Punjab

Ludhiana

CC/21/374

Sewak Singh - Complainant(s)

Versus

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

Puneet Chhabra

13 Sep 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No:  374 dated 12.08.2021.                                       Date of decision: 13.09.2024. 

 

Sewak Singh S/o. Avatar Singh, resident of H. No.167, 02, Village Bhaini Gujjran, Tehsil Jagraon, District Ludhiana.                                                                                                                                             ..…Complainant

                                                Versus

1. Tata AIG General Insurance Co. Ltd., Suite 108, Ground Floor, Srinilaya Cyber Spazio, Road no.02, Banjara Hills, Hyderabad-500034, through its Manager/Authorized.
2. Axis Bank Ltd., Branch Sidhwan Bet, Tehsil and Distt. Ludhiana, through its Manager.                                                                                                                                                          …..Opposite parties 

Complaint Under Section 35 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Puneet Chhabra, Advocate.

For OP1                         :         Sh. Rajeev Abhi, Advocate.

For OP2                         :         Sh. Sachin Goel, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that the complainant firstly purchased Family Health Plan insurance from 14.11.2017 to 13.11.2018 but the policy was discontinued. The complainant again purchased policy through OP2 on 29.08.2019 to 28.08.2020 and further from 29.08.2020 to 28.08.2021 having master policy No.0237868334. The complainant further stated that he undergone surgery for the disease Calcific pancreatitis with pseudocyst head of pancreas from Orison Super Specialty Hospital, Infertility & Trauma Centre, Barewal Road, Ludhiana and spent Rs.1,58,500/- on his pre and post surgery expenses. The surgery was to be conducted immediately to avoid any danger to life of the complainant after examining the medical reports of the complainant. The complainant lodged claim through OP2 with OP1 for disbursement of treatment expenses but OP1 illegally rejected the claim stating the reason “The submitted claim is for the illness which has a specific two years of waiting period as per the policy and the policy start date is 29-Aug-2019. Hence we regret to inform you that your claim is repudiated under Section 3(1) of the Policy.” According to the complainant, OP1 has illegally rejected his claim which amounts to malpractice on the part of OP1 due to which the complainant claimed to have suffered mental pain and agony. In the end, the complainant has prayed for issuing direction to the OPs to pay him an amount of Rs.1,58,000/- along with compensation of Rs.50,00,000/- besides litigation expenses.

2.                Upon notice, OP1 appeared and filed written statement and assailed the complaint by taking preliminary objections on the grounds of maintainability; the complainant being estopped by his own act and conduct; concealment of material facts etc. OP1 stated that on receipt of the claim, it was duly registered, entertained and processed. Axis Bank Ltd. had obtained Group Medicare Master policy No.0237868334 for the customers of the bank and Mr. Sewak Singh Manjhu, the complainant along with his other family members namely Binderjit Kaur (spouse), children Ravleen Kaur and Japveer Singh. The complainant is one of the beneficiary under the policy vide certificate No.009418 certificate period valid from 29.08.2020 00:01 hours (commencement date) to 28.08.2021 23:59 hours (expiry date).  According to OP1, the insurance policy is a contract in itself and the parties are bound by the terms and conditions of the insurance policy. It is one of the conditions No.3.1 in the policy Exclusion 3.02 under the head Specified disease / procedure waiting period: (Code- Excl 02)

"(a) Expenses related to the treatment of a listed conditions, surgeries/treatment shall be excluded until the expiry of  as specified under the policy Schedule/Certificate of Insurance months of continues coverage after the date of inception of the first policy with us. That exclusion shall not be applicable for claims arising due to an accident.

(b)In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.

(c) If any of the specified disease/procedure falls under the waiting period specified for pre-Existing diseases, then the longer of the two waiting periods shall apply.

(d) the waiting period for listed conditions shall apply if contracted after the policy or declared and accepted without a specific exclusion.

(e) If the insured Person is continuously covered without any break as defined under the applicable norms on portability stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage.

(f) List of specific diseases /procedures as furnished below:

a. _______

b. ______

c. _______

m. Pancreatits

f. _______

g. _______

h. _______

nn. ______

All other policy terms and conditions remain unaltered.”

 

OP1 further stated that the complainant was admitted with Orison Super Specialty Hospital, Infertility and Trauma Centre (Unit of Conjoint) Health Care Pvt. Ltd. with the diagnosis of Chronic Clacific Pancreatitis with pseudocyst head of pancreas with date of admission as 23.10.2020 and date of discharge as 25.10.2020 and the claim was registered at claim No.2021010600072. After the receipt of the medical record and other claim documents including claim form and after scrutinizing the documents placed in the claim file and after due application of the mind by the officials of OP1, the claim file of the complainant was repudiated as no claim vide letter dated 14.01.2021 on the grounds that the submitted claim is for the illness which has a specific two years of waiting period as per the policy and the policy start date is 29.08.2019. Hence we regret to inform you that your claim is repudiated under section 3(1) of the policy. The claim of the complainant as such has rightly been repudiated as no claim and the grounds of repudiation are legal, valid, enforceable and are in accordance with the terms and conditions of the policy.                  On merits, OP1 reiterated the crux of averments made in the preliminary objections. OP1 has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                OP2 filed separate written statement and assailed the complaint by taking preliminary objection on the ground of maintainability. OP2 has no concern with the insurance policy as it is only a service facilitator and terms and conditions of the insurance policy are between insurance company and the complainant which does not pertain to OP2. Further there is no privity of contract between it and the complainant.

                   On merits, OP2 reiterated the crux of averments made in the preliminary objections. OP2 has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

4.                In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents i.e. Ex. C1 is the copy of insurance certificate w.e.f. 29.08.2020 to 28.08.2021, Ex. C2 is the copy of CECT Whole abdomen, Ex. C3 is the copy of insurance certificate w.e.f. 29.08.2019 to 28.08.2020, Ex. C4 is the copy of insurance certificate w.e.f. 29.08.2020 to 28.08.2021, Ex. C5 is the copy of claim rejection letter dated 14.01.2021, Ex. C6, Ex. C7 is the copy of ultrasound report, Ex. C8 is the copy of invoice dated 25.10.2020, Ex. C9 to Ex. C17 are the copies of bills/invoices, Ex. C18 is the copy of legal notice dated 17.03.2021, Ex. C19 and Ex. C20 are the postal receipts,   Ex. C21 is the copy of reply dated 09.04.2021 to legal notice dated 17.03.2021 and closed the evidence.

5.                On the other hand, the counsel for OP1 tendered affidavit  Ex. RA of Sh. Rohit Udaiwal, DVP of OP1 along with documents i.e. Ex. R1 is the copy of claim rejection dated 14.01.2021, Ex. R2 is the copy of claim document acknowledgement letter dated 06.01.2021, Ex. R3 is the copy of claim form, Ex. R4 is the copy of OP receipt dated 16.09.2020, Ex. R5 is the copy of prescription slip of AGI Hospital, Ex. 5A is the copy of ultrasound report, Ex. R6 is the copy of insurance certificate w.e.f. 29.08.2020 to 28.08.2021, Ex. R7 is the copy of Enrolment Form for Group Health Ex. R8 is the copy of terms and conditions of policy, Ex. R9 is the copy of insurance certificate w.e.f. 29.08.2019 to 28.08.2020 and closed the evidence.           

                   The counsel for OP2 tendered affidavit Ex. RA2 of Sh. Vikrant Aggarwal, Senior Manager of OP2 and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written statements along with affidavits and documents produced on record by both the parties.                 

7.                The complainant, a beneficiary of Group Medicare Master Policy issued by OP bank, was admitted with Orison Super Specialty Hospital, Ludhiana with diagnosis of Chronic Clacific Pancreatitis with pseudocyst head of pancreas on 23.10.2020 and remained admitted there till 25.10.2020. He incurred total expenses of Rs.1,58,500/- for his pre and post hospitalization. The complainant preferred a claim through Ex. R3 along with documents which was processed and considered by OP1 insurance company. The claim of the complainant was declined by OP1 vide letter dated 14.01.2021 as “No Claim” by invoking one of the condition No.3 of the policy.

8.                Now the point of consideration arises whether OP1 was justified in declining the claim of the complainant as “No Claim”.

9.                Perusal of record shows that the complainant initially enrolled as member of Group Medicare Master Policy on 14.11.2017 but that was discontinued on 13.11.2018. Again after a gap of about more than 9 months on 29.08.2019, the complainant again purchased the policy having validity till 28.08.2020 and the same was renewed on 29.08.2020 to 28.08.2021 meaning thereby  that on 23.10.2020 i.e. on the date of hospitalization, the policy was of about 14 months of its continuance. The counsel for OP1 has drawn attention of this Commission towards the enrolment form Ex. R7, Ex. R8 and towards exclusion clause 3.1 of the terms and conditions which defines the waiting period for the specified disease including Pancreatitis. The complainant was required to have continuous coverage without any break from the inception of the policy of two years in order to avail the benefits. As such, OP1 has rightly

invoked condition No.1 of the policy terms and conditions and as such, was justified in declining the claim of the complainant as “No Claim.”

10.              As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.   

11.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:13.09.2024.

Gobind Ram.