National Consumer Disputes Redressal
M/S Bajaj Allianz General Life ... vs Firoj Khan on 8 August, 2023
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI REVISION PETITION NO. 549 OF 2021 (Against the Order dated 16/03/2021 in Appeal No. 303/2012 of the State Commission Rajasthan) 1. M/S BAJAJ ALLIANZ GENERAL LIFE INSURANCE COMPANY LTD. AND ANR BAJAJ ALLIANZ LIFE INSURANCE LIMITED COMPANY, 3RD FLOOR, SCO- 14, URBAN ESTATE, SECTOR 14, GURUGRAM 122001 GURUGRAM HARYANA ...........Petitioner(s) Versus 1. FIROJ KHAN ADV FIROJ KHAN, BUNGLOW NO 6, AS NAGAR PRATAPGARH RAJASTHAN ...........Respondent(s)
BEFORE: HON'BLE MR. JUSTICE A. P. SAHI,PRESIDENT HON'BLE MR. JUSTICE RAM SURAT RAM MAURYA,MEMBER FOR THE PETITIONER : MR. SATYAM DWIVEDI, ADVOCATE FOR THE RESPONDENT : MOHD. ADEEL SIDDIQUI, ADVOCATE Dated : 08 August 2023 ORDER HON'BLE MR. JUSTICE A. P. SAHI, PRESIDENT
1. The complainant approached the District Forum contending that the health insurance policy taken by him clearly covered the relief of reimbursement. The claim was allowed by the District Forum on the ground that the insurance company failed to support the defence taken by it. Since the policy was valid and the issuance thereof was admitted, therefore, the claim was liable to be allowed.
2. The insurance company preferred an appeal before the State Commission and it was held that the exclusionary clause on the basis whereof the defence is being set up, namely, that the claim in respect of the congenital disease was not admissible, was not made known to the complainant nor the policy had been provided and as such in the absence of information to the insured, the claim was rightly allowed.
3. Learned counsel for the respondent has vehemently supported the impugned judgment and has urged that the exclusionary clause is not attracted and even otherwise when the insured was not informed of any such condition, the revision petition deserves to be dismissed.
4. Learned counsel for the revisionist however contends that the exclusion clause is statutory in as much as in terms of Section 34(1) of the Insurance Act, 1938 read with section 14(2)(e) of the IRDAI Act, 1999, the guidelines issued in this respect clearly provides under Chapter IV thereof that any heart ailment of congenital nature stands permanently excluded from protection under the policy. It is contended that as per the medical reports on records and the line of treatment as well as discharge slip from Appollo Hospital, there is no room for any doubt that the insured was suffering from Patent Ductus Arteriosus (PDA). It is further contended that the Protection of Policyholders' Interests Regulation 2017 read with the provisions above mentioned categorically exclude the protection of the disease suffered by the insured. It is further pointed out that the proposal form which was filled up by the insured incorrectly depicted about no existence of any disease by marking the column meant for the same as "No". The proposal form required an honest declaration and no suppression of fact. It is also evident that the proposal form's clause 6(i) clearly provided for exclusion of the liability of treatment for congenital condition including physical defect present from birth. The filling up of the form is not denied by the insured. It is, therefore, submitted that the insured definitely knew that no such claim relating to congenital heart disease would be admissible either under the terms of the proposal and policy or even keeping in view the statutory provisions that have been referred to hereinabove. The insured was, therefore, bound by the said provisions and therefore, any claim said to be contrary to the same had to be rejected.
5. The District Forum as well as the State Commission have therefore committed an error by totally ignoring these facts and legal provisions and have erroneously concluded that the insured had no information.
6. We have considered the submissions raised and it is undoubtedly clear that the right from the stage of proposal form having been filled up by the insured and to the issuance of the policy, the insured had been informed categorically that the treatment for congenial conditions would not be liable or subject to any payment of reimbursement under the insurance policy. The contention that the insured was not informed is also not correct in as much as the proposal form which was submitted by the insured clearly stipulated this exclusionary clause as indicated above and, therefore, the plea of not having knowledge is incorrect. The defence taken by the insured that he had no knowledge about the congenital disease at the time when the proposal form was initiated, is of no avail in as much as if the disease has been diagnosed as congenital and was there since birth, the proposal form itself excluded the liability of covering any such disease. The fact that the insured was suffering from the said disease and was diagnosed as such remains undisputed in the background of the medical service, the discharge summary, and other medical documents, which are on record. Accordingly, the assumption of the District Forum and the State Commission that the insured had no information as against the weight of evidence on record, is a perverse finding.
7. In view of the legal position as well as the conditions as referred to above in terms of the proposal form as well as the policy, the grounds taken for claiming the benefits under the policy were neither sustainable nor was the claim entertainable. In our considered view, the District Commission and the State Commission have committed an error, that has resulted in material irregularity in the light of what has been discussed above. Therefore, the Orders deserve reversal. Accordingly, the revision petition is allowed. The Order of the District Forum dated 26.07.2012 and that of the State Commission dated 16.03.2021 are set aside.
8. The revision petition is accordingly allowed.
.........................J A. P. SAHI PRESIDENT ..................................................J RAM SURAT RAM MAURYA MEMBER