Haryana

Karnal

CC/368/2021

Vijender Singh - Complainant(s)

Versus

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

Dhirender Rana

19 Jul 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No.368 of 2021

                                                        Date of instt.30.01.2021

                                                        Date of Decision:19.07.2024

 

Vijender Singh age 39 years son of Om Pal, resident of village Kalron, Tehsil Gharaunda, District Karnal.

 

                                                 …….Complainant.

                                              Versus

 

1. Tata AIG General Insurance Company Ltd. registered address SCO 127-128, First Floor Behind Citco Petrol Pump sector 9-C, Chandigarh 160009 through its authorized persons.
2. Axis Bank Railway Road Gharaunda, District Karnal through its Manager.

 

…..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member

      Ms. Sarvjeet Kaur…..Member

 

Argued by: Shri Dhirender Rana, counsel for the complainant.

                   Shri Gaurav Gupta, counsel for the OP no.1.

                   Shri Deepak Saini, counsel for the OP no.2.

 

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant got insured his family under family group insurance through the OP in health insurance policy, vide policy no.0237868334 dated 03.10.2020, valid upto 02.10.2021 through OP no.2 i.e. Axis Bank. The complainant deposited the premium amount as per guidance and instructions of the OPs. The complainant completed all the formalities as per their guidance. Complainant falls ill and got admitted in Amritdhara Hospital, Karnal on 20.04.2021, where he remained admitted and was treated properly and a sum of Rs.42713/- spent on the medicines, treatment etc. and same was intimated to OPs. At that time all bills were also submitted to the OPs. Officials of the OPs gave assurance that the OPs will paid all expenses to the complainant.  Complainant visited to the office of OPs many times and requested for reimbursement of the claim but OPs did not pay the same and lastly denied to pay the claim of complainant, vide letter dated 23.04.2021 on the false and frivolous ground. In this way there is a deficiency in service and unfair trade practice on the part of the OP. Hence this complaint.

2.             On notice, OP no.1 appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action and concealment of true and material facts. On merits, it is pleaded that after getting the intimation regarding the claim and documents submitted by complainant, it  reveals that claim of the complainant is not maintainable because claim is submitted for Lumbosacral spondylosis with radiculopathy which has a specific twenty four months waiting period as per the policy. The policy incepted from 03.10.2019 and complainant was admitted in hospital on 20.04.2021, hence as per terms and conditions of the policy Section 31 (ii) of the policy and exclusion 02, claim of the complainant was not maintainable, so same has been repudiated by the OP and same is communicated to complainant, vide letter dated 17.07.2021. 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.             OP no.2 filed its separate written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the policy no.0237868334 was purchased by the complainant on 03.10.2020 and was valid upto 02.10.2021. The complainant sought the refund of amount of Rs.42713/- from OP no.1 and OP no.1 has rejected with the claim of the complainant for the reasons that “the complainant has submitted claim for Lumbosacral spondylosis with radiculopathy which has a specific two years of waiting period as per the policy and the policy starts w.e.f.03.10.2019 and the claim was repudiated under section 3(i)(ii) of the policy. Hence, OP has no concern with the claim of the complainant and complaint against the OP is liable to be dismissed. It is further pleaded that OP never received any intimation regarding illness of the complainant and never received any document. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.       

4.             Parties then led their respective evidence

5.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.C1, copy of insurance policy Ex.C2, copy of Grievance Redressal Policy Ex.C3, copy of discharge slip E.C4, copy of bill Ex.C5, copy of final bill Ex.C6, copy of rejection letter Ex.C7, cop of message of process Ex.C8 and closed the evidence on 08.09.2022 by suffering separate statement..

6.             On the other hand, learned counsel for the OP no.1 has tendered into evidence affidavit of Smir Paul Ex.RW1/A, copy of claim form Ex.R1, copy of hospital record Ex.R2, copy of repudiation letter Ex.R3, copy of terms and conditions of the policy Ex.R4 and closed the evidence on 05.09.2023 by suffering separate statement.

7.             Learned counsel for the OP no.2 has tendered into evidence affidavit of Nishant Malik, Branch Manager Ex.OP2/A, copy of claim rejection letter dated 17.07.2021 Ex.OP2/1 and closed the evidence on 11.07.2023 by suffering separate statement.

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

9.             Learned counsel for the complainant, while reiterating the contents of complaint, has vehemently argued that complainant purchased a health insurance policy from the OP no.1 through OP no.2. On 20.04.2021, complainant fell ill and got admitted in Amritdhara Hospital, Karnal.  The complainant  spent Rs.42713/- on his treatment. After discharge from the hospital, complainant lodged the claim with the OP no.1 for reimbursement of the said amount but OP did not pay the claim and repudiated the same on the false and frivolous ground. He further argued that He further argued that OPs never supplied any terms and conditions of the insurance policy to the complainant and lastly prayed for allowing the complaint.

10.           Per contra, learned counsel for the OP no.1, while reiterating the contents of written version, has vehemently argued that on scrutiny of the documents submitted by the complainant, it reveals that claim of the complainant is not maintainable, because claim submitted for Lumbosacral spondylosis with radiculopathy which has a specific twenty four months waiting period as per the policy. The policy incepted from 03.10.2019 and complainant was admitted in hospital on 20.04.2021, hence as per terms and conditions of the policy, the claim is not maintainable, and same was rightly repudiated by the OP and lastly prayed for dismissal of the complaint.   

11.           Learned counsel for the OP no.2 has argued that the complainant sought the refund of amount of Rs.42713/- from OP no.1 and OP no.1 has rejected the claim of the complainant. OP no.2 only deducted the premium amount from the account of complainant and remitted the same in the account of OP no.1 OP no.2 has no concern with the claim of the complainant and lastly prayed for dismissal of the complaint qua OP no.2.

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

13.           Admittedly, complainant purchased a health insurance policy from the OP no.1 through OP no.2. It is also admitted that during the subsistence of said insurance policy, complainant was hospitalized in Amritdhara Hospital, Karnal and submitted the medical bills of Rs.42713/- to the OP no.1 for reimbursement.

 14.          The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.C7/Ex.R3/Ex.OP2/1 dated 17.07.2021 on the ground, which is reproduced as under:-

“The submitted claim is for Lumbosacral spondylosis with radiculopathy which has a specific two years of waiting period as per the policy and the policy start date is 03.10.2019. Hence, we regret to inform you that your claim is repudiated under Section 3(1)(i) of the policy and exclusion 2.

The claim does not fall within the ambit of the policy in the light of the facts given above, read with the relevant policy condition/exclusion cited. We regret, therefore, that we are unable to entertain this claim.”

15.           The claim of the insured has been repudiated by the OP no.1 on the aforesaid ground. OP no.1 has alleged that as per terms and conditions of insurance policy, the claim is not liable under waiting period 3(1)(i) and exclusion 2 of the policy. The onus to prove its version was relied upon the OP no.1 but OP no.1has miserably failed to prove the same by leading any cogent and convincing evidence. OP no.1 has alleged that copy of insurance policy alongwith terms and conditions supplied/dispatched to the complainant but OPs have failed to place on file receipt, issued by the complainant, with regard to the delivery of the alleged terms and conditions of the policy. If the policy documents had been delivered by the OPs as alleged by them, they would have placed on file, the courier receipt or any other documents in respect of supply of the terms and conditions of the policy to the complainant. Meaning, thereby, OPs have never supplied the policy to the complainant. Hence, we found no substance in the contention of the OP no1. In this regard, we relied upon case titled as New India Assurance Co. Ltd Versus Anil Manglunia 2016 (1) CPR 150 (NC),wherein Hon’ble National Commission held that OPs failed to provide policy clause to the complainant and rejected genuine claim of the complainant. Hence, they do not find any merit in the revision petition and the same is hereby dismissed.

16.           Furthermore, now a days it has become a trend of insurance companies, they issue the policies by giving false assurances and when insured amount is claimed, they make such type of excuses. Thus, the denial of the claim of complainant is arbitrary and unjustified. In this regard, we place reliance on the judgment of Hon’ble Punjab and Haryana High Court titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“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”.

17.           Keeping in view the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, the act of the OP no.1 amounts to deficiency in service and unfair trade practice, while repudiating the claim of complainant, which is otherwise proved genuine one.

18.           The complainant has spent Rs.42,713/- on his treatment, this fact has been proved from the bill Ex.C5 and final bill Ex.C6. The said bills neither denied nor rebutted by the OP no.1. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

19.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP no.1 to pay Rs.42,713/- (Rs. forty two thousand seven hundred thirteen only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 17.07.2021 till its realization. We further direct the OP  no.1 to pay Rs.15,000/- to the complainant on account of mental agony and harassment and Rs.5500/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. Complaint qua OP no.2 stands dismissed. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:19.07.2024                                                                    

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal

 

 (Vineet Kaushik)       (Sarvjeet Kaur)

                          Member                          Member