State Consumer Disputes Redressal Commission
United India Insurance Co. Ltd. vs Sandeep Jindal on 17 August, 2015
F.A. No. 289 of 2013 1
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, DAKSHIN MARG, SECTOR 37-A, CHANDIGARH.
First Appeal No. 289 of 2013
Date of institution: 13.03.2013
Date of decision : 17.08.2015
United India Insurance Company Ltd., having its Regional
Office at 136, Feroze Gandhi Market, Ludhiana through its duly
Constituted Attorney DR.S.K. Takyar, Manger.
.......Appellant/Opposite Party No2
Versus
Sandeep Jindal Son of Shri Krishan Dayal Jindal, C/O M/R
Jindal Sons Mahian Street, GhassMandi,Ludhiana
Respondent/Complainant
First Appeal against the order dated
30.01.2013 passed by the District
Consumer Disputes Redressal
Forum, Ludhiana.
Quorum:-
Shri Gurcharan Singh Saran, Presiding Judicial Member
Shri Jasbir Singh Gill, Member
Smt. Surinder Pal Kaur, Member.
Present:-
For the appellant : Sh.Parminder Singh, Advocate
For the respondent : Sh. Sidharth Gulati, Advocate
MRS. SURINDER PAL KAUR, Member
ORDER
The appellant/Opposite PartyNo2 (hereinafter referred as the OP) has filed the present appeal against the order dated 30.01.2013 passed by the District Consumer Disputes Redressal Forum Ludhiana (hereinafter referred as the District Forum) in Consumer Complaint No. 311 of 10.04.2012, vide which, the complaint filed by the complainant was allowed and OPs were F.A. No289 of 2013 2 directed to pay the claim of the complainant as per terms and conditions of the policy along with Rs.5000/- as compensation and Rs.2000/- as litigation expenses within 30 days from the date of receipt of the copy of the order.
2. A consumer complaint was filed by the complainant under the Consumer Protection Act 1986(in short 'the Act') against the opposite parties (hereinafter referred as OPs ) where in complainant averred that he purchased Health Insurance policy No.200700/48/10/97/00000933 which was issued by the OPs for the period from 29.09.2010 till 28.09.2011 under the name of his entire family members, i.e. his wife Nidhi Jindal, minor son Deepak Jindal. Before this policy, complainant and his family were having the following Health Insurance Policy from the Ops:
Policy No. Duration 200700/48/09/97/00000862 29.09.2009 to 28.09.2010 200700/48/08/97/00000864 29.09.2008 to 28.09.2009 200700/48/07/97/00000875 29.09.2007 to 28.09.2008 200700/48/06/12/00000284 29.09.2006 to 28.09.2007
Complainant had filled the proposal form when the first policy was issued by OPs for the period from 29.9.2005 to 28.9.2006. At that time complainant had gone through the terms and conditions of the policy and all the diseases were covered under the policy. After the First policy OPs never asked the complainant to fill up any new proposal form and represented that said policies were in continuation of the earlier policies without any change in the terms and conditions. Consequently, he paid the annual premium, as such, the above said F.A. No289 of 2013 3 polices were renewed by OPs from time to time. During the subsistence of the policy starting from 29.09.2010 to 28.09.2011 son of the complainant was suffered from pain in the chest and they consulted the Doctors in DMC & Hospital. It was diagnosed that his son was suffering from ACYANOTIC CONGENITAL HEART DISEASE-PDA WITH LEFT TO RIGHT SHUNT and he was admitted in the hospital on 01.06.2011.to 5.6.2011. Thereafter, complainant moved an application before OPs for the reimbursement of the amount. But they refused as his son was suffering from congenital disease and his case fell under the exclusion clause of the policy i.e. 29.09.2010 to 28.09.2011. Complainant visited the office of the OPs number of time to settle the claim but the OPs did not pay any heed to his genuine request. The above said act of the OPs amounted to deficiency in services. Hence, he filed the complaint before the District Forum seeking, following directions against the Op. i. to pay Rs.1,39,865/- spent on the treatment of his son along with interest @12% from the date of treatment till realization. ii. to pay Rs.1 lac as compensation on account of mental tension and harassment.
3. The complaint was contested by the OPs. They filed the written reply by taking the preliminary objections that complaint was not maintainable as there was no deficiency in services on their part. The claim of the complainant was not payable because it fall under the exclusion clause 4.1 of the insurance policy. Complainant did not approach with the District Forum with clean hands and suppressed the material facts from the Forum. Earlier complainant had taken medi guard policy and later on took the Health Insurance Policy. The F.A. No289 of 2013 4 terms and conditions of both the policies were different but the complainant kept insisting to settle the claim as per terms and conditions of pervious policy i.e. Medi Guard Policy. Therefore, it was not possible to settle the claim as per terms and conditions of the previous policy. On merits all the facts were retreated and they prayed for dismissal of the complaint.
4. District Forum allowed the parties to lead their evidence in support of their averments.
5. The complainant had tendered into evidence as Ex.CW1/A along with other documents Ex.C1 to C-8 and closed his evidence. On other hand the OPs had tendered into evidence affidavit of Baljeet Singh Deputy Manager along with terms and conditions of the Health Insurance Policy Ex.R1 and close their evidence.
6. After going through the allegations alleged in the complaint, written reply filed by the OPs, evidence and documents brought on the record and allowed the complaint as referred above.
7. Aggrieved against the order passed by the Ld District Forum, the Appellant/OP No 2 has preferred the present appeal.
8. We have heard the learned counsel for appellant as no one appeared on behalf of the complainant and have carefully gone through the record of the case.
9. OP has alleged in the grounds of the appeal that complainant had purchased MEDI GUARD POLICY from 2005 to 2006 which was renewed from 29.9.2006 to 28.9.2007. After that complainant had purchased the INDIVIDUAL HEALTH INSURANCE POLICY from 2007 to 2008. This, policy was renewed from 2008 to F.A. No289 of 2013 5 2009, 2009 to 2010, and 2010 to 2011. The terms and conditions of the above said policy was different from the Medi Guard policy and congenital disease was falling under exclusion clause 4.1 of the Individual Health Insurance policy reproduced as under:-
Exclusions:-
The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of: 4.1 All Congenital disease (Internal and external).
Son of the complainant was diagnosed as ACYANOTIC CONGENITAL HEART DISEASE-PDA WITH LEFT TO RIGHT SHUNT as per discharge summary ExC7. OPNO2 has placed on record Individual Health Insurance Policy as Ex.R1 in which it was mentioned that all the congenital diseases fall under the Exclusion Clause 4.1. Complainant alleged that he was not aware about the terms and conditions of the Individual Health Insurance Policy. The law has been settled in the judgment of 5 Judge Bench of the Hon'ble Supreme Court reported in AIR 1966 Supreme Court 1644 (General Assurance Society Ltd. v. Chandmull Jain and another), that a person obtaining a particular insurance policy is supposed to know the terms and conditions of that particular type of insurance policy. In Deokar Exports Pvt. Ltd. vs New India Assurance Company Ltd 2009(2) CLT Hon'ble S.C. held that in a contract of insurance, rights and obligations are strictly governed by the policy of Insurance-No exception or relaxation can be made on the ground of equity. Therefore, the case of the complainant falls under the exclusion clause4.1 of the Individual Health Insurance Policy. Accordingly, the F.A. No289 of 2013 6 claim for the expenditure incurred on the treatment of congenital heart disease is not payable. The District Forum wrongly held that the case of complainant falls under the Medi guard policy and Health Insurance Policy is in continuation of the earlier policy. The District Forum has erroneously allowed the claim ignoring the terms and conditions of the policy.
10. In view of the above discussion and law laid down by the Hon'ble Supreme Court, the appeal of the appellant/OPNO2 is accepted and the impugned order of the District Forum is set aside. Consequently, complaint filed by the complainant is dismissed.
11. The appellant/OPNO2 had deposited an amount of Rs.25,000/- with this Commission at the time of filing the appeal. This amount with interest accrued thereon, if any, be remitted by the registry to the Appellant by way of a crossed cheque/demand draft after the expiry of 45 days, from the dispatch of the order to the parties; subject to say, if any, by the higher Fora/Court.
12. Arguments in this appeal were heard on 03.08.2015 and the order was reserved. Now the order is communicated to the parties.
13. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(GURCHARAN SINGH SARAN) Presiding Judicial Member (JASBIR SINGH GILL) Member (SURINDER PAL KAUR) August 17, 2015 Member SK F.A. No289 of 2013 7