Haryana

Karnal

246/2012

Mukesh Devi W/o RAndeep Singh - Complainant(s)

Versus

SBI life Insurance Company - Opp.Party(s)

Sh. Sanjeev Kamboj

15 Feb 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                               Complaint No.246 of 2012

                                                              Date of instt. 15.05.2012

                                                               Date of decision:15.2.2017

 

Mukesh Devi wife of Shri Randeep Singh resident of village Kambohpura Tehsil and District Karnal.

 

                                                                   ……..Complainant.

                                      Versus.

1. SBI Life Insurance Company, having Branch Office at 144, near Bangla Sweets, Sector-13, Karnal through its Branch Manager.

2. Mr. Aditya Kaushik (CIF code no.17582445) of SBI Life Insurance Company, having Branch office at 144, near Bangla Sweets, Sector-13e, Karnal.

 

                                                                   ………… Opposite Parties.

                     Complaint u/s 12  of the Consumer Protection Act.

 

Before                   Sh.K.C.Sharma……….President.

                   Sh.Anil Sharma…….Member.

 

Present:      Shri Sanjeev Kamboj Advocate for the complainant.

                   Shri N.K.Zak Advocate for opposite parties.

 

 ORDER:

 

                   This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986, on the averments that at the instigation of opposite party no.2, she purchased insurance policy known as SBI Life Hospital Cash  bearing no.4600249001 from opposite party no.1, on 29.10.2011 and the assured sum of the policy was Rs.3,00,000/-. She started suffering from depression, therefore, she was admitted in Brain and Spine Hospital, Karnal where she remained admitted from 16.1.2012 to 18.1.2012 and again from 25.1.2012 to 28.1.2012. During that period, her MRI was conducted. Doctors observed that there was problem in her left leg, but her illness could not be cured. Thereafter, she was shifted to Fortis Hospital, Mohali on 1.2.2012 and since then she had been getting treatment from there. An amount of Rs.45077/- was spent on her treatment, which was continuing. On 8.2.2012, she lodged claim with opposite party no.1 and completed all the formalities. She was assured that the amount would be given to her within a period of 15 days, but not even a single penny was paid. Therefore, she approached opposite party no.1 for payment of the claim, but opposite party no.1 postponed the matter on one pretext or the other and ultimately refused to pay any amount. Such acts and conduct on the part of the opposite party no.1 amounted to deficiency in service and unfair trade practice due to which he suffered mental pain, agony and harassment apart from financial loss.

2.                Notice of the complaint was given to the opposite parties, who appeared and filed written statement controverting the claim of the complainant. Objections have been raised that the complainant has no locus standi and cause of action to file the complaint; that the complaint is malafide and that there was no deficiency in service on the part of the opposite parties.

                   On merits, it has been submitted that the complainant was reported to have been hospitalized in Brain and Spine Hospital from 16.1.2012 to 18.1.2012 and again from 25.1.2012 to 28.1.2012, for spinal ailment. As per clause 2, definition 19, the said hospital was not registered for allopathic treatment. Moreover, the complainant was suffering from spinal disease, which was not covered irrespective her declaration, in view of waiting period and exclusion clause 6.2.1 of the policy, therefore, the claim of the complainant was rightly repudiated.

3.                In evidence of the complainant, her affidavit Ex.C1 and documents Ex.C2 to Ex.C29 have been tendered.

4.                On the other hand, in evidence of the opposite parties, affidavit of V.Srinivas Ex.O1 and documents  Ex.O2 to Ex.O10  have been tendered.

5.                We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

6.                The complainant had obtained SBI Life Hospital Cash insurance policy from opposite party no.1 on 29.10.2011 and the assured sum of the policy was Rs.3,00,000/-. She suffered from the problem of depression, therefore, she remained admitted in Brain and Spine Hospital Karnal from 16.1.2012 to 18.1.2012 and again on 25.1.2012 to 28.1.2012. Thereafter, she got treatment from Fortis Hospital, Mohali. An amount of Rs.45077/- was allegedly spent by her and claim for the same was lodged with opposite party no.1 on 8.2.2012, but the opposite party no.1 refused to pay the amount. The opposite party no.1 put defence that the complainant got treatment in Brain and Spine Hospital, Karnal for spinal ailment and such disease was not covered under the policy as per exclusion clause 6.2.1, therefore, no claim was payable.

7.                The discharge card issued by Brain and Spine Hospital Karnal Ex.C3 is the most material document and a perusal of the same shows that the complainant was diagnosed as Transient Ischemic Attack and Left sided L5 and S1 Radiculopathy. The problem was spine spondylite. Thus, it is emphatically clear that the complainant got treatment for spine problem. The copy of the repudiation letter Ex.O9 shows that section 6 of the policy is with regard to the waiting period and exclusions, according to which exclusions would apply to the life assured for two years from the date of commencement of the risk for certain an ailments mentioned therein. Under clause 6.3.2.10 spinal disease has been mentioned in the list of exclusions. The policy obtained by the complainant commenced from 29.10.2011 and she got treatment for spinal problem w.e.f.16.1.2012 in Brain and Spine Hospital, Karnal and thereafter from Fortis Hospital, Mohali. Thus, the case of the complainant is well covered in the exclusions clause of the policy. Under such facts and circumstances, we have no hesitation in concluding that the repudiation of the claim of the complainant as per the exclusion clause of the policy was legally justified and as such there was no deficiency in service on the part of the opposite party no.1.

8.                As a sequel to the foregoing reasons, we do not find any merit in the present complaint. Therefore, the same is hereby dismissed. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:15.02.2017

                                                                                      (K.C.Sharma)

                                                                                         President,

                                                                             District Consumer Disputes

                                                                             Redressal Forum, Karnal.

                             (Anil Sharma)

                               Member