District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.422/2021.
Date of Institution: 24.08.2021.
Date of Order: 04.11.2022.
Smt. Sushila Butola Wife of Shri Shivdayal Singh, R/o H.NO. 353, C Block, Gali No.3, 22 feet Road, S.G.M.Nagar, NIT, Faridabad – 121001,
…….Complainant……..
Versus
1. Reliance General Insurance Co. Ltd. Servicing Branch Unit No. 306, 3rd floor, Palm Court Building, Near MDI Chowk, Sector-14, Gurugram Haryana through its authorized person.
2. Reliance General Insurance Co. Ltd., Registered office: Reliance Centre, South Wing, 4th floor, Off. Western Express Highway Santacruz (East) Mumbai – 400 0535 through its authorized person.
3. Reliance General Insurance Co. Ltd., Corporate Office: Reliance Centre, South Wing 4th floor off. Western Express Highway Santacruz (East) Mumbai – 400 0535 through its authorized person.
4. Bank of India, 2-A/6, Banglow Plot, Township Faridabad Haryana – 121001 through its authorized person.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. M.S.Baghel, counsel for the complainant.
Sh. Rakesh Dabaas, counsel for opposite parties Nos.1 to 3.
Sh. Y.s.Yaduvanshi, counsel for opposite party No.4.
ORDER:
The facts in brief of the complaint are that the complainant was having the saving bank account No. 670011100036225 in Bank of India i.e. opposite party No.4 and the complainant regularly and continuously maintaining the said account with opposite party No.4. As per the scheme of the group mediclaim policy to their customers of the opposite party No.4, the complainant had taken the group mediclaim policy bearing NO. 130492028451000451 (previous policy No. 1304919284510000410) dated 18.09.2020 to 17.09.2021 for a sum of Rs.5,00,000/- and the complainant time to time making the premium amount pertaining to the said group mediclaim policy to opposite party No.4 The complainant was a continue member/customer of the Group Medi claim policy of the New India Assurance company Limited since 2011 to 2019 through opposite party No.4. Later on in the year 2019 the tie up between then opposite party No.4 and M/s. new India Assurance company Limited broken up and new tie up taken place with opposite party No.4 of the oppose parties Nos.1 to 3 and opposite parties Nos.1 to 3 had given the seniority/continuity benefit of the previous continuous group mediclaim policy between the opposite party No.4 and the complainant. In that condition, the complainant accepted the proposal of opposite parties Nos.1 to 3 and continue the said group mediclaim policy without any interruption with new policy No. which was mentioned above with the continuity benefits. On 17.5.2021 the complainant was not feeling well and feel the chest pain and then the complainant went in Sharma Nursing Home Urological Centre, 136, N.H.5, Railway Road, NIT, Faridabad and where the doctor suggested to the complainant for X-ray and test etc. and also given the medicines to the complainant. The complainant did the X-ray test from Shivam Diagnostic Centre 5-K/120, NIT 5, Faridabad and also taken the Urine examination report from Goel Pathology Laboratory & X-ray Centre and on the basis of the X-ray report and test reports etc. then the doctor of Sharma Nursing Home had given 10 days medicines to the complainant on 19.05.2021 but no relief to the complainant and then the complainant voluntarily went in Fortis Escorts Hospital Faridabad on 27.05.2021 and where the complainant was admitted on 27.05.2021 and her treatment/operation was conducted and she was discharge don 295.2021 and the hospital had raised the bill amount of Rs.1,82,679/-. During the treatment the complainant requested to the opposite parties for cashless facility but the same was denied by opposite parties Nos.1 to 3 vide letter dated 30.05.2021 with the remarks Cashless facility was denied and member was requested to avail possible reimbursement. The complainant had paid the amount of Rs.1,82,679/- as a full and final payment to notice. Later on the complainant had submitted the relevant documents for getting the reimbursement for the mediclaim form the opposite parties Nos.1 to 3 but they also repudiated the claim of the complainant vide its letter dated 21.6.2021. Later on the complainant again personally requested to the opposite parties to make the reimbursement amount but the opposite parties totally refused and the opposite parties intentionally repudiated the claim and held that the policy of the complainant void and all premium paid hereon should be forfeited with the remarks” it was noticed that patient was known case of hypertension since 2017 on regular medication Tan, amlong 40 mg and the same was not disclosed by insured at the time of policy inception 18.9.2019 as per the policy terms and condition under clause 5.1.1.1 Disclosure of information norms the policy should be void an d all premium paid hereon should be forfeited to the company in the event of misrepresentation” and knowingly want to grab the policy amount with an intention not to make the said amount by hook or crook. The complainant requested to the opposite parties to make the reimbursement amount of Rs.1,82,679/- but the opposite parties linger on the matter on one pretext to the another. The complainant sent legal notice dated 12.7.2021 to the opposite parties but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) make the reimbursement amount of Rs.1,82,679/- in respect of Group Mediclaim policy i.e. claim amount alongwith interest @ 18% p.a. to the complainant which had been beared by the complainant from her own pocket during the insurance mediclaim policy.
b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 22,000 /-as litigation expenses.
2. Opposite parties Nos.1 to 3 put in appearance through counsel and filed written statement wherein Opposite parties Nos.1 to 3 refuted claim of the complainant and submitted that the answering opposite parties issued the policy bearing No. 130492028451000451 valid from 18.09.2020 to 17.09.2021 for the insured sum of Rs.5,00,000/-, subject to policy terms and conditions. The complainant intimated claim towards hospitalization form 27.05.2021 to 29.05.2021 and claimed expenses incurred towards hospitalization and the answering opposite party registered the claim of the complainant for processing the same. On scrutiny of the claim and claim elated documents more particularly the claim form, the answering opposite party observed that the complainant was suffering from hypertension had withheld material information in regard to her pre-existing hypertension at the time of taking the policy. It was submitted that hypertension was declining risk and if the complainant had disclosed regarding hypertension, the answering opposite party insurance company would have considered underwriting the risk with proportionate premium. Since the disease was not disclosed at the time of availing the policy, the insurance company was deprived to underwrite the risk and charge appropriate premium. As per 64 VB of Insurance Act, 1938, the insurer should not assume any risk until the premium payable was received by it. In the present matter appropriate premium could not charged due to non disclosure of disease/risk form the complainant. Hence, the claim was not payable under the policy. As per the policy terms and conditions, Clause 5 Disclosure to Information Norm, it was clearly stipulated that in the even of mis-representation or non-disclosure of material facts, the policy should be void. Opposite parties Nos. 1 to 3 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Opposite party No.4 put in appearance through counsel and filed written statement wherein Opposite party No.4 refuted claim of the complainant and submitted that before submitting a paragraph wise reply to the present complaint, the opposite party craves leave of this Hon’ble Commission to submit the following preliminary objections which goes to the very root of maintainability of the present dispute before the Hon’ble Commission and which needs to be considered by the Hon’ble Commission before adjudicating the present complaint on merit. The averments herein were in alternative and without prejudice to one another and the answering opposite party reserves its right to file the evidence by way of affidavit at the appropriate time of proceedings. Opposite party NO.4 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
4. The parties led evidence in support of their respective versions.
5. We have heard learned counsel for the parties and have gone through the record on the file.
6. In this case the complaint was filed by the complainant against opposite parties– Reliance General Insurance Co. Ltd. with the prayer to: a) make the reimbursement amount of Rs.1,82,679/- in respect of Group Mediclaim policy i.e. claim amount alongwith interest @ 18% p.a. to the complainant which had been beared by the complainant from her own pocket during the insurance mediclaim policy. b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 22,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Sushila Butola,, Ex.C-1 – covering page of pass book, Ex.C-2 – Certificate of insurance valid from 18.09.2020 to 17.09.2021, Ex.C-3 – Certificate of Insurance valid form 18.09.2019 to 17.09.2020, Ex.C-4 – prescription, Ex.C-5 to 8 – tests, Ex.C-9 to 12 – Discharge summary, Ex.C-13 – Test, Ex.C-14 – Test report status, Ex.C-15 – Coronary Angiography report, Ex.C-16 - Coronary Angiogram,, Ex,C-17 – Coronary Angioplasty Report, Ex.C-18 – photos, Ex.C-19 – Blood Grouping and Screening for Red Cell alloantibodies, Ex.C-20 to 25 – Tests,Ex.C-26 to 27 – Inpatient Summary Bills, Ex.C-28 to 29– Deposit Receipts, Ex.C-30 – Claim form, Ex.C-31 – denial letter dated 30.05.2021,, Ex.C-32 – letter regarding claim repudiation , Ex.C-34 – letter, Ex.C-35 – insurance policy valid from 10.9.2012 to 09.09.2013, Ex.C-36 – insurance policy valid from 10.09.2013 to 09.09.2014, Ex.C-37 – insurance policy valid from 10.09.2014 to 09.09.2015, Ex.C-38 – insurance policy valid from 10.09.2015 to 09.09.2016, Ex.C-39 – Policy Schedule – BOI National Swasthya Bima Policy, for the period 10.09.2018 to 09.09.2017, Ex.C-40 – Policy Schedule – BOI National Swasthya Bima Policy for the period 18.09.2017 to 17.09.2018, Ex.C-41 – Policy Schedule – BOI National Swasthya Bima Policy, Ex.C-42 – legal notice, Ex.C-43 to 46 – postal receipts, Ex.C-47 to 50– Track consignments, Ex.C-51 – Postal card, Ex.C-52 – Cancelled cheque, Ex.C-53 – photocopy of pan card, ex.C-54 – Adhaar card
On the other hand counsel for the opposite parties strongly agitated
and opposed. As per the evidence of the opposite parties – affidavit of Shri Suryadeep Thakur, Ara Manager (Legal) M/s. Reliance General Insurance Company Limited, Regional Office, SCO-57-58-59, 4th floor, Opposite Hotel Taj, Sector-17A, Chandigarh, Ex.R-1 - Application Form for RGI-BOI Swasthya Bima, Ex.R-2 - Claim Form, Ex.R-3 – letter.
As per the evidence of opposite party No.4 Ex.RW1/A – affidavit of
Priyani Mohan.
7. In this case, the complainant was having the saving bank account No. 670011100036225 in Bank of India i.e. opposite party No.4 and the complainant regularly and continuously maintaining the said account with opposite party No.4. As per the scheme of the group mediclaim policy to their customers of the opposite party No.4, the complainant had taken the group mediclaim policy bearing NO. 130492028451000451 (previous policy No. 1304919284510000410) dated 18.09.2020 to 17.09.2021 for a sum of Rs.5,00,000/- and the complainant time to time making the premium amount pertaining to the said group mediclaim policy to opposite party No.4. Opposite party No.4 has repudiated the claim of the complainant on the ground that patient was known case of hypertension since 2017 on regular medication Tab. Amlong 40 mg and the same was not disclosed by insured at the time of policy inception – 18.09.2019. As per policy T&C – under Clause 5.1.1 disclosure of information norm – the policy shall be void and all premium paid hereon shall be forfeited to the company, in the event of misrepresentation, miss description or non-disclosure of any material fact. 5.1.2 duty of disclosure – in the event of untrue or incorrect statements, misrepresentation, miss description or non-disclosure in the proposal form, personal statement. Declaration+ and connected documents, or any material information having been withheld, or a claim being fraudulent or any fraudulent means or device being used by the policyholder/insured person or any one acting on his/their behalf to obtain a benefit under this policy, the company may cancel this policy at its sole discretion and the premium paid shall be forfeited in its favour. Hence, we regret to inform you that this claim stands non payable.
8. In this case, the repudiation was made only for B.P.Sugar. As per settled law now-a- days it is a life style. Opposite party cannot repudiate the claim of the complainant only this B.P.Sugar. After through the evidence led by both the parties and as per the repudiation letter, the Commission is of the opinion that the complaint is allowed with the payment of 60% of the prayer amount i.e.1,82,679/-.
9. Opposite parties Nos.1 to 3, jointly & severally, are directed to :
a) pay Rs. 1,09,607/- alongwith interest @ 6% p.a. from the date of filing of complaint till its realization.
b) pay Rs.2200/- as compensation on account of mental tension, agony and harassment.
c) pay Rs.2200/- as litigation expenses to the complainant.
Compliance of this order be made within 30 days from the date of receipt of copy of order. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 04.11.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
