Chandigarh

DF-I

CC/896/2022

JAGSIR SINGH S/O SH.GURDEV SINGH - Complainant(s)

Versus

TATA AIG GENERAL INSURANCE COMPANY LTD - Opp.Party(s)

GAURAV BHARDWAJ

05 Mar 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/896/2022
Date of Institution	:	02/11/2022
Date of Decision	:	05/03/2024

Jagsir Singh, S/o Sh. Gurdev Singh, Permanent Resident of VPO Fatehpur, District Mansa. Punjab.

… Complainant

V E R S U S

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

        2nd Address

        TATA AIG General Insurance Company Ltd, Peninsula Business park. Tower -A, 15th floor Ganpatrao Kadam Marg, Lower Parel, Mumbai- 400013 through its Managing Director.

2. AXIS BANK LTD., SCO No.141-142, Sector-9, Madhya Marg Chandigarh.

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Gaurav Bhardwaj, Advocate for complainant
	:	Sh. Sahil Abhi, Advocate for OP-1
	:	OP-2 ex-parte

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Jagsir Singh, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that the complainant is having his bank account in Axis Bank (OP-2), who had offered a group mediclaim insurance policy to all its account holders. At that time, complainant was informed that all the treatment shall be covered and the same shall be cashless and the said cover was offered to the complainant, his wife and child. The complainant had given his consent for the said policy and on this, premium of ₹14,489/- was debited from his account and Group Medicare Certificate of Insurance (Annexure C-1) (hereinafter referred to as “subject policy”) valid w.e.f 4.8.2021 to 3.8.2022 was duly sent to the complainant by OP-2 with total sum insured of ₹5.00 lacs. At the time of purchasing the subject policy, complainant and his family members were hale and hearty and were not suffering from any ailment or disease.  Suddenly on 15.5.2022, complainant suffered with severe pain in his ear as a result of which he was admitted in Abrol ENT Institute, Chandigarh (hereinafter referred to as “treating hospital”) on 16.5.2022 and on the advice of doctors, surgery was performed and after keeping the complainant under observation, he was discharged on 17.5.2022. Copy of discharge summary is Annexure C-2.  The treating hospital raised had bills (Annexure C-3 & C-4) of ₹41,700/-. Thereafter the said bills were submitted by the complainant with OP-1 for reimbursement alongwith claim form (Annexure C-5 & C-6). Vide email (Annexure C-7), OP-1 acknowledged the receipt of the claim papers and the complainant was intimated that the claim has been registered. However, vide letter dated 27.7.2022 (Annexure C-8), complainant was informed that as treatment taken by him for the said disease i.e. right chronic suppurative otitis media for tympanoplasty falls in the first two years waiting period, the claim has been repudiated.  The subject policy was given by OP-2 bank through telecalling and he was never informed about any two year waiting period and not only this even the copy of policy certificate nowhere mentions that any such waiting period was required for making the claim for such disease, rather OP-2/bank had offered the subject policy to the complainant which was accepted by him in good faith.  In this manner, the aforesaid acts of the OPs amounts to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OP-1/insurer resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of limitation, maintainability, cause of action, jurisdiction and estoppel.  However, it is admitted that the subject policy, valid w.e.f. 4.8.2021 to 3.8.2022, was issued to the complainant with sum insured of ₹5.00 lacs, but, it is alleged that as per one of the conditions under Section 3(1)(ii) of the policy, there is a waiting period of two years for the diseases to be covered as detailed in the policy and as the treatment, which the complainant had taken, i.e. right chronic suppurative otitis media for tympanoplasty from 16.5.2022 to 17.5.2022, was also covered under exclusion clause i.e. within two years waiting period and the claim had been lodged by the complainant within the said waiting period, same was rightly repudiated by the answering OP. On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. Pursuant to the notice, initially OP-2 put in appearance through Sharvan Kumar, Assistant Manager.  However, subsequently, neither anybody appeared on behalf of OP-2 nor reply and evidence were filed on its behalf. Hence, OP-2 was proceeded against ex-parte vide order dated 27.2.2023.
4. Complainant chose not to file rejoinder.

2. In order to prove their case, contesting parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the contesting parties and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the subject policy/certificate was obtained by OP-2/bank  in the name of the complainant covering complainant, his wife and minor child with sum insured of ₹5.00 lacs valid w.e.f. 4.8.2021 to 3.8.2022, as is also evident from the copy of subject policy/certificate (Annexure C-1) and the complainant or the insured persons were not suffering from any ailment at the time of obtaining the subject policy and even the premium of the said policy to the tune of ₹14,489/- was debited from the account of the complainant  and on 16.5.2022 complainant had undergone surgery of right chronic suppurative otitis media for tympanoplasty at the treating hospital where he remained admitted w.e.f. 16.5.2022 to 17.5.2022, as is also evident from the discharge summary (Annexure C-2) and the complainant had to incur and amount of ₹41,700/- on his treatment, as is also evident from the bills (Annexure C-3 & C-4),  the case is reduced to a narrow compass as it is to be determined if there is any deficiency in service and unfair trade practice on the part of OPs while repudiating the claim of the complainant on the ground that the said claim was lodged within the waiting period of two years and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if there is no deficiency in service or unfair trade practice on the part of the OPs and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy certificate, medical record as well as the repudiation letter and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Perusal of the Group Medicare Certificate of Insurance (Annexure C-1) clearly indicates that the subject policy was obtained by the policy holder i.e. Axis Bank Limited/OP-2 in the name of the insured person i.e. complainant, his wife and dependent child. 
   4. Perusal of the discharge summary (Annexure C-2) clearly indicates that the complainant was admitted in the treating hospital on 16.5.2022 and after performing surgery for “Rt Tmpanoplasty under LA (MAC)”, he was discharged on 17.5.2022. Annexure C-3 and C-4 are bills through which the complainant had paid an amount of ₹41,700/- to the treating hospital for the said aforesaid surgery and hospitalisation. Annexure C-8 is letter dated 27.7.2022, through which the claim of the complainant was repudiated and the relevant portion of the same reads as under :-

        “The submitted claim is for Right chronic suppurative otitis media for tympanoplasty which has a specific two years of waiting period as per the policy and the policy start date is 04-Aug-2021.  Hence we regret to inform you that your claim is repudiated under Section 3(i)(ii) of the policy and IRDA Excl. 02.”

5. As per the case of complainant, he had only received the Group Medicare Certificate of Insurance alongwith receipt of the amount of premium, ID cards and enrolment form from OP-2/bank and except these documents, no other document, including complete policy schedule containing the terms and conditions, were ever sent to him by any of the OPs to make him aware about the exclusion clause of the two years waiting period being there for reimbursement of any claim with respect to a particular disease. In order to prove this fact, complainant has led his evidence by tendering his affidavit alongwith Annexure C-1 (colly.) and the said evidence is unrebutted by OP-2, who did not turn up before this Commission despite of service and was proceeded against ex-parte, in order to counter the claim of the complainant that he was never supplied the terms and conditions of the subject policy. 
6. In this manner, one thing is clear that the complainant, who had subscribed to the subject policy by paying requisite premium of ₹14,489/-, was never served/supplied with the terms and conditions of the subject policy, containing the exclusion clause, including the two years waiting period for a particular disease, which otherwise was the bounden duty of OP-2/bank as it was OP-2 who was the policy holder and it had obtained the subject policy for complainant from the insurer/OP-1.  Hence, it is safe to hold that the claim of the complainant was repudiated by OP-1 solely due to the deficiency in service and unfair trade practice on the part of OP-2, as discussed above.
7. Now coming to the liability of OP-1/insurer, since it is the defence of OP-1/insurer that it had supplied terms and conditions of the subject policy to OP-2 and further as it has come on record that OP-2 has not supplied the same to the complainant, no deficiency in service or unfair trade practice can be attributed on the part of OP-1.  As a result, the consumer complaint against OP-1 stands dismissed with no order as to costs. 

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP-2 is directed as under :-

1. to pay ₹41,700/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 27.7.2022 onwards.
2. to pay ₹7,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹5,000/- to the complainant as costs of litigation.

5. This order be complied with by OP-2 within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

05/03/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Suresh Kumar Sardana] Member