This complaint under the provision of C.P. Act, 2019 was initially filed against the Opposite Parties (O.P.s)- 1) Tata AIG General Insurance Company Limited, Peninsula Business Park, Tower- A, 15^th Floor, G.K. Marg, Lower Parel, Mumbai, Maharashtra- 400013 and 2) Tata AIG General Insurance Company Limited, Infinity Square, 2^nd, Sevoke Road, near Cosmos Mall, Siliguri, West Bengal, Pin Code- 734001 who contested the case by filing Written Version (W.V.).

The case of the compliment as per her complaint is as follows-

The complainant argued in his plaint that the husband of the Complainant No.1 and the father of Complainant No.2 and 3 namely Badal Paul, now deceased (hereinafter called and referred him as “said Badal Paul”) was a bonafide group credit secure plus Certificate of Insurance Policy holder of Tata AIG General Insurance Company Limited (the O.P.s) bearing Master Policy No.- 0236120911, Certificate No.- 013616 and the effective certificate date was from 03/09/2019 to 02/09/2024 and the said Badal Paul had been paying required Insurance Premium money from the beginning of the policy in a regular manner. The complainants also added that the right leg of said Badal Paul was amputated by a surgery at Kanva Sri Sai Hospital on 10/07/2021 and he had become permanently disabled person due to the amputation of his right leg and dismemberment his said leg. The complainants also argued that such permanent disability had been duly covered in the said Insurance Policy of said Badal Paul for the benefit of Rs. 7,00,000/- (Rupees Seven Lakh) only and thus according to the terms and conditions of the policy the said Badal Paul was entitled to get Rs. 7,00,000/- (Rupees Seven Lakh) only from the O.P. in C/W his said Insurance Policy for the aforesaid reason and for his such permanent disability and the said Badal Paul submitted his claim of Rs. 7,00,000/- (Rupees Seven Lakh) only to the O.P.s for the said reason but till his lifetime the O.P.s did not pay the said claim amount to him. The complainants also argued that on 25/03/2022 the said Badal Paul sent a lawyer’s notice to the O.P.s but did not get any result. The complainants also argued that due to the amputation of his right leg the said Badal Paul was not able to do anything and his business was shut down and he died on 06/01/2023 leaving the complainants as his only legal heirs and successors.           

 The prayer of complainant is as follows: -

1. To pass an order directing the O.P.s to pay Rs. 7,00,000/- (Rupees Seven Lakh) only to the complainants as the said Insurance claim money along with interest @ 18% per annum calculating from 11/07/2021 till the payment of the same to them by the O.P.
2. To pass an order directing the O.P.s to pay a sum of Rs. 2,00,000/- (Rupees Two Lakh) only for compensation to them for the ends of justice.  

   List of Documents filed by the complainant:

1. Photocopy of Aadhaar Card of Badal Paul. (Annex. 1)
2. Photocopy of PAN of Badal Paul. (Annex. 2)
3. Photocopy of Legal Notice, dated 25/03/2022. (Annex. 3)
4. Photocopy of Group Credit Secure Plus Certificate of Insurance. (Annex. 4)
5. Photocopy of Personal Accident Claim Form before Tata AIG Insurance Company Ltd., dated 19/08/2021. (Annex. 5)
6. Photocopy of Grievance Redressal Policy Brochure. (Annex. 6)
7. Photocopies of Medical Documents of Badal Paul. (Annex. 7)
8. Photocopy of Death Certificate of Badal Paul.

   On behalf of the O.P.s, 1) Tata AIG General Insurance Company Limited, Peninsula Business Park, Tower- A, 15^th Floor, G.K. Marg, Lower Parel, Mumbai, Maharashtra- 400013 and 2) Tata AIG General Insurance Company Limited, Infinity Square, 2^nd, Sevoke Road, near Cosmos Mall, Siliguri, West Bengal, Pin Code- 734001 who contested the case by filing Written Version (W.V.).and in their W.V. the O.P.s categorically denied all the allegations made by the complainant.     

The O.P.s in their Written Version (W.V.) argued that the intimation of the alleged operation was given to the O.P.s long thereafter on 19/08/2021 whereas the operation was done on 10/07/2021 violating the terms and conditions of the Insurance Policy and there was no deficiency in service on the part of the O.P.s and the complainant had not made the hospitals where the treatment was availed as the party of this complaint. The O.P.s also added that the complaint had taken the Group Credit Secure Plus Policy of Tata AIG Insurance Company vide Policy No.- 0236120911, valid from 03/09/2019 to 02/09/2024 and total premium of Rs. 6,930/- (Rupees Six Thousand Nine Hundred and Thirty) only was taken by them to cover certain base risks including additional coverage for accidental dismemberment. The O.P.s also argued that the complainant had suppressed his hospitalization at Shanti Swasthalaya & Anusandhan Kendra Pvt. Ltd., Siliguri for his treatment of diabetic foot with gangrene of right 2^nd toe prior to his treatment at Kanva Sri Sai Hospital, Bengaluru and he also suppressed about his previous aliments of Type II diabetes Mellitus and to have peripheral vascular disease of limb which was a cause of development of Gangrene and thus the dismemberment of 2^nd and 3^rd toe of the right foot was due to underlying sickness condition and was thereby beyond the scope of the policy.

The O.P.s also argued in their W.V. that as per the terms and conditions of the policy, the complainant was not entitled to the alleged claim for his treatment cost and thus on 16/11/2021 the O.P.s had no other alternative to close the said file and repudiated the claim of the complainant.

List of documents filed by the O.P.s:

1. Photocopy of Policy and Wordings of Group Credit Secure plus Insurance Policy. (Annex.- A )
2. Photocopy of Discharge summary & Certificate issued by Shanti Swasthalaya & Anusandhan Kendra Pvt. Ltd., Siliguri. (Annex.- B)
3. Photocopy of Medical Certificate, dated 02/07/2021. (Annex.- C)
4. Medical prescriptions of Kanva Sri Sai Hospital. (Annex.- D)
5. Photocopy of Claim Form, dated 19/08/2021. (Annex.- E)
6. Photocopy of Repudiation Letter, dated 16/11/2021. (Annex.- F)  

Points for consideration

1) Whether the complainant is a consumer?

2) Whether the case is maintainable under the CP act 2019?

3) Whether this Commission has its jurisdiction to decide this case? 

4) Whether there is any deficiency in service in the part of the O.P. as alleged by the complainant?

5) Is the complainant is entitled to get any award and relief as prayed for? If so, what extent?             

Decision with reason:-

All the points are taken up together for consideration and decision.

Seen and perused the complaint petition and Written Version (W.V.) filed by the parties which are supported by the affidavit, documents filed by the parties. We are also heard arguments of both the parties in full length.

The complainant resides at P.S.- Rajganj, Dist.- Jalpaiguri and thus, this Commission has its territorial jurisdiction to decide this case.

In this case, the husband of the Complainant No.1 and the father of Complainant No.2 and 3 namely Badal Paul, now deceased (hereinafter called and referred him as “said Badal Paul”) was a bonafide group credit secure plus Certificate of Insurance Policy holder of Tata AIG General Insurance Company Limited (the O.P.s) bearing Master Policy No.- 0236120911, Certificate No.- 013616 and the effective certificate date was from 03/09/2019 to 02/09/2024 and this Commission holds that the complainant is a very much consumer under the as per C.P. Act 2019.

As per the statement of the complainant, the husband of the Complainant No.1 and the father of Complainant No.2 and 3 namely Badal Paul, now deceased (hereinafter called and referred him as “said Badal Paul”) was a bonafide group credit secure plus Certificate of Insurance Policy holder of Tata AIG General Insurance Company Limited (the O.P.s) bearing Master Policy No.- 0236120911, Certificate No.- 013616 and the effective certificate date was from 03/09/2019 to 02/09/2024 and the said Badal Paul had been paying required Insurance Premium money from the beginning of the policy in a regular manner. The right leg of said Badal Paul was amputated by a surgery at Kanva Sri Sai Hospital on 10/07/2021 and he had become permanently disabled person due to the amputation of his right leg and dismemberment his said leg. Such permanent disability had been duly covered in the said Insurance Policy of said Badal Paul for the benefit of Rs. 7,00,000/- (Rupees Seven Lakh) only and thus according to the terms and conditions of the policy the said Badal Paul was entitled to get Rs. 7,00,000/- (Rupees Seven Lakh) only from the O.P. in C/W his said Insurance Policy for the aforesaid reason and for his such permanent disability. The said Badal Paul submitted his claim of Rs. 7,00,000/- (Rupees Seven Lakh) only to the O.P.s for the said reason but till his lifetime the O.P.s did not pay the said claim amount to him. On 25/03/2022 the said Badal Paul sent a lawyer’s notice to the O.P.s but did not get any result. Due to the amputation of his right leg the said Badal Paul was not able to do anything and his business was shut down and he died on 06/01/2023 leaving the complainants as his only legal heirs and successors.

In support of their defense, the O.P.s stated that the intimation of the alleged operation was given to the O.P.s long thereafter on 19/08/2021 whereas the operation was done on 10/07/2021 violating the terms and conditions of the Insurance Policy and there was no deficiency in service on the part of the O.P.s and the complainant had not made the hospitals where the treatment was availed as the party of this complaint. The complaint had taken the Group Credit Secure Plus Policy of Tata AIG Insurance Company vide Policy No.- 0236120911, valid from 03/09/2019 to 02/09/2024 and total premium of Rs. 6,930/- (Rupees Six Thousand Nine Hundred and Thirty) only was taken by them to cover certain base risks including additional coverage for accidental dismemberment. The complainant had suppressed his hospitalization at Shanti Swasthalaya & Anusandhan Kendra Pvt. Ltd., Siliguri for his treatment of diabetic foot with gangrene of right 2^nd toe prior to his treatment at Kanva Sri Sai Hospital, Bengaluru and he also suppressed about his previous aliments of Type II diabetes Mellitus and to have peripheral vascular disease of limb which was a cause of development of Gangrene and thus the dismemberment of 2^nd and 3^rd toe of the right foot was due to underlying sickness condition and was thereby beyond the scope of the policy and as per the terms and conditions of the policy, the complainant was not entitled to the alleged claim for his treatment cost and thus on 16/11/2021 the O.P.s had no other alternative to close the said file and repudiated the claim of the complainant.

In this case, we can refer the observation of the Hon'ble Calcutta High Court, (2023) ACJ 2465 Cal. – Accident Insurance:

Personal Accident Insurance (Death/ Disability) is admissible only in case of death/ disablement resulting solely and directly from accident caused by external violent and visible means and as defined in IRDA norms/ guidelines.

The IRDA guidelines on Standard Personal Accident Insurance Product define an accident as “…… a sudden, unforeseen and involuntary event caused by external visible and violent means”.

So, this Commission has no doubt that the deceased Badal Paul met with an accident.   

In this instant case, there is no doubt that the complainant had already supplied all necessary documents like Discharge Summary and Certificate etc. to the Insurance Company as the Insurance Company filed these documents before this Commission. In his defense, the Insurance Company argued that the present case is a case of treatment undergone by the insured was owing to his previous ailment. But surprisingly the Insurance Company in support of his defense did not file the Proposal Form of the complainant. This cannot be ascertained that whether the deceased Badal Paul had disclosed his particulars in his Proposal Form or not. So, the Insurance Company cannot get any defense in this point without proving the deceased had a pre existing disease.

The Insurance Company in his letter, dated 16/11/2021 (marked as Annex. F) stated that “ It was noted from medical records that you were hospitalized at Shanti Swasthalaya & Anusandhan Kendra Pvt. Ltd. from 17June,2021 to 19^th June, 2021 and was diagnosed with Diabetic Foot with Gangrene foot 2^nd toe and underwent amputation of 2^nd toe”. So, the date mentioned in the Insurance Company’s letter comes within the coverage of Insurance Policy, i.e., 03/09/2019 to 02/09/2024.

Now, another objection was raised by the Ld. Advocate of the O.P. Insurance Company that in Attending Physician Statement in point no.- 07 “ NO HOSPITALISED HAPPENED PREVIOUS” and the Ld. Advocate argued that this is a false statement and That’s why, the complainant will not get any claim. In this point the Commission is considering the mental condition of deceased Badal Paul and it is not possible for him to check the said “Form” point to point before submitting the claim and moreover the “Form” was filled up by Dr. Pradeep Kumar Paul. If there is any doubt of the O.P. regarding this statement made by the deceased Badal Paul then the O.P. can easily prove this matter before this Commission by the evidence in the form of an affidavit and in this case, the complainant side can get a chance to cross examine the witness. But the O.P. failed to do this. Moreover, as per decision  I (2021)CPJ 429(N.C)- Insurance Company after accepting premium cannot escape from its liability and repudiate claim on this technical ground……

On another judgment- Gurmel Singh v. National Insurance Co. Ltd., (2022) SCC ONLINE sc 666, dated 20/05.2022 where it sated that-

…….the insurance company ought not to have become too technical and ought not to have refused to settle the claim…..

As per Claim Form, the date of accident was 26/05/2021 which is under the coverage of Insurance Policy, i.e., from 03/09/2019 to 02/09/2024. To counter this point, the O.P. Insurance Company did not file any evidence to prove that the accident was not happened on that date.

In this instant case, we can refer the decision of the Hon'ble NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION, NEW DELHI, IV (2023) CPJ 523 where it stated that-

- After considering medical examination reports, impugned policy was issued – It cannot be said that DLA had knowledge of elevated sugar level and knowingly concealed this fact as medical report were never provided to him – Opposite party had failed to prove that DLA was suffering from diabetes and heart related diseases prior to obtaining policy in question and had knowingly withheld information in this respect in proposal form –

In this situation the Commission always follows the decision of the Hon’ble NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION and this Commission has no right to ignore the decision of the Hon’ble NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION of India.

Followed the principle of this decision, the O.P. failed to prove that the deceased Badal Paul was suffering from undefined sickness condition prior to obtaining the policy is in question and had knowingly withheld information in this respect in the Proposal Form.

In view of the aforesaid discussion, the complainant is allowed repudiation letter dated 16/11/2021 is not justified. So, in this instant case, this Commission holds that there is a deficiency in service from the part of the O.P. (Tata AIG General Insurance Company Limited) and the complainant is entitled to get Rs. 7,00,000/- (Rupees Seven Lakh) only from the O.P.

Hence, it is therefore,

ORDERED

That the Consumer Case No. 102/2022 be and same is allowed in contest against the O.P.s, (Tata AIG General Insurance Company Limited) with cost.

The O.P.s, (Tata AIG General Insurance Company Limited) is directed to pay Rs. 7,00,000/- (Rupees Seven Lakh) only to the complainant in equal share within 45 dates from the date of this order failing which the complainant is entitled to get @ 6% simple interest per annum from the date of filing of this case, i.e., from 13/12/2022. The O.P.s are also directed to pay Rs. 5,000/- (Rupees Five Thousand) only for mental pain, agony, harassment and litigation cost and also to deposit Rs. 5,000/- (Rupees Five Thousand) only in the Legal Aid Account of this Commission within 30 days from the date of this order.  

 Let a copy of this judgment be given to the parties directly or through their representative Ld. Advocate for compliance free of cost.