BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 540 of 2022
Date of Institution : 30.08.2022
Date of Decision : 21.03.2024
Mohit Bajaj, aged 32 years son of Shri Umesh Bajaj, resident of House No. 15/16, Gali No.1, Near Railway Phatak, Sirsa, District Sirsa.
……Complainant.
Versus.
1. TATA AIG General Insurance Company Ltd., 5th and 6th Floor, Imperial Tower H. No. 7-1-617/A, GHML No. 615, 616, Ameerrpet, Hyderabad- 500 016 (Telangana), through its authorized person.
2. TATA AIG General Insurance Company Ltd., 3rd Floor, Shanti Complex, Opposite Civil Hospital, Ambala- 133 001 (Haryana) through its authorized person.
3. TATA AIG, C/o Axis Bank, Sangwan Chowk, Sirsa, District Sirsa through its Branch Manager.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
Present: Sh. Rakesh Bajaj, Advocate for the complainant.
Sh. A.S. Kalra, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint 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 purchased a Tata AIG Medicare Insurance policy from the ops through their authorized agent namely Kuldeep Singh for medical insurance of himself, his wife Smt. Shruti Bajaj, father Sh. Umesh Bajaj and mother Smt. Anita Bajaj vide insurance policy No. 0237742082 00 for the sum assured of Rs.3,00,000/- for the period 25.06.2019 to 24.06.2020 and had remitted a sum of Rs.31,080/- as insurance premium for the same. Subsequently this policy was got renewed for the period 25.06.2020 to 24.06.2021 and a sum of Rs.34,554/- was remitted by complainant as insurance premium to the ops. Thereafter, the said policy has been further got renewed w.e.f. 25.06.2021 to 25.06.2022 for insurance of above said persons except mother of complainant who died unfortunately on 18.05.2021 due to Covid-19. It is further averred that before issuing the above policy and thereafter on every subsequent renewal, the ops had got medically checkup of all the insured persons through their medical staff and ops after fully satisfying with the medical conditions of all the insured persons had issued the above policy to the complainant and charged the insurance premium from the complainant. That during the spread of Covid-19 pandemic, all the aforesaid insured persons were affected by the said pandemic. The father and wife of the complainant recovered from said disease at home, whereas complainant and his mother Smt. Anita were hospitalized. On 08.05.2021, mother of complainant was got admitted in Shah Satnam Ji Specialty Hospital, Sirsa and she remained admitted there, however, she could not survive and died during treatment on 18.05.2021. A sum of Rs.1,30,447/- was incurred on the treatment of his mother. It is further averred that after the death of mother of complainant, he lodged his claim with the ops and supplied all the relevant documents as required by them from time to time and also completed all the necessary formalities for settlement of his claim but till today the ops have neither rejected nor accepted the claim of complainant. That complainant has visited the ops on many occasions and requested for settlement of his claim and payment of the claimed amount but the ops did not pay any heed to the same and have caused deficiency in service, harassment and adopted unfair trade practice towards the complainant. Hence, this complaint.
3. On notice, ops appeared and filed written statement taking certain preliminary objections that there is no deficiency in service in any manner on the part of company or its officials; that complaint is estopped by his own act and conduct to file present complaint and complaint is without any cause of action and is pre-mature one, since the complainant had failed to submit the documents required for proceeding further with the claim. The queries were raised and documents required from complainant were sought i.e. treating doctors certificate for etiology, past history duration and follow up records of hypertension, diabetes mellitus when diagnosed for first time including first consultation paper, policy copy with updated policy details, legal heir certificate were sought by answering ops vide letters dated 26.08.2021, 09.09.2021, 22.09.2021, 08.11.2021, 01.02.2022 and 08.02.2022 which were/ are never supplied to answering ops, hence no final decision on the admissibility of the claim could be made and as such this Commission should not proceed further and decide the claim by exercising the powers vested with the Competent Authority. It is further submitted that death summary issued and submitted by the complainant revealed that the deceased/ insured was a known case of Diabetes Mellitus and Hypertension. The insured/ deceased was noted to be a known case of Diabetes Mellitus for one year and Hypertension for 15 years as per documents received whereas proposer at the time of proposing of the policy had declared that deceased/ insured had no history of hypertension or blood sugar. That in order to formally conclude that there was non disclosure of material fact, the complainant was requested to submit the documents as mentioned above which are material to conclude the admissibility of the claim and that this Commission has no jurisdiction to entertain and decide the present complaint as answering ops has no office here at Sirsa.
4. On merits, it is submitted that it is wrong that before issuance of policy and subsequent renewal all the insured persons were checked and after satisfying with the medical condition, policies were issued. The contract of insurance is based upon principle of utmost good faith and believing the contention given by insured in the proposal form policy is/ was issued. As per term and conditions of policy, insurance company has right to repudiate the claim, in case any of the contention mentioned in the proposal form is found wrong, incorrect at any point of time. It is further submitted that answering op has only partial record of Smt. Anita Bajaj and complete record is still awaited and it is wrong that complainant has completed all the formalities. While reiterating the above said pleas of preliminary objections, it is also submitted that whatever is admissible according to policy terms and conditions will be paid by insurance company but also only after compliance and fulfillment of requirements of company i.e. submission of relevant documents, treatment record etc. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
5. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents mark A to W.
6. On the other hand, ops have tendered affidavit of Sh. Amit Chawla, DVP (Legal) as Ex.R1 and documents Ex.R2 to Ex.R8 and failed to produce remaining evidence despite availing opportunities and as such evidence of ops was closed by order.
7. We have heard learned counsel for the parties and have gone through the case file carefully.
8. The complainant has claimed insurance claim amount of Rs.1,30,447/- spent on the treatment of his mother Smt. Anita Bajaj during the period of medical insurance policy effective from 25.06.2020 to 24.06.2021 issued by the ops for complainant, his wife Smt. Shruti, father Sh. Umesh Bajaj and mother Smt. Anita Bajaj as his mother Smt. Anita Bajaj remained admitted in the above said hospital from 08.5.2021 due to Covid-19 disease and she expired on 18.05.2021. All the above said insured persons were insured by the ops for the said period 25.06.2020 to 24.06.2021 for the sum insured amount of Rs.3,00,000/- as is evident from policy schedule mark P and policy in question for the first time was purchased by complainant for all the above said insured persons from 25.06.2019 to 24.06.2020 as is evident from policy schedule mark K. The ops also issued separate cards for the insurance period of 25.06.2020 to 24.06.2021 to all the insured persons which are also placed on file as mark R to mark U. From the discharge receipt mark H, it is proved on record that Smt. Anita Bajaj mother of complainant was admitted in Shah Satnam Ji Specialty Hospital, Sirsa on 08.05.2021 as she suffered disease of Covid-19 and she remained admitted there up to 18.05.2021 and she could not be saved and died on 18.05.2021 and her death certificate is placed on file as mark W. The claim lodged by complainant has not been reimbursed by the ops on the above said ground. However, we are of the considered opinion that ops have wrongly and illegally withheld the genuine claim amount of complainant which was spent on the treatment of his insured mother for the treatment of Covid-19 disease during valid period of medical insurance. There is nothing on file to prove that insured now deceased herself replied to the ops that she is not suffering from any disease and it is very common known fact to the general public at large that agent of the insurance company at the time of filling proposal form himself tick marks all the queries to the health condition on the column of ‘NO’ and therefore it cannot be said that deceased/ insured had himself declared that she is not having any history of any disease. Moreover, the insured Smt. Anita now deceased suffered disease of Covid-19 and also died due to said disease and not due to effect of disease of Diabetes Mellitus and hypertension which has also no concern with the disease of Covid-19. So, it is proved on record that ops have wrongly and illegally demanded the past history record of above said diseases which have no connection with the claim and disease of Covid-19. Moreover, the complainant vide application dated 24.08.2021 copy of which is placed on file during the course of arguments has clarified that her mother did not have any pre existing disease of diabetes and hypertension. The ops have failed to prove on record through any cogent and convincing evidence that i.e. affidavit of treating doctor that how he came to know that insured Smt. Anita has diabetes and hypertension. Moreover, it has been held by Hon’ble Appellate Courts in several judgments diseases like hypertension and diabetes cannot be used as concealment of pre existing disease for repudiation of the insurance claim. It is a commonly known that a person of 60 years of age has a high probability of suffering from common lifestyle diseases like diabetes and hypertension. If the company is ready to take the risk at this age of the proposer that too without any preliminary medical examination as per own plea of ops, then the company should be ready to honour the claim also. Moreover, the diseases of diabetes and hypertension are life style diseases and if the insurance companies will deny the claim on this types of grounds then nobody will receive any genuine claim from the insurance companies and insurance companies will reject the genuine grounds on such grounds. The ops are also not justified in demanding policy copy with details because same is in possession of insurance company who issues the policies and as such ops have caused unnecessary harassment to the complainant. So the ops have wrongly and illegally withheld the genuine claim of the complainant and as such complainant being son and legal heir who got insured his mother through ops is legally entitled to reimbursement of the claim amount of Rs.1,30,447/- spent by him on the treatment of his insured mother for which claim has already been lodged by complainant with the ops and in this regard complainant has also placed on file various receipts/ bills and discharge receipt as Mark H, Mark I and mark L to mark O. As such it cannot be said that ops have only partial record and that complaint is pre-mature when ops have already prepared their mind for not reimbursement of the genuine claim of the complainant on the above said ground.
9. In view of our above discussion, we allow the present complaint and direct the opposite parties to reimburse the claim amount of Rs.1,30,447/- (or the actual expenses incurred on above said treatment of his mother) 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 payable amount alongwith interest at the rate of @6% per annum from the date of this order till actual realization from ops. We also direct the ops to further pay a sum of Rs.10,000/- as compensation for harassment and Rs.5000/- 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 President,
Dated: 21.03.2024. District Consumer Disputes
Redressal Commission, Sirsa.
