DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/174/2021
Date of Institution: 17.08.2021
Date of Decision: 13.08.2024
Pawan Kumar aged 57 years, son of Roop Lal son of Ganpatai Rai, resident of Ward No. 3, Tapa, Tehsil Tapa, District Barnala.
…Complainant Versus
1. Tata AIG General Insurance Company Ltd. Registered office Peninsula Business Park, Tower-A, 15th floor G.K. Marg Lower Parel Mumabi-400013 through its authorized signatory.
2. AXIS Bank (Intermediary) through its Branch Manager Branch Tapa, District Barnala.
3. Policy serving Office TATA AIG General Insurance Company Ltd. 2nd floor SCO/232/234 sector 34 Chandigarh-160022 through its Manager.
…Opposite Parties
Complaint under Section 35 of the Consumer Protection Act, 2019
Present: Sh. S.S. Sidhu Adv counsel for complainant.
Sh. Anuj Mohan Adv counsel for opposite parties No. 1 & 3.
Sh. A.K. Jindal Adv counsel for opposite party No. 2.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Smt. Urmila Kumari: Member
3. Sh. Navdeep Kumar Garg: Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Tata AIG General Insurance Company Ltd. Registered office Peninsula Business Park, Tower-A, 15th floor G.K. Marg Lower Parel Mumabi-400013 through its authorized signatory & others (in short the opposite parties).
2. The facts leading to the present complaint as stated by the complainant are that Pawan Kumar who purchased the policy from opposite party No. 2 under the heading Group Medicare Micro Insurance Product Insurance policy No.0237868334 on 8.10.2020 for a period of w.e.f. 31.10.2020 to 30.10.2021. It is alleged that the complainant had paid an amount of Rs.16,639/- towards premium on 8.10.2020 vide receipt No. 109151016249213 and its covering patient treatment amount is up to Rs.10,00,000/- and at the time of release of policy it was assured to the complainant that policy cover under cashless scheme for providing free treatment to the policy holder. It is further alleged that the complainant fell sick all of sudden and was admitted in the Dayanand Medical College and Hospital Ludhiana on 25.1.2021 where he was treated under the care of Dr Ajit Sood and remained admitted up to 2.2.2021 and during this treatment a sum of Rs.1,45,000/- was incurred. It is alleged that at the time of discharge of the complainant from the said Hospital, the Hospital authorities refused to refund amount of Rs.1,45,000/- to the complainant by alleging that the applicant was having past medical history and it was not covered under the scheme for which the policy was released. The complainant made many requests to the opposite party No. 2 to get paid the amount in question but opposite party No. 2 refused to it without assigning any reasons. It is further alleged that the above said acts of the opposite parties caused mental tension, agony and physical harassment to the complainant. Hence, the present complaint is filed for seeking the following reliefs.-
The opposite parties be directed to pay premium amount of Rs. 1,45,000/- + Rs. 50,000/- on account of mental tension, agony and physical harassment. Total Rs. 1,45,000/- amount already paid + Rs. 50,000/- on account of mental tension, agony, physical harassment + Rs. 10,000/- as costs of the proceedings and total claim is Rs. 2,05,000/- alongwith interest @ 12% per annum till realization.
3. Upon notice of this complaint opposite parties No. 1 & 3 appeared and filed written reply by taking preliminary objections on the grounds that the complaint is not maintainable in the present form & as such same deserves to be dismissed with costs. The complainant has no cause of action & locus-standi to file the present complaint. The complainant has not come to the Commission with clean hands & has suppressed the material facts from this Commission etc.
4. On merits, it is admitted that complainant Pawan Kumar obtained Group Medicare Insurance Policy No. 0237868334 on 8.10.2020 for a period of 31.10.2020 to 30.10.2021. It is further submitted that the policy was issued subject to its terms and conditions. It is also admitted that an amount of Rs 16,639/- including GST was paid by the complainant as premium for the above mentioned policy. It is also admitted that coverage for treatment under the policy was upto Rs 10,00,000/-. However, it is denied that the policy cover under cashless scheme for providing treatment to the policy holder. It is submitted that cashless facility is extended to provide easy treatment to the insured. However, the same is governed with respect to the terms and conditions of the policy. It is also admitted that complainant remained admitted in DMCH from 25.1.2021 till 2.2.2021. It is specifically submitted that as per the available documents, the complainant was suffering from CVA since 2018 and was on continuous treatment for the same and the complainant never disclosed about the ailment to the answering opposite parties before preferring present policy in proposal form. It is submitted that cashless treatment to the complainant was denied as his pre-authorization request was declined as he was found to have a pre-existing ailment which was not disclosed at the time of making proposal for the policy in question. It is further alleged that as per the initial course of treatment as was advised by the Hospital Authorities and as per preliminary reports submitted with pre-authorization request, answering opposite parties approved pre-authorization request for treatment of complainant for a limit upto Rs 30,000/- vide cashless authorization letter dated 25.1.2021 and was further extended upto the limit of Rs 70,000/- during the course of treatment, however at the time of discharge, after going through the treatment record, it was found that complainant had concealed material information about his previous ailment, hence cashless treatment was denied vide letter dated 2.2.2021 and claim of the complainant was rejected by the answering opposite parties vide letter dated 6.3.2021 as per terms and conditions of the policy. All other allegations of the complaint are denied and prayed for the dismissal of complaint.
5. The opposite party No. 2 filed written reply by taking legal objections on the grounds that the opposite party No. 2 is not in the business of insurance nor under law can it carry on the business of insurance. It is further submitted that opposite party No. 2 is only doing the business of Banking and the actual insurance policy issued by the opposite party No. 1, therefore no cause of action arose against the opposite party No. 2 and the opposite party No. 2 is not liable to pay any amount to the complainant. The complainant has not come in the Commission with clean hands and the present complaint is frivolous, vexatious and liable to be dismissed under Section 36 of the Consumer Protection Act etc.
6. On merits, it is admitted only to the extent that the complainant purchased the insurance policy from opposite party No. 1 & 3. It is submitted that the complainant maintains his saving account with the answering opposite party. All other allegations of the complaint are denied and prayed for the dismissal of complaint.
7. The complainant filed rejoinder to the written version filed by opposite parties vide which he denied the averments as mentioned in the written version.
8. The complainant tendered into evidence copy of policy as Ex.C-1 (containing 2 pages), copy of receipt as Ex C-2 (containing 5 pages), affidavit of Pawan Kumar as Ex.C-3, copies of bills and receipts are Ex.C-4 to C-54, copy of repudiation of claim dated 03.06.2021 as Ex.C-55 and closed the evidence.
9. The opposite parties No. 1 & 3 tendered into evidence affidavit of Amit Chawla as OP1.3/1, copy of Group Medicare Certificate of Insurance as Ex.OP1.3/2 (containing 4 pages), copy of Policy wordings alongwith terms and conditions are Ex.OP1.3/3 (containing 20 pages), copy of Discharge Summary as Ex.OP1.3/4 (containing 3 pages), copy of cashless authorization letter as Ex.OP1.3/5, copy of case summary alongwith bills as Ex.OP1.3/6 (containing 4 pages), copy of letter dated 30.01.2021 as Ex.OP1.3/7, copy of application form as Ex.OP1.3/8 (containing 4 pares), copy of letters dated 02.02.2021, 26.02.2021 are Ex.OP1.3/9 & OP1.3/10, copy of claim rejection letter dated 06.03.2021 as Ex.OP1.3/11 and closed the evidence.
10. The opposite party No. 2 tendered into evidence copy of statement of account for the period 1.01.2019 to 31.12.2019 as Ex.OP2/1, copy of statement of account for the period 01.01.2020 to 31.12.2020 as Ex.OP2/2, affidavit of Navnish Kumar Goyal as Ex.OP2/3 and closed the evidence
11. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments filed by opposite party No. 2.
12. It is admitted case of the opposite parties No. 1 & 3 that complainant Pawan Kumar obtained Group Medicare Insurance Policy No. 0237868334 on 8.10.2020 for a period of 31.10.2020 to 30.10.2021 (Ex.C-1). It is also admitted case of the opposite parties No. 1 & 3 that an amount of Rs 16,639/- including GST was paid by the complainant as premium for the above mentioned policy and coverage for treatment under the policy was upto Rs 10,00,000/-. It is also admitted case of the opposite parties No. 1 & 3 that complainant remained admitted in DMCH, Ludhiana from 25.1.2021 till 2.2.2021 (as per Ex.O.P1.3/4).
13. Ld. Counsel for the complainant argued that the complainant fell sick all of sudden and was admitted in the Dayanand Medical College and Hospital Ludhiana on 25.1.2021 where he was treated under the care of Dr Ajit Sood and remained admitted up to 2.2.2021 and during this treatment a sum of Rs.1,45,000/- was incurred. It is further argued that at the time of discharge of the complainant from the said Hospital, the Hospital Authorities refused to refund amount of Rs.1,45,000/- to the complainant by alleging that the applicant was having past medical history and it was not covered under the scheme for which the policy was released.
14. Ld. Counsel for the opposite parties No. 1 & 3 argued that as per the available documents the complainant was suffering from CVA since 2018 and was on continuous treatment for the same and the complainant never disclosed about the ailment to the opposite parties before preferring present policy in proposal form. It is further argued that cashless treatment to the complainant was denied as his pre-authorization request was declined as he was found to have a pre-existing ailment which was not disclosed at the time of making proposal for the policy in question. It is further argued that as per the initial course of treatment as was advised by the Hospital Authorities and as per preliminary reports submitted with pre-authorization request, opposite parties approved pre-authorization request for treatment of complainant for a limit upto Rs 30,000/- vide cashless authorization letter dated 25.1.2021 and was further extended upto the limit of Rs 70,000/- during the course of treatment, however at the time of discharge, after going through the treatment record, it was found that complainant had concealed material information about his previous ailment, hence cashless treatment was denied vide letter dated 2.2.2021 (Ex.O.P1.3/9) and claim of the complainant was rejected by the opposite parties vide letter dated 6.3.2021 (Ex.O.P1.3/11) as per terms and conditions of the policy.
15. Ld. Counsel for the opposite party No. 2 argued that the opposite party No. 2 is not in the business of insurance nor under law can it carry on the business of insurance. It is further argued that opposite party No. 2 is only doing the business of Banking and the actual insurance policy issued by the opposite party No. 1, therefore no cause of action arose against the opposite party No. 2. It is further argued that the complainant maintains his saving account with the opposite party No. 2.
16. It is the specific plea of the opposite parties No. 1 & 3 that as per the available documents the complainant was suffering from CVA since 2018 and was on continuous treatment for the same and the complainant never disclosed about the ailment (pre-existing diseases) to the opposite parties before preferring present policy in proposal form and cashless treatment to the complainant was denied as his pre-authorization request was declined because he was found to have a pre-existing ailment which was not disclosed at the time of making proposal, hence the claim of the complainant was rejected by the opposite parties vide letter dated 6.3.2021 (Ex.O.P1.3/11) as per terms and conditions of the policy. On the other hand, Ld. Counsel for the complainant further argued that the terms and conditions were not supplied to the complainant alongwith policy, therefore the same are not part of contract. We have gone through the claim rejection letter dated 6.3.2021 Ex.O.P1.3/11 vide which it is mentioned that “As per the scrutiny of the documents member is a known case of Cerebrovascular accident since 2018 which is prior to policy inception and the policy start date is 31-Oct-2019 and the same have not been disclosed in proposal form. Hence, your policy is being cancelled and we regret to inform you that your claim is repudiated under non-disclosure Section 4.7.i”. Ld. Counsel for the opposite parties No. 1 & 3 further argued that the complainant has failed to disclose about the pre-existing disease at the time of submitting the proposal for taking the policy for the first time in the year 2019 and this fact is also mentioned at Para No. 3 on merits in the written version filed by the opposite parties. But the opposite parties have failed to place on record the proposal form to prove the fact that the complainant has not disclosed regarding the pre-existing disease at the time of taking the policy in the year 2019 in the proposal form. So, we are of the view that the above said plea of the opposite parties No. 1 & 3 is not tenable. Moreover, from the file it shows that the complainant has purchased the above said policy on 30.4.2019 and after that the said policy was renewed, so at this stage how the opposite parties could have raised the objection that the complainant has pre-existing disease prior to the policy inception date. We are of the view that it was in the hands of insurance company to see and not to issue or renew the policy where person is not entitled to claim on account of treatment of Pre-existing disease. Moreover, there is nothing on record from the side of opposite parties that they have conducted the medical examination/investigation of the insured at the time of issuing the policy. So, we are of the view that at this stage the opposite parties (insurance company) cannot be escaped from their liabilities by raising these types of unreasonable and unjustified grounds. The learned counsel for the complainant also relied upon the judgment of the Hon'ble Punjab and Haryana High Court (DB) 2012 (1) RCR (Civil)-901 in which the Hon'ble High Court held that “Claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the policy. Single judge allowed the claim on the ground that it was for Insurance Company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. No interference called for in the order of Single Judge. Held the pre-existing condition existed in the year 2002 which was five years prior to acquiring Insurance Policy. Claim cannot be denied. Ld. Counsel for the complainant also relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that it seems that the insurance companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the effected people to fight for getting their genuine claims.
17. From the above discussion, it is proved that the claim of the complainant was repudiated by the opposite parties No. 1 & 3 on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties No. 1 & 3.
18. However, on the perusal of copies of bills and receipts Ex.C-4 to Ex.C-54 shows that the total amount of Rs. 1,41,931/- has been spent on the treatment of complainant. But in the present complaint the complainant has claimed an amount of Rs. 1,45,000/-. So, we are of the view that the complainant is entitled for the amount of Rs. 1,41,931/-.
19. In view of the above discussion, the present complaint is partly allowed against the opposite parties No. 1 & 3 and the opposite parties No. 1 & 3 are directed to pay an amount of Rs. 1,41,931/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties No. 1 & 3 are further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
13th Day of August, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
(Navdeep Kumar Garg)
Member
