Haryana

Karnal

98/2014

Sh. Dhan Parkash Garg - Complainant(s)

Versus

Oriental Insurance Company - Opp.Party(s)

Sh. J.P. Singh

06 Nov 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL. 

                                                     Complaint No. 98 of 2014

                                                    Date of instt. 07.04.2014

                                                     Date of decision 06.11.2017

 

Dhan Parkash Garg son of Shri Matu Ram Garg resident of House no.48, Sector-8, Part-II, Urban Estate, Karnal as a Nominee of his brother Late Shri Mahabir Parshad i.e. Policy Holder.

                                                                                 ……..Complainant.

                                        Versus

1. The Oriental Insurance Company Limited Regd. Office:- A-25/27, Asaf Ali Road, New Delhi-110002 through its M.D.

2. The Oriental Insurance Company Limited C.B.O.-1, Karnal New York Hotel, G.T. Road, Karnal through its Branch Manager.

3. M/s Medi Assist India TPA Pvt. Ltd. SCO no.61, 2^nd floor, Phase-7, Mohali Punjab-160062.

                                                   

     ..…Opposite Parties.

 

    Complaint u/s 12  of the Consumer Protection Act 1986.

 

Before     Sh. Jagmal Singh…….President.

                Ms. Veena Rani……….Member

                Sh.Anil Sharma…….Member.

 

Present: Shri J.P. Singh Advocate for the complainant.

               Shri Amit Gupta Adv. for opposite parties.

              

               

                (JAGMAL SINGH, PRESIDENT)

 

 ORDER:

 

                This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986, on the averments that Mahabir Parshad (deceased life assured) brother of complainant had purchased an insurance policy i.e. P.N.B. Oriental Royal Medi-Claim Policy, vide policy no.261301/48/2012/1649, valid from 1.3.2012 to 28.2.2013 and the same was again renewed vide policy no.261301/48/2013/2032, valid from 1.3.2013 to 28.2.2014. Complainant was the beneficiary in the said policies. Policy holder remained under treatment from 6.7.2013 to 15.07.2013 in Life Care Hospital, Sector-7, Urban Estate, Karnal and after discharged on 15.7.2013, the 60 days outdoor treatment continued and huge amount was spent. Policy holder spent Rs.94,731/- on his treatment. The policy holder claimed for Re-imbursement as per policy, but OPs repudiated the claim without any sufficient cause and rhyme on 7.10.2013. Unfortunately, the policy holder died on 17.10.2013. Complainant being beneficiary of the policy requested the OPs to admit the claim, but OPs did not pay any heed to the request of the complainant and refused to admit the claim of the present complainant and hence complainant filed the present complaint.

2.             Notice of the complaint was given to the opposite parties, opposite parties no.1 and 2 appeared and filed written statement raising preliminary objections with regard to maintainability; not consumer; locus standi and concealments of true and material facts. The true facts are that Mahabir Parshad (deceased life assured hereinafter referred as DLA) had purchased Mediclaim policy no.261301/48/2013/ 2032 from the OPs valid from 1.3.2013 to 28.2.2014. At the time of issuance of the policy DLA did not disclose that he was a chronic smoker and was suffering from Pulmonary disease/respiratory ailments. As per exclusion clause no.4.7, which reads as under:-

        “Convalescence, general debility, “run down” condition or rest cure, congenital, external and internal diseases or defects or anomalies, sterility any fertility, sub fertility or assisted conception procedure, venereal diseases, intentional self injury, suicide, all psychiatric and psychosomatic disorders and disease, accident due to and/or use, misuse or abuse of drugs/alcohol or use of intoxicating substances or such abuse or addiction etc.”

 

The opposite parties were not liable to pay any amount, in case the ailment/death of the insured has occurred due to his/her misuse or abuse of any intoxicating substances or addiction etc. A perusal of the medical documents submitted by DLA revealed that he was a chronic smoker. The claim lodged by DLA was covered under aforesaid exclusion clause no.4.7, the OPs repudiated the claim, vide letter dated 7.10.2013 on the ground of withholding true, complete facts regarding his ailment, addiction etc.  It has further been submitted that complainant has claimed himself to be a nominee under the policy. The complainant was neither a consumer of the OPs nor any service was provided by the OPs to the complainant. Hence there was no deficiency in service on the part of the opposite parties no.1 and 2 and prayed for dismissal of the complaint.

3.             OP no.3 has not filed any separate written statement and learned counsel for opposite party no.3 made statement that the written statement of OPs no.1 and 2 be read as written statement of OP no.3.

4.             Complainant tendered into evidence his affidavit Ex.C1 and documents Ex.C2 to Ex.C17 and closed the evidence on 23.2.2016.

5.             On the other hand, opposite parties tendered into evidence affidavit of R.S. Rahlan Ex.OP1/A and documents Ex.OP1/B to Ex.OP1/J and closed the evidenced on 27.7.2016.

6.             We have heard the learned counsel for the both the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             It is admitted case of the parties as is clear from the pleadings that the brother of the complainant obtained a mediclaim   policy no.261301/48/2012/1649 from OPs, valid from 1.3.2012 to 28.2.2013 and the same was again renewed vide policy no.261301/48/2013/2032, valid from 1.3.2013 to 28.2.2014. It is  also admitted that DLA admitted in the hospital from 6.7.2013 to 15.7.2013 and spent Rs.68,475/- on his treatment. It is also admitted that DLA taken 60 days treatment as outdoor patient and spent Rs.26,256/-. OPs repudiated the claim on the ground that claimant was chronic smoker. The question arises that whether the insured was chronic smoker and to prove this fact, the onus was on the OPs. The OPs tendered into evidence affidavit Ex.OP-1/A and documents Ex.OP-1/B to Ex.OP-1/J. Out of these documents Ex.OP-1/I and Ex.OP-1/J are the repudiation letter dated 28.8.2013 and 8.9.2013 regarding claim as indoor and outdoor treatment respectively. None of the document from Ex.OP-1/B to Ex.OP-1/H shows that the insured was a chronic smoker. The OPs has alleged in the repudiation letter Ex.OP-1/i that as per the submitted documents it is evident that the claimant was chronic smoker which is predisposing factor to the development of Respiratory Ailments including COPD. The OPs did not produce the relevant document on the basis of which the OPs presumed that insured was chronic smoker. Rather the complainant has placed on the file a document Ex.C-13 which was issued by the treating doctor and it is mentioned in this document that the patient was chronic smoker but had stopped smoking since 4 years. If the OPs has taken this fact from this document submitted by the complainant for his claim, then the OPs have taken it partly and the OPs have not taken into consideration that the said doctor has also mention is the same document that the insured had stopped smoking since 4 years. Moreover, the OPs even did not place on the file, the copy of proposal form on the file, whereas the complainant has produced the same on the file as Ex.C-3. On perusal of Ex.C-3, it is found that there is no such column in it vide which any question regarding smoking was asked. As already stated above the OPs have failed to prove on the file that the insured was chronic smoker at the time of taking treatment in question as well as at the time of taking the policy in question. In these circumstances, we are of the considered view that the OPs have wrongly repudiated the claim of the complainant and hence are deficient.

8.             The OPs contended that complainant is not a consumer of OPs. No doubt the insured had died and this fact has not been disputed by the OPs. The complainant filed the present complaint being nominee and beneficiary of DLA Mahavir Parshad and to prove the same, the complainant has placed on the file the copy of proposal form Ex.C-3. In the column of name of Nominee, the name of complainant has been mentioned as beneficiary in the case of death of insured. So, the complainant is consumer and the present complaint is maintainable.

9.             Thus, as a sequel to the foregoing reasons, we allow the present complaint and direct the opposite parties to pay Rs.94,731/-  to the complainant within 30 days from the receipt of copy of this order. We further direct the opposite party to pay Rs.5000/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. It is made clear if the abovesaid amount is not paid within stipulated period of 30 days then this amount will carry interest @ 8% per annum from the date of order till its realization. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 06.11.2017

                                                                  

                                                                  President,

                                                         District Consumer Disputes

                                                        Redressal Forum, Karnal.

 

 

                        (Veena Rani)       (Anil Sharma)

                          Member                Member