Punjab

Nawanshahr

CC/54/2015

Sunita Rani - Complainant(s)

Versus

Star Health and Allied Insurance Company Ltd. - Opp.Party(s)

A.K Sareen

09 Jun 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

SHAHEED BHAGAT SINGH NAGAR

Consumer Complaint No.         :    54 of 25.05.2015

Date of Decision:                    :     09.06.2016

Sunita Rani, w/o Late Keshav Narayan, resident of B-3/38, Shiv Colony, Nawanshahr, Tehsil & District SBS Nagar.

                                                                             …Complainant

Versus

1.       Star Health and Allied Insurance Company Limited, Jalandhar through its Manager.

2.       Star Health and Allied Insurance Company Limited, No.1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034.  

               …Opposite Parties

Complaint under the Provisions of Consumer Protection Act, 1986

QUORUM:

SMT.NEENA SANDHU, PRESIDENT

S.KANWALJEET SINGH, MEMBER

ARGUED BY:

For complainant                      :         Sh. A.K. Sareen, Advocate,

For OPs                                   :         Sh. Nipun Bhalla, Advocate,

ORDER

SMT.NEENA SANDHU, PRESIDENT

1.       Smt.Sunita Rani has filed this complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the Opposite Party (hereinafter referred to as ‘the OPs.)  Prayed that O.Ps. be directed to pay to the complainant:-

1.       Rs.4,20,000/- as insurance.

2.       Rs.70,000/- as compensation on account of mental agony, physical harassment and litigation expenses.

2.       In brief, the case of the complainant is that her deceased husband namely Keshav Narayan after paying the due premium amount, had obtained insurance policy bearing No.P/161125/03/2014/000313PYLE-10-02122 from O.P. No.1 having coverage of 5 Lac US$ on 19.05.2015, which was valid for the period from 20.5.2013 to 05.07.2013.  Her husband (now deceased) went to U.S.A on 20.05.2013 and was got admitted in the hospital i.e. University Medical Centre, Jackson, Mississippi (USA) and died on 26.5.2013. Information regarding the admission of her husband (now deceased) was given to the OPs and after receipt of the information, the OPs paid all the medical bills to the hospital. As per the policy in question, OPs were bound to pay medical expense, funeral expenses and other expenses. The OPs after paying the medical expenses did not pay funeral expenses and other expenses. The complainant and her family on the instructions of OPs had paid 6900 US Dollars as funeral charges. She being nominee of the life assured approached and submitted the copy of funeral charges with the OP No.1. But it refused to pay the amount on the ground of non disclosure of pre existing decease.  Since the OPs have refused to pay the funeral charges, therefore, she has suffered mental agony and physical harassment. Hence this complaint. 

3.       On being put to the notice, the OPs No.1 & 2 filed written version taking preliminary objections that; no cause of action has arisen in faovur of the complainant to file the present complaint; that this complaint has been filed by the complainant with a malafide intention, which is abuse of process of law; that complainant does not fall under the purview and jurisdiction of this Hon’ble Forum because mere reading of application filed by the complainant makes it clear that the complaint was filed for recovery of amount and nothing more than that; that this Forum has no jurisdiction to try and decide the present complaint; that the relief sought in the present complaint is in violation of the terms and conditions contained in the policy. The terms and conditions are the base of the insurance contract and have paramount importance in the eyes of law and as such both the parties can neither go nor claim beyond the terms and conditions of the contract; that the complainant has not approached this Hon’ble Forum with clean hands; that the complainant has not disclose the material facts; that the present complaint is false, frivolous, misconceived and vexatious in nature; that the complainant has concealed the true and material facts from this Forum. On merits, it is stated that life assured visited the office of the OPs to purchase the overseas insurance policy. The representative of the OPs explained the insurance plan to the life assured and thereafter after fully understanding the terms and conditions of the insurance plan, life assured opted to purchase the said overseas policy from the OPs by signing the proposal form and accordingly the said policy was issued to the life assured. It is wrong that on receipt of information of admission of life assured in the hospital, the OPs had paid medical bills. It is further stated that the life assured during his visit to USA was admitted to University of Mississippi Medical Centre on 23.05.2013 and was diagnosed with STEMI (St Elevation Myocardial Infarction) and as such he expired on 26.5.2013 and the funeral was performed in USA only. The claim was rejected by the OPs because the life assured was suffering from pre existing deceased and he has not disclosed the said fact at the time of taking the policy. The contract of insurance is based on utmost good faith between the parties, moreover, contract of insurance is governed by terms and conditions of policy and none of the parties can go beyond the terms and conditions of the contract. The claim intimation was received on 01.06.2013 and the complete documents were received on 17.9.2014 by the OPs. The hospital record clearly shows that life assured had past history of Myocardial Infarction, Coronary stenting and uncontrolled diabeties. After going through the hospital records, the OPs further referred the case for expert opinion and as per the opinion of the experts STEMI is a complication of LA’s preexisting condition of coronary disease and uncontrolled diabetes Mellitus. Since the policy specifically excludes any treatment for an already existing condition under exclusion clause No.3, therefore, claim was rightly repudiated by the OPs. Rest of the allegations made in the complaint have been empathically denied.

4.       On being called to do so, the learned counsel for complainant has tendered in evidence affidavit of complainant as Ex.CW1/A, alongwith Photostat copies of documents i.e. policy document Ex.C-1 (consisting 4 pages) and closed the evidence. Learned counsel for Ops has tendered in evidence copy of proposal form Ex.R-1, copy of policy schedule Ex.R-2, copy of covering letter Ex.R-3, copy of death summary Ex.R-4, copy of expert opinion Ex.R-5, copy of death certificate Ex.R-6, copy of letter dated 21.10.2014 Ex.R-7 , affidavit of Rajnish Kohli as Ex.OP1/A, terms and conditions Ex.R-8 and closed the evidence.

5.       We have heard the learned counsel for the parties and also gone the record carefully.

6.       At the outset, the learned counsel for the OPs argued that since the complainant had purchased policy in question from OP No.1, situated at  Jalandhar and as such no cause of action has arisen within district Nawanshahr, therefore, this Forum has no territorial jurisdiction to adjudicate upon the matter and the same is liable to be dismissed solely on this ground.

7.       From the policy schedule Ex.C-1, it is apparent the policy in question was issued by Star Health and Allied Insurance Company Limited, from Branch Office situated at Jalandhar – OP-1. As per section 11 of Consumer Protection Act, 1986 complaint can only be filed within the local limits of District Forum in whose jurisdiction, the OP is doing business or any cause of action has arisen.  But in the present case none of the OPs is doing its business nor any cause of action has arisen against them within the territorial jurisdiction of this Forum.  In the case of Raj Kumar Dhiman Vs M/s Trehan Automotives Pvt. Ltd & Anr, 2013 © CLT 40 (NC) passed by the Hon’ble National Commission and in the case of M/s Stan Auto Pvt. Ltd Vs Beant Singh passed by Hon’ble State Commission Punjab in FA No.881 of 2012 decided on 30.09.2013.  In the above said judgment the view taken by the Hon’ble Courts/Commissions are that jurisdiction is to be determined on the basis of actual residential, business and working place of opposite party.  Accordingly, in view of the above discussion, we dispose of the complaint, with liberty to the complainant to avail remedy before the appropriate court or any other appropriate Forum, for redressal of her grievance and to seek condonation of delay, for the period, the complaint remained pending in this Forum, as permissible under Section 14 of the Indian Limitation Act, 1963.

8.       The certified copies of this order be supplied to the parties free of costs and the file be indexed and consigned to the Record Room.

Dated:  09.06.2016

                                                                                                                                                                                 (NEENA SANDHU)

                                                                      President

 

                                                          

                                                          (KANWALJEET SINGH)

                                                          Member