for reimbursement of the expenses for treatment of the Complainant no.2 After carrying out investigation, the claim was settled and a sum of Rs.3,88,353/- was paid by the opposite party no.1. It has further been added by the OP that during processing the claim of the Complainant no.2, it was found that the hospitalization of the Complainant no.2 was on account of the complete heart blockage and there was non-disclosure of disease of diabetes mellitus as the Complainant no.2 was suffering with the disease for the last 4 years. On account of the non-disclosure of the facts relating to the pre-existing disease, mediclaim insurance policy for the second year was cancelled by the opposite party on 19.3.2020. However, prior to the cancellation of the aforesaid mediclaim insurance policy, notice was sent to the Complainant about the non-disclosure of the facts but the same was not replied by the Complainants. Therefore, after the cancellation of second year policy, such claim was not admissible in the present facts.

7.       The OP has further stated that the Complainant no.1 never lodged any claim with the opposite party in respect of her hospitalization on 6.8.2020 on account of being suffered due to Corona Disease. It is also stated by the OP that opposite party did not accept any further insurance premium from the Complainants towards further renewal of the mediclaim insurance policy for the third year, which was otherwise expired on 5.9.2020. Since there was no such claim pending with opposite party, the question of its settlement/payment by the opposite party does not arise at all. The OP has also filed a copy of policy issued on 06-09-2019 alongwith copy of terms & conditions (at Pages-17-41 of the reply)  in support of its contention/defense. The OP has also filed evidence and written arguments claiming no deficiency in service.

8.       The Complainants have also filed rejoinder, Evidence & arguments and rebutted the reply filed by the OP stating that the terms & conditions filed alongwith reply of the OP, are not the same as issued to complainant. The complainants have denied the contents of the reply of the OP and have affirmed the allegations levelled in the complaint. It has also been contended by the Complainants that as per clause mentioned at Part-D(7) (III) (1) of Contract with OP No.1, renewal will not be refused except on the grounds of moral hazard, misrepresentation or fraud. There was no allegation whatsoever by the OP against the complainants and therefore, policy was ought to be renewed. Even otherwise, as per the terms of the contract, policy could not be cancelled without giving at least 15 days written notice.  It is further been stated by the Complainants that while cancelling the policy or while denying the renewal, no notice was issued by the OP. It was the banker of the Complainant No.1 i.e. ICICI Bank Ltd. who had informed that insurance company had refunded the amount of ₹16,546/-which had been credited to the credit card account of Complainant No. 1. Thus, OP has violated principles of natural justice and has refunded the Premium without giving any reason.

9.       The complainants have also contended that in the written statement, OP  has stated that the 2nd year Mediclaim insurance policy was cancelled on 19.03.2020 and notice was sent to the complainants  prior to such cancellation but no notice had ever been issued/served to complainants. During inquiry, the complainants were verbally informed by the representative of OP that there was non-disclosure of hypertension by Complainant No.2 in the application while applying for the policy whereas in the written statement, the OP has stated that there was non-disclosure of diabetes mellitus by Complainant No.2, who was suffering for last 04 years.  The complainants have further contended that there was no non-disclosure by Complainant No.2 which is evident from the fact that his claim for implanting of pace maker was successfully allowed by OP No.1 on 24.03.2020. If policy was cancelled on 19.03.2020 as stated in the written statement by OP, the said claim would not have been allowed by them.

10.     On the point of pre-existing disease referred by the OP, the complainants have contended that diabetes on borderline is a normal phenomenon.  As held by the Hon'ble Delhi State Consumer Dispute Redressal Commission, New Delhi in the case of Life Insurance Corporation of India vs Sudha Jain [(2007) (2) CLT 423] "9(iii) malaise of hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work in and out of house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim. The complainant have also relied upon the following cases:-

1.        Maxlife Insurance Co Pvt. Ltd. vs Veero

(First Appeal No. 118 of 2017 decided on

 08.03.2017 by Chandigarh Bench of State Commission)

2.       Satish Chander Madan vs Bajaj Allianz GIC Ltd.

 I (2016) CPJ 613 (NC)

                        3.      Max New York Life Ins Co. Ltd. vs Insurance   

                                Ombudsman.

CWP No.20040 of 2008 decided on 17.12.2008

by P&H High Court

4.       Veena Sharma vs LIC of India

1999 (1) RCR (Civil) 646 (P&H)

5.       Shiva Ratan Bajoria vs Star Health & Allied Insurance Co. Ltd. First Appeal No. A/87/2018 decided on 23.04.2019

          by Kolkata Bench State Commission

6.       D. Srinivas vs SBI Life Insurance Co. Ltd.

Civil Appeal No.2216 of 2018 dated 16.02.2018 (SC)

 

11.     The complainants have also contended that in all these cases, it has been settled that hypertension, diabetes etc are common ailment and it can be controlled by medication, therefore, non-mentioning of insured being a patient of hypertension does not amount to suppression of material fact so as to entitle the OP to repudiate the claim. Therefore, OP has deliberately rejected the policy to the Complainants looking to their age which is arbitrary and malicious.

12.     The complaint has been examined in view of the facts of the case and averments/evidence/arguments submitted by both the parties and it has been observed that :-            

1. The OP has stated that mediclaim insurance policy was cancelled on 19.3.2020 on account of the non-disclosure of the facts relating to the pre-existing disease and prior to the cancellation of the aforesaid policy, notice was sent to the Complainant about the non-disclosure of the facts but the same was not replied by the Complainants. The said explanation of the OP cannot be considered valid in the absence of any proof of service of this notice to the complainants as the OP has neither filed any copy of the notice nor any evidence/proof of service of such notice. The OP was bound to issue and serve notice to the complainants before cancellation of the policy.
2. The OP has claimed cancellation of the policy on 19-03-2020 on the basis of medical records of  treatment of Complainant No.2 but has reimbursed the claim of treatment of complainant No.2 on 24-03-2020.
3. The OP has failed to produce any medical records to prove that the complainant no. 2 was suffering from diabetes mellitus for the last 4 years and the same has not been reflected in the application form.
4. The OP claims to have cancelled the policy on 19-03-2020 but has accepted the premium on 25-08-2020 for renewal of the policy for the period from 06-09-2020 to 05-09-2021 which was returned to complainants on 11-09-2020 i.e. after the start of 3^rd term of the policy.
5. The OP has denied the receipt of any claim of treatment of complainant no.1 filed on 09-09-2020 and the complainants have also not filed any proof of the submission of the claim with OP with proper stamp, signatures and claim number though copies of the duly filled claim form has been filed with the complaint at pages 55-67.

13.     In view of the above observations, we are of the considered view that the OP has proceeded for cancellation of the policy arbitrarily without issuing proper notice to the complainants which amounts to deficiency in service and the Complainants have suffered directly due to deficiency in service on the part of the OP in terms of the deficiency defined in the Act which includes any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance which is required to be maintained in relation to any service and includes any act of negligence or omission or commission by such person which causes loss or injury to the consumer. Therefore, we feel appropriate to direct the OP to:-

1. Restore the mediclaim insurance policy to its original position with the terms & conditions applicable at the time of issuance of first policy and renew the policy thereafter after accepting the necessary premium and consider the claims of the complainants as per terms and conditions;

2. Process the claim of Rs.1,34,688/- for the period from 06-08-2020 to 13-08-2020 to be filed by the complainant No.1 afresh after issue of this order ;

3. pay Rs. 50,000/- (Rupees Fifty Thousand only) as compensation to the Complainants for the mental pain, agony and harassment within 30 days failing which OP shall be liable to pay this amount with interest @9% per annum from the date of expiry of 30 days period.

 

14.     Order be given dasti to the parties in accordance with rules. Order be also uploaded on the website. Thereafter, file be consigned to the record room.

 

  

                                    ASHWANI KUMAR MEHTA                              HARPREET KAUR CHARYA

                        Member                                                                   Member

                       DCDRC-1 (North)                                           DCDRC-1 (North)

 

DIVYA JYOTI JAIPURIAR

President       

                                            DCDRC-1 (North)