Delhi

New Delhi

CC/1146/2006

Mukesh Kumar Garg - Complainant(s)

Versus

M/S. Bajaj Allianz Life Insurance Corporation - Opp.Party(s)

07 Jun 2018

ORDER

 

 

                                      CONSUMER DISPUTES REDRESSAL FORUM-VI

                                        (DISTT. NEW DELHI),

                               ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

                                                                       NEW DELHI-110001

 

Case No.C.C.1146/2006                                                                    Dated:

In the matter of:

Sh. Mukesh Kumar Garg,

Sh. Ghanshyam Dass Gupta,

R/o E-17, East Uttam Nagar,

Uttam Nagar, New Delhi.

                 ……..COMPLAINANT

VERSUS

1. The Manager,

Bajaj Allianz Life Insurance Co. Ltd.

C-31/32,1st Floor,

     Connaught Place, Hunting Lines,

      New Delhi-110001.

 

2.            Managing Director,

Bajaj Allianz LifeInsurance Co. Ltd.,

GE-Plaza, Airport Road,

Yerawade, Pune-411 006.

 

Opposite Party.

                

NIPUR CHANDNA, MEMBER

 

ORDER

       

The complainant has filed the present complaint against the OPs under section 12 of Consumer Protection Act, 1986.  The brief facts as alleged in the complaint are that the complainant is the Mediclaim Policy holder of the OP Co. vide policy bearing No.OG-06-1104-8401-00001300 which also issued the Health Card valid upto 27.11.2006.  It is alleged on behalf of complainant that on 22.2.2006 he had pain in his stomach and as such was admitted in Kukreja Hospital and Heart Center Pvt. Ltd. where the surgery was done and his left renal stone was removed. On 26.02.2006 he was discharged from the hospital by paying a bill of Rs.30,585/-. It is alleged by the complainant that he lodged a claim with OP Insurance Co. vide claim No.OC-06-1101-8401-00000348 but the same was repudiated by the OP vide its letter dated 16.3.2006 on false and frivolous grounds,  hence this complaint.

2.     Complaint has been contested by both the OPs.  In its written statement, OPs denied any deficiency in service on its part.  It is stated on behalf of OPs that claim of the complainant was rightly repudiated vide letter dated 16.3.2006 on the ground that OP will not pay for the claim arising out of howsoever connected to the following:

“C-2 any medical expenses incurred during the first two consecutive annual period which the complainant has benefit of health guard policy with the respondent in connection with stone in urinary and biliary system.”

 

3.     Complainant has filed his evidence by way of affidavit wherein he has corroborated the contents of his complaint.  On the other hand, on behalf of OP, Sanjay Gupta, Asstt. Manager,Legal has filed his evidence by way of Affidavit.  

4.     We have heard argument advanced at the Bar and have perused the record.

5.     Complainant has placed on record the copy of the Health Card, copy of the discharge summary, copy of the Hospital bill, copy of receipts issued by the hospital against the payment, copy of the Legal Notice served to the OP,  Copy of the repudiation letter dt.16.3.2006 in support of his case. 

6.     Some facts are not denied by the parties such as the insurance policy and treatment taken. OP has referred to the policy and stated that it is annexing the same as Annexure  “A”  but no documents or policy have been annexed either with the reply or with the OP evidence filed on 12.3.2007 or its evidence dated 22.8.2007.  The clause C-2 of the terms and conditions of policy that “any medical expenses incurred during the first two consecutive annual period which the complainant has benefit of health guard policy with the respondent in connection with stone in urinary and biliary system” referred to by OP in its repudiation letter and its reply has no bearing due to absence of any documentary evidence. Till date, despite opportunities, OP after completing its pleading has not filed any policy or terms and conditions relied by it.  OP has kept the complainant as well as the Forum in the dark regarding the exact condition specified in the policy.  The complainant even after taking a medical policy was not given the copy of medicalim policy, which was mandatorily to be given by the OP.

 

7.     The controversy as to whether the repudiation is justified, the answer in the negative. No evidence has placed on record as to whether the terms

and condition ever supply to the complainant. In case titled IV (2014) CPJ 14A (CL) HAR. Oriental Insurance Co. Ltd. Vs Vivek Rekhan, the claim filed on the basis of mediclaim policy was repudiated by the insurance company on the basis of exclusion clause. The court held that the insurance company vaguely denied without pointing out as to in which manner and on which date terms and condition were supplied to the complainant. Therefore, unless terms and condition have been supplied to the complainant before taking a policy, exclusion clause cannot be enforced. Since the OP has failed to place on record, the copy of policy and its terms and conditions on which it is relying for repudiation of the claim, we are of the opinion that repudiation of the claim of the complainant by OP is wholly unwarranted and unjustified.  The complainant has succeeded in establishing the case of deficiency in services against OP.   We therefore hold, OP guilty of deficiency in services and direct it as under:

1. Pay to the complainant sum of Rs.30,585/- along with 9% interest from the date of filing of complaint i.e. 21.11.2006 till payment.

 

2. Pay to the complainant sum of Rs.5,000/- toward compensation for pain and  mental agony suffered by him which will include cost  of litigation.

 

The order shall be complied with within 30 days of the receipt of the copy of the order. If the said amount is not paid by the OP within a period of one month from the date of receipt of this order, the same shall be recovered by the complainant along with simple interest at the rate of 9% per annum from the date of this order till recovery of the said amount. This final order be sent to server (www.confonet.nic.in ). A copy each of this order each be sent to both parties free of cost by post.

Announced in open Forum on 07/06/2018. 

 

 

            (ARUN KUMAR ARYA)

                         PRESIDENT

 

                            (NIPUR CHANDNA)                                                  (H M VYAS)

                                     MEMBER                                                                MEMBER