Punjab

Sangrur

CC/211/2020

Yash Paul Advocate - Complainant(s)

Versus

Reliance General Insurance Company Limited - Opp.Party(s)

Sh. Sanjeev Goyal

22 Feb 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

                                                                         Complaint No. 211

 Instituted on:   04.08.2020

                                                                         Decided on:     22.02.2024

Yash Paul Advocate aged about 51 years son of Sh. Dev Raj, resident of Veer Colony, Near Post Office, Ward No.12, Bhawanigarh, Tehsil Bhawanigarh, District Sangrur.

                                                         …. Complainant.     

                                                 Versus

1.             Reliance General Insurance Company Limited, 1^st Floor, 36/27, Near Leela Bhawan, Patiala through its Branch Manager.

2.             Reliance General Insurance Company Limited, Registered Office: H-Block, 1^st Floor, Dhirubhai Ambani Knowledge City, Navi, Mumbai through its Managing Director.

                                                        ..Opposite parties.

 

For the complainant    :       Shri Udit Goyal, Adv.

For Opp.parties          :       Shri Amit Goyal, Adv.

 

Quorum                                           

Jot Naranjan Singh Gill, President

Sarita Garg, Member

                        Kanwaljeet Singh, Member

 

ORDER

SARITA GARG, MEMBER

1.             Complainant has preferred the present complaint against the opposite parties  on the ground that in the month of March, 2018 the agent of OPs approached the complainant for selling the health insurance policy and the complainant accordingly proposed for the insurance policy of OPs for himself and his wife for an amount of Rs.6,00,000/- by paying the requisite premium of Rs.19,900/- in cash to the agent of the OPs and accordingly the OPs issued policy bearing number 201021828280000087 for the period from 08.03.2018 to 07.03.2019 and the policy was on floater basis.  Further case of complainant is that in the first week of December, 2018 wife of the complainant, namely, Krishna Rani suddenly fell in the kitchen and suffered injuries for her left knee, as such she was immediately taken to Dr. Gupta Hospital, Bhawanigarh for treatment, but she could not get much relief. As the complainant came to know that Dr. Jatinder Singla, M.S. Ortho is visiting at Dr. Garcha Hospital, Sangrur and accordingly on 8.12.2018 Krishna Rani was taken to Dr. Garcha Hospital, where Dr. Jatinder Singla after checking advised certain medicines and complete bed rest for 10 days. Thereafter complainant sought the second opinion from Dr. Raj Kumar Bajaj, MS (Ortho) Panchkula and after check up he advised medicines and bed rest and regular physiotherapy. The wife of the complainant remained on bed rest for about four months and thereafter she was advised for knee replacement surgery as the gap has come in the knee.  Thereafter on the advice of Dr. Jatinder Singla, surgery at Kare Partners Hospital, Chandigarh was conducted where an amount of Rs.3,00,000/- were spent. The complainant accordingly intimated the OPs for pre-authorisation request for the cashless treatment for the surgery of his wife, which was rejected by the OPs on wrong and false allegations.  The claim of the complainant was also rejected on the ground that wife of the complainant was suffering from hypertension. Though the complainant spent total amount of Rs.3,80,000/- on the treatment, but the claim was not paid by the OPs. 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 the claim amount of Rs.3,80,000/- alongwith with interest @ 18% per annum and further claimed compensation and litigation expenses.

2.             In reply filed by OPs, legal objections are taken up on the grounds that the complaint is not maintainable in the present form, that the complainant has not come to this Commission with clean hands, that the complainant had not disclosed the previous medical condition while taking the policy in question and the claim is said to has rightly been repudiated and that the complaint is false and frivolous which should be dismissed. On merits,  it is admitted that the complainant obtained the insurance policy in question for the period from 8.3.2018 to 7.3.2019 for a sum of Rs.6,00,000/- on floater basis for himself and his wife Krishna Rani. It is further averred that in fact as per the x-ray reports and diagnosis of treating doctor at Mukat Hospital, Chandigarh clearly shows that wife of the complainant was suffering from Osteoarthritis both knees and was advised total knee replacement (left). Further she was suffering from hypertension for the last 5-8 years and was taking regular medicine for the same, which was not disclosed at that time.  It is admitted that claim of the complainant i.e. pre-authorisation request for total knee replacement of left knee was declined by the OPs vide letter dated 29.5.2019 on the ground that as per pre-authorisation request being sent by the concerned hospital, patient was suffering from hypertension for the last 5-8 years. It has been denied that the claim was rejected. The other allegations levelled in the complaint have been denied and prayed for dismissal of the complaint with costs.

3.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-11 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OP/1 to Ex.OPs/13 and closed evidence.

4.             We have gone through the pleadings put in by  the parties along with their supporting documents with their valuable assistance. 

5.             It is an admitted fact between the parties that complainant and his wife were insured with the OPs under the medical insurance policy in question. The contention of the complainant is that during the subsistence of the insurance policy in the first week of December, 2018 wife of the complainant suddenly fell in the kitchen and suffered injuries in her left knee, as such she was immediately taken to Dr. Gupta Hospital, Bhawanigarh and thereafter to Dr. Jatinder Singla, M.S. Ortho who is visiting at Dr. Garcha Hospital, Sangrur and accordingly on 8.12.2018 Krishna Rani was taken to Dr. Garcha Hospital, where Dr. Jatinder Singla after checking advised certain medicines and complete bed rest for 10 days. Thereafter the complainant sought the second opinion of Dr. Raj Kumar Bajaj, MS (Ortho) Panchkula and after check up he advised medicines and bed rest and regular physiotherapy. The wife of the complainant remained on bed rest for about four months and thereafter she was advised for knee replacement surgery as there was a gap in the knee.  Thereafter on the advice of Dr. Jatinder Singla, surgery at Kare Partners Hospital, Chandigarh was conducted where an amount of Rs.3,00,000/- were spent. The complainant accordingly intimated the OPs for pre-authorisation request for the cashless treatment for the surgery of his wife, which was rejected by the OPs on wrong and false allegations.  The claim of the complainant was also rejected on the ground that wife of the complainant was suffering from hypertension. Though the complainant spent total amount of Rs.3,80,000/- on the treatment, but the claim was not paid by the OPs, as such has prayed for acceptance of the complaint.  Ex.C-3 is the copy of insurance policy which shows that Krishna Rani wife of the complainant was insured with the OPs. Ex.C-4 is the copy of prescription slip which shows that she was brought to the doctor Jatinder Singla for felling at home. Ex.C-5 is again the prescription slip. Ex.C-6 is the copy of prescription slip of Bajaj Orthopaedic Centre whereby some medicines were prescribed and also advised physiotherapy. Ex.C-8 are the copies of various medicine and treatment bills. Ex.C-9  is the copy of certificate issued by the Physiotherapist. Ex.C-10 is the copy of SMS whereby the pre authorisation request of the complainant was rejected.  

6.             On the other hand, the learned counsel for the OPs has admitted the insurance of the complainant and his wife Krishna Devi and it is further admitted that the pre-authorisation of the complainant was denied. Ex.OP/11 is the copy of repudiation letter and a bare perusal of it reveals that as per clause 3.2 Specific Waiting Period: expenses related to the treatment of the following listed conditions, surgeries/treatments shall be excluded until the expiry of 24 months of continuous coverage, as may be the case after the date of inception of the first policy with the company. The company reserves the right to add reasons of repudiation on other grounds not listed above and available to the company at a later stage.   But in the present case the learned counsel for complainant has drawn our attention towards the clause 3.3 of the insurance policy, Ex.OP/11 which mentions that: First Thirty Days Waiting Period: Expenses related to the treatment of any illness within 30 days from the policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered. A bare perusal of the insurance policy Ex.C-2 clearly shows that it was issued on 8.3.2018 and ending on 7.3.2019, but in the present case the complainant suffered accidental injuries on her left knee by felling in the kitchen in December, 2018 meaning thereby she suffered injuries after the period of thirty days of commencement of the insurance policy in question. As such, we are of the considered opinion that OPs have wrongly and illegally repudiated the rightful claim of the complainant.  Further a bare perusal of the written reply clearly finds mention that the claim of the complainant i.e. pre-authorisation request for total knee replacement of left knee was declined by the OPs vide letter dated 29.5.2019 on the ground that as per pre-authorisation request being sent by the concerned hospital, patient was suffering from hypertension for the last 5-8 years however, this fact was not disclosed at the time of making the proposal for the policy, hence the claim was repudiated as per policy terms and conditions.  But we are unable to go with the contention of the learned counsel for the OPs that the claim can be rejected on the ground of hypertension as the Hon’ble National Commission in Bajaj Allianz General Insurance Company Limited versus Valsa Jose 2012(4) CPJ 839 (NC), wherein it has been held that patient was taking medicine for hypertension for some time does not amount to suppression of material fact because as is well known hypertension is usually a lifestyle disease and easily controlled with conservation medication. There is no evidence that it was so acute or high that it was responsible for respondents subsequent angioplasty or any other past major illness. Repudiation of claim was held to be unjustified on this ground.   The same view has also been taken by the Hon’ble National Commission in Satish Chander Madan versus M/s. Bajaj Allianz General Insurance Co. Ltd. 2016 (1) CPJ 613 (NC).   Further in Life Insurance Corporation of India versus Sushma Sharma 2008(2) CPJ 213 (Punjab State Commission),  wherein the case was that insured was suffering from hypertension and diabetes for last 10 years before death and it was not disclosed. Repudiation of claim under section 45 of Insurance Act. It is not concealed fact of every fact that gives right of repudiation of claim. Hypertension and diabetes are not material diseases. If these diseases had been material insured would not have survived for 10 years. Complaint allowed by Forum. Payment of insurance claim with interest was directed and the appeal of the opposite parties/insurance company was dismissed. In the circumstances of the case, we find that the OPs have wrongly and illegally repudiated the rightful claim of the complainant.

7.             Now, coming to the quantum of compensation payable to the complainant. Admittedly, the insurance policy is for the sum insured of Rs.6,00,000/- on floater basis.  The complainant has though claimed an amount of Rs.3,80,000/-, but the complainant has produced the treatment bills Ex.C-8, a total of which comes to Rs.2,45,571/-. Further the complainant has spent an amount of Rs.23,200/- on the physiotherapy  as per certificate Ex.C-9 of Your PHYSIO and conducted physiotherapy for the period from 29.1.2019 to 13.2.2019 and 3.6.2019 to 30.7.2019 for total 74 days. The total amount spent by the complainant comes to Rs.2,68,771/-. As  such, we find that the OPs are liable to pay to the complainant an amount of Rs.2,68,771/- which were illegally and wrongly withheld by the Ops. 

8.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

9.             Accordingly, in view of our above discussion, we allow the complaint and direct OPs to pay to the complainant the claim amount of Rs.2,68,771/- alongwith interest @ 7% per annum from the date of filing of the present complaint i.e. 04.08.2020 till realisation. Further OPs are directed to pay to the complainant an amount of Rs.5000/- as compensation for mental tension, agony and harassment and further an amount of Rs.5000/- on account of litigation expenses. This order be complied with within a period of sixty days of receipt of copy of this order.

10.            The complaint could not be decided within the statutory time period due to heavy pendency of cases.

11.            Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance. 

                        Pronounced.

                        February 22, 2024.