Haryana

Ambala

CC/114/2018

Sahab Singh - Complainant(s)

Versus

SBI General Insurance Ltd. - Opp.Party(s)

04 Jul 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMBALA.

                                                          Complaint case No.       :  114 of 2018.

                                                          Date of Institution         :  02.04.2018.

                                                          Date of decision             :  05.07.2019.

Sahab Singh son of Shri Surjan Singh, resident of H.No.46 Greater Kailash Colony, Jandli, Ambala City.

          ……. Complainant.

1. SBI General Insurance Ltd., Co-operate & Registered Office- Natraj, 101,201 & 301, Junction of Western Express Highway & Andheri- Kurla Road, Andheri (East), Mumbai-400069, through its General Manager.
2. SBI General Insurance Ltd. Company, Opposite Municipal Community office Ambala Cantt. through its Manager.
3. State Bank of India, Main Branch, Ambala City, through its Manager.

               ….…. Opposite Parties.

Before:        Smt. Neena Sandhu, President.

                   Smt. Ruby Sharma, Member.

Shri Vinod Kumar Sharma, Member.                                             

Present:       Shri L.R. Saini, Advocate, counsel for complainant.

Shri R.K. Vig, Advocate, counsel for the OPs No.1 & 2.

Shri U.S. Chauhan, Advocate, counsel for the OP No.3.

Order:        Smt. Neena Sandhu, President

Complainant has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To settle the claim.
2. To pay Rs.2,00,000/- as compensation for the mental agony and harassment suffered by the him.
3. To pay Rs.22,000/- as litigation expenses.
   382.  

                   Any other relief which this Hon’ble Forum may deem fit.

 

Brief facts of the case are that the complainant is a businessman and is having his business as well as other accounts with the OP No.3. On the asking of official of the OP No.3, he purchased a SBI General Health Insurance Policy bearing No.4595641 dated 24.06.2016 with the impression that in the event of any mis-happening/disease, the insurance company will pay all the expenses incurred by him for the hospitalization, medicine etc. and the amount of the policy premium was deducted from his account. On 02.12.2016 at 10:30 PM, suddenly he felt pain in the chest and was taken to Mehta Hospital, Ambala. On seeing his serious condition, he was referred to Max Superspeciality Hospital, Chandigarh, where his Angioplasty was done, for which he had incurred expenses of Rs.2,57,376/-. After discharged from the hospital on 04.12.2016, he lodged his claim vide application having SBI General claim No.HI-053316, TPA Claim No.3397750 with the OPs No.1 & 2, but they repudiated his genuine claim on the flimsy ground that “the claimant was admitted in the hospital with the history of diabetes since 2-3 years, which was pre-existing in nature. The first policy inception date is 24.06.2016. As per terms of policy, the expenses arising out of the above ailment, is not payable as pre-existing illness is not covered under the policy exclusion clause”. It is pertinent to mention here that the disease for which he was admitted in the hospital and got operated, was mentioned by the doctor of Max Hospital, regarding the sign and symptom of illness epigastria pain and discomfort on and off since 2-3 days, complaints of severe and sudden chest pain at around 10:00 PM on 02.12.2016, meaning thereby, he felt pain in the chest about 2-3 days before operation and the other disease i.e. diabetes has no concern of any kind with the disease for which he was operated upon. The complainant is above the age of 45 years and as per instructions of the Insurance Regulatory and Development Authority of India (IRDAI), it was the duty of the insurer to issue the policy after thorough medical examination, but they did not do so. He issued a legal notice dated 16.06.2017 upon the OPs to settle the claim, but all in vain, which tantamount to deficiency in services. Hence, the present complaint.

2.                 Upon notice, OPs No.1 & 2 appeared through counsel and filed written version, raising preliminary objections regarding filing of false and frivolous complaint. On merits, it is stated that the complainant history reveals that he was suffering from diabetes since 2-3 years, which is pre-existing in nature. The first policy inception date is 24.06.2016. As per terms & conditions of the policy, the expenses arises out of above ailment is not payable as pre-existing illness is not covered under the policy Exclusion Clause which reads as under:-

          “Insurer will not pay expenses incurred by the insured in respect of claims arising out of or however related to any of the following: Pre existing disease exclusion:- 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 upto 4 years of this Policy being in force continuously.

                   The repudiation by the insurance company is fully backed by the terms & conditions of the policy, as such, claim for hospitalization falls beyond the preview of the policy coverage, hence, not payable. The complainant was informed accordingly vide letter dated 25.01.2017. There is no deficiency in service on their part. The rest of the allegations levelled by the complainant were denied for lack of knowledge and prayer has been made for dismissal of the present complaint.

                    The OP No.3 also appeared through the counsel and filed written version, raising preliminary objections regarding jurisdiction; locus-standi and concealment of true & material facts. On merits, it is stated that the complainant was pressurized or assured to purchase the policy in question. As a matter of fact, the complainant has voluntarily purchased the policy after knowing the benefits and has signed the proposal form acknowledging the terms & conditions of the policy. The OP No.3 is not concerned with the rejection or approval of any claim by the OPs No.1 & 2. The claim amount, if any, has to be paid by the OPs No.1 & 2 and not by the OP No.3. Thus, the complaint filed against it, may be dismissed with cost. 

3.                The ld. counsel for the complainant tendered affidavit of the complainant as Annexure CW1/A alongwith documents as Annexure C-1 to C-15 and closed the evidence on behalf of the complainant. On the other hand, learned counsel for OPs No.1 & 2 tendered affidavit of Shri Jitendra Dhabhai, Authorized Signatory, Consumer Litigation, SBI General Insurance Company Ltd. as Annexure OP1/A alongwith documents Annexure OP1 to OP9 and closed the evidence on behalf of OP No.1 & 2. However, the ld. counsel for the OP No.3 has made a statement that written version filed by OP No.3, may be read as its evidence.

4.                We have heard the learned counsel of the parties and carefully gone through the case file and also the case laws referred by the ld. counsel for the complainant and for the OP No.1 & 2.

5.                 The learned counsel for the complainant has argued that the complainant is having his account with OP No.3 and on the asking of the official of OP No.3, he purchased policy in question from the OPs No.1 & 2 on 24.06.2016. On 02.12.2016, complainant suddenly felt pain in his chest and was taken to Mehta Hospital, Ambala, which referred him to Max Superspeciality Hospital, Chandigarh, where his Angioplasty was done, for which he had incurred an expenses of Rs.2,57,376/-. Accordingly, the complainant lodged the claim with the OPs No.1 & 2, but they repudiated his genuine claim vide letter 25.01.2017 (Annexure C-1/OP5) on the flimsy ground that the complainant had concealed the material facts about his health. It is further argued that the complainant is above the age of 45 years and as per instructions of the Insurance Regulatory and Development Authority of India (IRDAI), it was the duty of the insurer to issue the policy after thorough medical examination, but OPs No.1 & 2 did not do so and now, they cannot deny to pay the claim amount to the complainant, therefore, they may be directed to pay him the due claim amount, as per the policy in question. To support of his contention, the ld. counsel for the complainant has placed reliance on the cases, titled as LIC of India Vs. Reena Nanda, 2019 (1) CLT, 380 (NC); M/s Royal Sundaram Alliance Insurance Co. Ltd. and others Vs. Melanie Das, 2018 (2) CLT, 459 (NC); SBI General Insurance Co. Ltd. Vs. Balwinder Singh Jolly & Anr., 2016 (4) CLT, 372 (Chandigarh State Commission, Chandigarh).  

6.                On the contrary, the learned counsel for OPs No.1 & 2 has argued that the complainant history reveals that he was suffering from diabetes since 2-3 years, but he did not disclose this fact at the time of taking the policy in question and as such, he has violated the terms & conditions of the policy. He further argued the complainant purchased the policy in question on 24.6.2016 and his Angioplasty was done on 02.12.2016, within the period of 6 months from the date of inception of the policy. Since the Angioplasty of the complainant was done within one year from the date of the commencement of the policy, therefore, as per Exclusion Clause V (2) of the terms & conditions of the policy, no amount is payable and the insurance company has rightly repudiated the claim of the complainant. To support of his contention, the ld. counsel for the OPs No.1 & 2 has placed reliance on Civil Appeal No.6075-6076 of 1995, date of decision 21.08.1996, titled as United India Insurance Co. Ltd. Vs. M.K.J. Corporation (SC) and Civil Appeal No.2776 of 2002, date of decision 10.07.2009, titled as Satwant Kaur Sandhu Vs. New India Assurance Company (SC).

7.                The ld. counsel for the OP No.3 has argued that no doubt, complainant is having his account with the OP No.3, but the complainant has voluntarily purchased the policy in question from the OPs No.1 & 2 by submitting a proposal form with them. The claim amount, if any, has to be paid by the OPs No.1 & 2 and not by the OP No.3. Thus, the complaint filed against it, may be dismissed with cost.  

8.                Admittedly, the complainant had taken the policy in question from the OPs No.1 & 2 on 24.06.2016. From the Discharge Summery Annexure C-8, it is evident that PTCA (Percutaneous Transluminal Coronary Angioplasty) was done on 03.12.2016. Meaning thereby, Angioplasty was done within the period of six months from the date of commencement of the policy in question. It may be stated here that parties are bound by the terms & conditions of the policy. The Clause V. EXCLUSIONS, reads as under:-

          Insurer will not pay expenses incurred by the Insured in respect of claims arising out of or howsoever related to any of the following:-

          1.       XXXXX

          2.       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. Any types of gastric or duodenal ulcers:

• XXXX
• XXX
• Hypertension, Heart Disease and related complications;
• XXXX

                    Since the Angioplasty of the complainant was done within the first year from the date of commencement of the policy, therefore, as per aforesaid Exclusion Clause, the insurance company is not liable to reimburse the amount, which the complainant incurred on his medical treatment and the complaint filed against them, is liable to be dismissed. Even the complaint filed against OP No.3 is also liable to be dismissed, because neither any specific allegations have been levelled by the complainant against the OP No.3, nor it has been proved.

9.                In view of the aforesaid discussion, we hereby dismiss the present complaint being devoid of merits. The parties are left to bear their own cost. Certified copies of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced on :05.07.2019.

 

 

 

          (Vinod Kumar Sharma)           (Ruby Sharma)               (Neena Sandhu)

          Member                                   Member                          President.