State Consumer Disputes Redressal Commission
Bajaj Allianz General Insurance ... vs Mr.Neeraj Vijay Dhanwani on 15 July, 2022
A-21-75
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
MAHARASHTRA, MUMBAI
Appeal No.A/21/75
M/s.Bajaj Allianz General Insurance Co.Ltd.
201/206, 2nd floor, Sun Magnetica
Near Teen Haath Naka
Near RTO, Loius wadi
Thane 400 602 ...........Appellant
Versus
Mr.Neeraj Vijay Dhanwani
204, Gayatri, 2nd floor
Seven Bungalow
Versova Road, Andheri (W)
Mumbai 400 058 ............Respondent
BEFORE: Justice S.P.Tavade President
A.Z.Khwaja, Judicial Member
PRESENT: Advocate D.S.Joshi is present for appellant
Advocate Jayesh Hemrajani i/b.Advocate U.B.Wavikar
is present for respondents.
ORDER
(15th July, 2022)
Per Hon'ble A.Z.Khwaja, Judicial Member
1. Appellant- M/s.Bajaj Allianz General Insurance Co.Ltd. has preferred the present appeal under section 15 of Consumer Protection Act, 1986, challenging the judgment and order passed by Learned District Consumer Disputes Redressal Commission, Thane, in consumer complaint no.194/2016 dated 09/09/2019, by which consumer complaint filed by the respondent -Neeraj Vijay Dhanwani came to be partly allowed and appellant was directed to pay to the complainant mediclaim amount of 1 A-21-75 Rs.46,353/- along with interest @ 9% p.a. (Appellant and respondent shall be referred as per their original status in the consumer complaint).
2. Short facts leading to filing of present appeal may be stated as under:-
Complainant -Neeraj Vijay Dhanwani is the son of Vijay Dhanwani. Vijay Vasudeo Dhanwani had taken Individual Health Guard Insurance policy for himself as well as three family members from M/s.Bajaj Allianz General Insurance Co.Ltd. and the policy was for the period from 24/03/2006 to 23/03/2007 and it was for sum of Rs.50,000/-. The said policy was renewed and continued further and the sum insured was enhanced from Rs.50,000/- to Rs.1 lakh and, thereafter, upto Rs.4 lakhs. Complainant has contended that he was diagnosed with Preauricular Sinus and advised to undergo surgery by Dr.R.D.Chavan on 02/05/2015. Complainant gave intimation to the opponent on 16/05/2015 regarding requirement of funds for the surgery and treatment. The opponent -Insurance company issued authorization letter on 16/05/2015 and authorized Sujay Hospital, Vile Parle(W), Mumbai to admit the complainant. The opponent -Insurance company initially sanctioned an amount of Rs.50,000/- by authorization letter dated 16/05/2015 and so he was admitted in Sujay Hospital on 19/05/2015 and was discharged on 20/05/2015. During surgery, complainant incurred expenses of Rs.75,815/- for which he was legally entitled. However, opponent/Insurance company arbitrarily reduced the sanctioned amount of Rs.50,000/- to Rs.18,630/- vide second authorization letter dated 20/05/2015, without giving any justification for the same. Complainant has contended that opponent/ Insurance company also did not issue any repudiation letter and paid a megre sum of Rs.18,630/-. Complainant has therefore claimed that the Insurance company has indulged in deficiency in service and has also committed unfair trade practice and further complainant has claimed a sum of Rs.46,353/- along with interest and compensation towards mental harassment as well as costs of legal expenses and so the present complaint.2
A-21-75
3. The opponent -Insurance company has resisted the complaint by filing written version on record. The Insurance Company has denied all the allegations. The Insurance Company has admitted that father of complainant had availed Individual Health Guard Insurance policy for himself as well as three family members and the policy was also duly renewed. The Insurance Company has also not disputed the hospital papers and the fact of treatment of complainant. According to the Insurance company, after submission of initial medical papers, the claim of complainant was settled for Rs.18,630/-. The Insurance Company has taken a defence that as per clause C-11 of the insurance policy, Insurance Company was not liable to pay for convalescence, general debility, rest cure, congenital diseases or defects or anomalies. The Insurance Company has contended that the ailment for which the surgery was conducted on complainant was ailment of congenital external defect covered by standard exclusions and so the entire claim made by the complainant was not payable. The Insurance company has therefore claimed that the consumer complaint filed by the complainant was devoid of any substance and deserves to be dismissed with costs.
4. Learned District Consumer Commission, Thane, thereafter recorded the evidence led by the complainant as well as the opponent-Insurance Company. The Learned District Commission also went through the documents filed by the complainant as well as opponent-Insurance Company as well as notes of arguments. After appreciating the evidence adduced on record, the Learned District Commission reached to the conclusion that the Insurance company had committed deficiency in service by not granting the full claim made by the complainant. Learned District Commission therefore allowed the complaint and directed opponent to pay to the complainant enhanced mediclaim amount of Rs.46,353/- along with interest @ 9% p.a. as well as Rs.25,000/- towards mental agony and Rs.10,000/- towards legal expenses. Against this judgment and order dated 09/09/2019 passed by the Learned 3 A-21-75 District Commission, Thane, the present appellant- M/s.Bajaj Allianz General Insurance Co.Ltd. has come up in appeal.
5. We have heard learned Advocate D.S.Joshi for appellant -Insurance company and learned Advocate Jayesh Hemrajani i/b.Advocate U.B.Wavikar for respondent.
6. Before dealing with the rival submissions and contentions advanced by the learned advocate appearing for appellant as well as respondent, it will be pertinent to point out certain undisputed facts. There is no dispute that the respondent/ complainant had taken Individual Health Guard Insurance policy for the period from 24/03/2006 to 23/03/2007 and the same was also duly renewed and was enhanced upto Rs.4 lakhs. There is also no dispute that the father of respondent/ complainant was diagnosed with Preauricular Sinus and had undertaken surgery on 02/05/2015. There is further no dispute that the appellant/Insurance company had issued first authorization letter on 16/05/2015 for sum of Rs.50,000/-, but, thereafter, had sent second authorization letter reducing the amount to Rs.18,630/-, despite the fact that complainant had incurred expenses of Rs.75,815/- for which the complainant had submitted the claim to the Insurance company. There is also no dispute that the appellant - M/s.Bajaj Allianz General Insurance Co.Ltd. had also not issued any repudiation letter nor given any reasons for rejecting the claim of the complainant/ respondent. If we go through the written version filed on record by the appellant before the Learned District Commission, appellant had taken a plea that the expenses incurred by the respondent/complainant were not at all payable under the policy in view of the terms mentioned in clause C-11 of the insurance policy, which stated that "Convalescence, general debility, rest cure, congenital diseases or defects or anomalies of the insurance policy being ailment of congenital external defect covered by standard exclusions".
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7. The entire dispute according to us revolves on this aspect, as to whether the ailment suffered by father of the complainant was covered by clause C-11 of the terms and conditions of the insurance policy. Learned advocate for the appellant has vehemently submitted before us that the appellant had rightly disallowed the claim of the complainant, since father of complainant was suffering from congenital disease. Further, Learned advocate for appellant has submitted that the second authorization letter dated 20/05/2015 reducing the claim to Rs.18,630/- was very much justified, as the complainant had not submitted the necessary documents and further the same was not payable as per the terms and conditions of the insurance policy. In this regard, learned advocate for appellant has drawn our attention to various documents on record, namely, copy of the insurance policy, first authorization letter dated 16/05/2015, second authorization letter dated 20/05/2015 and other documents.
8. Learned advocate for respondent/complainant has strongly rebutted these contentions and has pointed out that the illness suffered by the father of the complainant was very much covered by the insurance policy and the illness for which surgery was undergone was also not a congenital disease as was made out by the opponent.
9. In order to buttress his contentions, learned advocate for respondent /complainant has drawn our attention, specifically to several medical papers including copy of medical bills and copy of discharge summary, which are placed on record. Learned advocate for the respondent has drawn our attention initially to copy of discharge summary issued to the complainant, wherein summary of illness is mentioned as 'infection in right ear'. Learned advocate has also drawn our attention to the copy of prescription and also to copy of first authorization letter. Learned advoate has pointed out that the first authorization letter issued by the respondent company specifically mentioned the provisional diagnosis as 'infected Preauricular Sinus 5 A-21-75 with phimosis'.
10. On the basis of these documents which were already filed on record before the Learned District Commission, it is submitted by the learned advocate for respondent / complainant that the surgery which was performed on father of the complainant cannot be termed as a congenital disease as claimed by the appellant as per clause C- 11 of the insurance policy. On the other hand, learned advocate for respondent has submitted that clause C-11 will not at all come into play so as to disallow the claim of the complainant. According to learned advocate for respondent, the learned District Commission has taken into consideration these aspects.
11. Further, in view of the submissions, we have also gone through the judgment delivered by the Learned District Consumer Commission, Thane and we find that the Learned District Consumer Commission has dealt with these aspects. Further, the Learned District Consumer Commission has also given finding that no specific reasons are assigned for not disbursing the total claim amount nor any repudiation letter was issued to the complainant. We find much force in these contentions made by the learned advocate for respondent, particularly, in view of the medical papers to which our attention has been drawn. On the other hand, we find that though the appellant/Insurance company had reduced the claim to Rs.18,630/-, no reasons are given nor any independent evidence is on record to show that the complainant was suffering from congenital disease. Appellant has also not placed on record any independent material which will go to show that the disorder or illness suffered by the complainant was present at or before the time of birth or before birth to term it as congenital disorder or disease.
12. In the light of aforesaid discussion held above, we find ourselves unable to accept the contentions advanced by the learned advocate for appellant that the Learned District Consumer Commission, Thane committed any error or illegality in 6 A-21-75 passing the impugned judgment and order dated 09/09/2019. On the other hand, we find that the Learned District Consumer Commission, Thane has passed the judgment and order after dealing with all the aspects elaborately and so we see no reason to interfere with the same. Hence, we pass the following order:-
ORDER
1. Appeal is hereby dismissed.
2. Parties to bear their own costs.
3. Copies of the order be furnished to the parties.
[Justice S.P.Tavade] President [A.Z.Khwaja] Judicial Member Ms. 7 A-21-75 8