Punjab

Faridkot

CC/17/84

Rajesh Kumar - Complainant(s)

Versus

Branch Manager Bajaj Allianz General Insurance co. - Opp.Party(s)

Mandeep singh Dhingra

09 Apr 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT

 

C. C. No. :            84 of 2017 

Date of Institution: 17.03.2017

Date of Decision :     9.04.2019

 

Rajesh Kumar, aged about 74 years son of Khem Chand r/o House No. B-IV/721, Old City, Gali Master Shiv Ram Wali, Kotkapura, Tehsil Kotkapura, District Faridkot.                                           

 

                                                                           .........Complainant

Versus

1.  Bajaj Allianz General Insurance Company Limited, Branch at S C O 7, 1^st Floor, Baba Faridkot Market, Bhai Ghanaiya Chowk, Faridkot through its Branch Manager.
2. Kamal Chhabra (Beema Wala) son of Ashok Chhabra, resident of Factory Road, Near Surgapuri, Kotkapura. Agent of Bajaj Allianz General Insurance Company Limited, c/o Bajaj Allianz General Insurance Company Limited, Branch at SCO 7,1^st Floor, Baba Farid Market, Bhai Ghanaiya Chowk, Faridkot.
3. Bajaj Allianz General Insurance Company Limited, through its Incharge, Feroze Gandhi Market, Ludhiana.

                                                                          .............OPs

Complaint under Section 12 of the

Consumer Protection Act, 1986.

 

Quorum: Sh. Ajit Aggarwal, President,

               Smt. Param Pal Kaur, Member.

 

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Present:  Sh Mandeep Dhingra, Ld Counsel for Complainant,

               Sh Satish Jain, Ld Counsel for OPs-1 & 3,

     (Complaint against OP-2 is dismissed

     as withdrawn vide order dated 13.09.2017)

ORDER

(Ajit Aggarwal, President)

                                             Complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against OPs seeking directions to OPs to make payment of insurance claim  with interest and for further directing OPs to pay Rs.2,00,000/- as compensation for deficiency in service and harassment alongwith litigation expenses of Rs.20,000/-.

2                                      Briefly stated, the case of the complainant is that on assurance of OP-2, who is agent of OP-1 and OP-3, complainant purchased an insurance policy from OPs. Complainant was having passport and he got tourist visa for Australia and got  renewed the policy when he was in Australia. It is submitted that unfortunately he fell ill in Australia and suffered from Acute Transmural Myocardial Infection and remained in Monash Health, Monash Medical Centre, Clayton, Victoria and he had to spent huge amount of from his own pocket and by borrowing from his relatives. Several pathological, biochemical and radiological tests were conducted upon him and he spent 5486 Australian dollars on his treatment and in Indian Currency, this amount

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comes to Rs.75,068/-. On reaching India, he lodged his claim with OPs and requested them to pass his genuine claim, but they kept putting him off on one pretext or the other. Complainant also served legal notice to OP and thereafter, they made payment of only Rs.25,322/-to complainant through NEFT on 3.01.2017 and withheld the remaining amount. All this act and conduct of OPs amounts to deficiency in service and has caused harassment and mental tension to complainant. Complainant has prayed for directing the OPs to pay compensation for harassment alongwith litigation expenses besides the main relief. Hence, the complaint.

3                                     The counsel for complainant was heard with regard to admission of the complaint and vide order dated 27.03.2017, complaint was admitted and notice was ordered to be issued to the OPs.

4                                     On receipt of the notice, the OPs. No. 1 and 3 filed written statement wherein asserted that there is no deficiency in service on their part as complainant has concealed the material facts from this Forum and has not disclosed about his pre existing ailments to them at the time of purchasing the policy in question. Non disclosure of pre existing ailments is a violation of terms and conditions of the policy. Complainant gave false information in the proposal form on the basis of which present policy was issued to him. It is further averred that complainant did not disclose them that he was suffering from hyperlipidaemia  and there was a possibility of previous history of AMI

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in 2013. It is denied that complainant fell ill in Australia. It is further averred that at the time of purchase of policy, the complainant was already suffering from these diseases. Complainant gave false declaration at the time of purchasing the policy that he was not suffering from any disease. It is further denied that on receipt of legal notice from counsel, they made payment of Rs.25,322/-under present claim, rather  that amount was paid to settle another claim filed by complainant. claim under policy in question has been repudiated by them vide letter dated 30.12.2016, on the ground of concealment of material facts regarding pre existing diseases from the OPs. Ops admitted before the Forum that complainant purchased the insurance policy in question from them and he was insured under the said policy, but denied all the other allegations of complainant being wrong and incorrect and prayed for dismissal of complaint with costs.

5                                              Ld counsel for complainant gave statement before the Forum that he does not want to pursue the present complaint against OP-2, therefore, vide order dated 13.09.2017, complaint against OP-2 was dismissed as withdrawn.

6                                              Parties were given proper opportunities to prove their respective case. Counsel for complainant tendered in evidence affidavit of complainant Ex.C-1 and documents Ex C-2 to C-17 and then, closed their evidence.

 

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7                                                          In order to rebut the evidence of the complainant, Counsel for OPs.1 and 3 tendered in evidence affidavit of Sarpreet Kaur Ex OP-1,3/1 and document Ex OP-1, 3/2 to Ex OP-1, 3/11 and then, closed the evidence.  

8                                                          We have heard the ld counsel for complainant as well as OPs and have carefully gone through evidence and documents placed on record by respective parties.

9                                                   The case of the complainant is that on assurance of OP-2/agent of OP-1 and 3, complainant got himself under policy in question. Thereafter, complainant went to Australia on tourist visa and he got renewed his insurance policy from there. It is submitted that while his stay in Australia, he suffered from Acute Transmural Myocardial Infection and was hospitalized in Monash Health, Monash Medical Centre, Clayton, Victoria and he spent huge amount of 5486 Australian dollars on pathological, biochemical and radiological tests  and on his treatment from his own pocket and by borrowing from his relatives. In Indian Currency, this amount comes to Rs.75,068/-. On reaching India, he lodged his claim with OPs, but they kept putting him off on one pretext or the other. On service of legal notice to OPs, they made payment of only Rs.25,322/-to complainant through NEFT on 3.01.2017 and withheld the remaining amount, which caused harassment and mental agony to him. He has prayed for accepting the present complaint

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10                                                          From the careful perusal of evidence and documents placed on record and pleading made by parties in above discussion, it is observed that there is no dispute regarding insurance of complainant with OPs. Ops have themselves admitted that complainant was insured with them for reimbursement of treatment expenses under the policy in question. Plea taken by OP-1 and 3 is that complainant did not provide correct information regarding his health and ailments to them and concealed about his pre existing diseases from them. It is denied that they passed claim for Rs.25,322/-on receiving legal notice from complainant and asserted that they have repudiated the claim of complainant as per terms and conditions of policy in question and asserted that complainant filed two claims before them and they paid Rs.25,322/-to complainant to settle his another claim. It is reiterated that there is no deficiency in service on the part of OP-1 and OP-3 and prayed for dismissal of complaint with costs.

11                                                            Ld Counsel for complainant argued that the OPs cannot deny the claim amount in dispute regarding expenses incurred by him on his treatment on the ground of alleged terms and conditions, which were never supplied or explained to him at the time of inception of insurance policy. He placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, it

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is generally seen that Insurance Companies are only interested in earning the premiums and find ways and means to decline the claims. He  further placed reliance on citation 2008(3)RCR (Civil) Page 111 titled as New India Assurance Company Ltd Vs Smt Usha Yadav & Others, wherein our Hon’ble Punjab & Haryana High Court held that it seems that Insurance Companies are only interested in earning premiums and find ways and means to decline the claims. It is also observed that OP-1 and OP-3 have failed to bring on record any kind of documentary evidence to prove that complainant was having any such pre existing disease in respect of which he undertook treatment in Australia. Nothing is placed on record to prove that complainant was ever hospitalized for treatment of disease from which he suffered while he was abroad or prior to taking insurance policy, he was suffering from any ailment.

12                                     From the careful observation of record and evidence put forward by complainant and in view of arguments advanced by respective parties, this Forum is of considered view that there is a deficiency in service on the part of OPs in not passing the genuine claim of complainant on account of expenses incurred by him on his treatment and OPs cannot deny claim on false grounds of terms and conditions of policy, which were never supplied to him though he was covered under the Mediclaim insurance policy. The present complaint is hereby accepted against OP-1, and 3 and they are directed to pay the claim amount of Rs.5486/- Australian Dollar or equivalent of

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same in Indian Currency to complainant, which he incurred on his treatment alongwith interest at the rate of 9 % per anum from 17.03.2017 i.e from the date of filing the present complaint till final realization. They are further directed to pay Rs.5,000/-to complainant as consolidated compensation for harassment and mental agony suffered by them and for litigation expenses. Compliance of this order be made within one month of the receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost. File be consigned to record room.

Announced in Open Forum

Dated : 9.04.2019

                                      (Param Pal Kaur)              (Ajit Aggarwal)

                                        Member                          President