BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.91 of 2019
Date of Instt. 25.03.2019
Date of Decision: 26.07.2024
Deepak Kumar Luthra aged about 39 years son of Late Sh. Banarasi Dass Luthra R/o H. No.WG-382, Nivan Suraj Ganj, Jalandhar.
..........Complainant
Versus
1. Universal Sompo General Insurance Co. Ltd., Corp. Office: Unit 401, 4th Floor, Sangam Complex, 127, Andheri Kurla Road, Andheri East, Mumbai Through its Mg. Director/Authorized Person.
2. Universal Sompo General Insurance Co. Ltd., SCO-4, 2nd Floor, PUDA Complex, Ladowali Road, Jalandhar, Through its Branch Manager/Authorized Person.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: None for the Complainant.
Sh. V. K. Gupta, Adv. Counsel for the OPs No.1 and 2.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the complainant has purchased a mediclaim policy bearing No.2825/56954169/01/000 from 20.02.2018 to 19.02.2019 and has paid a premium for the same. Immediately after obtaining the insurance policy, the complainant suffered a paralysis attack and thereafter the complainant treated in NASA Hospital, Kapurthala Road, Jalandhar and the complainant has spent an amount of Rs.2,50,000/- on the said treatment. The complainant submitted documents to the OPs alongwith medical claim, but the OPs refused to pay medical claim on that ground that the complainant is having found disease of HIV Positive but while rejecting the claim of the complainant, OPs not disclose the source from when and where the above said disease came to body of the complainant. The above said reason given by the OPs while rejecting the claim only to decline the claim of the complainant by giving false excuse. Due to the above said act of the OPs, the complainant has suffered mental tension and harassment 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 the claim amount of Rs.2,50,000/- alongwith Rs.50,000/- as compensation for causing mental tension and harassment to the complainant and Rs.22,000/- as litigation expenses.
2. Notice of the complaint was given to the OPs, who filed reply and contested the complaint by taking preliminary objections that the present complaint is frivolous, vexatious and devoid of merits and hence, the same is liable to be dismissed with heavy cost. It is further averred that there is no negligence and unfair trade practice on the part of the answering OP. The complainant has not approached this Forum with clean hands. The complainant has suppressed various material facts in the present complaint. It is further averred that the present complaint filed by the complainant with the malafide intention and has not come before this Forum with clean hands, being litigation for the sake of litigations is liable to be dismissed with exemplary costs. On merits, the factum with regard to purchasing a mediclaim policy by the complainant is admitted. It is also admitted that the complainant suffered a paralysis attack and treated in NASA Hospital, Jalandhar, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder not filed by the complainant.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the OPs only as none has appeared on behalf of the complainant and have also gone through the case file very minutely.
6. The complainant has proved the policy Ex.C-1, vide which the complainant purchased the medical insurance, which commenced from 20.02.2018 to 19.02.2019. The complainant has alleged that he suffered paralysis attack and was admitted and treated from NASA Hospital, Kapurthala Road, Jalandhar and spent Rs.2,50,000/- on treatment. He has proved on record copies of the bills Ex.C2 to Ex.C91 and copies of the reports of the hospital Ex.C-92 to Ex.C-157. The claim was lodged which was repudiated on the ground the complainant was having found disease of HIV positive and the concealment of the pre-existing disease. The complainant has alleged that he never knew that he was having the disease and he came to know about the disease first time from the OP only. The complainant sent legal notice Ex.C158 and has proved on record the postal receipts and photographs Ex.C159 to Ex.C168.
7. The OP has relied upon the query letters and repudiation letter Ex.OP3 and Ex.OP4 and insurance policies Ex.OP1 and Ex.OP2. He has relied upon the exclusion clause of the policy booklet which is the part of Ex.OP-2. Perusal of the conditions on page 14 of the Booklet shows the coverage part for people living with HIV/Aids. As per Cover for People Living with HIV/ AIDS (PLHA), which reads as under:-
1. Medical Expenses which arise from or are in any way related to Human Immunodeficiency Virus (HIV) and/or HIV related illnesses and including Acquired Immune Deficiency Syndrome (AIDS) being maintained throughout or AIDS Related Complex (ARC) and/or any mutant the period, derivative or variations thereof provided that
2. The benefit is covered as mentioned in the Summary of Benefits
3. The Medical Expenses are related to Diagnostic Procedures, Room Rent and boarding Expenses, Medical Practitioner and Nursing Fees, medicines, drugs and consumables
4. Your Medical Expenses would be covered up to 20% of the Sum Insured.
5. Your CD 4count is more than 400Mircolitr
For this benefit, the general exclusion for sexually transmitted diseases/AIDS related diseases does not apply.
Note: Even if the Insured purchases the Policy for a term of 2/3 years, the benefits will be payable as entitled per Policy year basis and not in cumulative basis.
8. Perusal of Ex.C-118 shows that the complainant was found HIV 1 positive and Immunochromatography was also positive and Line Immunoassay was also positive. The investigation report Ex.C128 shows that CD4 count of the complainant was 10.49%, whereas required results were 31 to 59 and absolute CD 4 was found 143, whereas the required units were 424 to 1509. As per the terms and conditions of the policy Ex.OP-2 the medical expenses for the hospitalization and which arose from or are related to HIV in any manner are payable, if the CD 4 count is more than 400 microliter, whereas the complainant was found having 143 counts only. None has come on behalf of the complainant to express as to whether he was aware of the terms and conditions of the policy or whether he has received the terms and conditions of the policy or not nor anything has been mentioned by the complainant in the complaint. The contract of insurance was executed between the complainant and the OP. As per the condition of the OP, treatment taken by the complainant was excluded from the benefits available under the mediclaim policy as the counts of the complainant were less than 400. So, there is no illegality and deficiency in service on the part of the OPs and accordingly, the complaint of the complainant is dismissed with no order of costs. Parties will bear their own costs. This complaint could not be decided within stipulated time frame due to rush of work.
9. 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 Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
26.07.2024 Member Member President
