BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KAITHAL.
Complaint No.72/2017.
Date of instt.:09.03.2017.
Date of Decision: 09.11.2017.
- Vishva Kant Dua s/o Shri Mahesh Kumar Dua;
- Shweta Dua w/o Vishva Kant Dua,
Both residents of H.No.235, Sector-19, HUDA, Kaithal. ……….Complainants.
Versus
- Piyush Hasija, Hasija Associates, 1st Floor, Ravindra Auto Parts, Pehowa Chowk, Park Road, Kaithal.
- IFFCO TOKIO General Insurance Company Ltd., Corporate Health Claim Team, Iffco Tower, Plot No.3, Sector-29, Gurgaon.
..……..Opposite Parties.
COMPLAINT UNDER SEC. 12 OF CONSUMER PROTECTION ACT, 1986.
Before: Shri Rajbir Singh, Presiding Member.
Smt. Harisha Mehta, Member.
Present : Shri M.K. Nirwani, Adv. for the complainant.
Shri Deepak Seth, Adv. for the Op No.1.
Shri Arvind Khurania, Adv. for the Op No.2.
ORDER
(RAJBIR SINGH, PRESIDING MEMBER).
The complainants have filed the present complaint under Section 12 of Consumer Protection Act, 1986, with the averments that they purchased Swasthya Kavach (Family Health) Policy bearing No.52604062 commencing from 31.3.2016 to 30.3.2017 and another policy No.51635626 in the name of complainant No.2 for individual personal accident policy from Op No.2 through agent Op No.1 commencing from 15.3.2016 to 14.3.2017. It is alleged that complainant no.2 met with an accident on 12.10.2016 due to bull hitting the vehicle and first aid was given by the Shah Hospital. It is further alleged that on 26.10.2016, the complainant was admitted in Shah Hospital, Opp. old Bus Stand, Kaithal and discharged on 9.11.2016. It is further alleged the complainant duly intimated to Ops about the claim of complainant no.2 and also submitted the claim from Part–A and Part-B with Ops, but rejected the claim of the complainant. It is further alleged that he approached to the Ops so many times to release the amount of Rs.87,804/- which was paid by him to Shah Hospital, but Ops did not pay any heed. This way, the Ops are deficient in service. Hence, this complaint is filed.
2. Upon notice, the opposite party No.1 appeared before this forum and filed reply raising preliminary objections with regard to maintainability; locus-standi and cause of action. It is further submitted that Op No.1 is working as an agent of Op No.2 and as such, it is the job of Op No.1 to collect the amount of the premium and all other relevant documents and to further proceed the same to Op No.2 for issuance of policy; that at the time of rising any claim again the Op No.1 will collect the relevant documents and whether the claim will be passed or not, it is the sole jurisdiction of Op No.2 and Op No.1 has no control or say whatsoever of any kind in this matter; that at the time of purchasing the policy through Op No.1, all the policy terms & conditions were made clear to the complainants by Op; that the complainants alleged about the injuries and duly lodged the claim petition before the OP No.2 and Op No.2 repudiated the claim of the complainants and in that repudiation, the Op No.1 has no concern or say whatsoever of any kind. On merits, rest of the contents are denied and so prayed for dismissal the complaint. Further, upon notice, the opposite party No.2 also appeared before this forum and filed reply raising preliminary objections with regard to maintainability and non-joinder & mis-joinder of necessary parties. It is further submitted that no copy of FIR/DDR and MLR regarding the accident was provided by the complainants to the Op No.2; that on scrutiny of claim documents submitted by the complainants, it is noticed that the disease for which the treatment was taken is falling under 2 year waiting period, as per policy Exclusion No.4; that claim of the complainants is beyond the terms & conditions of the policy and the claim of the complainants was rightly repudiated. On merit, it is submitted that the complainant submitted his claim documents on 2.11.2016 without Part-B and Part-B was submitted by the complainants after receiving the repudiation letter, which shows malafide intention of the complainants; that treating doctors has not given any remarks in the discharge slip about the accident of the complainant. Rest of the contents are denied and so, prayed for dismissal the complaint.
3. In support of his case, the complainant tendered in evidence affidavits Ex.CW1/A, Ex.CW2/A; documents Ex.C1 to Ex.C10 and closed evidence on 11.8.2017. On the other hand, Op No.1 tendered in evidence affidavit Ex.RW1/A; documents Mark RA and closed the evidence on 10.10.2017. Further, Op No.2 tendered in evidence affidavit Ex.RW2/A; documents Ex.R-1 to Ex.R-5 and closed the evidence on 10.10.2017.
4. We have heard ld. counsel for both the parties and perused the case file carefully and minutely and have also gone through the evidence led by the parties.
5. Ld. counsel for the complainant reiterated all the points mentioned in the complaint. He argued that they purchased Swasthya Kavach (Family Health) Policy and another policy in the name of complainant No.2 for individual personal accident policy from Op No.2 through agent Op No.1. It is argued that on 12.10.16, the complainant no.2 met with an accident and received first aid by the Shah Hospital. It is further argued that on 26.10.2016, the complainant was admitted in Shah Hospital and discharged on 9.11.2016. It is further argued the complainant duly intimated to Ops about the claim of complainant no.2 and submitted the claim from Part–A and Part-B with Ops, but Ops illegally rejected the claim. It is further argued that the complainant approached to the Ops so many times to release the amount of Rs.87,804/- which was paid by him to Shah Hospital, but Ops did not pay any heed.
6. On the other hand, ld. counsel for the Op No.1 argued that Op No.1 is working as an agent of Op No.2 and as such, it is the job of Op No.1 to collect the amount of the premium and all other relevant documents and to further proceed the same to Op No.2 for issuance of policy. It is further argued that at the time of raising any claim again the Op No.1 will collect the relevant documents and whether the claim will be passed or not, it is the sole jurisdiction of Op No.2 and Op No.1 has no control or say whatsoever of any kind in this matter. Further, it is argued by ld. counsel for the OP No.2 that no copy of FIR/DDR and MLR regarding the accident was provided by the complainants to the Op No.2. It is further argued that on scrutiny of claim documents submitted by the complainants, it is noticed that the disease for which the treatment was taken is falling under 2 year waiting period, as per policy Exclusion No.4. It is further argued that claim of the complainants is beyond the terms & conditions of the policy, hence the same was rightly repudiated. It is further argued that the complainant submitted his claim documents on 2.11.2016 without Part-B and Part-B was submitted by the complainants after receiving the repudiation letter, which shows malafide intention of the complainants. It is further argued that treating doctors has not given any remarks in the discharge slip about the accident of the complainant and prayed for dismissal the complaint.
7. From the pleadings and evidence of the parties, it is not disputed that the complainants had purchased Swasthya Kavach (Family Health) Policy bearing No.52604062 (Ex.C3) commencing from 31.3.2016 to 30.3.2017 and another Individual Personal Accident Policy bearing No.51635626 (Ex.C2) commencing from 15.3.2016 to 14.3.2017 from Op No.2 through agent Op No.1. The complainants alleged that on 12.10.2016, complainant No.2 met with an accident and admitted in Shah Hospital, Opp. Old Bus Stand, Kaithal from 26.10.2016 to 09.11.2016 and paid Rs.87,804/- to the said hospital for the treatment of complainant No.2.
8. According to the complainants, the dispute between the parties is that the Op No.2 has repudiated the claim of the complainants vide letter dt. 20.1.2017 (Ex.C1) on the ground that as per Exclusion No.4 of the policy terms & conditions (Ex.R-5), the “Inter-vertebral Disc Prolapse” disease, for which, the complainant No.2 has taken the treatment from Shah Hospital, Opp. Old Bus Stand, Kaithal, is falling under two year waiting period (other than caused by an accident). (It is pertinent to mention here that the said repudiation letter was also produced by Ops as Ex.R3 on the file). The reasons mentioned in letter Ex.C1 for repudiation the claim of the complainants by the Op No.2, is as under:-
“(1). There is 2 year waiting period for Inter vertebral Disc Prolapse while the policy incepted on 31.03.2015.
(2) The claim is falling under Second year of the policy.
From the above you will appreciate that the disease for which treatment was taken is falling under 2 year waiting period, as per policy exclusion No.4, which read as under:
EXCLUSION NO.4: Any expense incurred during the first two continuous years of operation of the insurance cover on treatment of the following diseases:
Inter-vertebral Disc Prolapse (other than caused by an accident)”
9. Now this Forum has to decide whether “Inter-vertebral Disc Prolapse” disease ‘for which the complainant No.2 has taken treatment from Shah Hospital, Opp. Old Bus Stand, Kaithal from 26.10.2016 to 09.11.2016 and spent there Rs.87,804/- (as alleged by the complainants) for the said treatment, was caused by a road side accident or not. Ld. counsel for the Op No.2 has contended that the complainants submitted the treatment documents ‘without Part B, on 02.11.2016 to Op No.2, from which, it is not proved that the cause of ailment was related to an accident. It is further contended by Op No.2 that Part-B was submitted by the complainants after receiving the repudiation letter from Op No.2. But this contention of Op No.2 has no force as the complainants produced “Doctor’s Initial Assessment (History)” as Ex.C5, in which, the treating doctor has specifically mentioned on the top “H/O RSA at around 12.10.16 C/o Pain in Lower back side” (hereinafter meaning of H/O is ‘History of’ and RSA is ‘Road Side Accident’). Further, the treating doctor also mentioned “RSA” in the column “Details of Procedure/s” of Claim Form – Part B (Ex.C6). The injury suffered by the complainant No.2 in a roadside accident, covers under the policy terms & conditions, as is clear from Exclusion No.4 “COVERAGE UNDER BASE PLAN”, of Ex.R-5 (produced by the Op No.2 on file) and the same reads as under:
“Any expense incurred during the first two continuous years of operation of the insurance cover on treatment of the following diseases: Inter – vertebral Disc Prolapse (other than caused by an accident)”
So, the fact that the complainant No.2 has received the injury Inter – vertebral Disc Prolapse in a roadside accident cannot be denied by the Ops as the same is well proved from Ex.C5 as well as from Ex.C6 and the said disease covers under Exclusion No.4 of the policy terms & conditions (Ex.R-5). The complainant has placed on file bills/receipts Ex.C8 for Rs.63740/- (charges for hospitalization); Ex.C10 to Ex.C32 for Rs.24064/- (charges for medicine, X-ray & OPD), which prove that the complainant No.2 had paid Rs.87,804/- to Shah Hospital, Opp. Old Bus Stand, Kaithal, for her treatment. In these facts and circumstances of the case, we are of the considered view that Ops have wrongly repudiated the claim of the complainants. Hence, the Ops are deficient in providing services to the complainant.
10. Thus, as a sequel of above discussion, we allow the complaint and direct the Ops to pay Rs.87,804/- to the complainants and further to pay Rs.2,200/- as lump sum compensation on account of harassment, mental agony and cost of litigation charges. Let the order be complied with within 30 days, failing which, the complainant shall be entitled interest @ 8% p.a. on the awarded amount from the date of commencement of this order till its realization. A copy of this order be sent to both the parties free of cost. File be consigned to the record room after due compliance.
Announced.
Dt.09.11.2017.
(Harisha Mehta), (Rajbir Singh),
Member. Presiding Member.
Present : Shri M.K. Nirwani, Adv. for the complainant.
Shri Deepak Seth, Adv. for both the Op No.1.
Shri Arvind Khurania, Adv. for Op No.2.
Remaining arguments heard. Order pronounced, vide our separate order in detail of even dated, the present complaint is allowed. File be consigned to record-room after due compliance.
Dated:09.11.2017. Member Presiding Member
