Haryana

Ambala

CC/271/2014

GULSHAN BAWEJA - Complainant(s)

Versus

NIA CO. - Opp.Party(s)

VIKAS AGGARWAL

24 Jul 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA

 

Consumer Complaint No.: 271 of 2014

Date of Institution: 29.09.2014

Date of Decision: 24.07.2017

 

Gulshan Baweja, S/o Late Sh. Gurditta Mal, R/o H. No. 110/11, Mahesh Nagar, Ambala Cantt.

                                                                                         ...................Complainant

VERSUS

1. The New India Assurance Co. Ltd. through its Regional manager, SCO 36-37, Sector 17-A, Chandigarh.     
2. The New India Assurance Co. Ltd. through its Branch Manager, 5406, Shree Complex, 2^nd Floor, Cross Road No.3, Punjabi Mohalla, Ambala Cantt.

                                                                                ...................Opposite Parties

 

BEFORE:    Shri D. N. Arora, President

        Shri Pushpender Kumar, Member

        Ms. Anamika Gupta, Member

       

Present:    Sh. Vikas Aggarwal, Advocate for Complainant.

                   Sh. Nikhilesh Bhagi and Ms. Jyoti Aggarwal, Advocates for OPs.

 

ORDER

PER ANAMIKA GUPTA, MEMBER

1.                  Sh. Gulshan Baweja, Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 against The New India Assurance Co. Ltd. and another, Opposite Parties (hereinafter referred to as “OPs”). The case of the Complainant is that he purchased a Mediclaim Policy from the OPs since 2010-11 which was renewed by the Complainant from time to time without any default. On 26.07.2014 the Complainant purchased a Mediclaim Policy from the OPs vide Policy No.35350134142500000306 for the sum insured Rs.3,00,000/- effective from 26.07.2014 to 25.07.2015 and has paid the premium of Rs.20,326/- for the above said policy (Annexure C-1). The Complainant got admitted in Fortis Hospital, Mohali on 10.08.2014 for his total knee replacement which was conducted on 11.08.2014. The Complainant was discharged from the hospital on 17.08.2014. Treatment record including discharge summary of the Complainant is Annexure C-2. The hospital had raised the bill of Rs.3,40,250/- for the treatment of the Complainant vide Bill No.FHM/14-15/I/Cr/00005378 dated 17.08.2014 (Annexure C-3). Against which, the Complainant had deposited Rs.1,00,000/- in the hospital vide Receipt No.FHM/14-15/Dp/20976 at the time of his admission on 10.08.2014 (Annexure C-4). The Complainant as well as the hospital had informed the OPs well within time for settlement of the claim against which the OPs made payment of Rs.1,05,000/- to the Complainant. It is alleged by the Complainant that due to short payment made by the OPs, he had to arrange the balance payment which caused great mental pressure to him. The Complainant made balance payment of Rs.1,30,650/- to the hospital through Credit card No.001615 drawn on Axis Bank vide Receipt No.FHM/14-15/Dp/22051 (Annexure C-5). Feeling aggrieved by the action taken by OPs while settling the claim, the Complainant approached OPs. The OPs in their reply dated 11.09.2014 stated, “that the disease Osteoarthritis Knees (against which Complainant has preferred claim) falls under clause 4.3, i.e. excluded from the scope of the policy for 48 months, hence the Sum Insured of 48 month prior has been taken into consideration and the claim was settled as per terms and conditions. The enhanced sum insured is to be treated as fresh one and all the clauses i.e. 4.1, 4.2, and 4.3 will be applicable to the enhanced sum insured”(Annexure C-6). It is alleged by the Complainant that the aforesaid reply dated 11.09.2014 was wrong and at the time of issuing the policy, the agent of the OPs neither disclosed this thing nor has shown it written anywhere to the Complainant. He further avers that OPs have induced him by misrepresenting that he is covered with a sum insured of Rs.3,00,000/- and that after issuance of the policy, the OPs would bear the expenses upto the aforesaid sum insured in case of any disease occurred to the Complainant.         
2.                  OPs in their reply have raised preliminary objection regarding jurisdiction of this Forum to entertain the present complaint. The OPs have denied any unfair trade practice or deficiency in service on their part and asserts that they have rightly settled the Mediclaim of the Complainant and that they have narrated true facts in their reply dated 11.09.2014. The OPs have denied that they have misrepresented the Complainant that all expenses upto Rs.3 lacs would be paid in case of any disease.
3.                  We have heard ld. Counsels for the Complainant and OPs and have also perused the case record as well as written arguments filed by the OPs.
4.                  Firstly, we would adjudicate upon the jurisdictional issue raised by the OPs. Since the contract of insurance between the parties was made at Ambala, this Forum, undoubtedly, has jurisdiction to entertain and adjudicate upon any complaint arising thereupon, subject to pecuniary limits.
5.                  On perusal of facts, it came to notice of this Forum that the first policy taken by the Complainant from the OPs was Mediclaim Policy 2007 (hereinafter referred to as “Policy A”) for the period 26.07.2010 to 25.07.2011 (Annexure R-1). Thereafter, the Complainant got the Policy A renewed with the enhancement of sum insured to Rs.1,50,000/- for the period 26.07.2011 to 25.07.2012  (Annexure R-2). The Complainant got the Policy A renewed with the enhancement of sum insured to Rs.2,00,000/- for the period 26.07.2012 to 25.07.2013  (Annexure R-3). Thereafter, the Complainant got the Policy A (with sum insured of Rs.2,00,000/-) renewed for the period 26.07.2013 to 25.07.2014  (Annexure R-4). And lastly, the Complainant took New Mediclaim Policy 2012 (hereinafter referred to as “Policy B”) from OPs for the period 26.07.2014 to 25.07.2015. Here, in this Policy B, the Complainant contracted with the OPs to the enhancement of sum insured to Rs.3,00,000/-. It is pertinent to mention here that the Complainant rests his claim on the Policy B.       
6.                  We are of the view that the mediclaim policies are provided to the insured on specific terms and conditions and contract of insurance is based on good faith. The Complainant is not allowed to dispute that he was kept in dark while issuing the policy in question (Policy B) as terms and conditions governing Policy A and Policy B are materially the same. Thus, by getting the policies having similar terms and conditions (disputed in present case) renewed year after year, would create an estoppel against the Complainant for asserting that he was unaware of the condition on the basis of which the OPs restricted his claim to Rs.1,05,000/-.
7.                  Clause 5.11 of Policy B is regarding “Enhancement of Sum Insured” which states that in respect of any enhancement of Sum Insured, exclusions 4.1, 4.2 and 4.3 would apply to the additional Sum Insured from such date. The exclusion clause 4.3.2 states that unless the Insured Person has Continuous Coverage in excess of forty eight months with us, the expenses related to treatment of Joint Replacement due to Degenerative Condition, and age-related Osteoarthritis & Osteoporosis are not payable. Thus, from the agreed terms and conditions of the policy, it is ample evident that in case of enhanced sum of insurance, a Continuous Coverage in excess of 48 months is necessary for claiming expenses related to the treatment in question. But what constitutes Continuous Coverage and to which sum insured would be the claimant entitled while determining Continuous Coverage, are the questions left that, we think, need to be addressed for settling the issue in the present case.  Going through the Policy in question (Policy B), we came across clause 2.8 which states that Continuous Coverage means uninterrupted coverage with us till the date of commencement of Period of Insurance of the Insured Person under Mediclaim 2007 Policy or under Mediclaim Insurance (Individual) Policy or under Mediclaim 2012 Policy from the time the coverage incepted under any of these Policies. In case of change in Sum Insured during such uninterrupted coverage, the lowest Sum Insured would be reckoned for determining Continuous Coverage. Thus, in the present case, the OPs are justified in restricting the claim of the Complainant to the lowest sum insured (i.e. Rs.1,00,000, the sum insured under First Policy) during the period of Continuous Coverage of 4 years which prevailed over the span from 26.07.2010 to 25.07.2014. The OPs have rightly paid the coverable insurance amount of Rs.1,05,000/- for the treatment of Osteoarthritis of the Complainant after taking due consideration of Sum Insured (Rs.1,00,000/-) and Cumulative Bonus Buffer (Rs.5,000/-) earned by the Complainant during previous years. Even Policy A adopted by the Complainant for the past four years speaks of the same thing, wherein clause 6(d) states that if the policy is to be renewed for enhanced sum insured then the restrictions i.e. 4.1, 4.2 & 4.3 will apply to additional sum insured as if it is a new policy. In other words, the benefit of difference of enhanced sum insured from the earlier one would accrue only after completing the contractual Continuous Coverage to be reckoned from the date of renewal for enhanced sum insured. Thus, the Complainant cannot allege misrepresentation on the part of OPs and is bound by the express written terms of the policy taken by him.  
8.                  For the reasons recorded above, we are of the considered opinion that the complaint being devoid of merit, must fail, and the same is dismissed, with no order as to costs.

Copies of the order be sent to the parties concerned free of costs, as per rules. File after due compliance be consigned to the record room.

Announced on: 24.07.2017

 

 

PUSHPENDER KUMAR                ANAMIKA GUPTA                            D.N. ARORA

MEMBER                                    MEMBER                                     PRESIDENT

 

 

Note: Each and every page of this order has been duly signed by me.

 

ANAMIKA GUPTA

         MEMBER