Orissa

Rayagada

CC/187/2017

Mrs. Rajaswini Mishra - Complainant(s)

Versus

The Branch Manager Axis Bank - Opp.Party(s)

Self

31 Oct 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

                                      PO/DIST; RAYAGADA,   STATE:  ODISHA ,Pin No. 765001

C.C. Case  No.    187/ 2017.                                     Date.      31      10   . 2019.

P R E S E N T .

Dr. Aswini  Kumar  Mohapatra,                                     President

Sri Gadadhara  Sahu,                                                        Member.

Smt.Padmalaya  Mishra,.                                                Member

 

Mrs. Rajheswini  Mishra, D/O: Banamali Mishra,  AT: Paika  Street, Old Gunupur, ,  Dist:    Rayagada, State:  Odisha.                                                                                                                                                                                                                                                                                                                                                                                                               …….Complainant

Vrs.

1.The  Branch  Manager,  Axis Bank, Gunupru Branch, At/Po:Gunupur, Dist: Rayagada.       

2. The  Manager, TATA AIG General Insurance Co. Ltd., Corporate office,A-501, 5^th. floor, building No.4, Infinity IT Park, Dindoshi, Malada(East) Mumbai 400097(India).    

                                                                                      ..…..Opp.Parties

Counsel for the parties:                                 

For the complainant: - Sri Pradeep Kumar Dash, Advocate,

For the O.P No.1  :- Sri Ganapati Rao and  Sri V.R.M. Patnaik, Advocates.

For the O.P. No 2.:- Sri K.Ch.G.S.Kumandan, Advocate, Rayagada.

                                                          J u d g e m e n t.

          The  present disputes arises out of the complaint petition filed by the above named complainant alleging deficiency in service  against  afore mentioned O.Ps for non reimbursement  of medical expenses towards medi claim    policy No.023506033300.

Upon  Notice, the O.Ps put in their appearance and filed  written version through their learned counsels in which  they refuting allegations made against them.  The above O.Ps  taking one and another pleas in the written version   sought to dismiss the complaint as it is not maintainable  under the C.P. Act, 1986. The facts which are not specifically admitted may be treated  as denial of the O.Ps. Hence the O.Ps prays the forum to dismiss the case against  them  to meet the ends of justice.

The O.Ps appeared and filed their written version.  Heard arguments from the  learned counsels for  the  O.Ps  and from the complainant.    Perused the record, documents, written version  filed by the parties. 

The  parties advanced arguments inter alia  vehemently opposed the complaint touching the points both on the facts  as well as on  law.

                                                         FINDINGS.

On the basis of the pleadings of the parties, the sole question of determination is  Whether  the complainant is entitled  to Medi claim made by her ?

On perusal of the record this forum observed  there is no dispute that life assured had  taken a whole life insurance plan health security Insurance plan policy   bearing No. 023506033300.for a yearly premium  of  Rs. 3,905/-   which  was commenced from Dt. 8.12.2015 to  7.12.2016 (Copies of the policy is in the file which is marked as Annexure-I).The complainant  was  suffered  from ailment in chest pain  for which  she was admitted  on 30.05.2016 at Command Hospital and was  discharged on  10.06.2016 for treatment of chest pain.   The complainant  had spend total Rs. 70,000/- and submitted  her claim along with  required documents  to the O.Ps  for reimbursement of above amount (copies of the medical bill is in the file which is marked as Annexure-2). Due to non reimbursement of the above amount  by the O.Ps  the  complainant  filed this C.C. case  before this forum.

The O.P. No.2 in their written version contended that after perusing the preauthorization   request scrutinized every details denied the claim of the complainant  that the disease is a congenital disease and the policy do not cover the congenital disease(Section  3 E 6). However there are no documents submitted   by  the complainant for  reimbursement of the same.

For better appreciation this forum relied citation which are mentioned here under :-

It is held and reported in CPR- 2010(3) page No. 386 the Hon’ble State Commission, Jammu and Kashmir where in  observed “ Insurance company can not unilaterally restrict ambit of insurance coverage”.

 

Further  It is held and reported in C.PR-2010(3) page No. 374  the Hon’ble State Commission, West Bengal  where in observed  “Benefits of Medi claim policy can not be with held on specious grounds”.

Again It  is held and reported in CPR  2010 (3) page No. 211  the Hon’ble State Commission, Himachal Pradesh where in observed “Where exclusion clause in the insurance policy has not been explained by the insurer to the life insured  while insuring him under  benefit  of policy. Claim under  the policy can not be denied  on basis of such exclusion clause.”

Further  It is held and reported  in CPR-2010(3) page No.228  the Hon’ble  State Commission,  Himachal  Pradesh  where  in observed  “Insurance company is required  to  explain the insured  expressly telling  him  all  pros and cons, benefits warrants  exceptions  and conditions of the insurance policy.”

 Again It is held and reported in CPR-2014(3) page No.1  the Hon’ble National Commission, New  Delhi  where in observed in para-10  “It will be unfortunate, if the insurance companies try to repudiate genuine  claims on such technical and flimsy grounds. Most of the innocent insured  will be victims and the beneficiaries will be deprived of the fruits of life insurance. The complainant  was a illeterate  did not suppress any material fact with any fraudulent intention.  It is unfortunate that on one hand the LIC raises the voice of “Utmost good faith” but, in contrast, the faith will  be lost while not setting the genuine  claims for some or other reasons.   It is the exploitation of the policy holders.   The consumers are literally under  fear of dilemma that, whether,   the beneficiaries ever certainly get any  fruits from the  LIC….! 

Further  it is held and reported  in   CPR-2011(1) page No. 312 the Hon’ble  State commission, Raipaur, in para No.9 where in observed  “When insured himself, was   not  knowing that she is patient or that she is suffering  from some diseases, then  it   can not be expected from him  to mention all these things in the proposal form for obtaining a new  policy or in the proposal  form of the  insurance policy.     

Again     it is held and reported  in CPR- 2012(1)  page No. 391  the Hon’ble  National Commission, New Delhi  where in observed  “The insurance company must investigate health issues before issuing insurance  policy”.

Further  It is held  and reported  in C.P.R. 2012 (3) page No. 65 where  in the  hon’ble  Rajstan  State  Commision observed  “that a common man is not supposed to know all the  niceties and technicalities of law.  Once accepting  the premium and having entered into an agreement without  verifying the facts, the Insurance Company can not wriggle out of the  liability merely by saying that the  contract was made by  misrepresentation and concealment. The insurance policies should not be issued and  repudiated  in such a casual mechanical manner. The policy entails  the liability on both sides.  It is rather exploitation of the consumer and more or less fraud on the public. Such practice should be strongly  deprecated”.

Again It is held and reported  in C.P.R 2007(3) page No.93 where in the  hon’ble Chatisgarh  State Commission observed  that the claim repudiated on  the ground that the complainant suppressed material fact regarding ailments he was suffering would not  constitute  deficiency in service and cause of death would have no relevance to  non-disclosure of  such facts.  The proposal form  have been filled  by the Agent of the O.P .

The  complainant  submitted  that  at the time of opening of the Health policy  she was free  from any  physical disease and  was also  mentally sound.

It is held and reported  in C.P.R. 2012 (4) page No. 231 wherein the hon’ble  National Commission observed that   “pre-existing  disease must be proved in documentary evidence”.

In the present  case the O.P.  should have  produced  some  concrete evidence in support of its  case. The examination of  doctor who checked  the patient, prior to the obtaining  of the policy in question, some treatment papers, some prescriptions etc. should have been produced. There is no evidence  which may  go to show that she had ever consulted  the doctor for taking treatment to the said disease.  In the present case the O.P. has not  established  suppression of material facts on the part of the complainant hence  the plea raised by the O.P. is hereby rejected.

Further we perused the case law  in the instant case. It is held and reported in  CPC- 1991, page -540 the  Hon’ble  Hariyana State  Commission held that when ever there is any delay or dilatoriness in finalizing  the insurance claim, the same would be tantamount to a  deficiency  in service and thus comes squarely within the  purview of Consumer Forum.  Once it is held that default or negligence in the  settlement of an insurance claim is a deficiency  in service then an arbitrary  or mischievous  rejection  of an insurance claim  would patently  be a default  within its larger  meaning. On principle , it would   seem  some what manifest that the mere repudiation of the insurance claim cannot itself operate  as a  jurisdiction bar for redressel forums under the Act.  it is held and reported  in CPR-1991(2), page No.18  the Hon’ble National Commission  clearly defines  the mere unilateral  rejection of an insured parties  claimed by the insurer does not  per  se  operate as jurisdictional bar to seek redressal before  the forums under the Act. It is on the strength of the  above decision  the instant case is admitted by this forum.

The sole ground for rejection of the claim of the complainant is non disclosure of an ailment.  As discussed earlier  the claim form used to be filled up by the agent  and the complainant  are mostly not aware of the entire contents of the claim  application. The complainant  claimed that she had never  suffered from any disease . The O.P. had also not filed any document as obtained through their Investigator that he was under treatment of any disease.

  As discussed  earlier it is  general practice that the claim form is  generally  filled up by the  agent and only  the signature the of the insured is taken.  The  exact terms and  condition  of the policy  are never explain  to the insured .   Insurer are never serious about the  terms and condition of the policy at the time of taking the policy but suddenly  became very sensitive  about the terms and condition  when any claim is made.  So in our opinion in the  instant case the  ground  of repudiation of claims i.e. for disclosure of previous ailment is not a valid ground  particularly when  the same is not    related to the disease for which    she is  treated and  insurance claim  is made to the O.P.

The complainant is directed to cooperate   and furnish  all the required documents available with her  as wanted    by  the O..Ps  for early  settlement  of her claim as the O.Ps are not repudiated the claim and ready to settle the claim  in favour of the complainant.

At  this stage this forum observed   the interest of justice  would met if  the O.P. received  all the documents filed by the complainant relating to the case from   the complainant  and be settled the matter and to pay the Medi claim amount to the complainant with in 90 days.

In the present case the complainant has not sought any relief from the O.P. No.1(Axis Bank,Gunupur).  So this forum need not  going  to the merit  of  the  case against the O.P. No.1.

In view of the above discussion relating to the above case and  In Res-IPSA-Loquiture  as well as  in the light of the settled legal position  discussed  as above referring citations  which is Aliance Juris. Hence  we allow the above complaint petition  in part.

Hence  to  meet the  ends of justice, the following order is passed.                                                                                           ORDER.

            In  resultant    the complaint petition is allowed  in  part  on  contest against  the O.P  No..2  (  TATA  AIG General insurance) and dismissed against the O.P. No.1 (Axis bank, Gunupur).

The    O.P  No..2  (  TATA  AIG General insurance) is  ordered  to receive all the documents  pertaining to  this case from the complainant and settle  the matter at their level  inter alia  to reimburse the Medi claim amount  as  per bill  issued by the   Hospital authority  to the complainant with in time frame.  The complainant is directed to  submit all the documents pertaining to the above case  to the O.Ps  within 15 days. Parties are left to bear their own cost.

The OP No. 2 (Insurance  company) is  ordered to make compliance the aforesaid Order within  90 days from the  date of  receipt  of documents from the complainant      failing which  an interest  @ Rs.9%  per annum  would  accrue on the above  amount . from  the date of  default  till   realization.  Serve the copies of above order to the parties free of cost.

Dictated and corrected by me

Pronounced on this              31^st.   Day of     October ,   2019.

 

Member.                                                             Member.                                                             President