State Consumer Disputes Redressal Commission
Patel Nirajbhai Govindbhai vs Bajaj Allianz Gen. Ins.Co.Ltd on 9 January, 2023
Details DD MM YY
Date of Judgement 09 01 2023
Date of filing 05 09 2022
Duration 04 04 -
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION
GUJARAT STATE, AHMEDABAD
First Appeal No. 545 of 2022
Court No. 1
1. Patel Nirajbhai Govindbhai
Age: 44 , Business: Job
Address: Shreeji Nagar,
Nr. Ram Bag School,
Ta.: Unjha, Dis.: Mahesana
Mobile No. 94276 78990 ..Appellant
Vs
1. Bajaj Allianz General Ins. Co. Ltd.
Bajaj Allianz House, Airport Road,
Yarwada, Puna. Maharashtra 411006
2. Authorized Signatory,
Health Administration Team,
Bajaj Allianz General Ins. Co. Ltd.,
Second Floor, Bajaj Finserve Building,
Survey No. 208/B-1, Back Field,
Behind I.T. Park
Puna, Maharashtra 411014 ..Respondants
Coram : Hon'ble Mr. Justice V. P. Patel, President
Ms. A.C.Raval, Member
APPERANCE :P.M. Rangwala, Advocate for the appellant Order: (By Ms. A.C. Raval, Member)
1.Appellant has filed this appeal under section 41 of the Consumer Protection Act 2019, being aggrieved and feeling dissatisfied with the judgement and order dated 29.07.2022 Passed by the Consumer Disputes Redressal Commission, Mahesana (for short Learned District Commission ) in consumer Case no. 368/2020.
ADIT A-545-2022 Page 1 of 51.1 Heard Ld. Advocate Mr. P.M Rangwala for the appellant. Perused record of the case and judgement and order passed by the Id. District commission.
1.2 The appellant is original complainant and respondent No. 1 is original opponent No. 1 and respondent No. 2 is original opponent 2 before the District Commission. Hereinafter the appellant and respondents will be referred as per their original status.
2. Order Under Challenge:
The Learned District Commission has rejected the complaint filed by the appellant/original complainant all the relief sought by the appellant is denied.
3. Fact of the case:
The complainant had purchased mediclaim star package policy from the opponent for the period 06.07.2019 to 05.07.2022 with the sum insured Rs. 3,00,000. The complainant, his wife and two children were insured by this policy. The wife of the complainant got unbearable neck pain. For the reason. The complainant and his wife contacted different Doctors and carried out various reports. It was opined by Dr. Bharat Dave that the wife of the complainant is required to under go operation of spine. The wife of the complainant admitted in the hospital on 29.08.2019 and discharge on
04.09.2019. The complainant filled up the mediclaim form along with the bills of treatment and operation. The opponent Insurance Company repudiated the claim of the complainant on the ground of claim not maintainable as per the terms and conditions of the policy regarding waiting period. The complainant approached the Learned District Commission Mahesana by filling C.C. No. 368 of 2020 which was rejected by the Learned District Commission Mahesana vide order dated 29.07.2022. Hence, this appeal.
ADIT A-545-2022 Page 2 of 54. Argument of the appellant:
It is argued by the advocate appearing for the appellant/original complainant that the complainant has taken the family health care policy to protect his family in any medical emergency. The wife of the complainant Sejalben was failed down while doing miscellaneous work at home on 07.08.2019. She got pain in the neck due to some injury on C6-C7 in spinal code. She was operated by Dr. Bharat Dave on 28.08.2019. The claim of the appellant/complainant is wrongly repudiated by the opponent Insurance Company. The complainant is entitled to receive the expense accrued due to operation. The Learned District Commission has wrongly held that as per the terms and conditions of the policy. The complainant is not entitled for the relief sought by him. The Learned District Commission has failed to appreciate the evidence on record and legal position. Hence, the order passed by the Learned District Commission is against the principal of natural justice, bed in law and fact and required to be quashed and set aside and this appeal may be admitted and allowed.
Merits of the case:
5.1 The duration of policy and sum insured are undisputed. The operation under gone by the wife of the appellant is also undisputed. The opponent has repudiated the claim of the complainant wide communication on the 28.09.2019. The copy of said letter is produced at pg. no. 41. The operative person of the order reads as under:
"On detailed scrutiny of the same, we find that the claim does not fall under the purview of the policy for reasons given below:
Verification of the claim document reveals the aforesaid claimant was hospitalized for the treatment of C6-C7 prolapse intervertebral disc with impending myelopathy and is claiming for expenses incurred of IN. 326884. The policy incepts on 06-JUL-
16. We regret to inform you that the claim stands repudiated as the policy does not extend coverage for any expenses incurred on Prolapsed Intervertebral Disc during the first four years of continuous policy with us.
The relevant clause of the policy is given below for your reference:
Part A: Coverage and Exclusions: Exclusion specific to reason 2: B3 We will also not pay for claims arising out of or howsoever connected to the following: any Medical Expenses incurred during the first four consecutive annual periods during which you have the benefit of Star Package Policy covering Health Guard Section with us in connection with joint replacement surgery, surgery for ADIT A-545-2022 Page 3 of 5 prolapsed inter vertebral disc(unless necessitated due to accident), surgery to connect deviated nasals septum and hypertrophied turbinate, congenital internal diseases or anomalies and laser treatment for correction of eyesight due to refractive error. In case of enhancement of sum insured the waiting periods shall apply afresh only to the extent of the amount by which the limit of indemnity has been increased( i.e. enhanced sun insured) if the policy is a renewal of Health Policy without break in cover.
It is mentioned in the repudiation letter that policy does not extend coverage for any expenses incurred on Prolapsed Intervertebral Disc during the first four years of continuous policy with the company. 5.2 The reliance is made by the opponent on Section 2B2 of the policy which is produced at pg. no. 96 and reads as under:
"Exclusion Clause [Policy Para-B Exclusion Specific to Section-2 sub para 3] Any medical expenses incurred during the first four consecutive annual periods during which you have the benefit of star package policy covering health guard section with us in connection with joint replacement surgery, surgery for prolapsed inter vertebral disc (Unless necessitated due to accident) surgery to correct deviated nasal septum and hypertrophied turbinate, congenital internal diseases or anomalies and laser treatment for correction of eyesight due to refractive error.
In case of enhancement of sum insured the waiting periods shall apply afresh only to the extent of the amount by which the limit of indemnity has been increased if the policy is a renewal of Health policy without break in cover."
5.3 The discharge summary is produced at pg. no. 31. In the column of principal diagnosis, it is mentioned that C6-C7 PID with impending Myelopathy. Here, PID means Prolapsed Inter Vertebral Disc. Hence, it can be seen that the illness for which the patient was operated is covered under the exclusion clause of the policy. The treating Dr. has given the certificate which is produced at pg. no. 33, where also he has reiterated the same, that the patient was having pain since last 25 days and was operated for C6-C7 scull PID. It is not the case of complainant that he was unaware of the terms and conditions of the policy. The complainant has signed the proposal form. Hence, the policy conditions are binding to both the sides.
5.4 It is the case of the complainant that the complainant has taken the initial policy on 06.07.2016. The policy is continuous policy from 06.07.2016 hence, this claim is maintainable under the policy terms and conditions. The complainant has produced the policy of 2016 at pg. no. 25 the period of coverage shown as 06.07.2016 to 05.07.2019 and it was renewed for the period 05.07.2019 to 05.07.2022. The wife of the complainant under gone surgery of spine ADIT A-545-2022 Page 4 of 5 on 30.08.2019. If the period of first policy also taken into consideration then also the surgery is done within four years of the inception of the policy. Hence, the complainant is not entitled to the expenditure occurred for the said surgery.
6. We have considered the grounds stated in memo of appeal, reasons stated in the impugned judgment and order passed by the Ld. District Commission, documentary evidence produced on record, argument by the appellants and facts and circumstances of the case. We are of the opinion that the judgment and order passed by the Ld. District Commission is legal, valid, correct and proper on facts as well as law. Hence, appeal is required to be dismissed. In the interest of justice following order is passed.
ORDER A) The appeal no. 545 of 2022 is dismissed at the stage of admission.
B) The order passed by the Consumer Disputed Redressal Forum, Mahesana in Consumer Complaint No. 368 of 2020 dated 29.07.2022 is hereby confirmed.
C) No order has to cost.
D) Office is directed to verify the amount deposited by the appellant in Appeal no. 545 of 2022. If found deposited, refund the same with interest, if any, accrued on the deposit to the appellant through RTGS after following due procedure and verification. For this purpose the appellant has to apply to the Account branch accordingly.
E) Registry is directed to send copy of this judgment to the parties. Registry is directed to send a copy this judgment to the District Commission Mahesana through E-mail in PDF format for taking necessary action.
Pronounced in the open court on 09.01.2023
[Ms. A.C. Raval] [Mr. Justice V. P. Patel]
Member President
ADIT A-545-2022 Page 5 of 5