Bhajan Bhagwant Singh vs United India Insurance Co. Ltd. & Anr

Sudip Ahluwalia, Member

This Revision Petition has been filed by Complainant Bhajan Bhagwant Singh under Section 21(b) of the Consumer Protection Act, 1986 against the impugned Order dated 26.03.2018 passed by the State Consumer Disputes Redressal Commission, Punjab at Chandigarh in F.A. No. 745 of 2017, vide which the Appeal filed by the Respondents was allowed, the Order of the District Forum was set-aside, and the Complaint was dismissed.

The factual background, in brief, is that the Complainant procured a Family Medicare Insurance Policy No. 0401012815P104216203, valued at Rs.6,00,000/-, covering the period from 21.07.2015 to 20.07.2016 from the Opposite Parties. During the policy tenure, the Complainant's wife, Dilrajpreet Kaur underwent medical treatment, including surgery for Gall Bladder and Bile Duct issues. The treatment spanned across multiple hospitals: Jalandhar Nursing and Maternity Hospital from 30.12.2015 to 06.01.2016, SGL Charitable Hospital from 07.01.2016 to 09.01.2016, and subsequently, Dayanand Medical College and Hospital, Ludhiana, from 09.01.2016 to 25.01.2016. Additional treatment was also sought from Dayanand Medical College and Hospital, Ludhiana, between 01.03.2016 to 07.03.2016. The Complainant incurred expenses amounting to Rs.2,22,808/- at the Jalandhar hospitals and Rs.80,541/- at the Ludhiana Hospital for his wife's medical care. The Complainant duly submitted all relevant bills and medical documentation to the OPs for reimbursement. However, the OPs declined the claim via a letter dated 09.04.2016, citing Clause 4.3 of the Policy, despite not having previously communicated the specifics of this Clause of the Policy. A Legal Notice was dispatched to the OPs on 21.04.2016, urging reimbursement, but to no response. Consequently, aggrieved by the unjustified claim denial, the Complainant sought recourse by filing his Complaint before the District Forum, Jalandhar.

The District Forum vide its Order dated 26.09.2017 partly allowed the Complaint and directed the Respondent to pay to the Complainant Rs. 3,03,349/- along with interest @9% p.a. from the date of repudiation of claim till the date of realisation, Rs. 25,000/- for mental agony, Rs. 5,000/- towards cost of litigation. The Respondent filed its Appeal before the State Commission, which, vide the impugned Order dated 26.03.2018 allowed the Appeal, set-aside the Order of the District Forum, and dismissed the Complaint. The relevant extracts of the impugned Order are set out as below –

“10. It was argued by the counsel for the respondent/complainant that the Exclusion Clause 4.3 had come to the notice of the complainant first time, when he received a repudiation letter Ex.C-6 only. No terms and conditions were supplied/told to the complainant. No policy containing terms and conditions was received by the complainant. The counsel further contended that only cover note was issued to the complainant therefore, Ops repudiated the claim of the complainant illegally and unlawfully. There is deficiency in service on the part of Ops. The counsel further prayed to dismiss the appeal.

During the arguments the counsel for the complainant stated that only cover note was issued and no insurance policy containing terms and conditions was received by the complainant. When he was asked to place the cover note on record, he showed his inability. Further it is evident from the documents placed on record, as per Ex.C-3 the complainant has himself placed magnified photocopy of the first two pages of the insurance policy booklet containing terms and conditions of the policy as per Ex O-2. As such the insurance policy containing terms and conditions was received by the complainant. Therefore, the complainant cannot say that the Exclusion Clause 4.3 was not in his knowledge. As per the insurance policy

Exclusion 4.3

Unless the Insured has 24 months of continuous coverage, the expenses on treatment of diseases such as Cataract, Benign Prostatic, Hyperthrophy, Hysterectomy for Menorrhagia or Fibromyoma, Hernia, Hydrocele, Congenital Internal disease, Fistula in anus, piles, Sinusitis and related disorders, Gall Bladder Stone removal, Gout & Rheumatism, Calculus Diseases are not payable.”

The District Forum has failed to appreciate that the terms and conditions of the Insurance Policy were in the knowledge of the complainant as the first two pages Ex.C-3 placed on the record are of the insurance policy booklet containing terms and conditions and these pages are not of the cover note. Accordingly, Clause 4.3, for Gall Bladder Stone removal treatment, the charges are not payable for the first two years. Treatment was taken before two years of the policy. Therefore, OP-company has rightly repudiated the claim under Clause 4.3 of the terms and conditions.

Sequel to the above, the appeal is accepted and the order of the District Forum is set aside. Consequently, the complaint filed by the complainant is hereby dismissed…”

4.Ld. Counsel for the Petitioner has argued that the District Forum had allowed that Complaint of the Petitioner as the Respondents failed to discharge the burden of proof that such terms and conditions were brought to the knowledge of the Petitioner; That that the State Commission wrongly dismissed the Complainant vide the impugned Order dated 26.03.2018, on the basis of assumptions and presumptions as the Respondents never discharged the burden of proving the delivery of the complete Policy documents to the Petitioner.

Ld. Counsel for Respondents has argued that as per the terms and conditions of the Policy, the Insurance Company is not liable to pay any compensation in respect of Gall Bladder Stone Removal, if the claim arises within 24 months of the issuance of the Policy. The Clause 4.3 explicitly states that such treatment is not covered under the Policy for the first two years; That the State Commission rightly held that the Insurance Company was not liable to pay any compensation in the view of Clause 4.3 of the Insurance Policy. Thus, the Revision Petition is not maintainable and the same is liable to be dismissed.

This Commission has heard both the Ld. Counsel of the Petitioner and the Respondents, and perused the material available on record.

The sole contention of the Complainant revolves around the fact that the Policy terms and conditions were not communicated to him at the time of issuance of Policy, and for this reason, the Exclusion Clauses shall not be applicable to repudiate his claim. The Complainant had raised the same contention before both the lower Fora. The Ld. District Forum accepted this contention of non-communication of the terms of the Policy while the Ld. State Commission rejected the same and dismissed the Complaint. Therefore, there are no concurrent findings, and the question of non-communication of the Policy documents is still to be decided.

It is an admitted fact that the Complainant availed the Policy from the Respondents. It is also admitted that the wife of the Complainant underwent Gall Bladder Stone Removal surgery. Further, the Complainant has not denied that there was an Exclusion Period of 2 years for the said procedure, but it is his case that he was not informed about the Clause 4.3 excluding the said treatment, because he had received only the Cover Note, and did not receive the complete Policy document. As per Para 11 of the impugned Order, the Petitioner was asked to place the said Cover Note on record, but he failed to do so. However, he placed on record a copy of the first two pages of the Policy Booklet which are also placed in the present Petition as Annexure-P3 (colly.) at pp. 41-42 of Part-1. On perusal of the same, it is apparent that the Petitioner had received the Policy document, as the contents are certainly not of a Cover Note. For the reasons best known to the Petitioner-Complainant, the Cover Note of a Mediclaim Policy issued by a different Insurance Company namely Oriental Insurance Co. Ltd. is also placed on record at pp. 46-47 of Part-1,which has no relevance whatsoever to the present Petition.

Further at pp. 48-65 of Part-1, the Petitioner has attached the terms and conditions booklet of the Policy, which is the point of dispute. The URL of the source states “gccore.uiic.in”, being the Respondent’s website and the date of printing of the document is mentioned as “22/09/2016”. Since this has document been filed by the Petitioner, it is apparent that the Petitioner had means to discover/download the terms and conditions of his Policy even if supposedly he had not received the Policy documents. It does not help the case of the Petitioner if he was able to obtain the terms and conditions of the Policy on his own at any time. The principle of onus probandi requires that the party making an affirmative claim must prove it. In the present case, the Petitioner-Complainant alleged that the Respondent-Insurance Company did not supply the terms and conditions booklet, but was unable to prove that he did not receive it, nor did he even place the sole document claimed to be the “Cover Note” alone which was allegedly delivered to him.

For the aforesaid reasons, this Commission finds no grounds to interfere with the well-reasoned decision of the Ld. State Commission.

The Revision Petition is, therefore, dismissed. Parties to bear their own costs.

Pending application(s), if any, also stand disposed off as having been rendered infructuous.