Punjab

Ludhiana

CC/14/561

Ram Singh - Complainant(s)

Versus

National Ins.Co.Ltd - Opp.Party(s)

Ashok Kumar Adv.

12 Feb 2015

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

                                                                 Complaint No: 561 of 14.08.2014

                                                                                                                    Date of Decision: 12.02.2015

                                                                                                                   

Ram Singh aged about 72 years s/o Sh.Niranjan Singh resident of Shaheed Bhagt Singh Colony, Near S.R.Foundary, Amloh Road Khanna Tehsil Khanna, District Ludhiana.

……Complainant

Versus 

1. The General Manager, The National Insurance Co. Ltd. Registered office 3, Middleton Street, Calcutta-700071.

2. Shekhar Verma, Sales Manager, The National Insurance Co. Ltd. c/o Janta Travelers near Dhian Singh Complex, Bus Stand, Ludhiana, Tehsil and District Ludhiana.

…..Opposite parties 

 

COMPLAINT UNDER SECTION 12 OF THE

CONSUMER PROTECTION ACT, 1986.

 

Quorum:     Sh.R.L.Ahuja, President

                   Sh.Sat Paul Garg, Member

 

Present:       Sh.Ashok Kumar Mago, Advocate for complainant.

                   Sh.Pardeep.K.Arora, Advocate for OPs.

 

                   

                        ORDER

 

(SAT PAUL GARG, MEMBER)

 

 

1.               Present complaint under Section 12 of The Consumer Protection Act, 1986 (herein-after in short to be referred as ‘Act’) has been filed by Sh.Ram Singh s/o Sh.Niranjan Singh r/o of Shaheed Bhagt Singh Colony, Near S.R.Foundary, Amloh Road Khanna, Tehsil Khanna, District Ludhiana (herein-after in short to be referred as ‘complainant’) against The General Manager, The National Insurance Co. Ltd. Registered office 3, Middleton Street, Calcutta and others (herein-after in short to be referred as ‘OPs’)- directing them to make the payment of 2887.43 Euros and to pay Rs.1.00 lac to the complainant as damages alongwith any other relief which this Forum may deem fit be awarded to the complainant.

2.                Brief facts of the complaint are that complainant purchased a Trawell Tag Medical policy, through OP2 of National Insurance Co. Ltd. on 5.11.13. The complainant visited Germany on a visitor visa for three months and went to Burzburg. During the stay of the complainant at Germany he suffered a stomach pain due to the heavy blood pressure and got admitted in the hospital missionzartliche Klinik. Gemeinnutzige Gessellschaft Mbh, Akademisches Lehrkrankenhaus der Julius-Maximilians-universitat Wurzburg and remained in the hospital from 14.12.13 to 18.12.13. The medical bill of the hospital is 2887.43 Euros. The complainant approached the branch office of the OPs at Franch and submitted the original bills, original medical report, photo copy of the air ticket, photo copy of passport duly visa signed by the German Embassy, photo copy of the policy bearing Trawell Tag Assist No.110080489364 and original boarding card. The complainant further submitted all the documents on 16.4.14 to the OP2 and the OP2 assured the complainant that the payment will be made within one month, but after the expiry of the two months’ period the payment was not made to the hospital and on the instruction of the hospital, the salary of the son of the complainant was stopped by the company, where he is working. The complainant also got issued a registered notice dated 20.06.14 to the Ops, through his counsel by registered post. The Ops received the notice, but they have not relied the notice. Claiming the above act as deficiency in service on the part of the OPs, the complainant has filed this complaint.

3.                On notice of the complaint, OP1 appeared through their counsel and filed written statement taking preliminary objections that the present complaint of the complainant is not maintainable; this Forum has no jurisdiction to try and decide the present complaint; no cause of action accrued to the complainant to file present complaint against the OPs; the complainant had concealed the true facts from the OPs with regard to his pre-existing illness and medications of hypertensive and chronic crisis at the time of inception of insurance policy and have also made wrong statements and information for the same to the Ops, which amounts to breach of terms and conditions of the policy, hence the complainant is not entitled to any claim; the claim of the complainant falls within the definition of ‘No Claim’ since complainant had breached and violated the terms and conditions of the policy as well as provisions of Insurance Act/Guidelines; the complainant has not come to the Forum with clean hands and has concealed the material facts from this Forum; the present complaint is hopelessly time barred. Further stated that during the stay of the complainant in Germany, he suffered stomach pain due to heavy blood pressure. On merits, denying the contents of all other paras of the complaint OP1 prayed for the dismissal of the complaint.

4.                Notice sent to OP2, through registered post on 14.11.14. But no report was received. As such, after expiry of 30 days waiting period, OP2 was proceeded exparte, vide order dated 18.12.14 of this Forum.

5.                Ld. counsel for complainant has adduced the evidence by way of duly sworn affidavit of complainant Sh.Ram Singh Ex.CA, wherein, the same facts have been reiterated as narrated in the complaint and also attached documents Ex.C1 to Ex.C10. On the other hand, Ld. counsel for OPs has adduced the evidence by way of duly sworn affidavit of Sh.Sanjeev Khurana aged about 51 years s/o Late Sh.K.K.Khurana, Assistant Manager, National Insurance Company, Divisional Office-I, Atam Nagar, Ludhiana Ex.RA, wherein again the same facts have been reiterated as narrated in the written statement and also attached documents Ex.R1 and Ex.R2.

6.                Case was fixed for arguments. Ld. counsel for complainant argued orally that there is no evidence with respect to pre-existing disease has been produced by the OPs, from which, it can be presumed that complainant was actually suffering from any pre-existing disease and the complainant never had this type of problem before inception of the policy as per Ex.C6, which is the report of the hospital in Germany, wherein it is stated that “the patient was in their treatment from 14.12 untill 18.12.2013. The reason was a decompensation of his chronic heart-failure and initially a hypertensive crisis. Under intensified diuretical therapy we achieved a rapid recompensation with significant improvement of the initial complaints. The body weight at discharge is 92.0 kg. The actual medication is to be seen in the official dismission paper of their clinic (german version).”

7.                Refuting the allegations leveled by the complainant, Ld. counsel for OPs argued that the complainant had concealed the material facts from the Hon’ble Forum that he was suffering from pre-existing disease and was suffering from Hypertensive and chronic crisis and the facts with respect to this pre-existing medical condition/ailment was concealed by the complainant from the OPs intentionally and malafidely and the pre-existing medical condition is excluded from the policy and the complainant is not entitled to claim the hospital charges from the OPs, as per the terms and conditions of the policy.

8.                We have gone through the pleadings of the complainant as well as defence taken by the Ops and also perused the entire record placed on file.

9.                It is evident that the complainant got insurance policy from the OPs on 5.11.13 and he visited his son at Burzburg (Germany) and during the stay there, he suffered stomach pain due to heavy (high) blood pressure and got admitted in the hospital Missionzartliche Klinik. Gemeinnutzige Gessellschaft Mbh, Akademisches Lehrkrankenhaus der Julius-Maximilians-universitat Wurzburg and remained in the hospital from 14.12.13 to 18.12.13, where the extract of treatment was as follows:-

“The patient was in their treatment from 14.12 untill 18.12.2013. The reason was a decompensation of his chronic heart-failure and initially a hypertensive crisis. Under intensified diuretical therapy we achieved a rapid recompensation with significant improvement of the initial complaints. The body weight at discharge is 92.0 kg. The actual medication is to be seen in the official dismission paper of their clinic (german version).”

 

                   The medical bill of the hospital is 2887.43 Euros. The complainant approached the branch office of the OPs and submitted all the required documents with them. The complainant further submitted all the documents on 16.4.14 to the OP2, but no payment was made to the hospital. The Ops have not been able to prove in any manner whatsoever that the complainant was having this pre-existing disease of Hypertensive and High Blood Pressure and failed to prove as to how the complainant had concealed this fact from the OPs at the time of inception of the policy. No documentary evidence or otherwise has been adduced by the Ops. Simply averring that the complainant was having pre-existing disease at the time of inception of the policy is not tenable in any manner. It was incumbent on the part of the Ops to prove beyond reasonable doubt about the averments regarding pre-existing disease. With regard to preliminary objections in written statement also nothing has been proved so the complaint is maintainable in the present form.

10.              Sequel to the above discussion, the present complaint is allowed and OPs are directed to settle and pay the claim of the complainant as per the terms and conditions of the policy. Further Ops are directed to pay Rs.2500/-(Two thousand five hundred only) as compensation and litigation expenses compositely assessed to the complainant. Order be complied within 30 days of receipt of the copy of the order, which be made available to the parties, free of costs. File be consigned to record room.

 

                   (S.P.Garg)                                         (R.L.Ahuja)

                     Member                                             President

Announced in Open Forum.

Dated:12.02.2015 

Hardeep Singh