Haryana

Fatehabad

CC/80/2020

Ikbran Mohmmed - Complainant(s)

Versus

Tata Aig General Insurance - Opp.Party(s)

Sukhbir Dhaka

09 Apr 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION FATEHABAD.

                                         Sh.Rajbir Singh, President.                                                      Dr.K.S.Nirania and Smt.Harisha Mehta, Members

 

                                                                    C.C.No.80 of 2020.                                                                                    Date of Instt.: 11.03.2020.                                                                           Date of Decision: 10.04.2024.

Ikbran Mohmmed son of Karmudin resident of village & Post Office: BhodiaKhera Tehsil & District Fatehabad.

                                                                             ..Complainant

                              Versus

TATA AIG General Insurance Company Limited, Registered Office: Pennisula Business Park, Tower A, 15^th Floor, G.K.Mark, Lower Parel, Mumbai through its Chairman-cum-Managing Director/Managing Director.

                                                                   ..Opposite Party.

Complaint U/S 12 of the Consumer Protection Act, 1986

Present:                 Sh.Sukhbir Dhaka, Advocate for complainant.                                            Sh.Vinod Kumar Mehta, Advocate for Op.          
ORDER

SH.RAJBIR SINGH, PRESIDENT

1.                                 The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 with the averments that he had purchased a Health policy No.0285332948 having validity for the period from 16.11.2018  to 15.11.2018 from Op for himself, his wife, daughter and son; that the complainant felt ill and got the treatment from Sanjivini Multi speciality Hospital, Fatehabad for the period 19.10.2019 to 23.10.2019 and spent Rs.30,000/- on his treatment; that the complainant submitted all the requisite document with the Op besides the bills etc. but it avoided the matter on one pretext or the other; that the complainant requested the Op to reimburse the amount spent by him on his treatment and even got served legal notice upon it but to no avail. The act and conduct of the Ops clearly amounts to deficiency in service on their part. In evidence, the complainant has tendered affidavit Ex.CW1/A and documents Annexure C1 to Annexure C6.

2.                          OP appeared and filed its reply wherein several preliminary objections such as cause of action, locus standi, estoppal and complaint being false and frivolous have been taken. It has been further submitted that on 07.11.2019, the complainant had submitted a claim for reimbursement of expenses for the treatment taken by him for mumps, bilateral orchitis, bilateral mild hydrocele for which he was admitted in the hospital for the period from 19.10.2019 to 23.10.2019; that the disease bilateral orchitis is a result of bacterial infection such as sexually transmitted infection and that disease specially excluded from the policy; that the complainant was required vide letter dated 11.11.2019 to submit certificate of treating doctor for eiology/cause of bilateral orchitis/bilateral hydrocele  in order to ascertain the exact cause of admission/treatment and to decide the claim but the complainant did not provide the same despite repeated letters dated 11.11.2019, 21.11.2019, 01.12.2019, 03.12.2019 and 13.12.2019, therefore, the Op left with no other alternative but to reject the claim of the complainant vide letter dated 23.12.2019. It has been further submitted that on the request of complainant the claim was re-opened and the complainant expressed his willingness to comply with the requirements  but he has failed to do so therefore, the claim was again repudiated on 13.01.2020; that there is no deficiency in service and unfair trade practice on the part of replying Op as it is still ready to settle the claim on merits subject to terms and conditions of the policy. Other contentions have been controverted and prayer for the dismissal of the claim, has been made. In evidence, the OP has tendered affidavit Ex.RW1/A with documents Annexure R1 to Annexure R11.

5.                          We have heard oral final arguments from both sides. We have also perused the case file minutely.

6.                          Undisputedly, the complainant has obtained an insurance policy (Annexure C3) from the Op having validity from 16.11.2018 to 15.11.2019. The fact regarding felling ill of the complainant (Annexure C6) during the subsistence of the policy is also not disputed. The Op has rejected the claim of the complainant (Annexure R6 and Annexure R8) on the ground that disease bilateral orchitis is a result of bacterial infection such as sexually transmitted infection and that disease specially excluded from the policy, therefore, in order to ascertain the real cause the complainant was asked to submit the certificate of treating doctor through many letters Annexure R1 to Annexure R5 and Annexure C7 but the complainant did not remove the queries and even did not submit the same when the claim file was re-opened on the request of the complainant.

7.                          Before proceeding further let us see the major exclusions of the policy. The relevant part thereof is as under:

Expenses arising from HIV or AIDs and related disease, sterility, treatment to effect or to treat infertility and fertility sub-fertility

 

Now, let us see as to for what reason the complainant was admitted in the hospital. The ultrasound report depicts in the impression the disease as Bilateral Orchitis, Bilateral Mild Hydrocoele. Now, have a look on the medical literature for causing the disease Hydrocoele.  In the literature, it has been written that Hydroceles can occur at any age, yet tend to be more common in newborns and for most people hydroceles are nothing more than an inconvenience-yet temporary condition. Hydroceles can also form later in life, mostly in men over 40 years. They can occur from a hernia but this is less common. Most of the time it is either from inflammation or from the sac (called the tunica vaginalis) not reabsorbing fluid properly. The epithelial cells in the sac produce and reabsorb the fluid constantly and there can be dysfunction with these cells leading to excess fluid. A hydroceles is an abnormal collection of serous fluid between the two layers of tunica vaginalis of testis.  The Op on one hand asked the complainant to remove the queries on the ground of producing certificate from the doctor, which has already been placed on the case file and attached with Annexure C5 and on the other hand concluded that bilateral orchitis is a result of bacterial infection such as sexually transmitted infection. The act and conduct of the OP shows that they are bent upon the reject the claim of the complainant, which has been proved to be genuine, by raising queries, which this Commission do not find material in order to settle/decide the genuine claim of the complainant. It is a well settled proposition of law that a contract of insurance is based on the principle of utmost good faith – uberrimae fidei, applicable to both the parties.  The rule of non-disclosure of material facts vitiating a policy still holds the field.  The bargaining position of the parties in a contract of insurance is unequal. The insured knows all the facts; the insurer is unaware of anything which may be material to the risk. Very often, it is the insured who is the sole person who has this knowledge.  The insurer may not even have the means to find out facts which would materially affect the risk.  But in the present case it cannot be said that the complainant was having the knowledge about the disease for which he had taken treatment. Moreover, the Op has even failed to prove on the case file as to for what reason it has concluded that the alleged disease is a bacterial infection being sexually transmitted infection. The policy in question may be bind with many clauses but it cannot be said that the complainant, who can be said as layman, was having knowledge about the terms and conditions of the policy in question and even there is nothing on the case file to show that the complainant was got understood all the terms and conditions of the policy in question at the time of inception of the policy.  The insurance company has wrongly and illegally repudiated the genuine claim of the complainant on technical grounds, therefore, we have no hitch to say that present complaint deserves acceptance.

8.                          Keeping in view the above facts and circumstances of the case we allow the present complaint with a direction to the OP/insurance company to pay a sum of Rs.29151/- (Rs.Twenty Nine Thousand One Hundred Fifty One only) to the complainant alongwith interest @ 7 % per annum from the date of filing of the complaint till its realisation. We further direct the Op/insurance company to pay Rs.11,000/-, (Rs. Eleven Thousand) in lump sum, towards mental harassment and agony suffered by the complainant and also towards litigation expenses . The compliance of the order be made by the appearing Ops within 45 days from today, failing which the above mentioned relief amount would carry interest @ 12 % per annum from date of filing of the present complaint till actual realization.  

9.                          In default of compliance of this order, proceedings against respondents shall be initiated under Section 72 of Consumer Protection Act, 2019 as non-compliance of court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both. A copy of this order be sent to the parties free of cost. This order be also uploaded forthwith on website of this Commission, as per rules, for perusal of parties herein. File be consigned to the record room after due compliance.     

Announced in open Commission.                                                                 Dated: 10.04.2024

 

                    (K.S.Nirania)                 (Harisha Mehta)                (Rajbir Singh)                                                    Member                               Member                                President