Complaint No: 222 of 2021.
Date of Institution: 18.10.2021.
Date of order: 01.04.2024.
Harmeet Kaur Wife of Sh. Bhupendra Singh, resident of Village Dulla Nangal P.O Bangowani Tehsil and District Gurdaspur.
….....Complainant.
VERSUS
1. Reliance General Insurance, Branch Rehan Complex Peer Baba Chowk, Dhangu Road, Pathankot, through its Manager.
2. Reliance General Insurance, R Care Heath No. 1- 89/B/40 to 42/KS/301, 3rd Floor, Krishe Block, Krishe Sapphire, Madhapur, Hyderabad, Telangana – 500081, through its General Manager / Authorized Signatory.
3. Reliance General Insurance Co. Ltd., Winway Building, 2nd & 3rd Floor, 11/12 Block No. 4, Old No. 67 South Tukoganj, Indore (M.P) 452001, through its Authorized Signatory.
….Opposite parties
Complaint U/s 35 of Consumer Protection Act.
Present: For the Complainant: Sh. L.S. Saini, Advocate.
For the Opposite Parties: Sh.Sandeep Ohri, Advocate.
Quorum: Sh.Lalit Mohan Dogra, President, Sh.Bhagwan Singh Matharu, Member.
ORDER
Lalit Mohan Dogra, President.
Harmeet Kaur, Complainant (here-in-after referred to as complainant) has filed this complaint under section 35 of the Consumer Protection Act (here-in-after referred to as 'Act') against Reliance General Insurance Co. Ltd. Etc. (here-in-after referred to as 'opposite parties).
2. Briefly stated, the case of the complainant is that the husband of the complainant has obtained Insurance Policy from the opposite parties under the scheme of Reliance Health Gail Policy Schedule vide Insurance Policy No. 24102192828000028. It is pleaded that the above said policy is valid from 16.03.2019 to 16.03.2020. The complainant paid premium of Rs.7,316/- to the opposite parties at the time of obtaining the policy. 1st premium of this policy was paid in the year 2018 and 2nd premium was paid in the year 2019. The policy was joint in the name of the complainant and her husband. The insured value is Rs.3,00,000/- and cumulative Bonus Family floater is Rs.1,00,000/- which is evident from the schedule of policy. It is further pleaded that the complainant suffered from health problem and she undergone surgery on account of Test Tube Blockage from Sukh Sagar Hospital, 5 Maqbool Road Amritsar, where the complainant was admitted on dated 29.10.2019 and discharged on dated 30.10.2019. The complainant underwent surgery for this disease. The complainant spent Rs.70,000/- on her treatment. It is further pleaded that thereafter, the complainant submitted claim to the opposite parties for making payment of the same, supported with all medical bills and other necessary documents, but to the utter surprise of the complainant, the opposite parties repudiated the claim of the complainant vide letter dated 22.11.2019 with the observations that as per health gain policy, Exclusion Clause 3.3.3 expenses of any treatment arising from or traceable to any pregnancy are not admissible. The observations raised by the opposite parties are totally false, imaginary and like day dreaming. No such term and condition was disclosed by the opposite parties at the time of issuing insurance policy to the complainant. It is further pleaded that it was the duly authorized representative of the opposite parties who completed all the formalities at the time of taking Insurance policy and got the complainant and her husband medically checked up and only after satisfying from all spheres, they were insured by the opposite parties. It is further pleaded that the above mentioned observations of the opposite parties are totally illegal, null and void, based on conjectures and surmises and have no legs to stand, against the rules of the Insurance policy. The opposite parties by repudiating the claim of the complainant on bogus and baseless observations are trying to back out from their pious obligation. This decision of the opposite parties is liable to be set aside and the complainant is entitled to get the amount reimbursed which he had spent on her treatment as per terms and conditions of policy in question. It is further pleaded that it is a case of clear cut deficiency gross negligence in service and unfair trade practice on the part of the opposite parties who did not pay the insured amount to the complainant on false and flimsy grounds and without any reason or rhyme. It is further pleaded that due to this illegal act and conduct of the opposite parties the complainant has suffered great loss and also suffered mental agony, Physical harassment and inconvenience. It is further pleaded that there is a clear cut deficiency in service on the part of the opposite parties.
On this backdrop of facts, the complainant has alleged deficiency and unfair trade practice on the part of the opposite parties and prayed that necessary directions may kindly be issued to the opposite parties to honour the claim of the complainant and make the payment of amount of Rs.80,000/- to the complainant spent on her treatment in terms of the Insurance policy in question alongwith interest @ 18% P.A. from the date of due till actual realization. It is further prayed that Compensation to the tune of Rs.50,000/- may also be awarded to the complainant besides the amount in question on account of mental agony, physical harassment and deficiency in service on the part of the opposite parties. It is further prayed that Litigation expenses to the tune of Rs.5,000/- may also be awarded in favour of the complainant after accepting this complaint, in the interest of justice and fair play.
3. Upon notice, the opposite parties appeared through counsel and contested the complaint and filing their written reply by taking the preliminary objections that at the outset, all allegations stated in the complaint are denied and nothing contained in the complaint shall be considered to be admitted by the answering opposite parties for want of specific traverse. It is pleaded that the insured in this instance Mr. Bhupendra Singh applied and purchased the Reliance Health Gain Policy bearing policy No. 241021928280000028, with validity period between 16.03.2019 to 15.03.2020, for a total sum insured of Rs.3,00,000/- (subject to policy terms and conditions) after reading and understanding the features, benefits, terms and conditions and exclusions mentioned under the policy schedule. As per policy terms and conditions under permanent exclusions, claims in respect of any insured person arising directly or indirectly due to any of the following shall not be admissible.
‘3.3.3 Any treatment arising from or traceable to any fertility, infertility, sub-fertility or assisted conception procedure or sterilization, birth control procedures, hormone replacement therapy, contraceptive supplies or services including complications arising due to supplying services or Assisted Reproductive Technology’.
It is further pleaded that the insured intimated a claim with the answering opposite parties and the answering opposite parties registered the claim of the complainant vide claim No. 201190069398, and requested the insured to submit the documents in support of the claim. On scrutiny of the claim by the answering opposite parties, it was observed that the claim of the complainant was pertaining to treatment of primary infertility, which is evident from the complainant's discharge summary and thus outside the scope of the policy. The claim was therefore, not tenable and the answering opposite parties repudiated the claim of the complainant and communicated the same to the complainant vide repudiation letter dated 17.02.2020. The contents of the repudiation letter are reproduced below for reference,
‘We have evaluated the claim based on the supporting documents submitted by your good self. On careful perusal of the claim documents, we regret to inform you that we are unable to admit the liability of your claim due to the reasons mentioned herein below:-
- As per provided documents patient got admitted and treated for Primary infertility. As per Health Gain Policy Exclusions Clause 3.3.3 expenses of any treatment arising from or traceable to any pregnancy are not admissible.
- Hence, we regret to inform you that the claim is denied as per policy T & C. The above claim reported by you is not admissible as per the terms and conditions of the policy. Hence, we are unable to reimburse / admit any amount under the captioned claim. We have retained the photocopy of the claim documents for future reference’.
It is further pleaded that a contract of Insurance is a bonafide contract between two parties and both the parties are bound by the terms and conditions mentioned in the policy schedule. Any claim that may arise under the policy is subject to these terms and conditions. In light of the above, the claim of the complainant is not tenable and the complainant is not entitled to any compensation from the answering opposite parties. The present complaint is therefore, without any cause of action and is not maintainable and is liable to be dismissed. It is further pleaded that on intimation of the claim by the insured, the answering opposite parties registered the same and requested the insured to submit the documents in support of his claim. On scrutiny of the claim, it was observed that as the ailment of the spouse of the insured was not covered under the policy terms and conditions, the claim of the complainant was not tenable and the same was therefore repudiated and communication of the repudiation was sent to the complainant vide letter dated 17.02.2020. It is further pleaded that there is no deficiency of service from the side of the answering opposite parties and the answering opposite parties has acted in line with the terms and conditions mentioned under the policy schedule and the complaint of the complainant is liable to be dismissed.
On merits, the opposite parties have reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in service on the part of the opposite parties. In the end, the opposite parties prayed for dismissal of complaint with costs.
4. Learned counsel for the complainant has placed on file Self-Attested affidavit of Harmeet Kaur, (Complainant) as Ex.CW-1/A alongwith other documents as Ex.C-1 to Ex.C-19 alongwith complaint.
5. Learned counsel for the opposite parties has placed on file affidavit of Sh. Suryedeep Thakur, (Area Manager (Legal) – cum – Authorized Representative of Reliance Gen. Ins. Co. Ltd., Chandigarh) as Ex.OPW-1,2,3/A alongwith other documents as Ex.OP-1to3/1 to Ex.OP-1to3/4 alongwith reply.
6. Rejoinder not filed by the complainant.
7. Written arguments not filed by both the parties.
8. Counsel for the complainant has argued that complainant had purchased health insurance from opposite parties and complainant and her husband were insured. It is further argued that during the continuation of policy of insurance complainant had to undergo surgery for test tube blockage from Sukh Sagar Hospital where complainant remained admitted from 29.10.2019 to 30.10.2019 and had spent Rs.70,000/- on her treatment. On claim having been lodged the same was repudiated by relying upon exclusion clause No.3.3.3. It is further argued that complainant is not bound by exclusion clause as mentioned above as the said exclusion clause was not part of the policy document and was never explained to the complainant. Accordingly, repudiation of the claim amounts to deficiency in service.
9. On the other hand counsel for the opposite parties has argued that complainant had lodged claim with the opposite parties but on scrutiny of claim it was found that claim of the complainant was regarding treatment of primary infertility, which is outside the scope of the policy. It is further argued that all the terms and conditions of the policy were read over by the complainant and as such the claim has been rightly repudiated and there is no deficiency in service.
10. We have heard the Ld. counsels for the parties and gone through the record.
11. To prove her case complainant has placed on record her self attested affidavit Ex.CW-1/A, copy policy schedule Ex.C1, copy of policy of smart card Ex.C2, copy of discharge card Ex.C3, copies of medical bills Ex.C4 to Ex.C15, copy of prescription slip Ex.C16, copy of Aadhaar Card Ex.C17, copy of repudiation letter Ex.C18 and copy of discharge card Ex.C19 whereas opposite parties have placed on record affidavit of Suryedeep Thakur Area Manager (Legal) Ex.OPW-1,2,3/A, copy of policy schedule Ex.OP-1 to 3/1, cop of claim form Ex.OP-1 to 3/2, copy of discharge card Ex.OP-1 to 3/3 and copy of repudiation letter Ex.OP-1 to 3/4.
12. It is admitted fact that complainant and her husband had purchased Reliance Health Gail Policy from opposite parties valid from 16.03.2019 to 16.03.2020. It is further admitted fact that complainant had undergone treatment from Sukh Sagar Hospital and had spent Rs.70,000/- on her treatment. It is further admitted fact that claim lodged by the complainant has been repudiated vide letter dated 22.11.2019. The only issue for adjudication before this Commission is whether the complainant was supplied with copy of exclusion clause and terms and conditions of the policy or not and if not supplied then whether the opposite parties can repudiate the claim by relying upon exclusion clause.
13. Perusal of policy schedule Ex.C1 shows that it is having only one page. However, on the other hand opposite parties have placed on record complete broacher regarding terms and conditions and policy wording with the complaint consisting of 51 pages and as per clause No.3.3.3. of Ex.OP-1 to 3/1 any treatment arising from or traceable to any fertility, infertility, sub-fertility or assisted conception procedure or sterilization, birth control procedure, hormone replacement therapy, contraceptive supplies or services including complications arising due to supplying services or Assisted Reproductive Technology is excluded under main clause 3.3. The only question which arises is that complainant has taken a plea that complainant was not supplied with the said terms and conditions containing exclusion clause, as such complainant is not bound by the same. Perusal of affidavit of Suryedeep Thakur shows that complainant had obtained policy after reading and understanding the features, benefits, terms and conditions and exclusions mentioned under the policy schedule but perusal of file shows that it is not the case of the opposite parties that policy document was issued on the same day when proposal document was signed by the complainant and when proposal document was signed, the policy schedule was not in existence and when the policy schedule was not in existence at the time of filling of proposal form, then how can opposite parties say that the complainant read and understood the features, benefits, terms and conditions and exclusions mentioned in policy schedule. Meaning thereby it is proved on record that opposite parties have only taken plea to avoid it liability to pay the claim to the complainant. As per settled law it has been categorically held that if the terms and conditions are not supplied and explained to the insured, the insured cannot be made bound with the said terms and conditions of which he/she was not aware. Accordingly, from the above said facts, evidence on record it is proved that said terms and conditions containing exclusion clause were never read over and explained and supplied to the complainant. Accordingly, repudiation of claim amounts to deficiency in service.
14. Accordingly, present complaint is partly allowed and opposite parties are directed to pay amount of Rs.70,000/- to the complainant alongwith interest @ 9% P.A. for the date of filing of the present complaint till realization within 30 days from the date of receipt of copy of this order. No order as to costs.
15. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases.
16. Copy of the order be communicated to the parties free of charges. File be consigned.
(Lalit Mohan Dogra)
President.
Announced: (B.S.Matharu)
April 01, 2024 Member.
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