DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
PATIALA.
Consumer Complaint No. 240 of 15.10.2015
Decided on: 9.11.2017
1. Ravinder Kumar Goyal aged about 28 years S/o Sh.Sham Lal Goyal
2. Smt.Nitika Goyal W/o Sh.Ravinder Kumar Goyal
3. Master Nividh Goyal minor S/o Sh.Ravinder Kumar Goyal through his next friend, his father and guardian Sh.Ravinder Kumar Goyal.
All residents of 7-A, Ekta Vihar, Bupindra Road, Patiala.
…………...Complainants
Versus
- Oriental Insurance Company Ltd., having its Registered & Head Office at A-25/27, Asaf Ali Road, New Delhi and one of is Divisional Offices at Sai Market, Lower Mall, Patiala through its Divisional Manager.
- Oriental Bank of Commerce, Branch office Bhupindra Road Patiala thrugh its Branch Manager.
- Medi Assist India TPA Pvt. Ltd., SCO 521, 2nd Floor, Sector 70 Near JLPC Office, Mohali.
…………Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
QUORUM
Smt. Neena Sandhu, President
Smt. Neelam Gupta, Member
ARGUED BY:
Sh.B.B.Gupta,Advocate,counsel for complainants.
Sh.B.L.Bhardwaj,Advocate,counsel for OPs No.1&3
Sh.Anand Puri,Advocate, counsel for OP No.2.
ORDER
SMT.NEENA SANDHU, PRESIDENT
Complainants Ravinder Kumar Goyal, his wife Smt.Nitika Goyal and Master Nividh Goyal through his father have filed this complaint under Section 12 of the Consumer Protection Act,1986 ( hereinafter referred to as the Act) against the Opposite Parties (hereinafter referred to as the O.Ps.) praying for the following reliefs:-
- To pay claim amount of Rs.5,13,635/- alongwith interest @2% per month from the date of lodging of claim till its actual payment;
- To pay Rs.50,000/- as compensation for causing mental agony and physical harassment
- To pay Rs.20,000/- as litigation expenses and
- To grant any other relief,which this Forum may deem fit.
2. The brief facts of the complaints are as under:
That complainant No.1 has been maintaining saving bank account bearing No.05902191002861 with Op no.1. Upon a scheme, complainants No.1&2 purchased Oriental Bank Medi-claim policy bearing No.233500/48/2015/1352 for the period from 11.9.2014 to 10.9.2015 from OP no.1. At the time of taking the insurance policy, complainant No.2 was pregnant having 7 months’ pregnancy, which fact was duly mentioned in the proposal form, at the time of taking the insurance policy. It was represented by the OPs that the baby to be born would also be covered under the above said policy without payment of extra premium and would be covered since the time of birth of baby. On 23.11.2014, complainants No.1&2 blessed with a healthy son named Nividh Goyal intimation with regard to which was sent by complainant No.1 to OPs No.1&2 vide letter dated 27.11.2014.It is stated that at the age of about five months, complainant No.3 became ill and was hospitalized in Chaitanya Hospital, Sector 44-C,Chandigarh on 17.4.2015 ,where he remained admitted up to 15.5.2015 and a sum of Rs.5,13,635/- was incurred on his medical treatment including hospitalization charges etc. Claim was lodged with OP No.1 for reimbursement of the expenses so incurred on his treatment. However, OP no.3 repudiated the claim vide letter dated 27.7.2015 on the ground that complainant No.3 was suffering from the ailment prior to the inception of the policy, which is illegal, untenable and based on hyper technical, shaky grounds and caused mental agony and physical harassments to the complainant. The complainants No.1&2 approached and requested OPs many times for payment of claim but to no effect. The act and conduct of the OPs amounted to deficiency of service on their part. Hence this complaint.
3. On being put to notice, OPs appeared and filed separate written versions. In the written version filed by OPs no.1&3 jointly, preliminary objections have been taken stating that the complaint is not maintainable; that the complainants have no cause or reason to file the present complaint and that the complainants have not come before the Forum with clean hands. On merits , it is stated that complainants No.1&2 were only insured under the subject Medical policy with facility to add on child on his birth for which request was to be made within three months on the birth of the child, which the complainants did not make and no intimation was received from him requesting to add on in the Mediclaim Insurance policy except intimation received on 20.4.2015 through e-mail as regards inclusion of name of the child Nividh Goyal in the insurance policy. Accordingly the name of Nividh Goyal was added in the Medi claim Insurance Policy w.e.f.21.4.2015 itself. Lateron, it was revealed that the child was admitted in the hospital on 17.4.2015 and prior to that was also suffering from fever and other ailments, which fact was concealed by the complainants at the time of making request of inclusion of his name in the insurance policy to cover up the hospitalization medical expenses for pre-existing disease. The claim case of the complainants was processed by OP no.3 and subsequently on its advice the same was repudiated vide letter dated 5.8.2015 under exclusion clause 4.1 for pre-existing diseases. It is stated that the complainants No.1&2 were also requested that if they have any other information or documents to substantiate admissibility of the claim, the same may be provided to them within 15 days but they did not do so. They were also advised that if they were not satisfied with the decision of the OPs, they may write to Grievance Cell for redressal and also in terms of the redressal of Public Grievance Rules,1988 they may also approach the office of Ombudsman but complainants did not do so. There is no deficiency of service on the part of the OPs and have rightly repudiated the claim of the complainant. After denouncing all other averments made in the complaint, it was prayed to dismiss the complaint.
4. In the written version filed by OP no.2 it has taken the preliminary objections that the complaint is not maintainable; that the complainant has not come to the Forum with clean hands and that the complaint is false, frivolous and vexatious and is liable to be dismissed. On merits, it is admitted that the complainant No.1 is maintaining saving bank account No.05902191002861.It is also admitted that the complainants No.1&2 have purchased the insurance policy. There is no deficiency of service on its part and has been wrongly and falsely involved in the present complaint. After denying all other averments made in the complaint, it was prayed to dismiss the complaint.
5. On being called to do so, the ld.counsel for the complainants have tendered in evidence Ex.CA affidavit of the complainant alongwith documents Exs.C1 to C48 and closed the evidence.
The ld.counsel for OPs No.1&3 has tendered in evidence Ex.OPA, affidavit of Smt.Madhu Kaul Tickoo, Sr.Divn.Manager alongwith documents Exs.OP1 to OP5 and closed the evidence.
The ld.counsel for OP no.2 has tendered in evidence Ex.OPB affidavit of Sh.Baljit Singh, Chief Manager, and closed the evidence.
6. We have heard the ld.counsel for the parties, gone through the written arguments filed by the ld. counsel for the complainant & OPs No.1&3 and have also gone through the record of the case, carefully.
7. From the policy document, Ex.C1, it is evident that the complainant No.1 had obtained medi claim insurance policy from OP1. Complainants No.1&2 were duly covered under the said policy as there names have been mentioned under the column, risk details, Ex.C2.As per term No.5.15 of the prospectus Ex.OP6, which reads as under:
“Mid term inclusion of newly wed spouse, new born child and adopted child is permitted provided such inclusion is within three months of marriage, birth and adoption respectively or at the time of renewal of the policy.In the case of new born child and adopted child the inclusion is permitted only if both the parents are covered under the policy”
the complainants no.1&2 were to request the Ops to add on the name of Nividh Goyal, complainant No.3, within three month from the date of his birth . As per complainants No.1&2 they blessed with a son i.e. complainant no.3 on 23.11.2014 and they informed and requested the insurance company vide letter dated 27.11.2014,Ex.C10 i.e. within the stipulated period to add the name of their newly born baby, in the insurance policy in question. Whereas the stand of the Op no.1 is that the letter 27.11.2014 had not been received by it and the complainant No.1 had informed it through e-mail on 20.4.2015,Ex.OP4, for adding the name of his child in the insurance policy. Accordingly, it added the name of complainant No.3 on 21.4.2015 in the insurance policy. Since, the policy inception is from 21.4.2015 and the complainant No.3 was suffering from the ailment prior to the inception of the policy, hence the present ailment is pre-existing and the claim is being denied under exclusion for pre-existing disease.
8. There is no dispute about the birth of Nividh Goyal i.e. complainant No.3, the son of complainants No.1&2 on 23.11.2014. From the copy of prescription card, Ex.C11, issued by Healthy Baby, (a centre of comprehensive child care), it is evident that Mrs. Nitika i.e. complainant No.2 gave birth to a healthy child on 23.11.2014 at 12:14AM. This fact is also not disputed that Nividh Goyal i.e. complainant no.3 fell ill at the age of five months, got admitted in Chaitanya hospital on 17.4.2015 and discharged on 15.5.2015.An amount of Rs.5,13,635/-was incurred on his treatment. For the argument sake, if we believe the contention of OPs no.1&3 that they did not receive the letter dated 27.11.2014, and the complainant no.1 informed it regarding the birth of his son, Nividh Goyal on 23.11.2014 and also made a request to add his name in the insurance policy on 20.4.2015, after the expiry of stipulated period of three months from the date of his birth and has breached the term No. 5.15 of the insurance policy, even, then at the most it could be said that only fault of the insured , complainant No.1 was that he did not inform about the birth of his son within three months but after a delay of two months. Under above circumstances, it could not be said to be a fundamental breach of terms and conditions of the insurance policy. As such the entire claim of the complainants cannot be repudiated on this ground. However, the question of pre-existing disease as raised by OPs No.1&3 did not at all arise in the present case because it is not the case of the Ops No.1&3 that complainant No.3 was suffering from any disease at the time of his birth or immediately thereafter . In the case of Om Parkash Vs. Reliance General Insurance Company Ltd. decided on 4Oct, 2017,the Hon’ble Supreme Court of India has held that, “condition regarding the delay shall not be a shelter to repudiate the insurance claim, which has been otherwise proved to be genuine”. The Hon’ble Supreme Court of India, in the case of Amalendu Sahoo Vs. Oriental Insurance Co. ltd. Vol. II(2010) CPJ 9 (SC) , by referring the decision of the Hob‘ble National Commission, rendered in the case of United India Insurance Company Limited Vs.Gian Singh II(2006)CPJ 83(NC),wherein it has been held that, in a case of violation of condition of the policy, the claim ought to be settled on a non standard basis, it has been held that even if there is any breach of condition of the insurance policy, the insurance company cannot repudiate the claim in toto and is liable to settle the claim on non standard basis .In view of the law laid down by the Hon’ble Supreme Court of India in the case referred above , the insurance company is liable to indemnify the complainants on non standard basis . It may be stated here that the complainants have claimed a sum of Rs.5,13,635/- incurred on the treatment of complainant No.3. However, from the copy of policy schedule Ex.OP5, it is apparent that the complainants were insured for a total sum of Rs.5lacs. Therefore,the insurance company i.e. the OP no.1 is liable to pay 75% of the total sum assured on non-standard basis. Since neither specific allegation has been leveled against OP no.2,nor it has been proved, therefore, the complaint filed against it is liable to be dismissed. It may be stated that OP no.3, which is a TPA is working for an on behalf of insurance company , therefore, no liability can be fastened upon it and the complaint filed against is also liable to be dismissed..
9. In view of the aforesaid discussion, we dismiss the complaint against Ops no.2&3 and partly allow the same against OP no.1 with a direction to it to pay 75% of the total sum assured of Rs.5lacs alongwith interest @7% per annum from the date of repudiation of the claim i.e. 5.8.2015 till its realization alongwith Rs.5000/- as litigation expenses. The OP no.1 is further directed to comply the said order within a period of 45 days from the receipt of the certified copy of this order. Certified copies of this order be sent to the parties under the rules. Thereafter file be indexed and consigned to the Record Room.
ANNOUNCED
DATED:9.11. 2017 NEENA SANDHU
PRESIDENT
NEELAM GUPTA
MEMBER
