Haryana

Karnal

CC/297/2018

Shakuntla - Complainant(s)

Versus

The Oriental Insurance Company Limited - Opp.Party(s)

Ranbir Singh

06 Aug 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No.297 of 2018

                                                         Date of instt. 02.11.2018

                                                         Date of decision:06.08.2019

 

Shakuntla wife of Shri Ranbir Singh, resident of Farm House, Baldi By pass, village Baldi, Tehsil & District Karnal.                                            

…….Complainant

                                        Versus

 

1. The Oriental Insurance Company Ltd., Upper floor of Oriental Bank of Commerce, Meera Ghati Chowk, Karnal-132001, through its Branch Manager.

2. Head Office, the Oriental Insurance Company Ltd. LIC Building, 2^nd floor, Jagadhari Road, TP HUB, Ambala Cantt.

                                                                      …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act.    

       

Before   Sh. Jaswant Singh……President.       

              Sh. Vineet Kaushik………Member

              Dr. Rekha Chaudhary……Member

 

 Present:  Shri Ranbir Singh Advocate for complainant.

                 Shri Randhir Singh Advocate for opposite party.

 

                (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant has obtained the health policy from the OP w.e.f.22.06.2013 to 21.04.2014 amounting to Rs.3,00,000/- bearing policy no.261301/48/2014/673 and it was further renewed on 22.06.2014 to 21.06.2015, vide policy no.261301/48/2015/834, further renewed on 22.06.2015 to 21.06.2016, vide policy no.261301/48/2016/871 amounting to Rs.3,00,000/- and further it was renewed on 30.06.2016 to 29.06.2017, vide policy no.261301/48/2017/1123 amounting to Rs.5,00,000/- and, therefore, it was again renewed on 30.06.2017 to 29.06.2018 amounting to Rs.6,00,000/-, vide policy no.261301/48/2018/1071 and now it has been again renewed on 30.06.2018 to 29.06.2019, vide policy no.261301/48/2019/751 amounting to Rs.5,00,000/-and as such, the complainant has obtained the health policy in the year 2013 and continuously renewed the same without any break/delay.  On 30.06.2018 the complainant suddenly fell ill and the complainant was taken to hospital of Dr. G.D. Sharma, Karnal on 30.05.2018 and found disease CVA, HYS & Metabol.C and discharged on 30.05.2018 and referred to Apollo Hospital, New Delhi where she remained admitted as indoor patient from 30.05.2018 to 12.06.2018 and major operation was conducted and she has given under went for major surgery in Apollo Hospital, New Delhi and remained admitted upto 12.06.2018 and spent a sum of Rs.8,27,406.27 paise and a sum of Rs.10,000/- was spent at Karnal at Dr. G.D.Sharma Hospital, Karnal, vide receipt no.40 dated 18.08.2018. The complainant submitted the claim file with the OP under the abovesaid health policy for the period of 30.06.2017 to 29.06.2018 but the OPs pad a sum of Rs.3,00,000/- only whereas the insurance policy was a sum of Rs.5,00,000/-. Complainant requested the OPs so many times for reimbursement of the balance amount but OPs did not pay any heed to the request of the complainant. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written version raising preliminary objections with regard to maintainability and concealment of true and material facts. On merits, it is pleaded that the OPs have paid a sum of Rs.3,00,000/- as per the terms and conditions of the policy. The complainant has purchased the health policy, firstly on 22.06.2013 for a sum of Rs.3,00,000/- and it was renewed successively for 3 years for Rs.3 lakhs. The complainant enhanced the sum insured from Rs.3 lakhs to 5 lakhs in policy commencing from 30.06.2016 to 29.06.2017 and it was again renewed on 30.06.2017 to 29.06.2018 for the same amount of Rs.5 lakhs and thereafter it was again renewed from 30.06.2018 to 29.06.2019 for Rs.6 lakhs. The complainant was patient of diabetic she fell ill on 30.05.2018 due to diabetes, she suffered surgery of Cerebral Angiography and Colling of Aneurysm. As per the exclusion clause of policy mentioned in clause 4 to 4.2, the expenses of treatment of diabetes are not payable within two years of the inception of the policy and if the sum insured is enhanced subsequent to the inception of the policy, the exclusion 4.1 and 4.2 will apply afresh for the enhanced portion of the sum insured for the purpose of this section. As per the exclusion clause the complainant was entitled to the enhanced sum insured i.e. Rs.5 only lakhs after the expiry of two years of taking the insurance of enhanced amount. The complainant was entitled to the amount of Rs.3 lakhs only which paid by the OPs immediately. Hence there is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence her affidavit Ex.CW1/A and documents Ex.C1 to Ex.C20 and closed the evidence on 03.04.2019.

4.             On the other hand, OPs tendered into evidence affidavit of Dinesh Kumar Jain Ex.R1 and documents Ex.R2 to Ex.R9 and closed the evidence on 01.08.2019.

5.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

6.             It is admitted case that the complainant has obtained the Health Policy from the OP no.1 commencing from 22.06.2013 to 21.06.2014 for Rs.3 lakhs and it was renewed from 22.06.2014 to 21.06.2015 for Rs.3 lakhs and further renewed from 21.06.2015 to 21.06.2016 for Rs.3 lakhs. It is also admitted that said policy further renewed on 30.06.2016 to 29.06.2017 for amounting to Rs.5 lakhs and further renewed from 30.06.2017 to 30.06.2018 for amounting to Rs.five lakhs and further renewed from 30.06.2018 to 29.06.2019 for Rs.6 lakhs.

7.             Learned counsel for OP argued that as per the exclusion clause mentioned in clause no.4.2 “to certain diseases which are pre-existing at the time of proposal and exclusion no.4.1 for existing condition shall be applicable in such cases. There are 23 types of diseases are mentioned in clause no.4.2 of the policy against which the duration of period is mentioned.” As per conditions mentioned in clause 4.2 of the policy, if the continuity of the renewal is not maintained with the company then subsequent cover shall be treated as fresh policy and clause 4.1.,4.2 shall apply afresh unless agreed by the complainant and suitable endorsement passed on the policy.

8.             Learned counsel of OPs further argued that in the present case the insurance policy commencing from 30.06.2016 to 29.06.2017 was obtained by the complainant after 9 days of the expiry of the previous policy commencing from 22.06.2015 to 21.06.2016 for Rs.3 lakhs. However, there is an endorsement of the policy for condonation of break in the renewal of the policy commencing from 30.06.2016 to 29.06.2017 and hence the policy commencing from 30.06.2016 to 29.06.2017 shall be treated as continuity in the previous policy. Similarly, if the sum insured is enhanced subsequent to the inception of the policy, the exclusion 4.1 and 4.2 will apply afresh for the enhanced portion of the sum insured for the purpose of this section.

9.             Learned counsel of OPs further argued that the amount of the policy was enhanced from Rs.3 lakhs to Rs.5 lakhs in the policy commencing from Rs.3 lakhs to Rs.5 lakhs in the policy commencing from 30.06.2016 to 29.06.2017. The complainant was patient of Diabetic as per the discharge card issued by PRP Hospital and Kidney Centre Karnal dated 30.05.2018 and further mentioned in the discharge summary of Apollo Hospital Delhi. As per clause 4.2 of the policy, the duration period of payment of treatment in Diabetes of two years which is mentioned at serial no.XVII in exclusion 4.2 mentioned in the policy.

10.           Further, the sum insured was enhanced for the first time in the policy commencing from 30.06.2016 to 29.06.2017, the patient fallen ill on 30.05.2018. The enhanced sum assured has not been paid by the OPs in view of the exclusion in clause 4.2 where the claimant is entitled for the enhanced sum insured after expiry of two years of obtaining the policy for the enhanced sum of Rs.5,00,000/-

11.           Further, as per condition mentioned in clause 4.2 of the policy, if the continuity of the renewal is not maintained with the company, then subsequent cover shall be treated as fresh policy and clause 4.1 & 4.2 shall apply afresh unless agreed by the company and suitable endorsement passed on the policy, as per endorsement mention in the policy Ex.C5 reproduced as under:-

                “The BREAK in the renewal has been condoned subject to the condition that Expenses for treatment of any disease/injury/illness contracted during the break period will not be payable. All other continuity benefits shall remain available Notwithstanding anything contained herein to the contrary in the within mentioned policy it is hereby declared and agreed that at the request of the insured vide letter dt.___ the name/address of the insured stands changed as indicated below with effect from_______and not as stated in the policy. Subject otherwise to the terms, conditions, exception, exclusions and limitation of the policy.”

12.           In the present case complainant has not taken the treatment during the break period, the policy in question was in force when complainant has taken the treatment. The complainant has obtained the insurance policy first time in the year of 2013 and subsequently said policy was renewed every year. It is not a case that the policy in question is a fresh policy, infact i.e. only a renewed and enhanced policy. Thus, the policy clause 4.1. and 4.2 is not applicable in the present case because as per the endorsement in Ex.C5 complainant has not taken the treatment during the break of the policy. Thus, the act of the OPs is amounts to deficiency in service while repudiating the enhanced claim of the complainant

13.           The complainant has paid Rs.8,37,406.27 paise for her treatment, this fact has been proved from the bills Ex.C13 and Ex.C14.  The sum assured amount of the policy is Rs.5 lakhs only. The OPs have already paid Rs.3 lakhs to complainant. Thus, complainant is entitled for the remaining sum assured amount i.e. Rs.2 lakhs.

14.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.2 lakhs to the complainant with interest @ 9% per annum from the date of paying only Rs.3 lakhs to the complainant till its realization. We further direct the OPs to pay Rs.20,000/- to the complainant on account of mental agony and harassment suffered by her and for the litigation expenses. This order shall be complied within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:06.08.2019

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

 

        (Vineet Kaushik)     (Dr. Rekha Chaudhary)

            Member                     Member