Punjab

Faridkot

CC/20/51

Anil Goyal - Complainant(s)

Versus

National Insurance co. Ltd - Opp.Party(s)

Anil Kumar Chawla

27 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, FARIDKOT

C. C. No. :                51 of 2020

Date of Institution:   25.02.2020

Date of Decision :    27.03.2023

 

Anil Goyal son of Om Parkash Goyal, Lajpat Nagar, Street No. 02, Kotkapura, Tehsil Kotkapura, District Faridkot.

 .........Complainant

Versus

National Insurance Co. Ltd. B O Tota Bargari Plaza, 2^nd Floor, Near Fly Over, Muktsar Road, Kotkapura, Tehsil Kotkapura, District Faridkot.

                                                                      .............OP

Complaint under Section 35 of the

Consumer Protection Act, 2019.

 

Quorum: Smt Param Pal Kaur, Member,

               Sh Vishav Kant Garg, Member.

 

Present:  Sh Anil Chawla, Ld Counsel for Complainant,

               Sh Yash Pal Bansal, Ld Counsel for OP.

ORDER

( Vishav Kant Garg, Member)

                                         Complainant Anil Goyal (hereinafter referred to as complainant) has filed this complaint under section 35 of the C.P. Act 2019 (hereinafter referred as ‘Act’ before this Commission against National Insurance Co. Ltd. (hereinafter referred as Opposite party).

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   2                                             Briefly stated, the case of the complainant is that complainant purchased a Family Medicare Policy bearing No.40170248178500000357 worth Rs.2,50,000/-from OP valid for the period from 23.10.2017 to 22.10.2018. During the subsistence of policy in question, wife of complainant suffered from low back ache radiating to her leg for which she got treatment from Global Health Pt Ltd Medanta the Medicity and amount of Rs.2,50,910/- was spent by him on her treatment and thereafter, complainant submitted the claim before OP.

3                                      Complainant has alleged that vide letter dated 05.11.2018, OP repudiated the claim of complainant on the ground that policy inception date is 23.10.2017 and the disease was pre-existing. Policy was in first year of inception and therefore, claim is not admissible as per pre-existing disease clause.

4                                        It is further alleged that after obtaining clarification from concerned doctor that disease of his wife was not pre existing, rather it occurred just before 2 months prior to treatment, complainant sent the same to OP, but this time OP again repudiated the claim on same grounds vide letter

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dated 10.09.2019. Complainant made several requests to OP to make payment of his genuine claim, but OP paid no heed to his requests.

5                                               It is further alleged that complainant has suffered huge financial loss as well as harassment and mental agony due to this act of OP, which amounts to deficiency in service and trade mal practice.

6                                                    On this backdrop of facts, the complainant has prayed for directions OP to make payment of Rs.2,50,910/-on account of amount spent by him on treatment of his wife and has sought further directions to OP to pay compensation to the tune of Rs.50,000/-  for harassment and mental agony suffered by him besides litigation expenses of Rs.10,000/-.

7                                           The counsel for complainant was heard with regard to admission of the complaint and vide order dated 26.02.2020,                                                                                                                                                                                       complaint was admitted and notice was ordered to be issued to the OP.

8                                     On receipt of the notice, the OP filed written statement wherein took preliminary objections that complainant has violated the terms and conditions of the policy. As per clause 4:1 Pre-existing diseases-all

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pre existing diseases shall be covered after the policy has been continuously in force for 36 months. This commission has no jurisdiction to hear and try the present complaint. It is averred that complainant has been conniving with concerned doctor as when patient Anita Goyal was admitted, doctor got recorded the previous history of disease as “46 years old female, presented with complaints of backache 7 years mild in nature, relieved by resting, increased by walking and standing, relief by medication, 2 months before patent had started noticing pain radiating to right lower limb, which was relieved by medications. Now, patient has complaints of difficulty in walking since two days associated with altered bladder habits. No bowel involvement. MRI Lumbar Spine showed L 4-5 & L 5-SI PIVD”. It is further averred that disease of the patient was seven years old and did not cover the policy in question and the insurance company rightly repudiated the claim of complainant as per terms and conditions of the policy. On repudiation complainant approached concerned doctor who gave favour to complainant and mentioned that after going through the patients records, it is found that patient was suffering from low back ache radiating to leg for two months, there is an early history of backache 7-8 years back that may not be related to present admission. Complaint filed by complainant is false

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and frivolous and if there is any liability on their part, then that is also limited only upto Rs.2,50,000/-, but that is also denied on the ground that disease for which treatment is undertaken by complainant is pre-existing disease. However, on merits, OP have denied all the allegations being wrong and incorrect. It is reiterated that there is no deficiency in service on the part of OP. All the other allegations and the allegation with regard to relief sought too were refuted with a prayer that complaint deserves to be dismissed with costs.

9                                              Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence affidavit of complainant Ex.C-1 and documents Ex C-2 to C-8 and then, closed their evidence.

10                                            In order to rebut the evidence of the complainant, ld counsel for OPs tendered in evidence affidavit of Manjit Singh, Branch Manager Ex OP-1 and document Ex OP-2 to 7 and then, closed the same on behalf of OPs.

 

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11                                            We have heard the ld counsel for complainant as well as OPs and have carefully gone through evidence and documents placed on record by respective parties.

12                                          The case of the complainant is that he purchased a Family Medicare Policy worth Rs.2,50,000/-from OP which was valid for the period from 23.10.2017 to 22.10.2018 and during the subsistence of policy in question, wife of complainant suffered from low back ache radiating to her leg for which she underwent treatment at Global Health Pt Ltd Medanta the Medicity and amount of Rs.2,50,910/- was spent by him on her treatment. After that he submitted the claim before OP. Grievance of complainant is that OP repudiated the claim of complainant on the ground that policy inception date is 23.10.2017 and the disease was pre-existing. Policy was in first year of inception and therefore, claim is not admissible as per pre-existing disease clause. Even thereafter, complainant obtained clarification from concerned doctor that disease of his wife was not pre existing, rather it occurred just before 2 months prior to treatment and  complainant sent the said clarification to OP, but OP again repudiated the claim on same ground of pre-existing disease under clause 4.1. Complainant has alleged that despite repeated requests, OP has

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refused to pay the insurance claim to him on false grounds which amounts to deficiency in service and has caused mental agony to him. He has prayed for accepting the present complaint. In reply, to controvert the allegations of complainant, ld counsel for OP stressed mainly on the point that disease for which wife of complainant took treatment was pre-existing and as per clause 4:1 Pre-existing diseases-all pre existing diseases shall be covered after the policy has been continuously in force for 36 months. However, plea taken by OP that disease of his wife was pre-exiting one, does not hold any water in the light of clarification given by concerned doctor as Ex C-4 wherein doctor has cleared the point that problem for which she took treatment in their hospital is not related with her 7 years old backache.

13                                     To prove his pleadings, he has placed on record copy of insurance policy document Ex C-2, that clearly proves the pleadings of complainant that he alongwith his family was insured under policy in question. Ex C-3 is copy of repudiation letter sent by OP to complainant vide which Opposite party has denied to make payment of insurance claim on the ground that disease of his wife is seven years old and pre existing disease is not covered under policy in question. ExC-4 is copy of letter written by treating doctor

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wherein he has mentioned that backache radiating to right lower limb was first noticed two months back. Though patient had early history of backache 7-8 years back, but this two months old back ache is not co-related to that disease. Through letter Ex C-5 complainant has requested Opposite Party to pass his genuine insurance claim. Letter dated 10.09.2019 Ex C-6 issued by Insurance Company to OP further mentions the repudiation of claim of complainant on the ground of Pre-existing disease clause 4.1. Ex C-7 is further clarification given by wife of complainant to OP regarding the fact that she was not suffering from any pre-existing disease.

14                From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainant with OP. Ops have themselves admitted that complainant and his wife were insured with them for cashless treatment under the policy in question. It is also admitted that wife of complainant suffered from low back ace and she undertook treatment from said Medanta Hospital. Plea taken by OP that disease of insured is pre-existing has no legs to stand upon in the light of document Ex C-4 which is copy of letter dated 15.04.2019 written by Dr Sudhir Dubey Director of Minimally Invasive

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Neuro Surgery, Medanta-The Medicity that clearly discloses that patient was suffering from low back ache radiating to leg for two months and his earlier history of back ache of 7-8 years back that may not be related with present admission of patient in their hospital for which she underwent treatment during said period.  Complainant has produced sufficient and cogent evidence to prove his pleadings. All the documents placed on record by complainant are authentic and are beyond any doubt.

15                                          OP cannot deny the amount in dispute regarding claim of complainant on the false grounds. Act of OPs in not passing the claim of complainant amounts to deficiency in service on the part of OP. It is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. He  further placed reliance on citation 2008 (3) RCR (Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims at the time of making payment.

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16                                From the above discussion and case law produced by the complainant, we are of considered opinion that OP has wrongly and illegally not processed the claim of complainant, which amounts to deficiency in service. Therefore, present complaint is hereby accepted against OP. OP is hereby directed to pay the claim amount of Rs.2,50,000/- (the maximum limit admissible as per insurance policy) to complainant, which as per bills, he incurred on treatment of his wife within 45 days of receipt of original documents from complainant. Opposite party is further directed to pay Rs.3,000/-to complainant as consolidated compensation for harassment and mental agony suffered by them and for litigation expenses. Complainant is directed to submit original bills in respect of treatment of his wife to Opposite party within 15 days of receipt of this order. Compliance of this order be made by respective parties within stipulated period failing which complainant shall be entitled to proceed as per Consumer Protection Act. Copy of the order be supplied to parties free of cost. File be consigned to record room.

Announced in Commission

Dated : 27.03.2023                                    

(Vishav Kant Garg)        (Param Pal Kaur) 

  Member                                   Member