DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/99/2022
Date of Institution: 31.03.2022
Date of Decision: 18.07.2024
Gurjant Singh son of Shri Ujagar Singh resident of Lakhi Colony, Street No. 3, Near Naresh Bawa, Advocate, Barnala, Tehsil and District Barnala (Pb).
…Complainant Versus
1. Tata AIG General Insurance Company Limited, 15th Floor, Tower-A, Peninsula Business Park, Ganpatrao Kadam Marg, Mumbai-400013 through its Authorized Signataory/Managing Director.
2. Tata AIG General Insurance Company Limited, Regd. Office 15th Floor, Peninsula Business Park, Ganpatrao Kadam Marg, Mumbai-400013 through its signatory.
…Opposite Parties
Complaint under Section 35 of the Consumer Protection Act, 2019
Present: Sh. A.K. Jindal Adv counsel for complainant.
Sh. Anuj Mohan Adv counsel for opposite parties.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Sh. Navdeep Kumar Garg: Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant Gurjant Singh filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Tata AIG General Insurance Company Limited, 15th Floor, Tower-A, Peninsula Business Park, Ganpatrao Kadam Marg, Mumbai-400013 through its Authorized Signataory/Managing Director & others (in short the opposite parties).
2. The facts leading to the present complaint as stated by the complainant are that the complainant purchased an Health Insurance Policy from the opposite parties through Axis Bank Limited, Branch Bamala, where the complaint have saving account No.913010010264230 for the period from 5-12-2020 to 04-12-2021 to secure his health, life and opposite parties told to the complains the if the complainant suffered from any diseases then the costs of the treatment will be bears by the opposite parties. It is alleged that the opposite parties issued the policy having No. 0238706946 in favour of the complainant and the amount of premium be deducted from the account of complainant. It is further alleged that the complainant suffered from Cardio and multiple diseases on 16.9.2021 and the complainant remained admitted in Dr. Naresh Hospital and Heart Centre, Barnala from 16-09-2021 to 23-09-2021 and the complainant spent an amount of Rs. 23,290/- for his treatment and again admitted in DMC Ludhiana from 6.11.2020 to 13.11.2021 and spent an amount of Rs. 56,320/- for his treatment. It is alleged that the complainant still under treatment of the DMC&H, Ludhiana and now complainant take medicine through OPD from the doctors of the DMC&H, Ludhiana regularly. It is alleged that after recovery from the diseases, the complainant applied to reimburse the amount of medical expenses and admission in his favour as agreed upon by the opposite parties in the above said policy. But the opposite parties have failed to reimburse the amount of claim to the complainant regarding the expenses incurred by the complainant upon his treatment till now despite repeated requests and demands were made to opposite parties to reimburse the claim of the complainant, but with no result. The complainant also served a legal notice dated 4.2.2022 through counsel upon the opposite parties but the opposite parties have failed to reimburse the amount of claim to the complainant yet today. The said acts of the opposite parties fall within the definition of deficiency of service on the part of opposite parties. Hence, the present complaint is filed for seeking the following reliefs.-
1) The opposite parties be directed to reimburse the amount of claim to the tune of Rs. 79,610/- alongwith interest @ 18% per annum from the date till realization.
2) To pay Rs. 50,000/- on account of compensation for mental agony and harassment and Rs. 10,000/- as litigation expenses.
3. Upon notice of this complaint opposite parties 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. The present complaint is false & frivolous complaint with an ulterior motive of extracting money from the opposite parties, hence the complaint is liable to be dismissed with costs.
4. On merits, it is admitted that the complainant Gurjant Singh obtained Tata Medicare Insurance Policy no. 028706946 for a period from 5.12.2020 to 4.12.2021 and premium was deducted for the same from his Bank Account maintained with Axis Bank, Barnala. It is further submitted that coverage for treatment under the policy was upto the limits as mentioned in the policy schedule and cashless hospitalization is provided under the policy through empanelled hospitals, however same is strictly subject to the terms and conditions of the policy. It is also admitted that complainant remained admitted in Dr. Naresh Hospital and Heart Care, Barnala from 16-09-2021 to 23-09-2021 and further remained admitted in DMCH, Ludhiana from 7.10.2021 till 10.10.2021, in DMCH Ludhiana from 6.11.2021 till 13.11.2021. It is further admitted that complainant lodged claim in respect of treatment taken by him from Dr. Naresh Hospital and Heart Care and Barnala as well as treatment taken by him from DMCH for the period of 7.10.2021 till 10.10.2021. It is further submitted that the complainant had submitted the claim form with the answering opposite parties for the reimbursement of treatment expenses and his claim was registered and claim document acknowledgement letter dated 9-10-2021 was issued to him by the opposite parties requesting the complainant to provide the following documents;-
1. Original detailed Discharge Summary on the Hospital Letterhead.
2. Positive Investigation reports supporting the diagnosis.
3. Related prescriptions and Investigation reports for the enclosed bills.
4. Treating Doctor Certificate for the past history and duration of Cardiac Failure when diagnosed for the first time including first consultation papers.
However, despite of above mentioned letter, complainant did not provide the complete treatment record as well as the past treatment record as he was aware that he was having pre-existing disease but he failed to disclose the same at the time of submitting proposal for taking the policy for the first time in year 2015. However, it was found that complainant was a known case of hypertension and Cardiomyopathy since the year 2009 i.e. prior to the policy inception date of 24.11.2015, hence his policy was cancelled and claim was repudiated vide letter dated 2.11.2021 on the grounds of Non disclosure. All other allegations of the complaint are denied and prayed for the dismissal of complaint.
5. The complainant filed replication to the written version filed by opposite parties vide which he denied the averments as mentioned in the written version.
6. The complainant tendered into evidence copies of account statements Ex.C-1 (Containing pages 6), copy of Insurance Policy EX.C-2 (Containing pages 1 to 15), copy of claim form Ex.C-3 (containing 6 pages), Copy of prescription slips alongwith bills of medicine EX.C-4 (Containing 10 pages), Consolidated bill of admission in DMC EX.C-5 (Containing 9 pages), Copy of termination letter dated 27.1.2022 EX.C-6, Copy of legal notice dated 4.2.2022 Ex.C-7, Postal receipt EX.C-8, Affidavit of Gurjant Singh EX.C-9 and closed the evidence.
7. The opposite parties tendered into evidence affidavit of Amit Chawla as Ex.OPs-1, copy of policy alongwith terms and conditions as Ex.OPs-2 (containing 11 pages), copy of request for cashless hospitalization as Ex.OPs-3 (containing 5 pages), copy of claim form as Ex.OPs-4, copy of letter claim intimation as Ex.OPs-5, copy of treatment summary as Ex.OPs-6, copy of letter dated 10.08.2021 as Ex.OPs-7, copy of claim document acknowledgement letter as Ex.OPs-8, copy of letter dated 16.10.2021 as Ex.OPs-9, copy of claim rejection as Ex.OPs-10, copy of claim document acknowledgement letter dated 03.11.2021 as Ex.OPs-11, copy of claim rejection dated 10.11.2021 as Ex.OPs-12 and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on the file.
9. It is admitted case of the opposite parties that the complainant Gurjant Singh obtained Tata Medicare Insurance Policy no. 028706946 for a period from 5.12.2020 to 4.12.2021 (as per Ex.C-2 & Ex.O.Ps-2) and premium was deducted for the same from his Bank Account maintained with Axis Bank, Barnala (as per Ex.C-1). It is also not disputed between the parties that complainant remained admitted in Dr. Naresh Hospital and Heart Care, Barnala from 16-09-2021 to 23-09-2021 and further remained admitted in DMCH, Ludhiana from 7-10-2021 till 10-10-2021, in DMCH Ludhiana from 6-11-2021 till 13-11-2021. It is also not disputed between the parties that complainant lodged claim in respect of treatment taken by him from Dr. Naresh Hospital and Heart Care and Barnala as well as treatment taken by him from DMCH.
10. Ld. Counsel for the complainant argued that the complainant suffered from Cardio and multiple diseases on 16.9.2021 and the complainant remained admitted in Dr. Naresh Hospital and Heart Centre, Barnala from 16-09-2021 to 23-09-2021 and the complainant spent an amount of Rs. 23,290/- (as per Ex.C-4) for his treatment and again admitted in DMC Ludhiana from 6.11.2020 to 13.11.2021 and spent an amount of Rs. 56,320/- (as per Ex.C-5) for his treatment. It is argued that the complainant still under treatment of the DMC&H, Ludhiana and now complainant take medicine through OPD from the doctors of the DMC&H, Ludhiana regularly. It is further argued that after recovery from the diseases the complainant applied to reimburse the amount of medical expenses alongwith requisite documents and admission in his favour as agreed upon by the opposite parties in the above said policy, but the opposite parties have failed to reimburse the amount of claim to the complainant regarding the expenses incurred by the complainant upon his treatment till now despite repeated requests and demands were made to opposite parties to reimburse the claim of the complainant, but with no result. It is argued that the complainant also served a legal notice dated 4.2.2022 (Ex.C-7) through counsel upon the opposite parties but the opposite parties have failed to reimburse the amount of claim to the complainant yet today. The complainant to prove his claim has placed on record copy of bill of Dr. Naresh Hospital & Heart Centre Ex.C-4 which shows at the Page No. 8 of Ex.C-4 that the complainant has spent an amount of Rs. 23,290/- on his treatment (i.e. from 16.9.2021 to 23.9.2021) in the said hospital. The complainant also placed on record copy of In-Patient Final Bill of Dayanand Medical College & Hospital Managing Society, Ludhiana Ex.C-5 which shows that the complainant has spent an amount of Rs. 56,320/- on his treatment (i.e. from 6.11.2021 to 13.11.2021) has been spent in the said hospital and the total expenses comes to Rs. 79,610/-.
11. On the other hand, Ld. Counsel for the opposite parties argued that the complainant had submitted the claim form with the opposite parties for the reimbursement of treatment expenses and his claim was registered and a letter dated 10.9.2021 and 10.16.2021 (Ex.O.Ps-8 & Ex.O.Ps-9) was issued to him by the opposite parties requesting the complainant to provide the requisite documents (as mentioned in the written version), but despite of above mentioned letters, complainant did not provide the complete treatment record as well as the past treatment record as he was aware that he was having pre-existing disease but he failed to disclose the same at the time of submitting proposal for taking the policy for the first time in year 2015, however it was found that complainant was a known case of hypertension and Cardiomyopathy since the year 2009 i.e. prior to the policy inception date of 24.11.2015, hence his policy was cancelled and claim was repudiated vide letter dated 11.2.2021 (as per Ex.O.Ps-10) on the grounds of Non disclosure.
12. It is the specific plea of the opposite parties that complainant did not provide the complete treatment record as well as the past treatment record as he was aware that he was having pre-existing disease but he failed to disclose the same at the time of submitting proposal for taking the policy for the first time in year 2015 and it was found that complainant was a known case of hypertension and Cardiomyopathy since the year 2009 i.e. prior to the policy inception date of 24.11.2015, hence his policy was cancelled and claim was repudiated vide letter dated 11.2.2021 on the grounds of Non disclosure. We have gone through the claim rejection letter dated 11.2.2021 Ex.O.Ps-10 vide which it is mentioned that “As per the scrutiny of the documents member is a known case of Hypertension and cardiomyopathy since 2009 that is prior to policy inception and the policy start date is 24 Nov 2015. 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”. Ld. Counsel for the opposite parties 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 2015 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 2015 in the proposal form. So, we are of the view that the above said plea of the opposite parties is not tenable. Moreover, from the file it shows that the complainant has purchased the above said policy on 24.11.2015 and after that the said policy was renewed regularly, 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 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.
13. From the above discussion, it is proved that the claim of the complainant was repudiated by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties.
14. In view of the above discussion, the present complaint is partly allowed and the opposite parties are directed to pay an amount of Rs. 79,610/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties 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:
18th Day of July, 2024
(Ashish Kumar Grover)
President
(Navdeep Kumar Garg)
Member
