Chandigarh

DF-II

CC/1196/2019

Jagdamba Prasad Shukla - Complainant(s)

Versus

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

Gaurav Bhardwaj Adv.

06 Apr 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

U.T. CHANDIGARH

 

 

Consumer Complaint No.	:	1196/2019
Date of Institution	:	24.12.2019
Date of Decision	:	06.04.2022

 

                     

            

 

Jagdamba Prasad Shukla c/o Children Traffic Park, Sector 23, Chandigarh permanent r/o Dashmesh Nagar, Naya Goan, Mohali.

                 ...  Complainant.

Versus

 

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, 15^th Floor, Ganpatrao Kadam Marg, Lower Parel, Mumbai-400013 through its Managing Director.

…. Opposite Parties

BEFORE:
	SMT.PRITI MALHOTRA,	PRESIDING MEMBER
	SHRI B.M.SHARMA	MEMBER
Argued by:-	Sh.Gaurav Bhardwaj, Adv. for the complainant
	Sh.Sahil Abhi, Adv. for the OPs.

   

 

PER PRITI MALHOTRA, PRESIDING MEMBER

1.     Briefly stated, the facts of case as alleged by the complainant are that he is having bank account in Axis Bank and was issued Medical Insurance Policy being the credit card holders of the Bank by the OPs by sending the Master Policy No.0260014872, which was valid from 06.11.2018 to 05.11.2019 for sum insured of Rs.3 lakhs and the premium of Rs.10,384/- was debited from his account.  The said cover was offered only for the complainant, his wife and two children only.  According to the complainant, he and his family members were hale and healthy 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 lever infection and acute necrotizing pancreatitis and discharged on 20.01.2019 after treatment. He remained under follow up treatment with the treating doctors from 21.01.2019 to 28.03.2019. He again admitted in the PGIMER on 28.03.2019 and discharged on 12.04.2019 and 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 the claim for an amount of Rs.1,54,085/- with the relevant documents with the OPs, 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 has been averred that no terms and conditions of the policy was supplied and as such he requested the OPs vide e-mail dated 19.11.2019 to pay the claim but to no effect. Alleging that the aforesaid acts of omission and commission on the part of the OPs amount to deficiency in service and unfair trade practice, the complainant has filed the instant complaint.
2.     In their written statement, the OPs while admitting the factual matrix of the case have 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 as per the law laid down by the Hon’ble Apex Court. It has further been pleaded that 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 has been further been pleaded that 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. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service on their part, a prayer for dismissal of the complaint has been made.
3.     We have heard the Counsel for the parties and have gone through the documents on record as well as written submissions.
4.     Admittedly, the complainant had obtained the Group Mediprime Insurance Policy in question (Annexure C-1) for himself, his wife and two children from the OPs and the same was valid from 06.11.2018 to 05.11.2019.  It is also a fact that the complainant suffered pain in his abdomen and was diagnosed to be suffering from acute necrotizing pancreatitis for which he took treatment from the PGIMER, Chandigarh on two occasions i.e. from 04.12.2018 to 20.01.2019 and 28.03.2019 to 12.04.2019 during the first year of the inception of the insurance policy in question. 
5.     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.)} being fall 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.
6.           We are also supported by the judgment of the Hon'ble Apex Court of India in the case of Suraj Mal Ram Niwas Oil Mills Pvt. Ltd., vs. United India Insurance Company and another (2011 (1) CLT 458), that " Contract of insurance- Construction of contract of insurance- in construing the terms of a contract of insurance, the words used therein must be given paramount importance- it is not open for court to add, delete or substitute any words- the endeavor of the Court should always be to interpret the words in which the contract is expressed by the parties".
7.     For the reasons stated above, we do not find any merit in the present complaint and the same is dismissed with no order as to costs.
8.     Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced 06/04/2022
	Sd/- (PRITI MALHOTRA) PRESIDING MEMBER
	Sd/-
	(B.M.SHARMA) MEMBER