STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

                                              U.T., CHANDIGARH 

                                                (ADDITIONAL BENCH)

Jagdamba Prasad Shukla c/o Children Traffic Park, Sector 23, Chandigarh Permanent Resident of Dashmesh Nagar, Naya Goan, Mohali.

                                                                                                …Appellant

                                         V e r s u s

1.       TATA AIG General Insurance Co. Ltd., SCO No.232-234, Second Floor, Near            Pathania Petrol Pump, Sector 34-A, Chandigarh -160022 through its Manager.

2.        TATA AIG General Insurance Co. Ltd., Peninsula Business Park, Tower-A,    15th Floor, Ganpatrao Kadam Marg, Lower Parel, Mumbai-400013 through its             Managing Director.

                                                                                           ...Respondents

Appeal under Section 41 of the Consumer Protection Act, 2019 against order dated 06.04.2022 passed by          District Consumer Disputes Redressal Commission-II, U.T. Chandigarh in Consumer Complaint No.1196/2019.

 BEFORE:        MRS. PADMA PANDEY, PRESIDING MEMBER

                         Mr.PREETINDER SINGH,MEMBER

Argued by:    Mr. Gaurav Bhardwaj, Advocate   for the appellant.

                       Mr. Sahil Abhi,Advocate  for the  respondents.

PER  PADMA PANDEY,PRESIDING MEMBER

                     This appeal is directed against the order dated 06.04.2022, rendered by the District Consumer Disputes Redressal Commission-II, U.T. Chandigarh          (hereinafter to be referred as “the Ld. Lower Commission”), vide which, it dismissed the complaint, being without any merit.

 2.            Before the Ld. Lower Commission, it was case of the complainant/appellant   that he was having bank account No.831006083531 in Axis Bank and was issued Medical Insurance Policy by the Opposite Parties/respondents, being the credit card holder of the Bank. Master Policy No.0260014872, which was valid from 06.11.2018 to 05.11.2019 for a sum insured of Rs.3 lakhs was sent to him and premium of Rs.10,384/- was debited from his account.  The said cover was offered for the complainant, his wife and two children only, out of three.  According to the complainant, he and his family members were hale and hearty prior to taking the policy in question and did not suffer from any disease.  On 25.11.2018, the complainant had severe pain in his abdomen and was taken to the PGIMER, Chandigarh where he was diagnosed to be suffering from advanced liver infection and acute necrotizing pancreatitis. He remained hospitalised there and was discharged on 20.01.2019, after treatment. Thereafter, he remained under follow up treatment with the treating doctors from 21.01.2019 to 28.03.2019. He was again admitted in the PGIMER on 28.03.2019 and discharged on 12.04.2019. The discharge summary proves that prior to 25.11.2018, he had no problem whatsoever and it is only on 25.11.2018, he felt pain in his abdomen.  Subsequently, he submitted medical claim for reimbursement of an amount of Rs.1,54,085/- with the relevant documents with the Opposite Parties, which was rejected, on the ground, that the treatment taken for the disease i.e. acute necrotizing pancreatitis falls in the first year waiting period.  It was alleged  that no terms and conditions of the policy were supplied, and as such, he requested the Opposite Parties vide e-mail dated 19.11.2019 to pay the claim but to no effect.  Hence, alleging deficiency in service and unfair trade practice on the part of the Opposite Parties/respondents, a consumer complaint was filed before the Ld. Lower Commission.

3.              Upon notice of the complaint, Opposite Parties/Respondents appeared before the Ld. Lower Commission and contested the complaint. In their written statement, the Opposite Parties/respondents while admitting the factual matrix of the policy having been issued to the complainant alongwith his wife and two children, pleaded that the insurance policy is a contract in itself and the parties are bound by its terms and conditions and nothing can be added or subtracted out of it.  It is averred that during the existence of the said policy, two claims were lodged for reimbursement amount of hospitalization expenses of Rs.2,26,466- incurred for the period from 4.12.2018 to 20.1.2019 and second claim on 4.11.2019 for hospitalization expenses of Rs.1,54,085/- incurred by the complainant during the period from 18.3.2019 to 12.5.2019. It was pleaded that as per the discharge summary for the above periods,  the complainant was diagnosed and treated for the acute necrotising pancreatitis and  as per Section 2 Clause (c) (d) for the treatment of pancreatitis is payable subject to the waiting period of one year i.e. claim for the treatment of pancreatitis is not payable in the first year of the policy and could be paid in the second year of the policy subject to terms and conditions of the insurance policy.  It was pleaded that both the claims were lodged within the  first year of the policy which was valid from 06.11.2018 to 05.11.2019, and as such,   the same were not payable as per the terms and conditions of the insurance policy and, therefore, the same were rejected vide letters dated 04.11.2019 and 05.11.2019.  It was stated that as per certificate of insurance, it was clearly stated that it was only summary of the product features and actual benefits available were as described in the policy and will be subject to the enclosed policy terms, conditions and exclusions, thus, the claims were rightly rejected as per terms and conditions of the Policy.  Pleading that there was no deficiency in service or unfair trade practice on their part,  a prayer was made for dismissal of the complaint.

4.           On appraisal of the pleadings, and the evidence adduced on record, Ld. Lower Commission came to the conclusion that there was no deficiency in providing service on the part of the Opposite Parties/respondents and the complaint was dismissed, being without merit.       

5.        Aggrieved against  the aforesaid order passed by the Ld. Lower Commission, the instant Appeal has been filed by the Appellant/complainant.

6.                    We have heard Learned Counsel for the parties and have gone through the evidence and record of the case with utmost care and circumspection.

7.                The core question that falls for consideration before us, is as to whether, the Ld. Lower Commission has rightly passed the impugned order by appreciating the entire material placed before it. 

8.             After giving our thoughtful consideration, to the contentions raised and material on record, we are of the considered opinion, that the instant Appeal is liable to be dismissed for the reasons to be recorded hereinafter.

9.              The main ground of the appellant/complainant is that he never approached the respondents for taking insurance policy  and there is no proposal form filled in that regard. Only a call was received but no terms and conditions of the policy were explained to him during the said call. Thus, the case of the appellant is that the terms and conditions which were never informed to him prior to issuing of policy are not binding upon him. It is further case of the appellant that there was sudden onset of pain and earlier there was no such medical condition or pre-existing disease as stated in the discharge summary. The entire medical record shows that there was no previous ailment but the claim has been illegally and wrongly repudiated. 

10.                      It is the case of the respondents that the appellant has never obtained the policy in question direct from them/respondents. The complainant was the member of the group policy obtained by the Axis Bank for his customers and the complainant became the member of the said group insurance policy. Thus, insured in the present case is the Axis Bank and it is the bank which was obliged to obtain terms and conditions of the policy from the respondents and then to supply the same to its customers who were beneficiaries under the insurance policy, being members of the group insurance policy.  The appellant has opted for group mediprime policy and  it was he, who was to obtain terms and conditions  of the said policy from the Axis bank.  The appellant has not raised any allegation against the AXIS Bank for not supplying the policy terms and conditions. It is admitted case of the parties that the policy was valid from 6.11.2018 to 5.11.2019 and the present claim was lodged for reimbursement of the medical expenses for  the treatment on 4.11.2018 and 4.12.2018 to 20.1.2019 i.e. in the first year of the policy. Furthermore, as per discharge summary, the appellant/complainant  obtained treatment for the disease of   acute necrotizing pancreatitis.

 11.                    The Ld. Lower Commission while  exonerating the respondents from the allegation of deficiency in service, rightly observed as under ;

“A bare perusal of Section 2(c)(d) of the terms and conditions of the insurance policy reproduced in para 5 of the preliminary objections of the written statement clearly reveals that the claim for the treatment of the pancreatitis is not payable in the first year of the policy and could be paid in the second year of the policy subject to the terms and conditions of the insurance policy. In the light of the terms and conditions of the insurance policy, we are of the considered view that the OPs have rightly repudiated the claim vide letters dated 04.11.2019 and 05.11.2019 {Annexure R-6 (Colly.)} falling under the waiting period of first year and not covered under the terms and conditions of the insurance policy.  Thus, it cannot be said that the OPs have committed any deficiency in service by repudiating the claim of the complainant.”

12.           After going through the contents of  appeal and the impugned order passed, we are of the view  that   the Ld. Lower Commission rightly observed that there was no deficiency in service on the part of the respondents in repudiating the claim of the appellant.  Had the appellant obtained insurance policy direct from the respondents, then the matter would have been different. Anyhow the appellant could not show anything contrary which may persuade us to interfere in the order, under challenge.

 13.                     In view of the above discussion, we are dissuaded to interfere with the impugned order rendered by the Ld. Lower Commission. The appeal, being bereft of merit, is accordingly dismissed, and the order of the Ld. Lower Commission is upheld.

14.                      Certified copies of this order be sent to the parties free of charge.

15.                       The file be consigned to Record Room, after completion.

(PREETINDER SINGH)

MEMBER