Haryana

Ambala

CC/5/2021

Dr Vikas Bhateja - Complainant(s)

Versus

The Branch Manager Paramount Health Services & Insurance - Opp.Party(s)

S.R. Bansal

17 Nov 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	05 of 2021
Date of Institution	:	01.01.2021
Date of decision	:	17.11.2022

Dr. Vikas Bhateja, aged about 56 years s/o Shri Siri Chand, R/o H.No.25, Ward No.07, Subhash Nagar, Ambala Cantt.         

……. Complainant

Versus

1. The Branch Manager, Paramount Health Services & Insurance TPA Private Limited, Plot No.A-442, Road No.28, MIDC, Industrial Area, Wagela Estate, Ram Nagar, Vithal, Rukhmani Mandir, Thane-400 604.
2. The Branch Manager, HDFC Life Insurance, Ist Floor, Sudarshan Towers Nicholson Rd, Cross Rd No.1, Ambala Cantt, Haryana-133 001...

 

….…. Opposite Parties.

 Before:       Smt. Neena Sandhu, President.

                             Smt. Ruby Sharma, Member,

          Shri. Vinod Kumar Sharma, Member.           

 

Present:      Shri S.R. Bansal, Advocate, counsel for the complainant

                   OP No.1 already ex parte.

                   Shri Puneet Sirpaul, Advocate, counsel for the OP No.2.

 

Order:        Smt. Neena Sandhu, President.

                   Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

                             (i) To pay Rs.80,318/- on account of Medical and other Expenses, which includes hospitalization of the                                           complainant;

(ii) To grant interest at the rate of 18% per annum, from the date of treatment of the complainant i.e. 03.01.2020 till the date of entire payment;

(iii) To pay Rs.3,00,000/- as compensation for the mental agony and physical harassment suffered by the complainant.

(iv) To pay Rs.22,000/- as cost of litigation.

(v) Grant any other relief this Commission may deems fit.

 

2.             Brief facts of this case are that the complainant is a Medical Policy  Holder valid from 16.12.2019 to 15.12.2020, which is issued by the OPs.  On 03.01.2020, he was coming on his motor cycle and all of a sudden some unknown vehicle hit his motor cycle from the backside, near Village Dappar, Tehsil Dera-Bassi. Resultantly, he fell on road and became unconscious. He was got admitted in GMCH Sector-32, Chandigarh. After treatment, he was discharged on 14.01.2020 and thereafter remained on bed rest till March, 2020. During the period intervening, lockdown was executed due to pandemic Corona. The complainant thereafter submitted all the documents with OP No.2 for settlement of his claim towards the money spent by him for his treatment. On 09.03.2020, the complainant received deficiency letter from the OPs stating therein that he has not submitted various documents, but, on the other hand, the same had been submitted by the complainant. However, thereafter, the OPs sent email dated 16.04.2020, wherein, it was informed that the claim filed by him is rejected because he was driving the vehicle in question in a rash manner. Under above circumstances, the complainant got served legal Notice dated 17.08.2020 upon the OPs asking them to make the payment of Rs.80,318/- alongwith interest @ 18% per annum but to no avail. Hence, the present complaint.
3.           Upon notice, none appeared on behalf of the OP No.1, before this Commission, therefore, it was proceeded against ex-parte vide order dated 12.04.2021.
4.           Upon notice, the OP No.2 appeared and filed written version and raised preliminary objections with regard to maintainability, cause of action, not come with clean hands and suppressed the material facts etc.  On merits, it has been stated that the complainant submitted an electronic/online proposal/application form dated 15.12.2015 for the purchase of HDFC Life Health Assure Plan for sum assured of Rs.5,00,000/- with annual premium of Rs.20,000/-. Consequently, insurance policy bearing Policy No.90213204 was issued on 16.12.2015. Before acceptance of the proposal, the contents of the proposal/application, illustrations and the addendum forms were read and explained to the complainant. After receiving the claim form, OP No.2 did some investigation to ascertain whether the complainant's claim is genuine or not. However, it came into the light that an FIR was registered against the complainant in Thana Lalru, District S.A.S Nagar, by Sh. Gurmeet Singh Under section 279, 337 and 304-A of Indian Penal Code. Sh. Gurmeet Singh has stated in the FIR that on 03.01.2020, Annexure OP-6, he was coming back from Ambala with his wife (Kuldeep Kaur) when around 5:30 P.M. they were crossing the road near Dappar Bus stand, one person came from the side of Chandigarh road driving in a rash and negligent manner & hit his wife. Resultantly his wife fell down on a divider and received injuries on her head and body. Motorcyclist also fell down and received injuries. Sh.Gurmeet Singh had noted the vehicle number of the motorcyclist as HR-01AM-4395 T.V.S which was black in color. The motorcyclist was identified as the complainant. Thus, OP No.2 rejected the claim of the complainant vide letter dated April 14, 2020 on the ground that as per clause-Breach of Law any illness or injury directly or indirectly resulting or arising from or occurring during commission of any breach of any law by the Life Insured with any criminal Intent is not payable. Rest of the averments of the complainant were denied by OP No.2 and prayed for dismissal of the present complaint with heavy costs.
5.           Learned counsel for the complainant tendered affidavit of the complainant as Annexure CA alongwith documents as Annexure C-1 to C-12 and closed the evidence on behalf of the complainant. On the other hand, Learned counsel for OP No.2  tendered affidavit of Sh. Arpit Higgins, Senior Manager Legal, HDFC Life Insurance Co. Ltd., first & Second Floor, SCO No.149-151, Sector 43-B, Chandigarh as Annexure OP-W1/A alongwith Annexure OP2/1 to OP-2/7 and closed evidence on behalf of OP No.2.
6.            We have heard the learned counsel for the complainant and learned counsel for the OP No.2 and carefully gone through the case file.
7.           Learned counsel for the complainant submitted that since the complainant was insured under the insurance policy in question, as such, the OPs were legally bound to pay the claim amount, arising out of it, yet, by rejecting his claim, the OPs indulged into unfair trade practice and are deficient in providing service.
8.           On the other hand, learned counsel for OP No.2 submitted that since the complainant concealed the material fact that he was driving the vehicle in question, in a very rash manner, as is evident from the contents of the FIR dated 03.01.2020, Annexure OP-6 lodged by Shri Gurmeet Singh, as such, the claim of the complainant was rightly rejected by the OPs. 
9.           Since, the facts with regard to issuance of the policy in question in favour of the complainant; occurrence of accident during subsistence of the said policy; and the treatment taken by the complainant in GMCH, Sector 32, Chandigarh, from where he was discharged on 14.01.2020 are not in dispute between the parties, therefore, the only question which needs to be decided by this Commission is, as to whether, the claim of the complainant was rightly rejected or not? It may be stated here that it is coming out from the record that the claim of the complainant was rejected, vide letter dated 14.04.2020, Annexure C-5 on the ground that the discharge summary submitted by the complainant retrieved that the complainant was driving the vehicle in question, rashly, which resulted into accident, which was a breach/violation of terms and conditions of the policy in question. However, it is significant to mention here that we have gone through the contents of discharge summary, Annexure OP-4 very minutely and did not find any such finding of the doctor concerned to the effect that the injury caused to the complainant was due to rash driving of vehicle by him.

The learned counsel for the OP No.2 contended that in the FIR dated 03.01.2020, Annexure OP-6 lodged by Sh. Gurmeet Singh, who met with the accident with the complainant, it has been clearly mentioned that the complainant was driving the vehicle very fast and rash, which resulted into accident, as such, there was breach of terms and conditions of the insurance policy in question. It may be stated here that it is well settled law that the contents of FIR are never to be treated as a substantive piece of evidence and its value must always depend on the facts and circumstances of a given case. Our this view is supported by the principle of law laid down by the Hon’ble Supreme Court in Dharma Rama Bhagare vs The State Of Maharashtra, Equivalent citations: 1973 AIR 476.

                   Except the contents of FIR referred to above, no other cogent and convincing evidence has been placed on record by OP No.2 to prove that the complainant breached any terms and conditions of the insurance policy, by driving the vehicle in question, at a high speed and rashly, which resulted into the said accident. In the absence of cogent and convincing evidence, plea taken by the OP No.2 in that regard cannot be considered. Thus, in our view the insurance company by rejecting the claim of the complainant has committed deficiency in service and is thus liable to reimburse the amount which the complainant incurred on his treatment.

10.                The complainant has placed on record the list of bills/invoices having been issued by the GMHS, Sector 32B, Chandigarh, alongwith details of medicines etc., Annexure C-9 which is signed by the Senior Resident of the said Hospital showing the total amount of Rs.72,587/-. Complainant has also placed on record the list of bills/invoices of Rs.7,996/- but the said list has not been signed either by the senior resident or some competent authority of the said hospital. Thus, the complainant is entitled to get the amount of Rs.72,587/-, spent by him, on his treatment, alongwith interest. Complainant is also entitled to get compensation for the mental agony and physical harassment suffered by him alongwith litigation expenses.
11.      Since, the OP No.1 being TPA is working for an on behalf of insurance company and has no privity of contract with the complainant, therefore, no liability can be fastened against it and the complaint filed by the complainant against it is liable to be dismissed.   

12.     In view of the aforesaid discussion, we hereby dismiss the present complaint against OP No.1 and partly allow the same against OP No.2 and direct it, in the following manner:-

1. To pay Rs.72,587/-, to the complainant alongwith interest @ 4% per annum, w.e.f 14.04.2020, i.e the date of repudiation of the claim, till its realization.    
2. To pay Rs.5,000/- as compensation for mental agony and physical harassment suffered by the complainant.
3. To pay Rs.3,000/- as litigation expenses.

                   The OP No.2 is further directed to comply with the aforesaid directions within the period of 45 days from the date of receipt of the certified copy of this order, failing which the OPs shall pay interest @ 6% per annum on the awarded amount besides litigation expenses, for the period of default, till realization. Certified copies of the order be sent to the parties concerned as per rules.  File be annexed and consigned to the record room.

 Announced:- 17.11.2022.

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President