BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 52 of 2020
Date of Institution : 27.01.2020
Date of Decision : 29.02.2024
Shakil Mehta, aged 27 years son of Shri Khan Chand, resident of village & PO Panjuana, Tehsil and District Sirsa.
……Complainant.
Versus.
1. SBI General Insurance Company Limited, 1st Floor, SCO 149, Red Square Market, CUE-1, Near to State Bank of India, Hisar Mandi Branch, Hisar, District Hisar, through its Manager.
2. SBI General Insurance Company Limited, through its Branch Manager at Sirsa, District Sirsa.
…….Opposite Parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA………..MEMBER
Present: Sh. JBL Garg, Advocate for the complainant.
Sh. R. K. Mehta, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 (after amendment under Section 35 of the Consumer Protection Act, 2019) against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that complainant had purchased health insurance policy from the ops for sum assured amount of Rs. three lacs for himself, his father Shri Khan Chand and mother Smt. Suman Mehta for the period w.e.f. 20.04.2017 to 19.04.2018 vide policy number 0000000006367344 and said policy was got renewed for the period 21.05.2018 to 20.05.2019. That on 21.03.2019 father of complainant Shri Khan Chand developed chest pain and he was got examined from Metro Hospital, Sirsa and then from Sanjivani Hospital, Sirsa where stent was put to him. The complainant incurred a sum of Rs.1,88,331/- on the said treatment of his father. It is further averred that thereafter complainant lodged his claim with the ops alongwith all requisite documents and also completed all the formalities as required from him but the ops have repudiated the claim of complainant on the ground that there was pre existing disease to his father. That the said ground taken by ops is totally false and baseless because Dr. Mandeep Garg of Sanjivani Hospital, Sirsa issued a certificate to the effect that there was no previous known heart disease and had no risk factor for CAD. This certificate was duly supplied by complainant to the ops alongwith claim form, but the same has not been considered and ops by their such act and conduct have adopted unfair trade practice and have caused gross deficiency in service, unnecessary harassment and mental agony to the complainant. The complainant approached the ops and requested them to settle and pay his claim but they did not pay any heed to the same and ultimately complainant got served a legal notice upon ops on 09.12.2019 but of no use. Hence, this complaint.
3. On notice, ops appeared and filed written statement taking certain preliminary objections regarding estoppal, maintainability, locus standi, cause of action, jurisdiction, mis joinder and non joinder of necessary parties and that insurance policy has been obtained by concealment of material facts and the insurer has not complied with all the terms and conditions of the insurance policy. That an utmost good faith is the basic principle of policy cover and violation of it causes insurance cover void ab-initio. On merits, it is submitted that it is wrong and incorrect that complainant submitted all the relevant documents to the answering ops. The complainant has lodged the cashless claim for the hospitalization but the same was denied by the answering ops’ company on the ground of pre existing disease and insured is diagnosed as case of Multivessel disease and known case of coronary syndrome and unstable angina since March 2016 and disease was prior to date of its policy inception and is not admissible and stands denied as pre existing disease and related condition are payable only after four years of policy coverage. The complainant thereafter lodged the reimbursement of claim with the answering ops and same is closed for pendency of documents and they sent several letters vide its letter dated 28.06.2019, 05.07.2019, 13.07.2019 , 24.07.2019, 05.08.2019, 13.08.2019, 24.08.2019 and final reminder letter dated 04.09.2019 for submission of documents/ clarification to enable the company to proceed with the settlement of his claim on merits but the complainant failed to supply the copies of required documents to the answering ops, therefore, answering ops vide its letter dated 04.09.2019 closed the claim of complainant for non submission of required documents. It is further submitted that no deficiency of service can be attributed to answering ops in declining the present claim and closing of the claim file of the insured as ‘No Claim’. The acts of the insurance company in closing the claim file of complainant are legal, justified and bonafide one and are based upon the insurance contract and terms and conditions and exclusion clauses of the policy cover obtained by the insured. Total fault lies upon the part of insured. The insured failed to comply with the contractual obligations and did not co-operate with insurance company and did not comply with the formalities and necessities. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
4. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C85.
5. On the other hand, ops have tendered affidavit of Sh. Nishant Gera, authorized person as Ex. RW1/A and documents Ex.R1 to Ex.R11.
6. We have heard learned counsel for the parties and have gone through the case file.
7. Admittedly the complainant purchased health insurance policy from ops for his father Khan Chand and mother Smt. Suman Mehta for the period 20.04.2017 to 19.04.2018 for the sum insured amount of Rs. three lacs and said policy was also got renewed by the complainant for the period 21.05.2018 to 20.05.2019 for the sum insured amount of Rs. three lacs and this fact is also evident from policy documents Ex.C1 to Ex.C5. According to the complainant during the period of policy in question on 21.03.2019 father of complainant Khan Chand developed chest pain and stent was put to him and he has incurred a sum of Rs.1,88,331/- on the said treatment of his father insured. However, the claim submitted by the complainant for reimbursement of said amount has been closed by the ops as No Claim and ops have taken the plea that claim is not payable as disease suffered by insured complainant was pre existing disease and complainant has not submitted the required documents despite several letters and have also placed on file treatment record dated 26.03.2016 Ex.R11. Learned counsel for ops during the course of arguments contended that moreover claim of complainant is not payable as per exclusive clause 1 regarding Pre existing diseases of the policy terms and conditions which stipulates that 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 the policy being in force continuously. But however, we are of the considered opinion that ops have wrongly and illegally denied the genuine claim of the complainant. The ops have not proved on record through any cogent and convincing evidence that terms and conditions of the policy were ever supplied to the complainant with policy schedule. Moreover, the ops could have examined the insured from their panel doctors before issuing of the policy in question which has also not been done by the ops. Further more, clause 2 of exclusions says that without derogation from above exclusion 1, during the first year of operation of the insurance cover any Medical expenses incurred on below treatment of illness, however, this exclusion would not be applicable in case of continuous renewal within grace period, up to sum insured and/ or limit under previous policy and Hypertension, Heart Disease and related complications are included in the said clause 2 and the policy was also got renewed by the complainant and as such complainant is entitled for reimbursement of the amount spent by him on the treatment of his father Khan Chand i.e. insured. The assertion of ops that relevant documents were not supplied by complainant is also baseless and moreover all the documents relevant for reimbursement of claim have been placed on file and therefore, denial of the claim of complainant on the above said basis is not justified at all. The complainant has claimed reimbursement of the amount of Rs.1,88,331/- spent on the treatment of his father insured and has also placed on file bills/ receipts Ex.C21 to Ex.C85 and as such he is entitled to said amount from ops.
8. In view of our above discussion, we allow the present complaint and direct the opposite parties to pay the claim amount of Rs.1,88,331/- to the complainant within a period of 45 days from the date of receipt of copy of this order, failing which complainant will be entitled to receive the said amount of Rs.1,88,331/- alongwith interest at the rate of @6% per annum from the date of this order till actual realization. We also direct the ops to further pay a sum of Rs.10,000/- as compensation for harassment and also to pay another sum of Rs.10,000/- as litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member Member President,
Dated: 29.02.2024. District Consumer Disputes
Redressal Commission, Sirsa.
