Punjab

Sangrur

CC/466/2017

Amrik Singh - Complainant(s)

Versus

TATA AIG General Insurance Company Ltd. - Opp.Party(s)

Sh.Udit Goyal

15 May 2018

ORDER

                             DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.    466

                                                Instituted on:      13.09.2017

                                                Decided on:       15.05.2018

 

Amrik Singh aged about 41 years son of Sh. Jeet Singh, resident of Village Ghanari Kalan, Tehsil Dhuri, District Sangrur.

                                                        …Complainant

                                Versus

 

1.             TATA AIG General Insurance Company Limited, Locus Tower, 1^st Floor, Community Centre, New Friends Colony, New Delhi through its Managing Director.

2.             TATA AIG General Insurance company Limited, Regd. Office: Delphi-B Wing, 2^nd Floor, Orchard Avenue, Hira Nandi Business Park, Powai, Mumbai 400076 through its Managing Director.

3.             AXIS Bank Limited, Branch Office: Opposite Bus Stand, Chhota Bazar Road, Malerkotla, District Sangrur through its Branch Manager.

                                                        ..Opposite parties.

 

 

For the complainant            :       Shri Udit Goyal, Adv.

For Opp.party No.1&2        :       Shri Ashish Garg, Adv.

For Opp.Party No.3            :       Shri Navit Puri, Adv.

 

Quorum:    Sukhpal Singh Gill, President

                Sarita Garg, Member

               

Order by : Sukhpal Singh Gill, President.

 

1.             Shri Amrik Singh, complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant is having a saving bank account number 419010100052960 with the OP number 3 since the year 2008.  The case of the complainant is that when in the year 2016, he visited the bank i.e. OP number 3 then the officials of the OP number 3 allured the complainant to get the medical insurance policy on floater basis, as such, the complainant took a medical insurance policy bearing number 028505148800 which was valid for the period from 22.3.2016 to 21.3.2017 for Rs.2,00,000/- and according to the policy, the complainant and his family members were entitled to get treatment anywhere in India and the OPs had to pay the claim.  

 

2.             The case of the complainant is that during the subsistence of the insurance policy in the fourth week of December, 2016, the complainant suddenly suffered acute stomach pain and uneasiness and as such he was immediately taken to Columbia Asia Hospital, Patiala, where he remained admitted from the period 24.12.2016 to 28.12.2016, where he spent an amount of Rs.1,07,212/- on his treatment i.e. medical tests and medicine etc.  Thereafter the complainant submitted all the bills to OP number 1 for payment, but the grievance of the complainant is that the OP number 1 repudiated the rightful claim of the complainant vide letter dated 29.4.2017, which is totally illegal.  Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the OPs be directed to pay to the complainant the insurance claim of Rs.1,07,213/-  along with interest @ 18% per annum from the date of treatment till realisation and further claimed compensation and litigation expenses.

 

3.             In reply of the complaint filed by OPs number 1 and 2, legal objections have been taken up on the grounds that the complaint is totally devoid of merits, that the complicated questions of law and facts are involved in the present case, that the complainant has not come to the Forum with clean hands, that the complainant was got admitted in hospital for ‘alcoholic hepatitis (ALC HEPATITIS) and treating doctor has clearly and specifically mentioned “still consuming alcohol” in the discharge summary dated 28.12.2016. It is also case of the OPs that the complainant is a case of CIRRHOSIS/PHT. On merits, it is admitted that the complainant was insured under the insurance policy as mentioned above for Rs.2,00,000/- on floater basis.  It is further stated that after perusing the claim for treatment i.e. from 24.12.2016 to 28.12.2016, it was observed by the OPs that it is clearly mentioned in the discharge summary that the complainant is a known case of cirrhosis/PHT, which fact was concealed by the complainant, as such, the complainant is said to be not entitled to get any claim.

 

4.             In reply filed by Op number 3, preliminary objections are taken up on the grounds that the complaint is false, frivolous, vague and vexatious in nature, that the complainant has not come to the Forum with clean hands and that the complainant has dragged the OP into uncalled litigation and as such the complaint is liable to be dismissed with special costs.  The territorial jurisdiction of this Forum is also disputed.  On merits, it is admitted that the complainant was having a saving bank account in question with the OP number 3. However, the other allegations levelled in the complaint have been denied in toto.

 

5.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-7 copies of documents and closed evidence. On the other hand, the learned counsel for the OP number 1 and 2 has produced Ex.OP-1&2/1 to Ex.OP1&2/7 copies of documents and affidavit and closed evidence. The learned counsel for OP number 3 has produced Ex.OP3/1 affidavit and closed evidence. 

 

6.             We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits  acceptance, for these reasons.

 

7.             It is an admitted fact between the parties that the complainant got family health insurance policy for the period from 22.03.2016 to 21.03.2017 from the OP number 1 for Rs.2,00,000/- on floater basis after paying the requisite premium, as is evident from the copy of insurance policy document Ex.C-3 on record. It is also not in dispute that the complainant suffered from the problem of acute stomach pain and uneasiness and was immediately taken to Columbia Asia Hospital, Patiala, where he remained admitted in the said hospital from 24.12.2016 to 28.12.2016, as is evident from the copy of bill on record as Ex.C-12.  It is not in dispute that the complainant had already lodged the claim with the Ops.  But, in the present case, the OP number 1 has repudiated the claim of the complainant vide letter dated 29.4.2017, Ex.C-5 on record on the basis that the complainant is an abuse of alcohol//intoxicating drugs consumption is established as a cause of accident which is not covered under the terms and conditions of the policy of insurance, as such any liability of the insurance company has been denied.  On the other hand, the learned counsel for the complainant has contended vehemently that no such terms and conditions were ever supplied to the complainant along with the insurance policy.  Though the OPs number 1 and 2 has produced on record the ‘policy wordings Mediprime’ on record as Ex.OP1&2/2, but it is not proved on record that such terms and conditions were ever supplied to the complainant nor any such documentary evidence is there on the file produced by the OPs number 1 and 2. To support this contention, reliance can also be placed on J.R.Bank versus National Insurance Company Limited 2017(2) CLT 376, wherein it has been held that non production of terms and conditions to the insured amounts to deficiency in service and the repudiation of claim is unjust and arbitrary. It has also been held by the Hon’ble National Commission that the agents of insurance companies to achieve a target of number of insurance policies, act in haste and collect premiums. As such, we are of the considered opinion that such terms and conditions are not binding on the complainant. In the circumstances of the case, we feel that the OP number 1 has wrongly repudiated the claim of the complainant, which is a clear cut deficiency in service on the part of OP number 1. As such, we feel that the ends of justice would be met if the OP number 1 is directed to pay to the complainant the claim amount after calculation.

 

8.             Further a bare perusal of the complaint reveals that the complainant has submitted only bills to the OP number 1 for the treatment taken by the complainant for the period from 24.12.2016 to 28.12.2016 and not thereafter, as such, we find that the complainant has spent an amount of Rs.68,408/- on the treatment and we further feel that ends of justice would be met if the OP number 1 and 2 are directed to pay to the complainant an amount of Rs.68,408/-.

 

9.             The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

 

10.            Accordingly, in view of our above discussion, we allow the complaint and direct the OP number 1 and 2 to pay to the complainant an amount of Rs.68,408/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 13.09.2017 till realisation.  We further order the OP number 1 and 2 to pay to the complainant an amount of Rs.5000/- in lieu of consolidated amount of compensation and litigation expenses.

 

11.            This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.

                        Pronounced.

                        May 15, 2017.

 

                                                        (Sukhpal Singh Gill)

                                                                President

 

                                                             

                                       

                                                                (Sarita Garg)

                                                                    Member