BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.276 of 2016

Date of Instt. 04.07.2016

Date of Decision: 26.09.2017

Bhajan Bhagwant Singh S/o Sh. N.P. Singh R/o 69, Durga Colony, Jalandhar.

..........Complainant

Versus

1. United India Insurance Co. Ltd. 19, G.T. Road, Jalandhar through its Branch Manager.

2. United India Insurance Co. Ltd. 705, Bhikaji Cama Bhawan, Bhikaji Cama Place, New Delhi through its Chairman.

….… Opposite parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Sh. Parminder Sharma (Member)

Present: Sh. Naveen Chhabra, Adv Counsel for the complainant.

Sh. RK Sharma, Adv Counsel for the OP No.1 and 2.

Order

Karnail Singh (President)

1. The instant complaint filed by the complainant, wherein alleged that the OPs are providing general insurance service to the general public for consideration throughout India and more particularly at Jalandhar. The complainant purchased a family medi-care Insurance Policy for a sum of Rs.6,00,000/-, vide policy No.0401012815P10421623 for the period of insurance 21.07.2015 to 20.07.2016 from the OPs. Unfortunately, the wife of the complainant namely Dilrajpreet Kaur, admitted in the hospital for her treatment of surgery to Gall bladder and Bile Duct, firstly in Jalandhar Nursing and maternity hospital from 30.12.2015 to 06.01.2016 and then to SGL Charitable Hospital from 07.01.2016 to 09.01.2016 and later on, she was shifted to Dayanand Medical College and Hospital, Ludhiana from 09.01.2016 to 25.01.2016 and afterwards also got her treatment from Dayanand Medical College and Hospital Ludhiana from 01.03.2016 to 07.03.2016. That the complainant spent a sum of Rs.2,22,808/- in Jalandhar hospitals and Rs.80,541/- in Ludhiana Hospital for the treatment of his wife. The requisite bills of the various medicines/discharge certificates issued by the said hospitals were submitted before the OPs for the necessary reimbursement of the said amount.

2. That the complainant was shocked, when he received a letter dated 09.04.2016 from the OP, wherein the claim of the complainant was repudiated as per the clause No.4.3 of the policy, whereas no such clause was ever told to the complainant at the time of covering of the insurance nor the policy contained the details of the term and condition is received by the complainant. On the receipt of the said letter dated 09.04.2016 from the OP, the complainant got served a legal notice dated 21.04.2016 through Regd. A.D. requesting therein for the reimbursement of the bills. The OP did not reply the legal notice after receiving the same and as such necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay Rs.3,03,349/- to the complainant being the medical expenses incurred, a sum of Rs.1,00,000/- as compensation for mental tension, harassment, inconvenience and financial loss caused due to the above said deficiency in service, negligence and unfair trade practice and further OPs be directed to pay Rs.25,000/- as litigation expenses.

3. Notice of the complaint was given to the OPs and accordingly both the OPs appeared through their counsel and filed written reply and contested the complaint by taking preliminary objections that the complaint is not maintainable against the OPs, as such, the same is liable to be dismissed and further averred that claim of the complainant was processed by the MD India Health Care Services (TPA) Pvt. Ltd., the third party administrator under the policy and repudiated the same as per terms and conditions of the insurance policy after due application of mind and the complainant was informed accordingly, vide letter of repudiation dated 09.04.2016. It is admitted fact that Dilrajpreet Kaur wife of the complainant was treated for removal of stones from her Gall Bladder and Bile Duct and such treatment is specifically excluded under Exclusion Clause 4.3 of the Insurance Policy if such treatment is within 24 months of the inception of the Medi-Claim policies and further averred that this Forum has no territorial jurisdiction to entertain, try and decide the present complaint as the policy has been issued by the Delhi Office of United India Insurance Co. Ltd and not Jalandhar nor there is any involvement of the Jalandhar office in the present claim of the complainant and Jalandhar office has been impleaded as OP No.1, just to show that this Forum has jurisdiction to entertain, try and decide the complaint, as such the complaint is liable to be dismissed and further alleged that there is no deficiency in service or negligence and unfair trade practice on the part of the OPs and further submitted that the claim of the complainant has been repudiated as per terms and conditions of the insurance policy after due application of mind, vide letter of repudiation dated 09.04.2016. On merits, issue of family medi-claim policy by the OP No.2 to the complainant is admitted but the remaining allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merit and the same may be dismissed.

4. In order to establish the case of the complainant, the counsel for the complainant tendered into evidence affidavit of the complainant Ex.CW1/A alongwith some documents Ex.C1 to Ex.C6 and closed the evidence of the complainant.

5. In order to rebut the evidence of the complainant, the counsel for the OP No.1 and 2 tendered into evidence affidavit of Jaspal Singh, Division Manager as Ex.OA alongwith some documents i.e. Discharge Summary of Dilpreet Kaur, issued by the DMC, Ludhiana dated 07.03.2016 as Ex.O1, Copy of Insurance Policy as Ex.O2, Copy of Repudiation Letter as Ex.O3 and closed the evidence of the OPs.

6. We have bestowed our thoughtful consideration to the submissions made by learned counsel for the respective parties and also scanned the case file very minutely.

7. After considering the over all factors as elaborated in the complaint as well as in the reply, we find that the factum in regard to purchase of family medi-care insurance policy for the sum assured Rs.6,00,000/- for the period of 21.07.2015 to 20.07.2016 is admitted fact because the OP while filing the reply categorically admitted this fact and even the OP has also admitted that the complainant has submitted a medi-claim of Dilrajpreet Kaur but the same was processed and considered with due application of mind and thereafter, the same was repudiated because the treatment of Gall Bladder and Bile Duct is specifically excluded under exclusion clause 4.3 of the insurance policy, if such treatment is within 24 months of the inception of the Medi-claim policies. In order to give strength to this aspect, the learned counsel for the OP referred this exclusion clause as mentioned in the terms and conditions of the insurance policy which is Ex.O2.

8. First of all, we have to consider the aforesaid exclusion clause 4.3, the said clause is also mentioned in the repudiation letter Ex.C6, but as per version of the complainant, the said exclusion clause has come to the notice of the complainant first time, when he received a repudiation letter Ex.C6 dated 09.04.2016. The aforesaid plea has been taken by the complainant in the complaint, in para No.5. So, thereafter duty casted upon the OP to discard this plea of the complainant by producing cogent and convincing evidence, whereby establish the said terms and conditions, which are part and parcel of the insurance policy and whether these terms and conditions was also supplied to the complainant at the time of inception of the insurance policy, but in order to establish this aspect, the OP has miserably failed to bring on the file any documentary evidence. So, under these circumstances, we are of the considered opinion that if the terms and conditions are not in the notice of the complainant, then how he is binding for that terms and conditions. So, this clause 4.3 of the policy is not attracted in the present case.

9. Apart from above, we have also considered the plea taken by the OP that this Forum has no territorial jurisdiction because the insurance policy has been issued by the Delhi office of United India Insurance Company but it is not denied by the OP that the OP No.1 United India Insurance Company is not having its branch office at Jalandhar, if so then, the jurisdiction of the Jalandhar Consumer Forum is not ousted in any manner. So, the plea taken by the OP is not justified in any manner and further it is established on the file that the complainant is entitled for the relief claimed.

10. In the light of above detailed discussion, the complaint of the complainant is partly accepted and OPs are directed to pay Rs.3,03,349/- to the complainant being the medical expenses incurred for the treatment of the wife of the complainant with interest @ 9% per annum from the date of repudiation of the claim i.e. 09.04.2016 and further OPs are directed to pay a sum of Rs.25,000/- as compensation for mental tension and harassment to the complainant and also directed to pay litigation expenses of Rs.5000/- to the complainant. The entire compliance be made within one month from the date of receipt of the copy of order. Complaint could not be decided within stipulated time frame due to rush of work.

11. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated Parminder Sharma Karnail Singh

26.09.2017 Member President