Haryana

Kurukshetra

CC/449/2019

Ramanjeet Kaur - Complainant(s)

Versus

TATA AIG Gen Ins - Opp.Party(s)

C.B.Sharma

06 Jun 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KURUKSHETRA.

 

                                                                    Complaint No.:    449 of 2019.

                                                                   Date of institution:         11.10.2019.

                                                                   Date of decision: 06.06.2022

 

Ramanjeet Kaur w/o Shri Suba Singh, r/o village Balahi, P.O. Dabkheri, Tehsil Thanesar, District Kurukshetra.

                                                                                                …Complainant.

                                                     Versus

 

1. The Branch Manager, TATA AIG General Insurance Co. Ltd., 3^rd Floor, Shanti Complex, Jagadhri Road, Opp. Civil Hospital, Ambala Cantt., District Ambala.
2. Regional Manager, TATA AIG General Insurance Co. Ltd., A-501, 5^th Floor, Building No.4, Infinity IT Park, Dindoshi, Malad (East), Mumbai-400097.

 

...Respondents.

CORAM:   NEELAM KASHYAP, PRESIDENT.    

                   NEELAM, MEMBER.

                   ISSAM SINGH SAGWAL, MEMBER.           

 

Present:       Shri C.B. Sharma, Advocate for the complainant.

                   Shri R.K. Singhal, Advocate for Opposite Parties.

 

ORDER:

 

1.                This is a complaint under Section 12 of the Consumer Protection Act, 1986 (for short “Act”).

2.                It is alleged in the complaint that the complainant was having Medi Prime Insurance Policy of Rs.3 lacs for two adults i.e. she and her husband Suba Singh and one child master Avraj and got the same through Axis Bank, Pipli Road, Kurukshetra vide ID C/3947879/00001102, Proposal No.P/3947879/020147/00000445 and Policy No.028526514400. She suffered from tenderness right knee swelling on and off and admitted in Anand Orthopedic Centre, Kurukshetra from 21.05.2019 to 26.05.2019 and still going on treatment with doctor Himanshu Anand and spent Rs.96,117/- on her treatment. Thereafter, the complainant approached to OPs and applied for reimbursement of money spent by her on her treatment by submitting all relevant documents with the OPs, but they illegally repudiated her genuine claim. She also served a legal notice upon OPs through her counsel on 29.07.2019, but despite acceptance the same, they neither replied the same nor redressed her grievance, which was an act of deficiency in service on the part of OPs, due to which, she suffered great mental agony, hardship and financial loss, constraining her to file the present complaint against the OPs.

3.                Upon notice of complaint, OPs appeared and filed their written statements admitting issuing of Mediprime policy in favour of complainant on floater plan basis for the period from 09.03.2018 to 08.03.2019 and renewed the same from 09.03.2019 to 08.03.2020 for a sum of Rs.3 lacs, subject to policy terms and conditions. During the existence of policy, complainant registered reimbursement claim with OPs on 03.06.2019 for Rs.66800/- with regard to expenses incurred during her admission in Anand Hospital Centre, Kurukshetra for the period from 21.05.2019 to 26.05.2019 for treatment of Medial Compartment Osteoarthritis Right Knee. The OPs acknowledged the receipt of claim intimation and documents sent by complainant, vide letter dated 03.06.2019. On perusal of claim form and documents, it was noted that the complainant was treated for Medial Compartment Osteoarthritis Right Knee, which falls under Section 3 (c) Exclusions of the policy, having waiting period of two years. The policy inception date is 09.3.2018 and the present claim was lodged on 21.5.2019 i.e. within two years from the date of inception of policy, hence same falls under two years waiting period clause and the claim is inadmissible and same was finally repudiated on 04.6.2019 u/s 3 (c) of the policy and complainant was informed in this regard vide letter dated 04.6.2019. There was no deficiency in service on the part of OPs and prayed for dismissal the present complaint with heavy costs.

4.                In support to support her case, complainant tendered affidavit Ex.CW1/A along with documents Ex.C-1 to Ex.C-30 and closed her evidence.

5.                On the other hand, the OPs tendered affidavit Ex.RW1/A along with documents Ex.R-1 to Ex.R-6 and closed their evidence.

6.                We have heard the learned counsel of the parties and carefully gone through the case file.

7.                Learned counsel for the complainant argued that complainant was having Medi Prime Insurance Policy of Rs.3 lacs for her, her husband and son. The complainant suffered from tenderness right knee swelling on and off and admitted in Anand Orthopedic Centre, Kurukshetra from 21.5.2019 to 26.5.2019 and spent Rs.96117/- on her treatment. The complainant approached to OPs and applied for reimbursement of money spent by her on her treatment by submitting all relevant documents with the OPs, but they illegally repudiated her genuine claim on the basis of Section 3 (c) Exclusions of the policy. He further argued that complainant was a young lady aged about 38 years, but the above clause 3 related to aged person, not for complainant and as such, this clause does not apply on the case of complainant. He further argued that the OPs illegally and wrongly repudiated the claim of complainant.

 8.               The learned counsel for OPs argued that OPs issued Mediprime policy in favour of complainant on floater plan basis for the period from 09.3.2018 to 08.3.2019 and renewed the same from 09.3.2019 to 08.3.2020 for a sum of Rs.3 lacs, subject to policy terms and conditions. During the existence of policy, complainant registered reimbursement claim with OPs on 03.6.2019 for Rs.66800/- with regard to expenses incurred during her admission in Anand Hospital Centre, Kurukshetra for the period from 21.5.2019 to 26.5.2019 for treatment of Medial Compartment Osteoarthritis Right Knee. The OPs acknowledged the receipt of claim intimation and documents sent by complainant vide letter dated 03.6.2019. On perusal of claim form and documents, it was noted that the complainant was treated for Medial Compartment Osteoarthritis Right Knee which falls under Section 3 (c) Exclusions of the policy, having waiting period of two years. The policy inception date is 09.3.2018 and the present claim was lodged on 21.5.2019 i.e. within two years from the date of inception of policy, hence same falls under two years waiting period clause and the claim is inadmissible and same was finally repudiated on 04.6.2019 u/s 3 (c) of the policy and complainant was informed in this regard vide letter dated 04.6.2019. There was no deficiency in service on the part of OPs and prayed for dismissal the present complaint.

9.                There is no dispute that the complainant took the Mediprime Insurance Policy valid from 09.03.2018 to 08.03.2019 (Ex.C-29) for a sum insured of Rs.3 lacs and lastly, renewed the same from 09.03.2019 to 08.03.2020 (Ex.R-1). Under the said policy, complainant, her husband Suba Singh and son Avraj were covered. There is also no dispute that the complainant admitted in Anand Orthopedic Centre, Kurukshetra on 21.05.2019 and discharged on 26.05.2019, vide Discharge Summary Ex.C-4. From the said Discharge Summary Ex.C-4, it is crystal clear that the complainant took the treatment for Tibial Osteotomy of Right Knee during that period in that hospital. The complainant lodged her claim with the OPs, but they repudiated the same, vide letter dated 06.04.2019 Ex.R-6 with the observations “The submitted claim is for the illness which has a specific two years of waiting period as per the policy and the policy start date is 09.03.2018. Hence, we regret to inform you that your claim is repudiated under Section 3 (c) of the policy”.

10.              Learned counsel for the complainant alleged that the complainant is a young lady of aged about 38 years, but the above “Section 3 Exclusion” is related to aged person, not for 38 years young aged person like complainant in the present case and as such, this Section does not apply on the case of complainant and OPs illegally and wrongly repudiated the claim of the complainant on the ground of this Section 3. 

11.              On the other hand, learned counsel for the OPs contended that the policy inception date was 09.03.2018 and the present claim was lodged by the complainant on 21.05.2019 i.e. within two years from the date of inception of the said policy, hence, the same falls under two years Section-3 “Exclusions” “Waiting Period Clause” and is inadmissible and same was rightly repudiated on 04.06.2019 and was informed in this regard to the complainant, vide letter dated 04.6.2019.

                   “Section 3 : Exclusions”, sub-Clause “Specific Waiting Periods”, is relevant, which reads as under:-

                   (c)      The illness and treatments listed below will be covered subject to a waiting period of 2 years as long as in the third Policy Year the Insured Person has been insured under an Mediprime Policy continuously and without any break;

                    i)       Illnesses: arthritis if non infective; calculus diseases of gall bladder and urogenital system; cataract; fissure/fistula in anus, hemorrhoids, pilonidal sinus, gastric and duodenal ulcers; gout and rheumatism; internal tumors, cysts, nodules, polyps including breast lumps (each of any kind unless malignant); osteoarthritis and osteoporosis if age related; polycystic ovarian diseases; sinusitis and related disorders and skin tumors unless malignant.

 

12.               From the perusal of said Section, we found that the complainant took the treatment for Tibial Osteotomy of Right Knee on 09.03.2018 to 08.03.2019 i.e. within the two years of inception of the policy in question and lodged the claim case with the OPs, who repudiated her claim on the ground that treatment of said disease falls under Section 3 : Exclusions i.e. two years of waiting period and complainant is not liable to receive the claim for the said disease during that period. But in this regard, we found force in the contention of the complainant that case of complainant does not fall under the said Section -3, because, from perusal of this Section, we found that said Section is related to aged person, not for 38 years young aged person like complainant in the present case and as such, this Section does not apply on the case of complainant. Moreover, at the time of providing the said health insurance to the complainant, the complainant was duly medically examined by the OPs and when she was found fit by the medical team of OPs, then the said policy in question was provided to her. For the sake of discussion, if the complainant has had the said problem/disease in question before taking the policy in question, then she might be suffered from the same in the very first inception year of the policy, but nothing such like has had happened in the case in hand. The complainant suffered from the said problem/disease in the second year of the inception of the policy in question, which might be caused in the same year or might be caused due to an injury/accident or any other reason.

13.              So, keeping in view the above facts and circumstances of the case, we are of the considered view that the OPs were not justified in repudiating the claim of the complainant, on the ground of this Section 3 and accordingly, they are liable to indemnify the complainant for the expenses, incurred by the complainant, during her treatment in Anand Orthopedic Centre, Kurukshetra from 21.05.2019 to 26.05.2019. Hence, the OPs are deficient in providing the services to the complainant while wrongly and illegally repudiating the claim of the complainant. With the complaint, complainant attached medical treatment bills from Ex.C-5 to Ex.C-12 for total amount of Rs.91,117/- (50000+30000+1100+100+220+2098+3755+2694+999+ 151) respectively). So, the OPs are liable to pay the said amount of Rs.91,117/- to the complainant, alongwith the compensation and litigation charges.

14.              In view of our above discussion, we partly accept the present complaint and direct the OPs to pay the claim amount of Rs.91,117/- to the complainant, alongwith interest @6% simple per annum, from the date of this order, till its actual realization. The OPs are also directed to pay Rs.10,000/-, to the complainant, as compensation for mental agony and physical harassment, caused to the complainant, due to deficiency in services on the part of the OPs, along with Rs.5,000/- as litigation expenses. The OPs are  further directed to make the compliance of this order within a period of 45 days from the date of preparation of certified copy of this order, failing which, the complainant will be at liberty to initiate proceedings under Section 25/27 of the Act against the OPs. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the record-room, after due compliance.

Announced in open Commission:

Dated:06.06.2022.

 

    

                                                                                        (Neelam Kashyap)               

(Neelam)                    (Issam Singh Sagwal)                   President,

Member.                    (Member).                                     DCDRC, Kurukshetra.           
 

 

 

Typed by: Sham Kalra, Stenographer.