Chandigarh

DF-I

CC/436/2022

Prem Shanker Agrawal - Complainant(s)

Versus

Tata Aig General Insurance Co. Ltd. - Opp.Party(s)

In Person

02 Nov 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/436/2022
Date of Institution	:	18/04/2022
Date of Decision	:	02/11/2023

 

Prem Shanker Agrawal, Senior citizen, age 70 years, resident of H.No.553, Vigyan Vihar, Sector 49-A, Chandigarh (U.T)-160047

… Complainant

V E R S U S

1. TATA AIG General Insurance Company Limited, Peninsula Business Park, Tower A, 15^th Floor, G.K. Marg, Lower Parel, Mumbai-400013.
2. Branch Manager, TATA AIG General Insurance Company Limited, SCO 232/234, 2^nd Floor, Sector 34-A, Chandigarh 160022.
3. Chief Manager, Canara Bank, S.C.O 255-256, Sector 44-C, Chandigarh 160047.

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Complainant in person
	:	Sh. Sahil Abhi, Advocate for OPs 1 & 2
	:	Sh. Vikas Goel, Advocate for OP-3

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Prem Shanker Aggarwal, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that on 27.8.2018, complainant took cashless health policy (Annexure C-1) under Group Assurance Health Plan through OP-3 from Apollo Munich Health Insurance Co. Ltd. (hereinafter referred to as “previous insurer”) with sum assured of ₹5.00 lacs by paying premium of ₹6,812/- alongwith another Group Personal Accident Policy (Annexure C-2) with sum assured of ₹5.00 lacs by paying premium of ₹295/- and total premium for both the policies was paid as ₹7,107/-.  At the time of taking the policies (Annexure C-1 & C-2), complainant had disclosed all the facts which were maximum known to him about the pre-existing disease happened in the year 2001. Thereafter both the policies were renewed from the aforesaid insurer vide policies (Annexure C-3 & C-4) till August 2020.  However, on 28.8.2020, complainant ported the aforesaid first policy to OP-1, by paying the same premium amount and the said policy (Annexure C-5) (hereinafter referred to as “subject policy”) was valid w.e.f. 28.8.2020 to 27.8.2021.  On 9.4.2021 i.e. after about 20 years, complainant felt heaviness in chest and accordingly he approached the Fortis Hospital, Mohali for investigation and got admitted there as per the advice of the consulting doctor.  During investigation, blockage in right coronary artery was found and accordingly one stent was inserted and the complainant was discharged on 10.4.2021.  The discharge summary and PTCA report are Annexure C-6 & C-7. The aforesaid hospital raised bill of ₹1.5 lacs and immediately the complainant intimated the OPs through emails dated 4.5.2021 about the said treatment given to him.  However, the complainant did not get approval of the claim from the OPs, even after sending several emails to the OPs alongwith subsequent bills qua his treatment of ₹13,137/- alongwith the total details of the bill amounting to ₹1,63,137/-.  On 19.10.2021, the complainant received an email (Annexure C-14) from the OP/insurer intimating that his claim has been repudiated on the ground of non-disclosure of facts related to previous ailment.  The said repudiation letter was properly replied by the complainant vide email (Annexure C-15).  In this manner, as the OPs have wrongly repudiated the claim of the complainant on flimsy grounds, the said act amounts to deficiency in service and unfair trade practice on their part. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their separate written versions.
3. In their written version, OPs 1 & 2, inter alia, took preliminary objections of maintainability, concealment of material facts and estoppel.  However, it is admitted that the complainant had obtained the subject policy from the answering OP covering the sum insured of ₹5.00 lacs, but, alleged that as the complainant has concealed material information about the pre-existing disease i.e. history of ailment of chronic artery disease, for which he had been taking treatment since 2001, which fact was not even disclosed by him in the proposal form, the claim was rightly repudiated by the answering OPs.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
4. In his written version, OP-3, inter alia, took preliminary objections of maintainability, cause of action, misjoinder of parties and also that the answering OP has been unnecessarily dragged into litigation.  It is further alleged that the complainant can make claim against the OPs 1 & 2 and he has no cause of action against answering OP.  The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
5. In separate replications, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the complainant in person, learned counsel for the OPs and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had been obtaining cashless health policy under Group Assurance Health Plan through OP-3, with sum insured of ₹5.00 lacs w.e.f.  27.8.2018 and the same was renewed and was valid upto 26.8.2020 and after porting the said policy from the previous insurer to the present insurer i.e. OP-1, complainant got the said policy extended through the subject policy (Annexure C-5) w.e.f. 28.8.2020 to 27.8.2021 and after that the complainant got the heart treatment from the Fortis Hospital, Mohali where one stent in the right coronary artery was inserted and the hospital raised total bill of ₹1,63,137/-, regarding which intimation was given to OPs 1 & 2, but, despite of repeated requests of the complainant they had not settled the claim of the complainant, rather repudiated the same vide repudiation letter dated 17.10.2021 sent through email dated 19.10.2021 (Annexure C-14), the case is reduced to a narrow compass as it is to be determined if OPs are unjustified in repudiating the claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, repudiation letter and the medical record, having been relied upon by the parties and the same is required to be scanned carefully.
   3. Perusal of Annexure C-1 to C-3 clearly indicates that the complainant had initially obtained the health insurance policy from the previous insurer which was valid upto 26.8.2020 and thereafter the complainant ported the said policy to OP-1 and got the subject policy (Annexure C-5) which was valid w.e.f. 28.8.2020 to 27.8.2021, covering the sum insured upto ₹5.00 lacs. Annexure C-6 is the discharge summary issued by the Fortis Hospital which clearly indicates that the complainant was admitted on 9.4.2021 and was discharged on 10.4.2021.  Annexure C-7 is the PTCA report making clear that pre stent dilatation was done with 3.0 x 12mm 4.0 x 12mm balloon, making further clear that the complainant was treated for the heart ailment in the Fortis Hospital where stent was inserted.
   4. The OPs have resisted the claim of the complainant on the sole ground that the complainant had not disclosed about the previous ailment as the discharge summary suggested that “CAD-S/P PTCA TO LAD (1996); S/P PTCA TO RCA (2001); CAG-LM-TVD (March 2021); BPH; COVID-INFECTION (March 2021)” regarding which reference has also been given in the repudiation letter (Annexure C-14). The OPs have also highlighted the reasons for rejection of the claim of the complainant in the aforesaid repudiation letter as under :-

       “On scrutiny of claim documents, it is observed that the ailment Coronary artery disease since 2001, has started prior to policy and disclosure of facts related to ailment are not provided prior to inception.  Hence we regret to inform that claim is repudiated as per Section 4(&)(i)”

5. In this manner, it is clear that OPs 1 & 2 have specifically come with the defence that the complainant had not disclosed the factum of his earlier ailment even in the proposal form where he has not disclosed anything about the pre-existing disease or the treatment taken by him in the year 1996 and 2001. 
6. On behalf of OPs, our attention has been drawn to the terms and conditions of the subject policy (Annexure R-1) which specifically provides that on the ground of non-disclosure of material facts by the insured, the claim of the insured can be repudiated. 
7. However, as it stands proved on record that the complainant had obtained the first policy from the previous insurer on 27.8.2018 and the previous policy was ported to the subject policy by the complainant and further that the OPs/insurer have been relying upon the reference made in the discharge summary (Annexure C-6) where the past history of “CAD-S/P PTCA TO LAD (1996); S/P PTCA TO RCA (2001); CAG-LM-TVD (March 2021); BPH; COVID-INFECTION (March 2021)” has been mentioned, making further clear that the complainant had complained of chest heaviness associated with dyspnea on exertion only since 3-4 months i.e. in the year 2021, which is also after about 20 years when the complainant had earlier taken treatment i.e. PTCA (Percutaneous transluminal coronary angioplasty), which is a minimally invasive procedure which opens blocked coronary arteries to improve blood flow to the heart muscle, in the year 2001, it is clear that the case of the complainant is even not covered as per the terms and conditions of the policy.
8. In view of the foregoing it is safe to hold that OPs 1 & 2 were unjustified in repudiating the claim of complainant and the said act amounts to deficiency in service on their part and, therefore, the present consumer complaint deserves to succeed.
9. Now coming to the quantum of relief to be awarded to the complainant, since the complainant has proved the bills (Annexure C-22 to C-30) totaling to ₹1,58,572/-, it is safe to hold that OPs 1 & 2 are liable to pay the said amount to the complainant alongwith interest and compensation etc. for the harassment suffered by him.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs 1 & 2 are directed as under :-

1. to pay ₹1,58,572/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 18.10.2021 onwards.
2. to pay an amount of ₹20,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by OPs 1 & 2 within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Since no deficiency in service or unfair trade practice has been proved against OP-3, consumer complaint against OP-3 stands dismissed with no order as to costs. 
7. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
8. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 02/11/2023 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Suresh Kumar Sardana] Member