DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/51/2023
Date of Institution: 25.04.2023
Date of Decision: 01.08.2024
Surinder Paul care of Om Prakash, Street No. 6, Patti Road, Piara Colony, Barnala, Tehsil and District Barnala.
…Complainant
Versus
1. SBI General Insurance Company Limited, SCO No. 457-458, First & Second Floors, Sector-35 Chandigarh through its Manager/Authorized Signatory;
2. SBI General Insurance Company Limited, 9th Floor, A & B Wing, Fulcrum Building, Sahar Road, Andheri (East), Mumbai 400099 through its Manager/Authorized Signatory.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Varun Kumar Singla Adv counsel for complainant.
Sh. Vickramjeet Singh Adv counsel for opposite parties.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Smt. Urmila Kumari: Member
3. Sh. Navdeep Kumar Garg: Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against SBI General Insurance Company Limited, SCO No. 457-458, First & Second Floors, Sector-35 Chandigarh through its Manager/Authorized Signatory & others (in short the opposite parties).
2. The facts leading to the present complaint are that the complainant is the permanent resident of Barnala and one of official/agent of opposite parties contacted the complainant and told about their various insurance schemes and on believing the words, the complainant agreed to purchase SBI General's "Arogya Plus Policy" and the complainant along with his wife namely Saroj Rani were medically examined. Thereafter, the complainant paid an amount of Rs.10,502/- and opposite parties issued one Policy No. 0000000012930513 for the period from 22.04.2019 to 21.04.2020. It is alleged that in the said policy, the complainant and his wife were insured. Thereafter, the complainant continued the said policy regularly without any discrimination and paid the premium amount of Rs.10,502/- for year 22.04.2020 to 21.04.2021 and issued Renewal Endorsement No. 0000000012930513-01. Thereafter, the complainant continued the said policy regularly without any discrimination and paid the premium amount of Rs.10,502/- for year 22.04.2021 to 21.04.2022 and issued Renewal Endorsement No. 0000000012930513-02. Thereafter, the complainant continued the said policy regularly without any discrimination and paid the premium amount of Rs.10,502/- for year 22.04.2022 to 21.04.2023 and issued Renewal Endorsement No. 0000000012930513-03. It is further alleged that the sum of Rs.3,00,000/- per year was insured under the above said policies. It is alleged that during the subsistence of the policy, in the month of June 2022 the complainant started facing Health Issues and was taken to local hospital for treatment but could not get cured and the complainant's right side of body was got weak and was unable to speak. Thereafter, the complainant was taken to Dayanand Medical College & Hospital Ludhiana for his treatment where the complainant was admitted on 09.06.2022 and was discharged on 20.06.2022 where hypertension, diabetes, acute cva-left mca infarct/ left ica dissection, external and internal HEMORRHOIDS/Anemia were diagnosed and treated and a total expenditure of Rs.1,26,660/- (Rs.1,02,448/- Hospital Main Bill + Rs.24,212/- Pharmacy Bill) was spent on the treatment of the complainant. It is further alleged that the complainant approached opposite parties for the medical claim which is covered under the policy and the complainant submitted all the original documents with them as said by them and opposite parties assured the complainant that they will incur all the expenses of treatment as per the policy bought and will give the claim amount within a week but the Ops repudiated the claim and sent claim denial letter dated 23 Nov 2022 to the complainant where the reason for rejection was that "insured has hemorrhoids since 10 years which is Pre-existing in nature". Thereafter, the complainant again approached opposite parties for the medical claim as assured by them to the complainant and even sent many mails but they again started harassing the complainant and refused to give the said claim which is withheld by opposite parties without any justified cause. As such, the act and conduct of the opposite parties comes within the definition of deficiency in service. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to pay the claim amount of Rs. 1,26,660/- to the complainant.
- To pay Rs. 50,000/- towards mental tension and harassment.
- Further, to pay Rs. 20,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties appeared and filed written version by taking preliminary objections interalia on the grounds that at the outset it is submitted that the captioned complaint is not tenable as there is no deficiency of service or unfair trade practice on the part of answering opposite parties invoking the jurisdiction of this Commission. The opposite parties denied the cashless request and repudiated the reimbursement claim of the complainant within the precincts of terms and conditions of the Policy. It is alleged that the complainant is guilty of violation of the sad ingredients and does not deserve any indulgence of this Commission. Further, the present complaint is false, frivolous and vexatious in nature etc.
4. On merits, it is submitted that Arogya Plus Policy bearing no. 0000000012930513-03 was issued for the period 22.04.2022 to 21.04.2023 with Sum Insured of Rs. 3,00,000/- and this policy is subject to certain terms, conditions, exclusions "The terms and conditions of the Policy were explained to the insured at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. Moreover, it is clearly stated in the policy schedule "THE INSURANCE UNDER THIS POLICY IS SUBJECT TO CONDITIONS, CLAUSES WARRANTIES, EXCLUSIONS ETC., ATTACHED". It is admitted that the policy of insurance was issued by the opposite parties but the same was subject to the terms and conditions of the said policy and terms and conditions are the part of the policy which were supplied to the insured. It is further alleged that the treatment of the insured falls outside the purview of the policy coverage and as per Exclusion Clause I of the policy terms & conditions "Pre-existing diseases: Any illness/ disease injuries/ health condition which are pre-existing (treated/untreated, declared/not declared in the proposal form), when the cover incepts for the first time are excluded up to 4 years of this Policy being in force continuously." As per the documents submitted, it is observed that patient was admitted on 09-06-2022 and first policy inception date is 22-04-2019 and as per terms & conditions of the policy. "This policy excludes for Mr. Surinder Paul. This exclusion will apply for the 4 consecutive policy years from the date of first policy inception." Also as per patient's statement received during claim investigation, insured has hemorrhoids since 10 years, which is pre-existing in nature and current ailment is the complication of the same. It is further alleged that as per terms and conditions of the policy expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer. Therefore, the claim of the insured was repudiated vide letter dated 23-Nov-2022. All other allegations are denied and prayed for the dismissal of complaint.
5. Ld. Counsel for complainant filed rejoinder to the written version of opposite parties and denied the averments as mentioned in the reply.
6. To prove the case the complainant tendered into evidence affidavit of complainant as Ex.C-1, copies of policies are Ex.C-2 to C-5, copy of reports are Ex.C-6 to C-13, copies of pharmacy bills are ex C-14 to C-105, copy of discharge summary as Ex.C-106, copy of detail bill as Ex.C-107, copy of denial letter as Ex.C-108, copy of adhaar card as Ex.C-109 and closed the evidence.
7. The opposite parties tendered into evidence copy of policy document as Ex.OPs-1 (containing 20 pages), copy of cashless denial letter dated 12.06.2022 as Ex.OPs-2, copy of investigation report, insured statement and consultation paper as Ex.OPs-3 (containing 15 pages), copy of repudiation letter as Ex.OPs-4 dated 23.11.2022 and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments filed by the parties.
9. It is admitted case of the opposite parties that Arogya Plus Policy bearing no. 0000000012930513-03 was issued for the period 22.04.2022 to 21.04.2023 with Sum Insured of Rs. 3,00,000/- vide which Surinder Paul and Saroj Rani was insured under the policy (as per Ex.C-5 & Ex.O.Ps-1). It is further not disputed between the parties that the complainant was taken to Dayanand Medical College & Hospital Ludhiana for his treatment where the complainant was admitted on 09.06.2022 and was discharged on 20.06.2022 (as per Ex.C-106).
10. Ld. Counsel for the complainant argued that on his treatment as mentioned a total expenditure of Rs.1,26,660/- (Rs.102448/- Hospital Main Bill + Rs.24212/- Pharmacy Bill) was spent (as per bills Ex.C-14 to Ex.C-105). It is further argued that the complainant approached the opposite parties for the medical claim which is covered under the policy and the complainant submitted all the original documents with them as said by them and opposite parties assured the complainant that they will incur all the expenses of treatment as per the policy bought and will give the claim amount within a week but they repudiated the claim and sent claim denial letter dated 23 Nov 2022 (Ex.C-108) to the complainant where the reason for rejection was that "insured has hemorrhoids since 10 years which is Pre-existing in nature". Thereafter, the complainant again approached opposite parties for the medical claim as assured by them to the complainant and even sent many mails but they again started harassing the complainant and refused to give the said claim which is withheld by opposite parties without any justified cause.
11. On the other hand, Ld. Counsel for the opposite parties argued that the treatment of the insured falls outside the purview of the policy coverage and as per Exclusion Clause I of the policy terms & conditions "Pre-existing diseases (treated/untreated, declared/not declared in the proposal form), when the cover incepts for the first time are excluded up to 4 years of this policy being in force continuously." It is further argued that as per the documents submitted it is observed that patient was admitted on 09-06-2022 and first policy inception date is 22-04-2019 and as per terms & conditions of the policy this policy excludes for Mr. Surinder Paul and this exclusion will apply for the 4 consecutive policy years from the date of first policy inception. It is further argued that as per patient's statement received during claim investigation, insured has hemorrhoids since 10 years, which is pre-existing in nature and current ailment is the complication of the same. It is further argued that as per terms and conditions of the policy expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer, therefore the claim of the insured was repudiated vide letter dated 23-Nov-2022 (Ex.O.Ps-4).
12. Ld. Counsel for the opposite parties specifically argued that the complainant has pre-existing disease and this fact has not been disclosed by the complainant at the time of filing the proposal form or at the time of purchasing the policy and this fact has come within the knowledge of opposite parties as per the documents submitted by the complainant and as per patient's statement received during claim investigation that the insured has hemorrhoids since 10 years, which is pre-existing in nature and current ailment is the complication of the same. Further, as per terms and conditions of the policy expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer, therefore the claim of the insured was repudiated vide letter dated 23-Nov-2022. The Ld. Counsel for the complainant further argued that the terms and conditions were not supplied to the complainant alongwith policy. Therefore, the same are not part of contract.
13. Moreover, we have carefully gone through the facts and evidence produced by both the parties and are of the view that the complainant has purchased the above said policy in year 2019 and since then the complainant continuously renewed the above said policy and paid the premium regularly and this fact is also admitted by the opposite parties, but the opposite parties have failed to produce any cogent evidence on record to prove that they have medically examined the complainant/insured at the time of filling the proposal form or at the time of issuing the policy. Moreover, the opposite parties have failed to place on record the proposal form. So, we are of the view that the above said plea of the opposite parties is not tenable. Further, from the file it shows that the complainant has purchased the above said policy on 24.11.2019 and after that the said policy was renewed regularly, so at this stage how the opposite parties could have raised the objection that the complainant has pre-existing disease prior to the policy inception date. We are of the view that it was in the hands of insurance company to see and not to issue or renew the policy where person is not entitled to claim on account of treatment of Pre-existing disease. So, we are of the view that at this stage the opposite parties cannot be escaped from their liabilities by raising these types of unreasonable and unjustified grounds. The learned counsel for the complainant also relied upon the judgment of the Hon'ble Punjab and Haryana High Court (DB) 2012 (1) RCR (Civil)-901 in which the Hon'ble High Court held that “Claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the policy. Single judge allowed the claim on the ground that it was for Insurance Company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. No interference called for in the order of Single Judge. Held the pre-existing condition existed in the year 2002 which was five years prior to acquiring Insurance Policy. Claim cannot be denied. The opposite parties specifically relied upon the proposal form but despite ample opportunities of evidence the opposite parties failed to produce the proposal form to support their version. The opposite parties failed to produce any evidence to prove that the terms and conditions were supplied.
14. The Hon'ble Supreme Court of India titled Modern Insulators Limited Versus Oriental Insurance Company Limited reported in 2000(1) CPC-596 in which Hon'ble Supreme Court held that “As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclose to the appellant, respondent cannot claim the benefit of the said exclusion clause.” The Hon’ble Supreme Court of India (2019) 6 SCC 212 in case titled Bharat Watch Company Through its Partner Vs National Insurance Company Limited held that “Conditions of exclusion under policy document not handed over to insured by insurer and in absence of insured being made aware of terms of exclusion, held, it is not open to insurer to rely upon exclusionary clauses”.
15. From the above discussion, it is proved that the claim of the complainant was repudiated by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties.
16. However, on the perusal of copies of pharmacy bills Ex.C-14 to Ex.C-105 and copy of detail bill of hospital Ex.C-107 shows that the total amount of Rs. 1,26,676 (i.e. Rs. 1,02,448/- hospital main bill + Rs. 24,228/- pharmacy bill) has been spent on the treatment of complainant. But in the present complaint the complainant has claimed an amount of Rs. 1,26,660/- (i.e. Rs. 1,02,448/- hospital main bill + Rs. 24,212/- pharmacy bill). So, we are of the view that the complainant is entitled for the amount of Rs. 1,26,660/- which was claimed by the complainant in the present complaint.
17. In view of the above discussion, the present complaint is partly allowed and the opposite parties are directed to pay an amount of Rs. 1,26,660/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties are further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
1st Day of August, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari
Member
(Navdeep Kumar Garg)
Member
