Haryana

Karnal

CC/32/2022

Ashok Kumar - Complainant(s)

Versus

Tata AIG General Insurance Company Limited - Opp.Party(s)

Vinod Sharma

07 May 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No. 32 of 2022

                                                        Date of instt.19.01.2022

                                                        Date of Decision:07.05.2024

 

Ashok Kumar son of Shri Mohan Lal, resident of village Bara Gaon, District Karnal.

                                                                        …….Complainant.

                                              Versus

 

TATA AIG General Insurance Co. Ltd. unit no.5, 2^nd floor, N.K. Tower, Grand Truck Rd, Panipat through its Divisional Manager.

 

                                                                        …..Opposite Party.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member

      Dr.  Suman Singh…..Member

 

 Argued by: Shri Vinod Sharma, counsel for the complainant.

                    Shri Naveen Khetarpal, counsel for the OP.

 

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant purchased a  mediclaim policy no.0238792896 from the OP, for which the complainant paid premium to the OP. The complainant met with an accident on 24.06.2021 and received injuries on head, Clavical and other parts of body and he remained admitted in Shri Hari Hospital, Karnal till 28.06.2021 and complainant had spent an amount of Rs.3,00,000/- on his treatment.  The intimation regarding the accident  and hospitalization was given to the OP. After discharge from the hospital, complainant lodged the claim with OP alongwith all the required documents for settlement of the claim but OP did not pay the claim amount till today. Then complainant sent a legal notice dated 24.12.2021 but it also did not yield any result. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence complainant filed the present complaint.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that on 25.06.2021, OP received pre-authorization cash request for treatment, which was declined by OP, vide letter dated 26.06.2021 because as per available information case needs to be reviewed thoroughly with complete past medical history and the same is not possible at this juncture in cashless. Hence, complainant was requested to come for reimbursement with all relevant documents. Thereafter, complainant submitted few documents on 02.08.2021 for reimbursement of his medical expenses. After perusal of the documents, a letter dated 28.09.2021 was sent to complainant to provide treating doctor certificate for the past history duration of diabetes and First Consultation paper of diabetes alongwith the treatment records but same was not provided. OP again sent letter dated 30.09.2021 to complainant to provide treating doctor certificate for the past history duration of Diabetes and first consultation paper of diabetes alongwith treatment records. But no document was provide, then left with no option OP rejected the claim of the complainant, vide letter dated 26.10.2021 due to following reasons:

.       On review of the same with reference to the policy terms and conditions we find that following documents/information are necessary for processing further: Kindly provide treating doctor certificate for the past history duration of Diabetes and First Consultation paper of diabetes alongwith treatment record.

.       We shall be under no obligation to make any payment under this policy, unless we have received al premium payments in full in time and we have been provided with documentation and information we or our TPA has requested to establish the circumstances of the claim, its quantum or our liability for it, and unless the insured person has complied with his obligations under this policy.

                So, the claim of the complainant was not maintainable and same was rightly repudiated by the OP. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             The parties then led their respective evidence.

4.             Complainant has tendered in evidence his affidavit Ex.CW1/A, copy of Discharge Summary Ex.C1, copy of patient history with Mediclaim charges Ex.C2, copy of Bill of C.T. Scan Ex.C3, copy of medical bills Ex.C4 to Ex.C13, copy of legal notice Ex.C14, postal receipt Ex.C15, copy of pre-authorization rejection letter dated 26.06.2021 Ex.C16, copy of aadhar card of complainant Ex.C17 and closed the evidence on 29.07.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Nidhi Kalra, Chief Manager Legal Ex.RW1/A, copy of query letter dated 25.06.2021 Ex.OP1, copy of query response Ex.OP2, copy of pre-authorization rejection letter dated 26.06.2021 Ex.OP3, copy of 1^st reminder dated 28.09.2021 Ex.OP4, copy of letter with regard to query to Member dated 30.09.2021 Ex.OP5, query response letter dated 26.10.2021 Ex.OP6, copy of claim rejection letter dated 26.10.2021 Ex.OP7, copy of policy schedule Ex.OP8, copy of terms and conditions of the insurance policy Ex.OP9 and closed the evidence on 03.11.2023 by suffering separate statement.

6.             We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for the complainant, while reiterating the contents of complaint, has vehemently argued that complainant purchased Mediclaim Insurance Policy from the OP, for the sum insured of Rs.3,00,000/-. On 24.06.2021, complainant met with an accident and received injuries and remained admitted in Shree Hari Hospital, Karnal and has also spent an amount of Rs.3,00,000/- on his treatment. After discharge from the hospital, complainant lodged a claim with the OP for reimbursement of the said amount alongwith required documents. Complainant requested the OP several times to release his claim but OP did not pay the same and lastly repudiated the claim of complainant on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that the claim of the complainant was duly processed and the same was not found payable on the ground that complainant was having the past history of diabetes and complainant has also failed to submit the treatment record with regard to past history. Thus, the claim of complainant was rightly rejected and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant purchased a Mediclaim Insurance Policy of OP. It is also admitted that during the subsistence of the insurance policy, complainant met with an road side accident and had taken treatment from Shri Hari Hospital, Karnal.

11.           The claim of the complainant has been repudiated on the ground that complainant has not provided the past history of diabetes. The onus to prove the fact that complainant was suffering from diabetes as alleged by the OP but OP has miserably failed to prove its version by leading any cogent and convincing evidence. Moreover, it is a case for accidental claim not for any other treatment. If for the sake of arguments, it is presumed that complainant is diabetic, then there is no nexus with the treatment taken by the complainant and diabetes as alleged by the OP. Thus, the repudiation of the claim has been made only on the basis of presumption and assumption, which is not admissible in the eyes of law.  In this regard, we are fortified with the observation of Hon’ble State Commission, Delhi, in case titled as Chanda Devi Vs. LIC in complaint no.551/2016, decided on 23.11.2021 wherein it has been held that if the reason of the death is not in nexus with pre-existing disease and there is no evidence placed on record by the OP to show that the death was on account of pre-existing disease of the life assured, then the contention of the OP in the repudiation letter has no merit.

12.  

“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. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.”

 

 13.          Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OPs while repudiating the claim of the complainant amounts to deficiency, which is otherwise proved genuine one. 

14.           Complainant has claimed Rs.3,00,000/- but he has placed on file medical bills Ex.C3 to Ex.C13, which are only for Rs.1,59,684/-. The sum insured under the policy is Rs.3,00,000/-. Hence the complainant is entitled for Rs.1,59,684/- alongwith interest, compensation for mental harassment and litigation expenses etc.

15.           Thus, as a sequel to abovesaid discussion, we partly allow the present complaint and direct the OP to pay Rs.1,59,684/- (Rs.one lakh fifty nine thousand six hundred eighty four only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of claim i.e. 30.11.2021 till its realization. We further direct the OP to pay Rs.25,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:07.05.2024

                                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Vineet Kaushik)        (Dr. Suman Singh)

     Member                                 Member