Haryana

Kurukshetra

126/2017

Bakshish Kaur - Complainant(s)

Versus

UII - Opp.Party(s)

SOhan Lal

04 Nov 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, KURUKSHETRA.

 

                                                     Complaint Case No.126 of 2017.

                                                     Date of institution: 23.06.2017.

                                                     Date of decision:04.11.2019.

 

Bakshish Kaur w/o Shri Suresh Kumar, r/o village Sunderpur, Tehsil Thanesar, District Kurukshetra.

…Complainant.

                                         Versus

 

United India Insurance Company Limited, Railway Road, Near Gole Bank, Kurukshetra, through its Branch Manager. 

….Opposite party.

 

Before:      Smt. Neelam Kashyap, President.

                   Ms. Neelam, Member.

                   Shri Sunil Mohan Trikha, Member.

       

Complaint under Section 12 of Consumer Protection Act.

 

Present:     Shri Sohan Lal, Advocate for the complainant.   

                Shri Vivek Garg, Advocate for the opposite party.

               

ORDER

                This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Smt. Bakshish Kaur against United India Insurance Company Ltd., the opposite party.

2.            It is stated in the complaint that complainant’s husband purchased a Family Medicare policy bearing No.110702/48/10/06/ 00000840 valid from 19.3.2011 to 18.3.2012 and paid Rs.7038/- to the opposite party and four members namely Suresh Kumar husband of complainant, complainant, Riya Saini daughter and Tushar Saini son of complainant were covered under this policy. That she suffered cyst in the maxillary region during the year 2011-2012 and claim for that was passed by the OP and paid the claim amount to her. That the policy is being got renewed every year by her i.e. from 19.3.2012 to 18.3.2013, 19.3.2014 to 18.3.2015, 19.3.2015 to 18.3.2016 after paying requisite premiums to the OP. It is further averred that complainant suffered the problem acute swelling with the pain in the maxillary region and contacted Ankur Nursing Home, Kurukshetra and upon examination found as Dentigerens cyst in the maxillary region and advised for surgery as bone plates are to be inserted. The complainant was admitted in Ankur Nursing Home for surgery on 20.10.2016 and remained admitted there till 23.10.2016 and surgery was done, plates were placed and an amount of Rs.1,56,000/- was charged from the complainant. She filed claim to the OP and completed all formalities and supplied all documents to it and approached the OP so many times and requested to pay the amount of treatment, but the OP refused to do so. The act and conduct of the op amounts to deficiency in service and unfair trade practice. Hence, this complaint.

3.             Upon notice, opposite party appeared and filed written statement raising preliminary objections regarding maintainability; locus standi and jurisdiction. It is stated that the complainant is not entitled for any claim at all because she was admitted in the Hospital for dental treatment, which is payable only if necessitated by accident and requiring hospitalization. As this is non-accidental claim, hence not payable as per terms and conditions of the policy. It is further submitted that the relevant term and condition is mentioned below:

                Sec.4 Exclusion- The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of (4.8) Dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalization.

                It is submitted that the claim of complainant has rightly been repudiated vide registered letter dated 09.06.2017 and the complaint is liable to be dismissed. The rest of the contents of the complaint denied and prayed for dismissal the same.

4.             The complainant tendered affidavit Ex.CW1/A alongwith documents Ex.C1 to Ex.C14. On the other hand, the OP tendered affidavit Ex.RW1/A alongwith documents Ex.R-1 and Ex.R-2.

5.             We have heard learned counsel for the parties and have perused the case file carefully.

6.             The learned counsel for the complainant reiterated all the averments mentioned in the complaint. He argued that husband of the complainant purchased a family Medicare policy from the OP after paying Rs.7038/-. He further argued that during the year 2011-2012, the complainant suffered cyst in the maxillary region and in this regard, claim was presented before the OP, which was passed and paid by the OP to him. The said policy is being got renewed every year by the complainant i.e. from 19.3.2012 to 18.3.2013, 19.3.2014 to 18.3.2015, 19.3.2015 to 18.3.2016 and lastly from 19.3.2016 to 18.3.2017 after paying requisite premiums to the OP. He further argued that the complainant suffered the problem of acute swelling with the pain in the maxillary region and in this regard, she was admitted in Ankur Nursing Home and surgery was done, plates were placed and an amount of Rs.1,56,000/- was charged from the complainant. The complainant filed the said claim with the OP, who illegally repudiated the same. He further argued that since her earlier claim for the said problem was paid by the OP, then how they can deny to pay the present claim. He further argued that the OP had changed the terms & conditions of the policy without intimating the complainant.

7.             Contrary to it, the learned counsel for the OP has also reiterated all the contents mentioned in the reply. He argued that the complainant is not entitled for any claim because she was admitted in the Hospital for dental treatment, which is payable only if necessitated by accident and requiring hospitalization. As this is non-accidental claim, hence not payable as per terms and conditions of the policy No.4.8 and claim of the complainant was rightly repudiated.

8.             There is no dispute that the complainant had taken Family Medicare Policy from the OP in the year 2011 valid from 19.3.2011 to 18.3.2012 for her and her family members and renewed the same time to time i.e. from 19.3.2012 to 18.3.2013, 19.3.2014 to 18.3.2015, 19.3.2015 to 18.3.2016 and lastly from 19.3.2016 to 18.3.2017, vide policy documents Ex.C-10 to C-13 & Ex.C-16. Initially, the learned counsel for the complainant alleged that during the year 2011-2012, the complainant suffered cyst in the maxillary region and in this regard, claim of Rs.86,000/- was paid by the OP to her as per condition No.4.7 “Dental treatment or surgery of any kind unless requiring hospitalisation” of terms & conditions of the policy Ex.C-13 for the period from 19.3.2011 to 18.3.2012. To support this contention, the complainant produced account statement of IDBI Bank as Ex.C-15, wherein, an amount of Rs.86,000/- was deposited on 28.06.2012 through cheque. The complainant has also mentioned this fact in Para No.3 of her complaint. However, it is pertinent to mention here that the OP did not deny the factum of Para No.3 of the complaint in its written statement at point No.3 ‘Reply On Merits, rather only mentioned that “Para No.3 of the complaint is matter of record”. So, from the above, it is clear that the OP had already paid the previous claim of Rs.86,000/- to the complainant regarding the treatment/problem in maxillary region.

9.             The learned counsel for the complainant further alleged that in the year 2016, the complainant again suffered from the said problem in the maxillary region and spent Rs.1,56,000/- in her surgery. In this regard, she filed the claim with the OP, who illegally repudiated her claim vide letter dated 09.06.2017 Ex.R-1, as per sub-Section 4.8 of Section 4 Exclusion “Dental treatment or surgery of any kind unless necessitated by accident and requiring hospitalisation” of the policy for the year 2013-14 and at that time only the complainant came to know that the OP had changed the terms & conditions of the policy. He further alleged that the complainant renewing the policy in question is continuing from 2011 to 2017, but during the year 2013-14, the OP changed the condition No.4.7 to 4.8 of terms & conditions and added word “necessitated by accident” in it, without giving any information/intimation to her. We found force in this contention of the complainant. Since the policy in question is continuing from 2011 to 2017, then it is the duty of the OP to inform/intimate the complainant about any change in the policy terms & conditions either through issuing notice or letter. But in the present case, the OP did not do so and the complainant came to know this fact only when the OP repudiated his claim. It seems that since the complainant had already taken the claim in the year 2011-2012 for the treatment/problem of maxillary region from the OP, as per condition No.4.7 of policy terms & condition of year 2011-12 (Ex.C-13), therefore, the OP deliberately and intentionally changed the condition No.4.7 to 4.8 in the policy of year 2013-14 by adding word “necessitated by accident”, in it, just to escape from its liability to pay the further claim to the complainant regarding the said problem/treatment. Moreover, since the policy is continue from 2011 to 2017, then the OP is not justified to repudiate the claim of the complainant for the problem/treatment, for which she had already taken the claim in the year 2011-2012. In this regard, we can rely upon the case law titled as United India Insurance Co. Ltd. Vs. Mohanlal Aggarwal, 2004, 1 GLR 637 decided on 5 December, 2003, wherein, the Hon’ble Gujarat High Court has held that “In case of renewal without break in the period, the mediclaim insurance policy will be renewed without excluding any disease already covered under the existing policy which may have been contracted during the period of the expiring policy. Renewal of mediclaim insurance policy cannot be refused on the ground that the insured had contracted disease during the period of the expiring policy so far as the basic sum insured under the existing policy is concerned”. Keeping in view the case law laid down by the Hon’ble Gujarat High Court in the case referred to above and the facts & circumstances of the present case, we are of the considered opinion that OP has wrongly repudiate claim of the complainant. Hence, OP committed an act of unfair trade practice and is deficient in providing the services to complainant. From the perusal of Certificate dated 04.11.2016 issued by the Ankur Nursing Home, Kurukshetra as Ex.C-4, it is evident that the complainant had spent Rs.1,56,000/- on her treatment. So the OP is liable to pay the said amount of Rs.1,56,000/- to the complainant alongwith the compensation and litigation charges.

10.            In view of the aforesaid discussion, we hereby allow the present complaint and direct the OP in the following manner:-

1. To pay the amount of Rs.1,56,000/- to the complainant.
2. To pay Rs.5,000/- as compensation for mental agony and         physical harassment suffered by the complainant alongwith   medical expenses.

 

                The OP is further directed to comply with the aforesaid directions within the period of 45 days from the date of communication of this order, failing which, the awarded amount shall carry interest @ 9% per annum from the date of order till actual payment and the complainant will be at liberty to initiate proceedings under Section 25/27 of the Act against the OPs. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the record-room, after due compliance.

 

Announced in open Forum:

Dt.:04.11.2019.                                                   (Neelam Kashyap)

                                                                        President.

 

(Sunil Mohan Trikha),           (Neelam)    

Member                             Member.