Punjab

Sangrur

CC/416/2016

Mohd. Younas - Complainant(s)

Versus

P.N.B.Met Life Insurance - Opp.Party(s)

Shri Mohd.Izhar

02 Nov 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.  416

                                                Instituted on:    07.06.2016

                                                Decided on:       02.11.2016

 

Mohd. Younas son of Niaz Mohd. Resident of H.No.337-A, Ward No.16, Niaz Bati, Eidgh Road, Malerkotla, Distt. Sangrur.

                                                        …Complainant

                                Versus

1.     PNB Metlife India Insurance Company Ltd. Brigade Seshamahal 5, Vani Vilas Road, Basavanagudi, Banglore-560004, Karnataka through its MD.

2.     Punjab National Bank, Branch Moti Bazar, Malerkotla through its Manager.

                                                        ..Opposite parties

 

For the complainant  :       Shri Mohd. Izhar, Adv.

For OP No.1             :       Shri G.P.Sharma, Adv.

For OP No.2             :       Exparte.

       

Quorum:   Sukhpal Singh Gill, President

                Sarita Garg, Member

 

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Mohd. Younas, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that  the complainant obtained one Metlife Major Illness Health Insurance plan from the Op number 1 at Malerkotla through OP number 2 for Rs.5,00,000/-. It is further averred that the term of the policy was 10 years and the payment mode of the policy was annual instalment of Rs.9650/-. The complainant paid the first premium of the policy through OP number 2 on 12.5.2015.  Further case of the complainant is that on 1.11.2015, the complainant felt stomach problem and as such he consulted Dr. Dinesh Gupta at Ludhiana who advised the complainant to get the lab test regarding the stomach pain.  When the complainant received his lab test, the doctor disclosed to the complainant that he is suffering from Chronic Disease Hepatitis-C, Genotype 3 and since then the complainant is getting the treatment from  Dr. Dinesh Gupta.  Further case of the complainant is that thereafter the complainant intimated the OP number 1 regarding his chronic disease and requested to pay the claim, but the OPs rejected the claim on the ground that the above mentioned disease does not come under the policy.  Further case of the complainant is that the OP wrongly repudiated the claim whereas in the list of major illness, the liver disease figures at serial number 8.  Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant an amount of Rs.5,00,000/- on account of claim amount along with interest @12% per annum and further claimed compensation and litigation expenses.

 

2.             In reply filed by the OP number 1, the allegations levelled in the complaint have been denied except the admitted by the Ops in their written reply. Preliminary objections are taken up on the grounds that the present complaint is false, malicious, incorrect and has been filed with malafide intention and that it is not a consumer dispute.  However, it is admitted that the complainant purchased the policy in question by paying the requisite premium of Rs.9361/-.  It is further stated that under the said plan Major Illness were covered including one mentioned at point 8 and the same have been mentioned in the written reply. It is further stated that the OPs received the critical illness claim intimation dated 21.12.2015 from the complainant thereby stating that the insured was diagnosed with chronic Hepatitus C, Genotype 3 on 28.11.2015 and after scrutiny it was found that the complainant was suffering from chronic Hepatitus C, Genotype 3 which is not an End Stage Liver Disease as mentioned under point 8 of the policy document, as such it was found that the complainant is not entitled to claim the amount. However, it is stated that the claim has righty been repudiated. Lastly, the OP has prayed for dismissal of the complaint with special costs.

 

3.             Record shows that the OP number 2 did not appear despite service, as such was proceeded exparte.

 

4.             The learned counsel for the complainant has produced Ex.C-1 copy of OPD slip, Ex.C-2 copy of bill dated 28.11.2015, Ex.C-3 copy of report, Ex.C-4 copy of letter dated 28.11.2015, Ex.C-5 copy of application, Ex.C-6 copy of reminder, Ex.C-7 copy of letter, Ex.C-8 copy of booklet, Ex.C-9 affidavit, Ex.C-10 CD, Ex.C-11 copy of conversation of CD and closed evidence. On the other hand, the learned counsel for the OP number 1 has produced Ex.Op1/1 affidavit along with annexure OP-1 and OP-2 and closed evidence.

 
5.             We have carefully perused the complaint, written version of the opposite parties, evidence of the parties and heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.

 

6.             It is an admitted fact that the complainant obtained the services of the OP number 1 by getting a policy, namely, PNB Metlife Major Illness Premium policy bearing number 21573414 dated 19.5.2015 for Rs.5,00,000/- by paying the requisite premium of Rs.9650/-, as is evident from the copy of  policy, Ex.C-5 on record.   Further it is an admitted fact that the complainant felt stomach problem on 1.11.2015 and as such he consulted Dr. Dinesh Gupta at Ludhiana and then the doctor advised the complainant to get laboratory test regarding the stomach pain it was found that the complainant was suffering from chronic disease Hepatitis-C, Genotype-3 and since then the complainant has been taking the treatment from Dr. Dinesh Gupta of Deepak Hospital, Ludhiana. The complainant has produced on record Ex.C-1 the copy of prescription slip issued by Dr. Dinesh Gupta and Ex.C-2 is the copy of consultation fee  and Ex.C-3 is the copy of the result card issued by SRL Diagnostics showing that the complainant is suffering from HCV RNA Genotyping Genotype 3, which is a liver disease and Ex.C-4 is the copy of certificate issued by Dr. Dinesh Gupta, MD, DM, wherein he has clearly mentioned that the complainant is suffering from Chronic Hepatitis C, Genotype 3.   But, the stand of the OPs in the present case is that the case of the complainant is not covered under clause 8.  Now, the question which arises for determination is whether the case of the complainant falls under the clause 8 of the terms and conditions of the policy.

 

7.             It is the case of the complainant that he was suffering from the Chronic Hepatitis C, Genotype 3, which is a liver disease and as such is covered under the clause 8 of the terms and conditions of the policy, which provides that End Stage Liver disease means chronic end stage liver failure evidenced by all of the uncontrollable ascites, permanent jaundice, Oesophageal or gastric varices and portal hypertension and hepatic encephalopathy, however the liver disease arising out of or secondary to alcohol or drug abuse is excluded.  Further the Ops have not got examined the complainant at the time of issuing the policy in question.  It is the case of the complainant that the OPs repudiated the claim vide letter dated 14.5.2016, Ex.C-7 on the ground that he is not covered under the clause 8, whereas it is specifically mentioned in the condition at point 8 that the end stage liver disease means chronic end liver failure.  Moreover, it is an admitted fact that the jaundice is a symptom of many medical problems, but it is most often associated with conditions of the liver or the gallbladder.  The fact remains that the complainant suffered from the disease Hepatitis-C, Genotype-3 which is also covered under the liver disease.  As such, we feel that by repudiating the genuine claim of the complainant, the Ops are deficient in service.   It is an admitted fact that the policy in question is for Rs.5,00,000/-, which is payable in case the insured is diagnosed under clause 8 of the terms and conditions of the policy.

 

8.             In view of our above discussion,  we allow the complaint and direct OP number 1 to pay to the complainant an amount of Rs.5,00,000/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 7.6.2016 till realisation in full. Op number 1 is further directed to pay to the complainant an amount of Rs.5,000/- in lieu of litigation expenses.

 

9.             This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

                Pronounced.

                November 2, 2016.

                                                        (Sukhpal Singh Gill)

                                                           President

 

 

                                                                (Sarita Garg)

                                                                    Member