Haryana

Bhiwani

CC/622/2019

Rahul - Complainant(s)

Versus

Royal Sundram - Opp.Party(s)

Jagdev sheoran

07 Dec 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                             Consumer Complaint No. : 622 of 2019

                                                        Date of Institution           : 29.07.2019

                                                                  Date of order                  : 07.12.2023

 

Rahul Panghal son of Sh. Ravinder Singh R/o H.No.908, Sector-23, Near Bhagat Singh Chowk, Bhiwani, Tehsil and District Bhiwani, minor through his father and natural guardian Sh. Ravinder Singh.

  

           …Complainant.

 

Versus

 

Royal Sundram General Insurance Company Limited, Vishranthi Meleram Towers, No.2/319, Rajiv Gandhi Salai (OMR), Karapakkam, Chennai-600097 through its Managing Director/authorized signatory.

 

… Opposite Party.

 

COMPLAINT U/S 12 OF CONSUMER PROECTION ACT, 1986.

 

BEFORE:       Hon’ble Mrs. Saroj Bala Bohra, Presiding Member.

  Hon’ble Ms. Shashi Kiran Panwar, Member.

 

Present:-        Sh. Jagdev Sheoran, Advocate for complainant.

Sh. Balbir Sharma, Advocate for OP.

 

ORDER:

 

Saroj Bala Bohra, Presiding Member:

 

1.                 In brief, facts of this case are that complainant purchased an online group health insurance policy no.SGP0016419000100 from OP by paying Rs.11,546/- on 09.10.2018 for himself and his family including his father-Sh. Ravinder Singh, mother-Smt. Munesh Devi and sister-Ms. Muskan and sum insured under the policy was Rs.5.00 lac. On 23.04.2019, complainant suddenly fell ill and was got admitted in Medi City Multispecialty Hospital and Neuro Care Centre, Sector-16, Hisar for treatment and remained admitted there upto 29.04.2019. A sum of Rs.3,36,160/- were incurred on the treatment and as per complainant treatment is still continuous. Complainant lodged a claim with OP but the same was repudiated vide letter dated 13.06.2019 on the ground that complainant was having a pre-existing disease i.e. history of Guillain-Barre Syndrome since March, 2018 which is violation of terms & conditions of insurance policy. Complainant has submitted that there is no mention of such pre-existing disease by the treating doctor in medical treatment history. Legal notice dated 08.07.2019 was served upon the OP but of no avail.  Hence, the present complaint has been preferred alleging deficiency in service on the part of Op resulting into monetary loss as well as mental and physical harassment with a prayer for issuance of directions to OP to pay Rs.3,36,160/- which incurred on treatment, Rs.1.00 lac as compensation alongwith interest @ 18% per annum from the date of intimation  till payment. Any other relief to which this Commission deems fit has also been sought.

2.                 OP appeared through counsel and tendered reply to the complaint submitting that the claim of complainant was rightly rejected by the OP insurance company as he was suffering from Guillain-Barre Syndrome before the policy was issued and thus was having pre-existing disease which was violation of terms & conditions of the insurance policy. OP has submitted that claim of complainant was scrutinized, M/s J.D. Healthcare Services was appointed to investigate into the matter, it submitted report whereby it was noticed that complainant had been treated for Guillain-Barre Syndrome and the doctor had observed that the patient had been diagnosed with the said condition in March 2018 and walking difficulty since 1-2 years prior to risk commencement under the policy. As such, OP has submitted no deficiency in service on it part and prayed for dismissal of the complaint with costs.

4.                 In evidence of complainant, his affidavit EX CW1/A alongwith documents as Annexure C-1 to Annexure C-15 were tendered and then closed the evidence on 29.10.2020.

5.                 In evidence of OP, documents Annexure R-1 to Annexure R-5 were filed and closed the evidence on 31.05.2023.

6.                 We have heard learned counsel for the parties and perused the record minutely.

7.                 The case of complainant is that during the period of insurance policy, complainant fell ill and remained admitted in the concerned hospital  for the relevant period and spent a sum of Rs.3,36,160/- but the OP insurance company did not reimburse the same rather repudiated the claim of complainant vide letter Annexure R-5. Ld. Counsel for complainant has argued that due to such act & conduct of OP, complainant has to suffer monetary loss as well as mental and physical harassment. In support of his contentions, learned counsel for complainant has placed reliance on case laws delivered by National Consumer Disputes Redressal Commission, New Delhi in case titled Bajaj Allianz Life Insurance Co. Ltd. and 2 Ors. Vs. Kanduru Gangadha Rao reported in 2021 (4) CPR-235.  The counsel has also placed reliance on case law delivered by Hon’ble Punjab & Haryana High Court in CWP No.26178 of 2016 titled as National Insurance Co.Ltd. Vs. Sandeep & others reported in 2017 (1) RCR (Civil) Page 621 wherein it has been  held that “Insurance companies give lucrative offers to attract customers-However, the moment any insured puts even the most genuine claim, seldom said claim would be accepted by any insurance company.”

8.                 On the other side, learned counsel for OP has argued that the complainant has suppressed material facts qua his ailment prior to commencement of the policy which his violation of  Section 1 Terms and conditions b. Pre-Existing Disease: “Claim will not be admissible for any medical expenses incurred as Hospitalization Expenses for diagnosis/treatment of any pre-existing disease; (ii) For Supreme variant, until 36 months of continuous coverage have elapsed since the inception of the first policy with us; Further, the history of the pre-existing condition was not declared to us at the time of proposing for insurance. The contract of insurance is based on the doctrine of utmost good faith and becomes null and void in the event of suppression of material facts.” As such, the repudiation was well within the policy terms and conditions. 

9.                 It is not in dispute that on the relevant period of time complainant was under the insurance cover. Complainant to prove that he was under treatment and incurred  medical expenses has placed on record bills (Annexure C-15) for Rs.3,35,590/- but the said amount was not released by the OP. The OP insurance company has repudiated the claim of complainant on the ground that the complainant was having pre-existing disease before commencement of the health insurance policy which is violation of terms & conditions of the policy. As we have known, symptom of Guillain-Barre Syndrome typically last a few weeks, with most individuals recovering without long-terms, severe neurological complications. The first symptoms of Guillain-Barre syndrome include weakness or tingling sensations. They usually start in the legs and can spread to the arms and face.

10.               Perusal of record reveals that the OP has repudiated the claim of complainant in a casual manner without mentioning any cogent and convincing reason thereof which shows that the OP insurance company has adopted a trend not to release claim of the poor persons rather compel them to knock the doors of the Consumer Commission. It is worthwhile to mention here that the OP(s) are not settling even genuine claims of consumers/complainants which is illegal and amounts to indulgence into unfair trade practice/malpractice. We have carefully gone through the case laws relied upon by complainant side, which are very relevant to the facts and circumstances of the present case and thus are helpful in deciding the present case.  

11.               In view of the above discussion as well as facts and circumstances of the present case, it is clear that OP insurance company has wrongly repudiated the claim of complainant just to cheat and harass the complainant which amounts to deficiency in service and mal-trade practice on their part resulting into monetary loss as well as mental and physical harassment.  Hence, the complaint is allowed and the OP is directed to comply with the following directions within 40 days from the date of order:-

(i)       To pay Rs.3,35,590/- (Rs. Three lac thirty five thousand five hundred ninety) to the complainant so incurred by him on treatment alongwith simple interest @ 9% per annum from the date of filing of complaint till actual realization.

(ii)      To pay Rs.15,000/- (Rs. Fifteen thousand) as compensation  on account of mental agony and physical harassment. 

3. To pay Rs.5500/- (Rs. Five thousand five hundred) as litigation expenses.

                    In case of default, the OP shall liable to pay simple interest @ 12% per annum on all the aforesaid amounts for the period of default. Certified copies of the order be sent to parties free of costs, as per rules. File be consigned to the record room, after due compliance.

Announced.

Dated:07.12.2023.

 

                              (Shashi Kiran Panwar)              (Saroj Bala Bohra)

                                                   Member                 Presiding Member

District Consumer

Disputes Redressal

Commission, Bhiwani.