Punjab

Sangrur

CC/196/2018

Sukhdev Singh - Complainant(s)

Versus

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

Sh.Udit Goyal

04 Feb 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.

 

                                                               

                                                Complaint No.  196

                                                Instituted on:    17.04.2018

                                                Decided on:       04.02.2019

 

 

Sukhdev Singh son of Niranjan Singh, resident of H.No.314, Village Harchandpura, Tehsil Dhuri, District Sangrur.

                                                        …Complainant

                                Versus

 

1.     TATA AIG General Insurance Company Limited, 301-308, 3^rd Floor, Aggarwal Prestige Mall, Plot No.2, Road No.44, NearM2K Cinema Rani Bagh, Pitampura, New Delhi through is Regional  Manager.

2.     TATA AIG General Insurance Company Limited, Registered office: Peninsula Business Park, Tower-A, 15^th Floor, G.K. Mark, Lower Parel, Mumbai through its Managing Director.

3.     Family Health Plan Insurance TPA Limited, Sirinilaya Cyber Spazio, Suite # 101, 102, 109 & 110, Ground Floor, Road No.2,  Banjara Hills, Hyderabad through its Managing Director.

4.     AXIS Bank Limited, Branch Office: Ground Floor, Dhuri Pind Road, Dhuri, Tehsil Dhuri,District Sangrur through its Branch Manager.

                                                        ..Opposite parties

 

 

For the complainant          :       Shri Udit Goyal, Adv.

For Opp.parties 1&2                 :       Shri Ashish Garg, Adv.

For OP No.4                     :       Shri N.S.Sahni, Adv.

For OP  NO.3.                   :       Exparte.

 

Quorum:   Vinod Kumar Gulati, Presiding Member

                  Manisha, Member

      

Order by : Vinod Kumar Gulati, Member.

1.             Shri Sukhdev 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 914010004354649 with the OP number 4 since 2014.  In the month of June 2015, the complainant visited OP number 4 for banking, who apprised the complainant to purchase a mediclaim insurance policy, which was purchased by him from the OP number 4 by paying a sum ofRs.7273/- on 1.5.2015, whereby the complainant and his wife were insured and the policy in question bearing number 020062788500 was subsequently got renewed for the period from 1.7.2016 to 30.6.2017 and from 1.7.2017 to 30.6.2018. 

 

2.             The case of the complainant is that in the month of October, 2017, the complainant suddenly suffered acute stomach pain and uneasiness and as such was taken to Suraj Nursing Home, Patiala, where he remained admitted in the said hospital from 21.10.2017 to 27.10.2017 and after discharge from the hospital the complainant got regular follow up treatment and by this way the complainant spent an amount of Rs.25,464/- on the treatment. Further case of the complainant is that thereafter the complainant lodged the claim with the OPs and submitted all the documents for payment of the insurance claim amount of Rs.25,464/-, but the claim of the complainant was repudiated by the Ops saying that the claim is not payable under the policy. 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.25,464/-  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 the OPs number 1 and 2, legal objections have been taken up on the grounds that the complainant dragged the OPs into unwanted litigation, that the complicated questions of law and facts are involved in the present case, that the complainant is not a consumer and has prayed for dismissal of the complaint with special costs. On merits, it is admitted that the complainant had purchased the policy in question for Rs.3,00,000/- on floater basis for the period from 1.7.2017 to  30.6.2018 subject to the terms and conditions and got renewed thereafter.  It is further averred that the complainant had submitted the bills for treatment for the period from 21.10.2017 to 27.10.2017 and spent an amount of Rs.25,464/-, but it is stated that the claim was found not payable as the complainant has violated policy section 3(e) and general condition number 4 i.e. abuse of alcohol/intoxicating drugs consumption is established as a cause of incident as per the conditions of the policy.  But, the other allegations levelled in the complaint have been denied in toto.

 

4.             Record shows that OP number 3 was proceeded against exparte.

 

5.             In reply filed by OP number 4, it is admitted that the complainant is having a saving bank account with the OP number 4, but it is denied that the officials of OP number 4 allured the complainant to purchase the health policy of OP number 1 and 2.  However, it is admitted that the complainant paid the amount of Rs.7273/- out of his saving account to the OP number 1 and 2. The other allegations levelled in the complaint have been denied.

 

6.             The parties produced their respective evidence in support of their case. None of the parties submitted written arguments.

 

7.             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.

 

8.                It is admitted fact that the complainant was admitted in Suraj Nursing Home, Patiala on 21/10/2017 and was discharged on 27/10/2017 after being treated for AC Pancreatitis by Dr. Madan Mohan Gupta of Suraj Nursing home, Patiala. Further the claim of the complaint was repudiated by the Ops on 26/12/2017 under section 3.E.IV on the grounds that AC Pancreatitis which is a consequent complication of Alcohol/drug in take treatment related to the Alcohol abuse/ substance abuse in excluded in the policy.  Further, the complainant vide Ex.C-2 has submitted the certificate dated 14/01/2018 from  Dr. M.M. Gupta in which “he mentioned that he checked his (complainant’s) file again in which history clearly reveals that he left the alcohol about 10 years back. It means that the present attack of AC. Pancreatitis does not seem to be related to alcohol”. This certificate has been found to be submitted approximate 75 days after the date of discharge of complainant from the clinic after his treatment for AC Pancreatitis and about 45 days after the repudiation of the claim by the Ops. No sworn in affidavit of the doctor who treated the complainant has been submitted by the learned counsel of the complainant to support his case. Further letter dated 14/01/2018 seems to be after thought. In the sequel of above discussion, the complainant could not make out any case for the claim in view of the repudiation of claim by the OPs. As such, the complaint is dismissed with no orders to costs. Copies of order be supplied to parties free of cost as per orders. File be consigned to records.

Pronounced.

                        Feb 4, 2018.                                     

                                                         

 

                                                        (Vinod Kumar Gulati)

                                                          Presiding Member

 

                                                               (Manisha)

                                                                 Member