Haryana

Ambala

CC/261/2019

Amarjit Singh - Complainant(s)

Versus

Tata AIG General Inss Co Ltd - Opp.Party(s)

10 Feb 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

 

                                                                      Complaint case no. :  261 of  2019.

                                                          Date of Institution :   22.08.2019.

                                                          Date of decision     :   10.02.2022.

 

Amarjit Singh, s/o Mohinder Singh, aged about 47 years, resident of H.No. 2039/A, Sai Mandir Wali Gali, Village Barara, Tehsil Barara, District Ambala, 133201.

          ……. Complainant.

 

1. Tata AIG General Insurance Company Ltd., Health Claims Hub, Suite, #108, Ground Floor, Srinilaya-Cyber  Spazio, Road No.2, Banjara Hills, Hyderabad-500034.
2. Tata AIG General Insurance Company Ltd., Registered Office at 15^th Floor, Peninsula Business Park, Ganpatrao Kadam Marg, Mumbai 400013.
3. Tata AIG General Insurance Company Ltd., Branch Office, Tata AIG General Insurance Company Ltd., #3^rd Floor, Shanti Complex, Opposite Civil Hospital, Ambala Cantt.
4. Axis Bank, Licensed Corporate Agent, Issuing Branch Office, Axis Bank, village Dhanora, Tehsil Barara, Sub-Tehsil Mullana, Ambala, Haryana 133203.

 

                                                                                  ….…. Opposite Parties.

         

Before:        Ms. Neena Sandhu, President.

                   Ms. Ruby Sharma, Member,

Sh. Vinod Kumar Sharma, Member.           

                            

Present:       Sh. Ashish Sharma, Advocate, counsel for complainant.

                   Sh. Mohinder Bindal, Advocate, counsel for OPs No. 1 to 3.

                   Sh. Amar Singh, Advocate, counsel for OP No.4.

 

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 pay  total sum of  Rs. 4,30,000/- to the complainant                                 which are as under:

1. To pay Rs. 3,00,000/- as medical expenses
2. To pay Rs.,1,00,000/- as compensation for mental agony and physical harassment suffered by the complainant.
3. To pay Rs.20,000 /- as  litigation expenses.
4. To pay Rs. 10,000/- as rehabilitation expenses.
   •  

 

Any other relief, which this Hon’ble Commission may deemfit.

 

2.  

3.            Upon notice, OPs No. 1 to 3 appeared through counsel and filed written version and have raised preliminary objections with regard to  maintainability, not come with clean hands and suppressed the material facts etc. On merits it is stated that complainant, his wife and two children were duly insured under Medi-prime policy bearing No. 0285325895 from 28.09.2018 to 27.09.2019, subject to the terms and conditions of the policy. Complainant registered claim with answering OPs and sent a request for reimbursement of the expenses for his alleged hospitalization from 26.10.2018 to 13.11.2018 at Alchemist Hospital. On scrutiny of claim form and medical record, it was noted that as per the discharge summary, complainant was diagnosed with right middle cerebral artery infarct and left hemi-paresis. Any claim under the policy has a specific waiting period of thirty days as per Section 3(b) of the policy which is reproduced hereunder for reference:

Section 3: Exclusions

30 days waiting period

(b) A waiting period of 30 days will apply to all claims unless

(i) The insured person has been insured under an Medi Prime Policy Continuously and without any break in the previous policy year or

(ii) The Insured Person was insured continuously and without interruption for at least 1 year under any retail health insurance policy of an Indian non life insurance company.

(iii) If the insured person renews with us or transfers from any other Indian non life insurer having any retail health insurance policy and increases the sum insured (other than as a result of the application of Benefit 2a) upon renewal with Us), then, this exclusion shall only apply in relation to the amount by which the sum insured has been increased.

In the instant case, the policy for the first time was taken for the period from 28.09.2018 to 27.09.2019 and complainant registered the claim, for his alleged hospitalization, for the period from 26.10.2018 to 13.11.2018, which is within thirty days, from the date of inception of the policy. Hence, his claim comes under the exclusion clause of the policy. The claim of complainant was rightly rejected by the answering OPs and he was duly informed vide letter dated 19.09.2019. There is no deficiency on the part of answering Ops. Thus, the complaint filed by the complainant against answering OPs, may be dismissed with special costs.

4.            Upon notice, OP No.4 appeared through counsel and filed written version and have raised preliminary objections with regard to maintainability, jurisdiction, not come with clean hands and suppressed with material facts. On merits it is stated that OP No. 4, is a scheduled commercial Bank and a corporate agent/facilitator of Ops No. 1 to 3. The role of the answering OP No. 4 was only to facilitate/assist the complainant to get the insurance policy from the OPs No.1 to 3. If the complainant is disputing regarding repudiation of his claim by OPs No.1  to 3, then he shall have filed the complaint only against them and not against the answering OP. It is settled principal of law that Under Section 230 of Indian Contract Act, 1872  an agent can neither sue and nor be sued except under the special circumstances mentioned therein. For ready reference, Section 230 of Indian Contract Act, 1872 is reproduced as under:-

Section -230:- Agent cannot personally enforce, nor be bound by, contracts on behalf of principal in the absence of any contact to that effect an agent cannot personally enforce contracts entered into by him on behalf of his principal, nor is he personally bound by them. In the absence of any contact to that effect an agent cannot personally enforce contracts entered into by him on behalf of his principal, nor is he personally bound by them”. Presumption of contract to contrary:-

Such a contract shall be presumed to exist in the following cases:-

1. Where the contract is made by an agent for sale or purchase of goods for a merchant resident abroad.
2. Where the agent does not disclose the name of his principal.
3. Where the principal, though disclosed, cannot be sued.

              There is no mention of any special circumstances in the complaint, which compelled the complainant to file the present complaint against the answering OP. There is no deficiency in service on the part of answering OP and complaint filed against it may be dismissed with special costs.

5.           Learned counsel for the complainant tendered his affidavit as Annexure CA along with documents as Annexure C-1 to C-9 and closed the evidence on behalf of the complainant. On the other hand, learned counsel for OPs No.1 to 3 tendered affidavit of Shri Rohit Udaiwal, son of Rajender Udaiwal, Associate Vice President-Auto Claims and authorized signatory, Tata AIG General Insurance Company Limited, Regional Office, Noida as Annexure OP-A alongwith documents Annexure OP-1 to OP-5 and closed the evidence on behalf of the OPs No.1 to 3. Learned counsel for the OP No.4 tendered affidavit of Shri Upmanyu Mittal, Branch Manager, Axis Bank Limited, Branch Village Dhanora, Tehsil Barara, Sub Tehsil Mullana, Ambala as Annexure OP4/A alongwith documents Annexure OP4/1 to OP4/6 and closed the evidence on behalf of OP No.4.

6.           We have heard the learned counsel for the parties and carefully gone through the case file.

7.           The Learned counsel for the complainant argued that complainant had taken a Medi-prime policy, for himself and his family members, from the Tata AIG General Insurance Company i.e. OPs No.1 to 3 for the period from 28.09.2018 to 27.09.2019. Unfortunately, on 26.10.2018, complainant got sick and was admitted in Alchemist Hospital, Panchkula, for treatment. Complainant was diagnosed with Right Middle Cerebral Artery large Infract-left hemi-paresis (De-compressive craniotomy), where he was operated upon and hospitalized from 26.10.2018 to 13.11.2018. Complainant lodged the claim for reimbursement of the amount incurred by the complainant on his treatment but the OPs No.1 to 3, arbitrarily rejected his claim vide letter dated 16.02.2019.

8.           On the contrary, the learned counsel for the OPs No.1 to 3, argued that any claim under the policy has a specific waiting period of thirty days as per Section No.3(b), of the policy. Complainant took the treatment before the expiry of thirty days, from the date of inception of the policy, as such, he is not entitled to get any amount and OPs No.1 to 3, have rightly repudiated the claim as per exclusion clause 3 (b) of the policy.

9.                     The learned counsel for the OP No.4, vehemently argued that the OP No.4, is a corporate agent/facilitator of the OPs No.1 to 3, its role was only to assist the complainant for getting the insurance policy from the OPs No.1 to 3. Claim of the complainant was repudiated by the OPs No.1 to 3 and OP No.4 has nothing to do with it. Complainant unnecessarily dragged the OP No.4 in this litigation therefore complaint filed by the complainant against it may be dismissed with special costs. 

10.                    Admittedly, the complainant and his family members were duly insured with the OP No.1 to 3 vide policy schedule Annexure C-5, for the period from 28.09.2018 to 27.09.2019, for sum assured of Rs.3,00,000/-. From the discharge summary, Annexure C-1, it is evident that the complainant was admitted in the Alchemist Hospital, Panchkula on 26.10.2018 and discharged on 13.11.2018. In Section 3 (b) of the terms and conditions of the policy, it is categorically mentioned that a waiting period of 30 days will apply to all claims. It may be stated here that parties are bound by the terms and conditions of the policy. It is an admitted fact that the policy in question was taken for the first time on 28.09.2018 and complainant was hospitalized from 26.10.2018 to 13.11.2018. Meaning thereby, complainant took the treatment within the thirty days from the date of inception of the policy. As such, as per Section 3(b) of the policy, no amount is payable to the complainant. By repudiating the claim of the complainant,  OPs No.1 to 3, have not committed any deficiency in service. The complaint filed by the complainant is devoid of merits, consequently, we dismiss the same. The parties are left to bear their own costs. 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 :10.02.2022.

 

 

 

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

              Member                                  Member                       President

 

Present:       Sh. Ashish Sharma, Advocate, counsel for complainant.                               Sh. Mohinder Bindal, Advocate, counsel for OPs No.1 to 3.                      Sh. Amar Singh, Advocate, counsel for OP No.4.

 

Vide our separate detailed order of even date, the present complaint has been dismissed. File be consigned to Record Room, after due compliance.

Announced on :10.02.2022.

 

 

 

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

              Member                         Member                       President