DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA
C.C.No. 281 of 17-11-2021
Decided on : 31-07-2024
Divya aged about 37 years W/o Rohit Sharma R/o Street No.4, Nachhattar Nagar, Mansa Road, Bathinda.
........Complainant
Versus
1. Tata AIG General Insurance Company Ltd., Regd. Office at 15th Floor, Peninsula Business Park, G.K. Mark, Lower Parel, Mumbai-400013, through its Managing Director/Chairman.
2. Tata AIG General Insurance Company Ltd., Branch 2nd Floor, Above PNB Bank, Tinkoni Branch, MCB-Z-3, GT Road, Office at Bathinda, through its Branch Manager.
.......Opposite parties
Complaint under Section 35 of the Consumer Protection Act, 2019
QUORUM
Smt. Priti Malhotra, President
Smt. Sharda Attri, Member
Present :
For the complainant : Sh.Rohit Sharma, Advocate.
For opposite parties : Sh.Vinod Garg, Advocate.
ORDER
Priti Malhotra, President
1. The complainant Divya (here-in-after referred to as complainant) has filed this complaint U/s 35 of Consumer Protection Act, 2019 (here-in after referred to as 'Act') before this Commission against Tata AIG General Insurance Company Ltd and another (here-in-after referred to as opposite parties).
2. Briefly stated, the case of the complainant is that she purchased the medical insurance Policy of 'TATA AIG General Insurance Co.Ltd.', vide master policy bearing No.0237868334, certificate No.014785 in her name, w.e.f. 3.9.2019 to 2.9.2020 by depositing the premium amount of Rs.14,489/- and it again got extended for the next year and it is still in force. As per the terms of the policy, the complainant, her husband Rohit Sharma and two minor children namely Pragya-daughter and Divya-son are covered under the medical insurance policy.
3. It is alleged that unfortunately, the husband of the complainant got injury on the left hand i.e. tear of flexor digitorm superficialis tendon on 19.11.2020. In simple words, he got a cut on the left hand with a knife and he was firstly taken to Max Hospital, Bathinda and he got admitted there on 19.11.2020. He got the treatment/surgery on the left hand from Max Hospital, Bathinda and thereafter he also got treatment from COSMO Superspeciality Hospital, Bathinda. The complainant lodged the claim with opposite party No.1 through Max Hospital, Bathinda before surgery vide claim No.2020111900120, but her claim was repudiated by opposite parties vide letter dated 23.11.2020 on the ground that 'the submitted claim is for the tear of flexor digitorm superficialis tendon, any ligament/tendon repair with/without injury has a specific two years waiting period as per the policy and the policy start date is 3.9.2019, hence we regret to inform you that your claim is repudiated under section 3)1)i) of the policy'. As such, the complainant and her husband have borne the entire expenses of the medical treatment of the husband of the complainant i.e. Rs.67,000/- approx., from their own pocket.
4. It is further alleged that opposite parties have illegally and arbitrarily repudiated the claim of the complainant although her husband suddenly got injury on the left hand in an incident and it does not fall within the exclusion clause or clause 3)1)i) of the policy as alleged by opposite parties. The injury is not a pre-existing rather it was sustained by her husband all of a sudden on 19.11.2020 and for an accidental injury, the complainant or her family members cannot wait for the expiry of the period of two years rather they are entitled to the insurance claim for the medical treatment.
On this backdrop of facts, the complainant has prayed for directions to opposite parties to reimburse him medical insurance claim of Rs.67,000/- and also to pay Rs.25,000/- as compensation and Rs.5500/- as litigation expenses.
5. Upon notice, opposite parties appeared through counsel and contested the complaint by filing written version and raising preliminary objections that the intricate questions of law and facts are involved in this complaint. They require voluminous documents and evidence for determination. It is not possible in the summary procedure under 'Act' and appropriate remedy, if any, lies only in the civil court. The complainant has concealed the material facts and documents from this Forum and opposite parties. As such, she is not entitled to any relief. She has concealed the fact that the claim is for the tear of flexor digitorm superficialis tendon. Any ligament/tendon repair with/without injury has specific two years of waiting period as per the policy and the policy start date is 3.9.2019. As such, the claim was rejected under Section -3(i)(ii) of the policy. Opposite parties have also referred Section 3 of General Clause, reproduction of which is not necessary.
6. It is pleaded that the complainant is not 'consumer' of opposite parties. She has no locus-standi or cause-of-action to file the complaint against opposite parties as the claim relates to her husband whereas the complaint has not been filed by him. The complaint is not maintainable in its present form and it is liable to be dismissed. Opposite parties reserve the right to file a fresh reply at any stage of present complaint, if new facts came to the knowledge of opposite parties.
7. On merits, opposite parties have pleaded that a claim was for pre- authorization for cashless treatment lodged. The claim is for the tear of flexor digitorm superficialis tendon. Any ligament/tendon repair with/without injury has specific two years of waiting period as per the policy and policy start date is 3.9.2019, hence no claim is payable and cashless was denied vide letter dated 23.11.2020. In further written version, opposite parties have controverted all other averments of the complainant and prayed for dismissal of complaint.
8. In support of his complaint, the complainant has tendered into evidence his affidavit dated 22.10.2021 (Ex. C1) and documents, (Ex.C2 to Ex.C31).
9. In order to rebut the evidence of complainant, the opposite parties have tendered into evidence affidavit of Amit Chawla dated 15.7.2022, (Ex.OP2/1) and documents, (Ex.OP2/2 to Ex.OP2/7).
10. We have heard learned counsel for the parties and gone through the file carefully.
11. Learned counsel for parties have reiterated their stand as taken in their respective pleadings as detailed above.
12. We have given careful consideration to these submissions.
13. Admittedly, the complainant obtained the medical insurance policy of 'TATA AIG General Insurance Co.Ltd.' and got the policy extended from time to time. The complainant, her husband Rohit Sharma and two minor children namely Pragya-daughter and Divya-son are covered under the above medical insurance policy.
14. It is proved on record that the husband of the complainant got injury on his left hand for the treatment which, he was firstly taken to Max Hospital, Bathinda and got admitted there on 19.11.2020 and get the surgery done on his left hand from Max Hospital, Bathinda and after that he got treatment from COSMO Superspecialty Hospital, Bathinda. Discharge summary, (Ex.C30) of COSMO Super Specialty Hospital proves this fact. The complainant lodged the claim with opposite party No.1, but her claim was repudiated by opposite parties vide letter dated 23.11.2020, (Ex.C28). The relevant portion of this letter is reproduced as under for ready reference:-
“The submitted claim is for the tear of flexor digitorm superficialis tendon, any ligament/tendon repair with/without injury has a specific two years waiting period as per the policy and the policy start date is 3.9.2019. Hence we regret to inform you that your claim is repudiated under section 3)1)i) of the policy.”
15. Opposite parties have produced on record Group Medicare 360 Certificate of Insurance, (OP2/6) in which Clause (f) (j) of Specified disease/procedure waiting period: (Code Excl 02) relates to the case of the complainant. The relevant portion of this Clause is reproduced as under for ready reference:-
Specified disease/procedure waiting period:
(Code Excl 02)
“a....
b....
c....
d....
e....
(f) List of specific diseases/procedures
g....
h....
i....
(j) Ligament, Tendon or Meniscal tear (Except for those arising out of injury during policy period.”
The husband of the complainant got injury on his left hand i.e. tear of flexor digitorm superficialis tendon. Thus, the above mentioned Clause covers the claim of the complainant as the complainant has undergone the surgery of the injury suffered during the policy coverage period. Therefore, opposite parties have wrongly repudiated the claim of the complainant. The complainant is entitled for reimbursement of insurance claim.
16. In view of what has been discussed above, present complaint is partly allowed with Rs.10,000/- as cost and compensation against opposite parties. Opposite parties are directed to pay the insurance claim to the tune of Rs.67,000/- (spent on the treatment of the husband of the complainant) to the complainant after verifying all the bills related to the treatment of her husband.
17. The compliance of this order be made within 45 days from the date of receipt of copy of this order.
18. In case of non-compliance of the order within the stipulated period, thereafter opposite parties will be liable to pay additional cost of Rs.7000/- to the complainant.
19. The complaint could not be decided within the statutory period due to heavy pendency of cases.
20. Copy of order be sent to the parties concerned free of cost and file be consigned to the record room.
Announced
31-07-2024
(Priti Malhotra)
President
(Sharda Attri)
Member
