DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FARIDKOT
Complaint No. : 383
Date of Institution: 30.11.2017
Date of Decision : 8.01.2019
Mamta Goyal alias Payal Goyal wife of Vijay Kumar son of Sadhu Ram r/o J P Nagar, Gali No. 3 Old Cantt Road, Faridkot 151203.
....Complainant
Versus
- Life Insurance Corporation Health Department (Claims) Jeevan Parkash Post Box Number 82, Model Town Road, Jallandhar.
- Life Insurance Corporation Bhan Singh Colony, Ferozepur Road, Faridkot through its Branch Manager.
.............OPs
Complaint under Section 12 of the
Consumer Protection Act, 1986.
Quorum: Sh. Ajit Aggarwal, President,
Smt Param Pal Kaur, Member.
Present: Sh Yash Pal Bansal, Ld Counsel for Complainant,
Sh Lakhwinder Singh, Ld Counsel for OPs.
(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 of Rs.64,628/-with interest and for further directing OPs to pay Rs.20,000/-as compensation for deficiency in service and harassment alongwith litigation expenses of Rs.11,000/-.
3 Briefly stated, the case of the complainant is that complainant purchased a mediclaim insurance policy bearing no.133444085 from OPs at Faridkot which was valid for the period from 14.10.2011 to 14.10.2019 and as per insurance policy, complainant and her son Sahil Goyal were insured with OPs. It is submitted that son of complainant was admitted in Fortis Hospital, Mohali on 16.03.2016 and was diagnosed as Tunjour Excision and was operated on and was discharged therefrom on 18.03.2016. Hospital Authorities charged Rs.64,628/- from them. thereafter, complainant lodged claim with OPs and submitted all the documents with OPs vide letter no.1 dated 18.08.2016. Despite completion of all formalities by complainant, OPs did not pay even a single penny as insurance claim to her. All this amounts to deficiency in service and has caused harassment and mental tension to complainant and her family for which prayer is made for directing the OPs to pay compensation and litigation expenses besides the main relief. Hence, the complaint.
4 The counsel for complainant was heard with regard to admission of the complaint and vide order dated 4.12.2017, complaint was admitted and notice was ordered to be issued to the opposite party.
5 On receipt of the notice, OPs appeared in the Forum through Counsel and filed reply taking preliminary objections that OPs have not been properly arrayed as parties as there is no Health Department with the name of Life Insurance Corporation Health Department/OP-1. As per terms and conditions of the policy, complainant is not legally entitled for any claim as sought by him under present complaint. Moreover, complaint is not maintainable on account of exclusion due to PED vide condition no.2 (XXV) and condition no. 7 of the policy. Complainant did not disclose the fact that Sahil Goyal was suffering from Tumour of Excision at the time of revival of policy i.e on 11.07.2015 and 20.07.2015. One year before the date of admission, Sahil Goyal was suffering from pain into right iliac, but complainant did not disclose about his health to Insurance Company. Had complainant disclosed about the material facts regarding health of Sahil Goyal, policy could have been revived after some special reports. After considering all the facts of the present case and due application of mind, claim of complainant was rightly repudiated on the grounds of Pre Existing Disease and Exclusion Clause of policy in question and it was duly intimated to complainant vide registered letter dated 6.05.2017. moreover, complaint of complainant is not verified and is required to be verified. Therefore, complaint in hand is liable to be dismissed. All the wrong statements given by her concealing the disease has affected the terms and conditions of policy in question and they have rightly repudiated the claim of complainant. However, on merits Ops have denied all the allegations levelled by complainant being wrong and incorrect and reiterated the same pleadings taken in preliminary objections and prayed for dismissal of complaint with costs.
6 Ld Counsel for complainant tendered in evidence affidavit of complainant as Ex.C-1, and documents Ex C-2 to Ex C-8 and then, closed the evidence.
7 To controvert the allegations of complainant, ld counsel for OPs tendered in evidence affidavit of Jagdeep Sharma as Ex OP-1 and documents Ex OP-2 to 26 and then, closed the evidence on behalf of OPs.
8 We have heard the learned counsel for complainant as well as OPs and have very carefully gone through the affidavits and documents placed on the file.
9 The Ld Counsel for complainant submitted that complainant purchased a mediclaim insurance policy from OPs valid for the period from 14.10.2011 to 14.10.2019 and as per insurance policy, complainant and her son Sahil Goyal were insured with OPs. It is further submitted that son of complainant was admitted in Fortis Hospital, Mohali on 16.03.2016 and was diagnosed as Tunjour Excision. He was operated on and was discharged therefrom on 18.03.2016. Hospital Authorities charged Rs.64,628/- from them and thereafter, complainant lodged claim with OPs and submitted all the requisite documents with OPs vide letter no.1 dated 18.08.2016, but despite completion of all formalities by complainant, OPs did not pay insurance claim to her. All this amounts to deficiency in service and has caused harassment and mental tension to her. Ld Counsel for complainant has prayed for accepting the present complaint alongwith compensation. Ld counsel for complainant has stressed on documents Ex C-1 to 8.
10 On the other hand, ld counsel for Ops argued before the Forum that as per terms and conditions of the insurance policy, complainant is not entitled to any relief sought by him. It is asserted that in present complaint OPs have not been properly arrayed as parties as there is no Health Department with the name of Life Insurance Corporation Health Department/OP-1. As per terms and conditions of the policy, complaint is not maintainable on account of exclusion due to PED vide condition no.2 (XXV) and condition no. 7 of the policy. Complainant did not disclose the fact that Sahil Goyal was suffering from Tumour of Excision at the time of revival of policy i.e on 11.07.2015 and 20.07.2015. One year before the date of admission, Sahil Goyal was suffering from pain into right iliac, but complainant did not disclose the real facts about the health of Sahil Goyal to Insurance Company. Had complainant disclosed about the material facts regarding health of Sahil Goyal, policy would have been revived after some special reports. After consideration of all the facts, claim of complainant was rightly repudiated on the grounds of Pre Existing Disease and Exclusion Clause of policy in question and it was duly intimated to complainant vide letter dated 6.05.2017. It is further argued that complaint is not verified and is required to be verified. Therefore, complaint in hand is liable to be dismissed. All the wrong statements given by her concealing the pre existing disease of Sahil Goyal has affected the terms and conditions of policy in question and they have rightly repudiated the claim of complainant. It is reiterated that there is no deficiency in service on the part of Ops and prayed for dismissal of complaint with costs.
11 From the careful perusal of record and documents placed on record, it is observed that case of the complainant is that complainant purchased the mediclaim insurance policy and both complainant and her son Sahil Goyal were insured under the said policy. Insured son of complainant was admitted in Fortis Hospital, Mohali on 16.03.2016 and was diagnosed as Tunjour Excision. He was operated on and was discharged therefrom on 18.03.2016. The complainant paid Rs.64,628/- to Hospital Authorities on account of treatment of her son and thereafter, she lodged claim with OPs and submitted all the documents with OPs vide letter no.1 dated 18.08.2016, but despite completion of all formalities and submission of requisite documents, OPs did not clear the claim, which amounts to deficiency in service on the part of OPs. On the other hand, ld counsel for OPs have denied all allegations of complainant being wrong and incorrect and asserted that claim of complainant has rightly been repudiated by them on the ground of concealment of pre existing disease of Sahil Goyal, which complainant did not disclose at the time of revival of policy in question. Complainant has intentionally and deliberately concealed the fact of illness of her son from OPs while signing the proposal form. As per OPs, they have rightly and legally repudiated the claim of complainant on account of exclusion due to Pre Existing Disease vide condition no.2 (XXV) and condition no. 7 of the policy.
12 Now, it is admitted case of the parties that complainant and her son Sahil Goyal were insured with Ops and during the subsistence of insurance period, her son suffered from Tunjour Excision and was operated on at Fortis Hospital, Mohali on 16.03.2016 and discharged therefrom on 18.03.2016 and complainant incurred Rs.64,628/-on treatment of his son. Complainant duly lodged her claim with Ops and completed requisite formalities to obtain her legal and genuine claim, but OPs repudiated the same for no reason. Plea taken by Ops that complainant has concealed the material fact of pre existing disease of her son from OPs at the time of revival of policy in question has no leg to stand upon in the light of document Ex OP-23 copy of Policy Revival Form produced by Ops themselves which clears the point that complainant has not concealed any information from OPs as complainant has replied to all queries of OPs very honestly and whatever is asked has rightly been answered. Whatsoever information Ops have tried to sought through policy revival form has correctly been furnished by complainant and there is no concealment of any fact on the part of complainant. Action of Ops in repudiating the claim of complainant on baseless grounds amounts to deficiency in service on their part. Complainant disclosed each and every thing regarding her health in proposal form and policy revival form and gave correct information to OPs and now, Ops wrongly and illegally repudiated the claim of complainant on false and flimsy grounds only to avoid the payment of insurance claim. The allegation of OPs is that in the revival form complainant did not disclose regarding health and disease of her son to them, but policy revival form is self explanatory and clears the fact that complainant has not suppressed anything regarding health or illness of her son from OPs. Moreover, Ops have failed to produce on record any document regarding pre existing disease of son of complainant.
13 The ld counsel for complainant further argued that prior to issuance of insurance policy in question, the OPs themselves got conducted the medical check up of complainant and her son, who declared them fit. If as per version of OPs, that they have not got medical check up of insured then, it is also their duty to get entire medical check up of the insured before issuance of Policy and at the time of revival of insurance policy in question and now, they have no right to repudiate the claim of complainant on false and flimsy grounds. He has placed reliance on citation 2016 (4) CLT 372 titled as SBI General Insurance Company Ltd Vs Balwinder Singh Jolly & anr wherein our Hon’ble Chandigarh State Consumer Disputes Redressal Commission, U T, Chandigarh held that Consumer Protection Act, 1986, Section 2(1) (g) – Insurance claim (Mediclaim) – Hypertension – Pre-existing disease – Age of insured when Mediclaim insurance policy was issued was more than 45 years – Held – In that event, as per instructions issued by Insurance Regulatory & Development Authority of India (IRDA), it was duty of the insurer to put insured to thorough medical examination – Claim raised after issuance of insurance policy cannot be rejected on account of non-disclosure of the fact of pre-existing disease when policy was obtained. Now, at this stage, they cannot repudiate the claim of complainant on false grounds.
14 From the above discussion, we are fully convinced with the arguments and case law produced by complainant and we are of considered opinion that Ops have wrongly and illegally repudiated the claim of complainant. Complainant has produced sufficient and cogent evidence to prove her case. Hence, complaint in hand is hereby allowed. OPs are directed to make payment of insurance claim of Rs.64,628/- to complainant on account of treatment of her insured son alongwith interest at the rate of 9 % from the date of filing the present complaint till final reralization. Ops are further directed to pay Rs.5000/-to complainant as consolidated compensation for harassment and mental agony suffered by him and litigation expenses. Compliance of this order be made within one month of receipt of the copy of the order, failing which complainant shall be entitled to proceed under Section 25 and 27 of the Consumer Protection Act. Copy of the order be supplied to parties free of cost under rules. File be consigned to record room.
Announced in Open Forum
Dated 8.01.2019
Member President
(Param Pal Kaur) (Ajit Aggarwal)
