Delhi

New Delhi

CC/247/2012

Smt. Shalini Dar & Anr. - Complainant(s)

Versus

M/S. Bajaj Allianz General Insurance - Opp.Party(s)

17 Feb 2020

ORDER

 

 

                    CONSUMER DISPUTES REDRESSAL FORUM-VI

                             (DISTT. NEW DELHI),

                   ‘M’ BLOCK, 1^STFLOOR, VIKAS BHAWAN, I.P.ESTATE,

                                                              NEW DELHI-110001

 

Case No.C.C.247/2012                                          Dated:

              In the matter of:

1.        Mrs. Shalini Dar,

    W/o Late Sh. Sham Mohan Dar,

 R/o  H.No.91, Sec. 16,

 Faridabad-121002.

 

2.       Sh. Gaurav Dar,

S/o Late Sh. Sham Mohan Dhar,

R/o House No.91, Sec.16,

Faridabad-121002.

Also at:

Rheinfahr Str. 106 C

41468, Meuss, Germany

Through his mother Mrs. Shalini Dar

Attorney holder.

                  ……..COMPLAINANTS

VERSUS

1. Bajaj Allianz General  Insurance   Co. Ltd.

          Having its Regional Office at:

          C-31 & 32, 1^st Floor, Connaught Place,

        New Delhi-01.

        Through its Branch Head.

 

2.        Health Administration Team,

Bajaj Allianz General  Insurance   Co. Ltd.

Ground  Floor, Ashok Plaza,

32/2, Nagar Road, Pune-411014.

Opposite Parties.

NIPUR CHANDNA, MEMBER

                                                                  ODER

The complainant has filed the  present complaint under section 12 of Consumer Protection Act.  The gist of the complaint is that the complainants are the nominee of the DLA in a Travel Insurance policy bearing No.OG-12-1101-9910-00006219 valid from  18.6.2011 to 31.8.2011  issued by OP-1 against payment of premium. The medical expenses, evacuation and repatriation amount to $2,00,000, hospitalization daily allowance of USD25/Day Max 125 and    any one illness USD15,000 were included in the said policy. In Travel Elite Proposal Form, the DLA had clearly mentioned that he was diabetic and was taking medicine for the last 30 years and the same was under control and he had not been admitted to any hospital/nursing home/clinic for treatment or observation. On 18.6.2011 the DLA(Deceased Life Assured) reached  Germany and on 29.6.2011, he complained of sudden severe chest pain and was taken to causality.  The son of the deceased informed the Insurance Co. about the admission.  The deceased remained in ICU till 5.7.2011 and he had died on the same day at 6.30 p.m. , due to development of Pneumonia and multiple organ failure.    After his death, the complainant being the nominee applied for settlement of the claim with the OP.  The complainant completed all the formalities and submitted all the required documents including medical treatment paper of DLA with OP but OP repudiated the claim of complainant vide email dt. 13.7.2011 on the ground that the treatment of deceased arise out of the pre-existing ailment which is not payable as per policy terms and conditions. Despite several requests and follow up OPs failed to settle the claim  of the  complainant, hence this complaint.

 

2.     Complaint has been contested by the OP. OP denied any deficiency in service on its part. It is further stated that the complainant has concealed the material facts from OP at the time of taking the policy referred above.  It is submitted that DLA was suffering from pre-existing diseases i.e.   diabetes and hypertension before the inception of the policy and the present ailment of deceased arises out of the pre-existing ailment which is not payable as per policy terms and conditions Therefore, present complaint is not maintainable and their claim is rightly repudiated vide letter dt.14.7.2011 and prayed for the dismissal of the complaint.

3.     Both the parties have filed their respective evidence by way of affidavits.

4.     We have heard arguments advance at the bar and peruse the records.

5.     Some facts are not denied by the OP  such as the policy documents, death of DLA.  OP repudiated the claim of complainant vide email dt. 13.7.2011 on the ground that the treatment of deceased arises out of the pre-existing ailment which is not payable as per policy terms and conditions.  

6.        It is argued on behalf of complainant that in Travel Elite Proposal Form, the DLA had clearly mentioned that he was diabetic and was taking medicine for the last 30 years and the same was under control and he had not been admitted to any hospital/nursing home/clinic for treatment or observation. It is further argued that the repudation is an arbitrary one and relief claim be granted

7.        Perusal of the proposal form placed on record by the complainant makes it clear that the complainant had mentioned in the proposal form that he was diabetic and was taking medicine for the last 30 years and the same was under control and he had not been admitted to any hospital/nursing home/clinic for treatment or observation. .  If the  insurance company was not satisfied with the information, the OP ought to got the insured medically examined and after being satisfied that insured was hale and hearty and was not suffering with any disease, policy was issued to the insured, but the OP failed to do so and raising the false and frivolous plea to escape from the liability. 

8.        The Insurance Co. has failed to place on record any admission document or discharge certificate of the DLA regarding the pre-existing ailment.   No substantive evidence to prove the earlier treatment of insured in any hospital prior to issuance of insurance policy has been placed on record by the OP to substantiate their contention.  

9.     In view of the above document, we come to the conclusion that the DLA  was physically fit, hale and hearty and not suffering with any disease on the date when the policy was issued.  It may be noted that at the time of earning profit O.P. accepted the said proposal form. However, as soon as liability arose, O.P. went to disbelieve the same.

10.    Thus we are of the considered view that the policy in question was issued on the basis of physical condition of the deceased and he had been found physically fit and, therefore, it cannot be said that any suppression or any earlier ailment had vitiated the contract of issuing policy to the deceased insured.  A contract of this nature cannot be termed bad and be terminated on ground of having obtained by fraud or can be declared as vitiated on facts which were not in existence on the day of contract.  There is no evidence that the deceased insured was suffering with any disease on the day the policy was issued to him. Reliance has been placed on the recent judgment of Hon’ble National Commission titled as Ratna Vs. LIC & 2 in RP. No.1151/2017 dt. 7.11.2019.

11.    In view of the above discussion and the judgment cited above, the repudiation of claim of the complainant by OP-1 is unjustified amounting to deficiency in services on its part. We therefore hold, OP-1 guilty of deficiency in services and direct it as under:

i).     Pay to the complainant USD200000  (to be calculated in Indian Rupees  @ prevailing in the year 2012) alongwith interest @ 9% from the date of filing of complaint i.e. 19.3.2012 till its realization.

ii)      Pay to the complainant a sum of Rs.20,000/- as compensation,  which will include the cost of litigation.

        The order shall be complied within 30 days of the receipt of the order. If the said amount is not paid by the OP within a period of one month from the date of receipt of this order, the same shall be recovered by the complainant along with simple interest at the rate of 9% per annum from the date of this order till recovery of the said amount. This final order be sent to server (www.confonet.nic.in ). A copy each of this order each be sent to both parties free of cost by post. File be consigned to Record Room.

     Pronounced in open Forum on  17/02/2020.  

          

(ARUN KUMAR ARYA)

PRESIDENT

            (NIPUR CHANDNA)                                                                                    (H M VYAS)

                  MEMBER                                                                                                MEMBER