Punjab

Sangrur

CC/15/2019

Vikas Aggarwal - Complainant(s)

Versus

The New India Assurance Company Limited - Opp.Party(s)

Sh. Yogesh Gupta

11 Jan 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

 

                                                                         Complaint No. 15

 Instituted on:   09.01.2019

                                                                         Decided on:     11.01.2021

Vikas Aggarwal aged 49 years son of Sh. K.C.Aggarwal, H.No.16-D, Mubarak Mehal Colony, Sangrur.

                                                          …. Complainant.     

                                                 Versus

1.     The New India Assurance Company Limited through its MD, New India Assurance Building, 87,MG Road, Fort, Mumbai.

2.             Branch Manager, The New India Assurance Company Limited, College Road, Sangrur.

             ….Opposite parties. 

For the complainant:             :Shri  Yogesh Gupta, Adv.              

For the OPs                         :Shri Ashish Garg, Adv.

 

Quorum:    Shri Jasjit Singh Bhinder, President

                  Shri V.K.Gulati, Member   

ORDER:   

Shri Jasjit Singh Bhinder, President

1.             The complainant has filed this complaint pleading that the complainant had taken New India Floater Mediclaim policy bearing number 3613023416280000007 from the OPs for a sum of Rs.5,00,000/- which was valid for the period from 25.12.2016 to 24.12.2017, but no terms and conditions of the policy were supplied to the complainant. It is further averred that the complainant is taking the insurance policy for the last 9/10 years.  The case of the complainant is that he fell ill suddenly and remained admitted in Patiala Heart Institute, Patiala from 24.2.2018 to 26.2.2018 and stunt was inserted and the complainant submitted the mediclaim policy, copy of discharge summary and detail of amount spent on his treatment to the OPs.  The complainant submitted two claim forms to the OPs i.e. one pertaining to the treatment taken from Patiala Heart Institute of Rs.1,69,698/- and second of Bansal Hospital and  Heart Institute Sangrur of Rs.26,973/-.  Further it is averred in the complaint that the OPs paid the claim amount of Rs.1,00,000/- only and balance amount was rejected vide letter dated 14.7.2017 and mentioned that enhanced amount is not payable as the complainant was suffering from pre-existing disease.  It is further averred that the complainant is legally entitled to receive the balance amount of Rs.96,871/- from the OPs, which the OPs have wrongly rejected.  Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the Opposite parties be directed to pay to the complainant the remaining amount of Rs.96,871/- along with interest @ 12% per annum from 1.4.2017 till realization and further to pay Rs.25,000/- as compensation on account of mental agony, tension and harassment and an amount of Rs.22,000/- on account of litigation expenses.

2.             In reply filed by the OPs, it is stated that at the request of the complainant OP number 2 issued a medi claim policy for Rs.5,00,000/- for the period from 25.12.2016 to 24.12.2017. It is stated further that the policy as well as terms and conditions of the policy were immediately supplied to the insured. It is further stated that the complainant availed the mediclaim policy first time on 25.12.2009 up to 24.12.2010 and the sum insured was Rs.1,00,000/- only.  The complainant enhanced the sum from Rs.1,00,000/- to Rs.5,00000/- w.e.f. 25.12.2015 to 24.12.2016 and renewed the same from 25.12.2016 to 24.12.2017. It is absolutely wrong that the complainant took the enhanced policy third time upto December, 2016.  It is denied that the complainant fell ill suddenly. On the other hand, it is stated that the complainant was suffering from HAD, HTN DM and history of  HTN since ten years, therefore, the enhanced sum is not payable for pre existing disease as per condition number 4.1. It is stated further that after receiving the entire papers the TPA of OPs sanctioned the amount of Rs.1,00,000/- as per the terms and conditions of the policy and the same was paid to the complainant.  It is denied that the complainant spent Rs.1,69,898/- at Patiala Heart Institute and Rs.26973/- at Bansal Hospital and Heart Centre.  The other allegations leveled in the complaint have been denied in toto.

3.             The learned counsel for the parties produced their respective evidence.

4.             The learned counsel for the complainant has argued that the complainant obtained the insurance policy from the OPs for Rs.5,00,000/- and the complainant fell ill during the subsistence of the insurance policy and submitted the claim for Rs.1,96,871/- but the OPs paid only an amount of Rs.1,00,000/- and rejected the remaining claim.  Further the learned counsel for the complainant has argued that the complainant was first treated at Bansal Hospital and Heart Institute Sangrur and thereafter he was referred to Patiala Heart Institute Patiala.  The learned counsel for the complainant has further argued that an amount of Rs.1,69,898/- was spent at Patiala Heart Institute and an amount of Rs.26973/- was spent at Bansal Hospital and Heart Institute Sangrur.  Learned counsel for the complainant further argued that first the complainant had taken the insurance policy for Rs.1,00,000/- and thereafter he extended the policy for the year 2017 for Rs.5,00,000/-.  Learned counsel for the complainant has further argued that the complainant fell ill and stunt was inserted.  The learned counsel for the complainant has further argued that all the bills are on file.  The learned counsel for the complainant has relied upon Bharat Watch Company versus National Insurance Company Limited, Civil Appeal No.3912 of 2019 decided on 12.4.2019, Rajesh Singla versus Max Bupa Health Insurance Co. Ltd. and another 2018(3) CPJ 172, Oriental Insurance Company Ltd. versus K. Anandam 2005(1) CPJ 571, SBI Life Insurance Co. Ltd. versus Kambala Sandhya, Abedin S Baldiwala versus United India Insurance Co. Ltd. 2016(3) CLT 584, Oriental Insurance Company Limited versus Rajinder Singh 2008(1) CPJ 258, Religare Health Insurance Company Limited versus Subhash Chander Aggarwal 2017(3) CLT 140 and Surinder Kaur and others versus LIC Of India 2005(2) CPJ 32 to support his case.

5.             On the other hand, the learned counsel for the OPs has argued that as per terms and conditions of the extended policy, the complainant was not entitled to more amount and the OP has already paid an amount of Rs.1,00,000/-.  The learned counsel for the OPs has further argued that the disease was pre-existing disease and the policy does not cover the pre existing disease.

6.             The learned counsel for the OPs has further argued that Bansal Hospital and Heart Institute, Sangrur has written that he was suffering from hypertension.  The learned counsel further argued that the complainant was paid Rs.1,00,000/- and the remaining claim has rightly been repudiated and the complaint be dismissed.

7.             As per the pleadings the complainant has taken the policy from the OPs for Rs.1,00,000/- and the policy continued for 9 years and in the month of December, 2016 the complainant enhanced the policy to Rs.5,00,000/-. The complainant suddenly fell ill and was taken to Bansal Hospital and Heart Institute Sangrur from where he was referred to Patiala Heart Institute, Patiala where stunt was inserted.  Ex.C-1 is the extended insurance policy which is for Rs.5,00,000/-. Ex.C-2 is the claim form vide which the claim of Rs.1,69898/- of Patiala Heart Institute was mentioned. Ex.C-3 is the discharge summary of Patiala Heart Institute Patiala.  Ex.C-4 to Ex.C-9 are the copies of the bills. Ex.C-11 is the PTCA bill break up of Patiala Heart Institute Patiala. Ex.C-12 to Ex.C-14 are the laboratory reports. Ex.C-15 is the hand written document of Patiala Heart Institute Patiala. Ex.C-16 is ECG report and Ex.C-17 is the report of coronary.  Ex.C-23 is the claim form showing claim of Bansal Hospital and Heart Institute Sangrur for Rs.26,973/-. Ex.C-24 is the summary of Bansal Hospital and Heart Institute Sangrur wherein it is mentioned that the patient was admitted on 19.2.2017 who was having chest pain and was also having fever and further he was referred to higher institute. Ex.C-26 to Ex.C-29 are the copies of the bills of medicines.

8.             Ex.C-33 is important document of New India Assurance Company Limited, wherein it was mentioned that the complainant was suffering from CAD, HTN, DM and history of HTN since 10 years and the complainant was entitled for Rs.1,00,000/-. It is stated further that a sum of Rs.1,00,000/- has been paid and the remaining claim has been declined. Ex.C-35 is the affidavit of the complainant stating all the facts of the complaint.

9.             On behalf of OPs, Shri Vipin Chowdhary, Divisional Manager has tendered affidavit Ex.OPs/4. Ex.OP-1 is the insurance policy and Ex.OP-2 is extended insurance policy on the basis on which the claim was rejected. The document Ex.OPs/2 is of 5 to 37 pages and at page 22 it is mentioned clause 4.1 which is as under :-

“4.1 Treatment of pre existing condition/disease, until 48 months of continuous coverage of such insured person have elapsed, from the date of inception of his/her first policy as mentioned in the schedule. “

So, it is clear that as per the OPs the complainant was suffering from heart disease for the last more than four years and due to this claim was rejected.  This argument of the OPs is without any force as the heart disease crops up at once and it is not possible to find the heart disease and the blockage of heart was prior to four years.  So this argument is not helpful to the OPs.  It is not proved that this disease i.e. heart veins were blocked prior to four years and there was pre-existing disease.  Further no evidence was brought that the conditions of the policy were brought to the notice of the complainant. Reliance can be taken on the citation of Hon’ble Supreme Court of India in  Bharat Watch Company versus National Insurance co. Ltd. (supra) wherein it has been held that the claim is payable if the exclusionary condition in policy is not communicated to the claimant.  In the present case, no such terms and conditions of the policy are shown to have been communicated to the complainant.

10.            In view of our above discussion, we allow the complaint and direct the  Opposite parties  to pay to the complainant the remaining amount of Rs.96,871/-  along with interest @ 6% per annum from 14.7.2017 i.e. the date of rejection of the claim till realization in full.  We further direct the OPs to pay to the complainant an amount of Rs.10,000/- on account of compensation for mental tension, agony and harassment and further an amount of Rs.10,000/- on account of  litigation expenses.  This order be complied with by the opposite parties within 60 days from the date of receipt of certified copy of this order. A certified copy of this order be issued to the parties free of cost as per rules. File be consigned to records.

Pronounced.

                        January 11, 2021.

 

(Vinod Kumar Gulati)  (Jasjit Singh Bhinder) 

           Member                  President