Punjab

Moga

CC/16/45

Darshan Singh - Complainant(s)

Versus

The INDUSIND Bank Limited - Opp.Party(s)

Sh. P.K.Sharma

05 Jul 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.

 

                                                                                                             C.C. No. 45 of 2016

                                                                                                Instituted on: 01.02.2016

             Decided on: 05.07.2016

 

Darshan Singh aged 68 years S/o Arjun Singh S/o Lal Singh, R/o V.P.O Daulatpura Niwan, Tehsil and District Moga.

                                                                             ……….   Complainant 

Versus

1.       The Indusind Bank Limited, S.C.O. 22, First Floor, Improvement Trust Building, Above Dena Bank, G.T. Road, Moga, through its Manager.

 

2.       The Indusind Bank Limited (Consumer Finance Division) S.C.O 22, First Floor, Phase 3-B-2, Sector 60, Mohali, Punjab, through Joginder Chand, Insurance Coordinator (CFD).

 

3.       Chola M.S. General Insurance Company Ltd. S.C.O 2463/64, Sector 22-C, Chandigarh, through its Divisional Manager.

                                                                           ………. Opposite Parties

 

 

Complaint under Section 12 of the Consumer Protection Act, 1986.

 

 

 

Quorum:   Sh. Ajit Aggarwal, President

                   Smt. Vinod Bala, Member

                   Smt. Bhupinder Kaur, Member

Present:       Sh. Pawan Kumar Sharma, Advocate Cl. for the complainant.

                   Opposite party nos. 1 & 2 exparte.

                   Sh. Vishal Jain, Advocate Cl. for opposite party no. 3.

 

ORDER :

(Per Ajit Aggarwal, President)

 

1.                Complainant has filed the instant complaint under Section 12 of the Consumer Protection Act, 1986  (hereinafter referred to as the 'Act') against The Indusind Bank Limited, S.C.O. 22, First Floor, Improvement Trust Building, Above Dena Bank, G.T. Road, Moga, through its Manager and others (hereinafter referred to as the opposite parties) for directing them to make payment of Rs.65,000/- under Health Care VFD Policy no.2842/00105305/0068/000/00 on account of medical treatment undergone by the insured Darshan Singh. Further opposite parties may be directed to pay Rs. 25,000/- on account of mental harassment, deficient services and Rs. 10,000/- on account of litigation expenses  to the  complainant or any other relief which this Forum deem fit and proper also be granted.

2.                Briefly stated the facts of the case are that complainant financed his vehicle Mahindra Max from opposite party nos. 1 & 2 and opposite party no.1 issued a CASA/Loan Account no. PLM00017G and customer code no/reference no. CU4329323 to the complainant. Opposite party no.2 is a Consumer Finance Division of opposite party no.1 and Joginder Chand is the Insurance Coordinator in the office of opposite party no.2. The complainant visited the Brance office of opposite party no.1 in the month of May/June 2014 and opposite partyno.1 introduced the policy plan name "Health Care VFD" and assured the complainant that in case during the policy period, if the complainant suffered any health problem then the entire expenses of medical treatment will be borne by the bank and insurance company i.e. opposite party nos. 1 to 3. On the assurance given by opposite party nos. 1 & 2, the complainant has purchased the policy "Health Care VFD" and paid premium amount of Rs. 3870/- and also signed the documents as directed by opposite party nos. 1 to 3 and in this regard opposite parties had issued Health Master Policy bearing certificate no.2842/00105305/0068/000/00 reference no.CU4329323. The total sum insured under the policy was Rs. 1,00,000/- and the policy was valid for the period from 13.06.2014 to 12.06.2015 in which the name of the complainant was mentioned as primary insured. During the said policy period, the said complainant suddenly suffered some health problem due to insect bite due to which his foot got injured and for about one month, he undergone home/desi treatment, but afterwards, he got admitted in Moga Medicity Multispecialty Hospital, Moga from 10.03.2015 to 17.03.2015 and spent an amount of Rs. 65,000/- on the hospitalization. In the treatment the doctors amputated three fingers and toe of left foot of the complainant. After discharge from the hospital, the complainant filed the claim with opposite parties and submitted all the required documents and bills to the opposite party nos. 1 to 3, but no needful action was taken by the opposite parties, despite repeated requests and reminders. Thereafter, the opposite party closed/denied the claim of the complainant vide letter dated 26^th August, 2015 on the pretext that the complainant has not submitted the previous past consultation papers and investigation reports related to diabetes, however, the complainant clarified to the opposite parties that he has not taken any kind of treatment regarding diabetes earlier and he came to know that he had diabetes only in March, 2015, when he got hospitalized in Moga Medicity Multispecialty Hospital for the treatment of insect bite. Complainant also got issued a registered notice dated 23.12.2015 upon the opposite parties for the payment of claim, but all in vain and even no reply to the notice was given by the opposite parties. The genuine claim of the complainant was denied by the opposite parties on false grounds. The complainant has been harassed by the opposite parties unnecessarily, due to which complainant has suffered mental tension, agony, physical harassment and economic loss. Hence this complaint.

3.                Upon notice, opposite parties nos. 1 to 3 appeared through their counsel and filed their separate written replies.

                   Opposite party nos. 1 & 2 filed written reply taking certain preliminary objections that the complaint is not maintainable; that the complainant has got no locus-standi; that no deficiency in service has been attributed to the opposite parties; that the complaint is absolutely false and frivolous; that the complainant has wilfully concealed the material and patent facts from this Forum. On merits, it is admitted correct to the extent that the complainant visited the office of opposite party no.1, then he saw the health care policy broucher of opposite party no.3 and he wanted his health care policy. Opposite party no.1 told him that the opposite party no.1 is working as an agent and he got all information regarding health care policy from opposite party no.1 and opposite party no.1 told him that opposite party no.3 is liable to give the claim, if any, according to his health care policy. Further submitted that the complainant has come to the office of answering opposite parties, after due enquiry and he told that he is ready to purchase the health care policy of opposite party no.3 and he has understood the terms and conditions of the policy. Thereafter, the relevant papers were got signed from the complainant and the same were sent to opposite party no.3. Further the all other allegations made in the complaint have been denied.

4.                Opposite party no.3 filed written reply, taking preliminary objections that the intricate questions of law and facts are involved in the present complaint which requires voluminous documents and evidence to determine, which is not possible in the summary procedure under Consumer Protection Act and appropriate remedy, if any lies only in the Civil Court; that the complainant has concealed material facts and documents from this Forum as well as the opposite parties, therefore, the complainant is not entitled to any relief. The complainant has concealed the fact that complainant was called upon to submit all past consultation papers and investigation reports related to diabetes and the complainant was sent letter dated 08.07.2015, 24.07.2015 and 10.08.2015, but the complainant did not furnish the said information/documents. Therefore, the answering opposite party was unable to decide the admissibility of claim and claim was closed vide letter dated 26.08.2015. As per policy terms and conditions, it was mandatory for the complainant to supply all the documents and even otherwise utmost good faith is the basis of contract of insurance; that the complainant is not the consumer of answering opposite party; that the complainant has no locus-standi or cause of action to file the present complaint against opposite parties; that the complaint is not maintainable in the present form and is liable to be dismissed; that this Forum has no territorial jurisdiction to try and decide the present complaint. There is no branch office of opposite parties nor any cause of action has arisen within the jurisdiction of this Forum. On merits, it is admitted correct to the extent that a claim was filed. However, it is wrong to state that the complainant submitted all the required documents or bills to answering opposite party rather the complainant did not submit all previous, past consultation papers and investigation reports relating to diabetes even after receipt of letters dated 08.07.2015, 24.07.2015 and 10.08.2015. It is wrong to state that the complainant did not take any kind of treatment regarding diabetes earlier. It is also wrong to state that the complainant came to know about diabetes only in March, 2015. Further all other allegations made in the complaint have been denied.

5.                It is pertinent to mention here that despite availing number of opportunities neither evidence of opposite party nos. 1 & 2 was produced nor anybody had come present on their behalf. As such, opposite party nos. 1 & 2 were proceeded against exparte vide order dated 15.06.2016.

6.                In order to prove the case, complainant Darshan Singh tendered in evidence his duly sworn affidavit Ex. C-1 and copies of documents Ex. C-2 to Ex. C-93  and closed the evidence. 

7.                In rebuttal, the opposite party no.3 tendered in evidence duly sworn affidavit of Sh. Ashutosh Kumar, Assistant Manager Legal, Cholamandalam MS General Insurance Company Ex. OP's 3/1 and copies of documents Ex. OP's 3/2 and Ex. OP's 3/3 and closed the evidence.

8.                We have heard the learned counsel for the parties and have carefully gone through the record placed on file.

9.                Ld. Counsel for the complainant argued that complainant was customer of OP-1 & 2 and in the month of May/June 2014 the OP-1 introduced the policy plan namely 'Health Care VFD' of OP-3 and assured the complainant that in case during the policy period if complainant suffered any health problem then the entire expenses of medical treatment will be borne by the OPs, on assurance of OPs he purchased the policy by paying Rs.3870/- as premium and signed the documents as directed by the OPs. A Health Care policy issued in the name of complainant for the sum of Rs.1,00,000/- for the period from 13.06.2014 to 12.06.2015. During the policy period the complainant suffered some health problem due to insect bite due to which his foot got injured and he got admitted in Moga Medicity Multispecialty Hospital, Moga from 10.03.2014 to 17.03.2015. During the treatment the doctors amputated three fingers and toe of left foot of the complainant. The complainant spent an amount of Rs.65000/-. He filed the claim with the Ops and submitted all required documents along with medical record and bills to Ops but till today they did not pay the claim to complainant despite repeated request and reminders. Complainant received a letter dated 26.08.2015 from the Ops vide which they close the claim of the complainant on the pretext that he has not submitted the previous past consultation papers and investigation reports related to diabetes. However, the complainant clarified to OPs that he has not taken any kind of treatment regarding diabetes earlier and he came to know that he had diabetes only in March 2015 when he got hospitalized in Moga Medicity Multispecialty Hospital for the treatment of insect bite. The complainant also issued a legal notice to OPs requesting them to make payment of his medical claim, but Ops even did not give any reply to the notice. The Ops denying the genuine claim of the complainant on false grounds. Due to these acts of the Ops complainant suffered mental tension, agony, physical harassment and financial loss. All these acts of the OPs amounts to deficiency in service and trade mal practice on the part of the Ops. The OPs may be directed to pay the insurance claim  along with compensation and litigation expenses.

10.              On notice, OP-1 & 2 appeared in this forum and filed their written reply but later on neither OP-1 & 2 in person or nor their counsel appeared in this forum and they were proceeded against ex-parte. However, for convenience the written reply filed by them is considered as part of the arguments on their part. The OP-1 & 2 submitted that the present complaint is not maintainable and there is no deficiency in service on their part, the complainant filed his false and frivolous complaint and concealed true and material facts from this Forum. However, they admitted that complainant visited their office where he saw the health care policy brochure of OP-3 and he wanted to purchase health care policy. OP-1 told him that they are working as an agent, Complainant take all information regarding the health care insurance from OP-1 and OP-1 told to him that OP-3 is liable to give the claim if any according to this health care policy. It is wrong that the complainant purchased the policy on assurance of Op-1 & 2, rather he purchased the policy after due enquiry and after understood the terms and conditions of the policy and thereafter he signed the policy documents. The complainant has not given any information regarding his health problem or treatment to OP-1 & 2. He has not submitted any document regarding insurance claim to OP-1 & 2. There is no deficiency in service on the part of OP-1 & 2 and complainant may be dismissed with costs.

11.              The Counsel for OP-3 argued that complainant is not their consumer. He has concealed true and material facts from this Forum. He is not entitled to any relief, however they admitted that the complainant was insured with them under Health care policy. They further admitted that the complainant submitted his claim with them, he argued that the insurance policy issued to complainant under the terms and conditions of the policy and benefit of the policy are subject to the terms and conditions of the policy and no benefit beyond the terms and conditions is allowed, as per the terms and conditions of the policy, the complainant have to disclose all his pre exiting disease at the time of purchase of the policy, but the complainant did not disclose his prior disease to the OPs, as per terms and conditions of the policy pre existing disease, if any is not covered under first 2 years of policy period, the disease of diabetes comes under this pre existing disease. As per medical record and discharge summary submitted by the complainant along with his claim, he was admitted in the hospital and with diagnose of diabetic foot and take treatment of diabetes during the hospitalization. The complainant concealed the facts of his prior disease from the OPs. The complainant has called upon to submit all past consultation papers and investigation reports relating to the disease vide letters dated 08.07.2015, 24.07.2015 and 10.08.2015 but the complainant did not furnish the said information to the OPs, therefore OP-3 was unable to decide admissibility of claim and the claim was closed vide letter dated 26.08.2015. The copy of the same is Ex.OPs-3/3. As per terms and conditions of the policy, it was mandatory to supply all the documents, even otherwise utmost good faith of contract of insurance. It is wrong that the complainant did not take any treatment prior to insurance policy and he came to know about that disease in March 2015. As per the discharge card Ex.C-8, the doctors diagnosed the diabetic foot which arose at very advance stage of diabetes and not on the initial stage, so it cannot presumed that the complainant came to know regarding disease when he admitted in hospital, the complainant create a false story regarding the insect bite only to cheat the OPs and to get the illegal insurance claim from the Ops. It is wrong that he paid Rs.65000/- on his treatment, he has not face any mental agony and financial loss due to non payment of insurance claim, rather he file false claim, the present complaint may be dismissed with cost.

12.              We have heard the arguments of both the parties and also gone through the pleadings and evidence led by both the parties. The case of the complainant is that he purchased Health Care insurance Policy from OP-3 through OP-1 & 2, during the insurance period he suffered from some health problem and he admitted in hospital where doctor amputed three fingers and one toe of left foot and he spent an amount of Rs.65000/-on hospitalization. He filed his claim with OPs for reimbursement of his medical claim but the OPs did not pay his rightful claim and repudiate his claim on false ground. In reply OP submitted that the complainant concealed the true and material facts that as per the terms and conditions of the policy he had to disclose his all prior disease at the time of purchase of policy but he did not disclose. The complainant was suffering from diabetes and due to the problem of diabetes he had to admit in the hospital but the complainant did not disclose regarding his disease of diabetes to Ops. The Op-3 called upon the complainant to give detail of his past treatment and medical record regarding the diabetes but he fail to supply his medical record regarding past consultation, so his claim rightly closed, as per terms and conditions of the policy. The Counsel for the complainant argued that prior to the purchase of the policy he is not suffering from diabetes and he is not concealing any fact from the Ops, it is only in March 2015 when admitted in the hospital due to insect bite, he got knowledge regarding the disease of diabetes and prior to this there is no knowledge about this disease and Ops illegally close his claim as no claim.

13.              We have gone through the file and documents. Ex C-8 discharge card issued by Moga Medicity Multispecialty Hospital from where the complainant took his treatment. It is clearly mentioned as diagnose of diabetic foot and gave him treatment for the diabetes. There is no where mention regarding the injury due to insect bit as alleged by the complainant. Further it is clear that the problem of diabetic foot is arose at advance stage of diabetes not at initial stage, the problem of diabetic foot arose even after years of history of diabetes, moreover the complainant has not placed any evidence regarding his version that injury due to insect bite and from the medical record it is clear that his problem was due to diabetes which he did not disclose to Ops at the time of purchase of the policy and concealed this fact from them.

14.                   From the above discussion, we are of the considered opinion that complainant concealed his prior disease from the opposite parties at the time of purchase of policy and concealed the true facts from them which is violation of the terms and conditions of the policy. The story narrated by the complainant of insect bite is false and concocted one. We found no merit in the complaint and the present complaint is hereby dismissed. The parties are left to bear their own costs. Copy of the order be supplied to parties free of cost. File be consigned to the record room. 

Announced in Open Forum

Dated: 05.07.2016

 

 

                        (Bupinder Kaur)           (Vinod Bala)                  (Ajit Aggarwal)

                              Member                   Member                         President