Haryana

Yamunanagar

CC/286/2011

Harbans Lal Bhatia S/o Malik Chand Bhatia - Complainant(s)

Versus

Royal Sundaram Alliance Insuarance Company Ltd. - Opp.Party(s)

Anuj Jain

02 Aug 2016

ORDER

 

BEFORE THE DISTT.CONSUMER DISPUTES REDRESSAL FORUM YAMUNA NAGAR JAGADHRI

 

                                                                                    Complaint No. 286  of 2011.

                                                                                    Date of Institution: 01.04.2011

                                                                                    Date of Decision: 02.08.2016

1. Harbans Lal Bhatia aged about 60 years son of Sh. Malik Chand Bhatia      
2. Smt. Janak Bala aged about 55 years wife of Sh. Harbans Lal Bhattia,

      Residents of 903-B, Harbans Pura Colony, Yamuna Nagar.

                                                                                                                ..Complainants

           Versus

 

1. Royal Sundaram Alliance Insurance Co. Ltd., Sundaram Towers, 45 & 46, Whites Road, Chennai through its M.D./Chairman.
2. TTK Healthcare TPA Private Limited, No. 88, Anmol Palani Building 2^nd Floor, G.N. Chetty Road, T. Nagar, Chennai through its M.D.
3. Citi Financial Consumer Finance India Limited, Gobindpuri Road, Opp. J.K. Residency, Yamuna Nagar through its Manager/Incharge.  

                                                                                                              ..Respondents.

 

BEFORE:         SH. ASHOK KUMAR GARG …………….    PRESIDENT

                        SH. S.C. SHARMA  …………………………MEMBER  

 

Present: Sh. Anuj Jain, Advocate, counsel for complainant.

              Sh. Rajiv Gupta, Advocate, counsel for respondent No.1.

              Respondent No.2 already ex-parte vide order dated 20.05.2011.

              Sh. P.K. Kashyap, Advocate counsel for respondent No.3.

ORDER   

1.                     The complainants have filed this complaint u/s 12 of the C. P. Act, 1986. 

2.                     Brief facts of the present complaint, as alleged by the complainant, are that complainant no.1 has got sanctioned a loan of Rs. 3,50,000/- from respondent No.3 (hereinafter referred as OP No.3.) on 18.01.2010 and at the time of sanctioning the said loan, the Op No.3 on behalf of Op No.1 company had introduced joint insurance scheme of Health Shield Classic and on their representation complainant No.1 agreed for the said scheme for himself and his wife i.e. complainant No.2. A sum of Rs. 5871/- was paid as Health Shield Premium by the complainants to the Op No.3 who has issued receipt and certificate of insurance dated 18.01.2010 on behalf of OP No.1 alongwith Health Card of complainants.  The complainant No.2 was diagnosed as Genitourinary koch’s and she was advised admission as she was suffering from hypotension and breathlessness and she had been admitted in Sir Ganga Ram Hospital, Delhi w.e.f. 18.05.2010 to 25.05.2010 where she was operated by the doctor. The complainants have spent Rs. 68,361.75 and for the said claim they completed all the formalities and sent all the required documents alongwith claim form to OP No.2 i.e. TTK Healthcare TPA Private Limited. The OP No.2 further demanded some documents vide letter dated 06.07.2010(Annexure C-4) for the claim, which were also supplied by the complainants. However OP No.1 rejected the claim of the complainants vide letter dated 14.09.2010 on false and frivolous grounds. The complainants again requested to the OPs to reconsider their claim vide letter dated 26.11.2010 but OP No.1 again repudiated the claim of the complainants vide letter dated 15.12.2010 (Annexure C-5) on the ground that ‘’The claim file has been reviewed again in the light of your representation and we wish to confirm the contract of insurance is based on the doctrine of “Utmost Good Faith” and as the pre-existing nature of diabetes was not revealed to us at the time of proposing of insurance hence the contract of insurance itself becomes null and void. Though present admission is for a different ailment and not related to diabetes, since pre-existing nature of diabetes was not disclosed to us hence, the claim was denied by us and policy was cancelled. Even after receiving the letter dated 15.12.2010(Annexure C-5) the complainants approached the Ops and requested them to make the payment but they have not paid any heed to their genuine request and have evaded the matter on one pretext or the other. Hence, this complaint.

3.                     Upon notice, OPs No.1 & 3 appeared and filed its written statement separately whereas OP No.2 failed to appear despite service, hence he was proceeded ex-parte vide order dated 20.05.2011.

4                      OP No.1 filed its written statement by taking some preliminary objections such as complaint is not maintainable; no territorial jurisdiction to entertain and try the present complaint as no part of insurance contract was made at Yamuna Nagar since the policy was issued from Chennai, Hospitalization was done at Delhi Mumbai and TPA claim was lodged at Bangalore and on merit it has been admitted that the complainants had taken a family health shield classic policy bearing No. SU16155159000100 from the OP No.1 for the period 18.01.2010 to 17.01.2011 and complainant had made a claim in respect of hospitalization expenses incurred by her wife i.e. 2^nd complainant Smt. Bala as she was remained admitted from 21.02.2010 to 28.02.2010 for the ailment of Genitourinary Koch’s at Sir Ganga Ram’s Hospital at New Delhi. It has been further submitted that the complainant’s claim was discreetly investigated and the investigation revealed that Smt. Bala was suffering from ailment of diabetes before the inception of the policy taken from OP No.1. The complainant had concealed a material fact on the health condition of Smt. Bala as the same was not disclosed to the OP Insurance Co. while taking the policy under the proposal form filled by the complainant. It is further submitted that the history of the ailment of diabetes was not disclosed to OP No.1 at the time of taking the policy. It has been further submitted that the claim of the complainant was carefully scrutinized on the basis of available records and discharge summary, in accordance with policy conditions, so, there is no deficiency or negligence in service on the part of Op No.1 in dealing with the claim. Lastly, prayed for dismissal of complaint.      

5.                     OP No. 3 filed its written statement by taking some preliminary objections such as complaint is not maintainable being false, frivolous, baseless, misconceived and is filed with ulterior motive and malafide intention by the complainant; complainant has not approached this Forum with clean hands and on merit it has been submitted that the complainant has defaulted in making the payment of the equal monthly installments( EMIs) and has failed to fulfill its obligations under the loan agreement No. 16155159 signed between the OP No.3 and complainant. It has been further submitted that the complainant paid only 18 EMIs out of 48 EMIs and Rs.2,66,418.26 is still outstanding. Although the Op No.3 is only involved in issuance of personal loan, it also endeavors to provide its customers, including the complainant with various other facilities. As a part of this endeavor, the Op No.3 facilitates certain other additional facilities/benefits to its customers, inter alia, introducing to insurance facility like joint insurance scheme of Health Shield Classic Floated by insurance Companies like Royal Sundaram Allianz Co. Private Ltd. It has been further submitted that the availing of these policies by the customers were optional. Complainant signed the documents after reading the loan agreement and Health Declaration Form and as per Health Declaration Form the Citi Financial Consumer Finance India Ltd. was not under any obligation. It has been admitted that the complainant approached to OP No.3 to avail the  said personal loan vide loan agreement No. 16155159 of Rs. 3,50,000/- repayable in 48 EMI’s and controverted the plea taken by the complainant and reiterated the stand taken in the preliminary objections and lastly prayed for dismissal of complaint.  

6.                     To prove the case, counsel for the complainants tendered into evidence affidavit of complainant Harbans Lal as Annexure CX and documents such as Photo copy of certificate of insurance- Health Shield Classic as Annexure C-1, Photo copy of Health Card as Annexure C-2, Photo copy of claim form as Annexure C-3, Photo copy of Photo copy of letter dated 06.07.2010 relating of medical as Annexure C-4, Photo copy of claim repudiation letter dated 15.12.2010 as Annexure C-5 and closed the evidence on behalf of complainants.  

7.                     On the other hand, counsel for the OP No.1  tendered into evidence affidavit of G.Vinay Prakash son of Shri K. Govinda Reddy as Annexure RW/A and documents such as Photo copy of claim repudiation letter dated 15.12.2010 as Annexure R-1, Photo copy of policy schedule as Annexure R-2 and closed the evidence on behalf of OP No.1. 

8.                     Counsel for OP No.3 tendered into evidence affidavit of Priya Ranjan authorized representative of M/s Citi Financial Consumer Finance India as Annexure RW3/A and documents such as Photo copy of Declaration-Cum- Health Declaration Form as Annexure R3/1, Photo copy of Certificate of Insurance as Annexure R3/2, Photo copy of statement of account as Annexure R3/3 and closed the evidence on behalf of OP No.3.    

9.                     We have heard the learned counsel for both the parties and have gone through the pleadings as well as documents placed on file very carefully and minutely.

10.                   It is not disputed that the complainant was having a Medi claim policy i.e. family health shield classic policy bearing No. SU16155159000100 which was valid from 18.01.2010 to 17.01.2011 for a sum of Rs. 1,00,000/- as admitted by the OP No.1 in its written statement. It is also not disputed that complainant has not lodged the claim with the OPs and requested for reimbursement of the amount of Rs. 68361.75 as admitted by the OP No.1 in para No.4 of its written statement which is evident from Annexure C-3. 

11.                   The only plea of OP No.1 insurance company is that the complainant had concealed the material facts from the OP No.1 while inception of policy as the complainant did not disclose to OP No.1 the history of pre-existing disease/ailment of diabetes. As such, the claim of complainant was rightly repudiated vide letter dated15.12.2010 (Annexure C-5) on the ground of non-disclosure of any material facts in the proposal form prior to inception of policy. Ld. Counsel for the Op no.1 Insurance Co. further argued that this forum have no territorial jurisdiction to entertain and try the present complaint as no part of insurance contract was made at Yamuna Nagar since the policy was issued from Chennai, Hospitalization was done at Delhi Mumbai and TPA claim was lodged at Bangalore and lastly referred the case law Sonic Surgical Vs NIC Ltd 2009(IV)CPJ page 40 SC 

12.                   On the other hand, learned counsel for the complainant argued that complainant No.2 was suffering from Genitourinary Koch’s and she was remained admitted in Sir Ganga Ram Hospital, Rajinder Nagar New Delhi from 18.05.2010 to 25.05.2010 which is evident from Annexure C-3 and the claim of the complainant amounting Rs. 68,361.75 has been wrongly repudiated by the OP No.1 on the flimsily ground that the complainant was having diabetes from the date of inception of policy. It has been further argued that at the time of issuance of insurance policy she was duly examined by the medical officer empanelled with op insurance Co. hence now and at the time of payment of claim, the OP No.1 Insurance Company cannot be permitted to take plea that wife of the complainant was suffering from ailment of diabetes Hence the genuine claim of the complainant has been wrongly repudiated by the OP Insurance Company. Ld counsel for the complainant referred the Case 1997(1)CPC275 Chd titled as Smt. S.K.Chhabra Vs The Divisional Manger, LIC C.P.Act 1986- Section 2 and 14-Insurance amount-Concealment of disease-Repudiation- Claim of the complainant was repudiated by L.I.C. on the ground that her deceased husband had concealed the fact of his illness – It was revealed that the insured was suffering from diabetes Mellitus which is not a serious disease and it was not necessary to disclose the same- moreover ,the deceased was checked up by the Insurance Company’s own doctor who did not detect any major ailment –Resultantly Insurance Company was directed to pay the claim. Ld Counsel for the complainant also referred the case law title Sunita Jain Vs L.I.C.of india 1999(1)CPC page 645 where it has been held that –The Insurer failed to prove by any cogent evidence that material facts was concealed by the insured- Burden of proof heavily lies on the insurer in such matters- Mere reference in the history sheet of the patient that he was suffering from diabetes is not enough- Even otherwise diabetes is not a serious disease to be brough to the notice of the insured.

Ld Counsel for the complainant also referred the another case law titled as L.I.C.Vs Murti Devi 2012(3) page 375 and case law titled as L.I.C. of india Vs Naseem Bano 2013(1) CPC page 491 National Commission where it has been held that –Evidence based on Bed Head Ticket only not sufficient to prove concealment of disease – No other medical record was produced-Heart attack has no nexus with ailment of diabetes and hypertension- Repudiation of claim set aside- Revision allowed.

13.                   After hearing both the parties, and going through the case law referred above referred,  we are of the considered view that the claim of the complainant has been wrongly repudiated by the OP no.1 Insurance Company as the OP No.1 Insurance Co. has only place on file copy of Repudiation letter as Annexure R-1 and Insurance policy Annexure R-2 but has totally failed to file any cogent documentary evidence that wife of the complainant Smt. Janak Bala was suffering from ailment of diabetes at the time of issuance of insurance policy. Even the OP No.1 Insurance Co. did not bother to file proposal Form to prove that the complainant had concealed a material fact on the health condition of Smt. Janak Bala and the same was not disclosed to the OP Insurance Co. while taking the policy under the proposal form filled by the complainant. Further From the perusal of repudiation letter dated 15.12.2010 (Annexure C-5) it is clear that Op No.1 Insurance Co. has itself admitted that Genitourinary koch’s for which she was advised for admission as she was suffering from hypotension and breathlessness, was not having any relation with the ailment of diabetes. Furthermore, no Affidavit of treating Doctor or any Doctor of TPA who examined the treatment record of the complainant has been place on file in support of the stands taken in the written statement by the OP No.1 Insurance Co. In the absence any cogent evidence, we are unable to hold that the complainant Smt. Janak Bala was suffering from ailment of diabetes before the inception of the policy taken from OP No.1 and complainant had concealed a material fact on the health condition of Smt.Janak Bala while taking the policy under the proposal form filled by the complainant.

14                    The second plea of the Op no.1 Insurance Co. that this forum has no territorial jurisdiction is also not tenable as complainant no.1 has specifically mentioned in para no.1 of his complaint that he has got sanctioned a loan of Rs. 3,50,000/- from respondent No.3 (hereinafter referred as OP No.3.) on 18.01.2010 and at the time of sanctioning the said loan, the Op No.3 on behalf of Op No.1 company had introduced joint insurance scheme of Health Shield Classic and on their representation complainant No.1 agreed for the said scheme for himself and his wife i.e. complainant No.2. A sum of Rs. 5871/- was paid as Health Shield Premium by the complainants to the Op No.3 who has issued receipt and certificate of insurance dated 18.01.2010 on behalf of OP No.1 alongwith Health Card of complainants.

15.                   After going through the above noted circumstances, we are of the view that the Ops Insurance Company has wrongly repudiated the claim of the complainant without any cogent reason which constitutes a deficiency in service on the part of OP no.1 Insurance Co. So we have no option except to partly allow the complaint.

16.                   Resultantly, we partly allow the complaint of complainant and direct the Ops to pay a sum of Rs. 68,362/-00 on account of medical expenses to the complainants alongwith interest at the rate of 7% per annum from the date of filing of complaint till its actual realization and further to pay a sum of Rs.2000//- as compensation for mental agony, harassment as well as litigation expenses. Order be complied within 30 days after preparation of copy of this order failing which complainant shall be entitled to invoke the jurisdiction of this Forum as per law. Copies of this order be sent to the parties concerned free of costs as per rules. File be consigned to the record room after due compliance.

Announced: 02.08.2016.

                                                                                                (ASHOK KUMAR GARG)

                                                                                                PRESIDENT

 

 

                                                                                                (S.C.SHARMA)

MEMBER