DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, FATEHGARH SAHIB. Consumer Complaint No.22 of 2017 Date of institution : 03.04.2017 Date of decision : 06.02.2018 Raj Kumar aged about 41 years, son of Sh. Shiv Dayal, resident of village Boran, Post Office Khera, Tehsil and District Fatehgarh Sahib. ??..Complainant Versus TATA AIG General Insurance Company Limited, having its registered office at 15th Floor, Tower-A, Peninsula Business Park, Ganpatrao Kadam Marg, Lower Patel, Mumbai, Maharashtra-400013 through its authorized person. TATA AIG General Insurance Company Limited, through (being in tie-up with) Axis Bank Limited, branch at village Hansali, Tehsil and District Fatehgarh Sahib, Punjab, through its Manager. Axis Bank Limited (agent/broker of TATA AIG General Insurance Company Limited), branch at village Hansali, Tehsil and District Fatehgarh Sahib, Punjab, through its Manager. ?..Opposite Parties Complaint Under Sections 11 to 14 of the Consumer Protection Act. Quorum Sh. Ajit Pal Singh Rajput, President Sh. Inder Jit, Member Present : Sh. Kuldeep Singh, Adv.cl. for complainant. Sh. Narinder Singh, Adv.Cl. for OP No.1. Opposite party No.2 exparte. Sh. Vinay Sood, Adv.Cl. for OP No.3. ORDER By Inder Jit, Member Complainant, Raj Kumar aged about 41 years, son of Sh. Shiv Dayal, resident of village Boran, Post Office Khera, Tehsil and District Fatehgarh Sahib, has filed this complaint against the Opposite Parties (hereinafter referred to as "OPs") under Sections 11 to 14 of the Consumer Protection Act. The brief facts of the complaint are as under: On 10.06.2016, the complainant purchased 'Medi Prime' Floater Plan type policy bearing No.0285034245 from the OPs at Hansali through Axis Bank Limited, village Hansali, bearing client ID No.C/3950134/0000087, Proposal No.P-3950134/020147/0000019 and the policy is valid for the period of one year i.e. from 10.06.2016 to 09.06.2017 for the sum assured of Rs.2,00,000/-. Under the said policy, the complainant and his wife Smt. Gita Rani were insured and his wife was the nominee of the complainant. As per the said policy, the medical expenses up to Rs.2,00,000/- incurred by the complainant in future on himself or on his wife on any medical treatment were to be paid by the OPs to the complainant. The wife of the complainant had to undergo medical treatment in respect of some serious disease of her abdomen and in this regard, she remained admitted in Ivy Hospital, Sector 71, Mohali from 19.08.2016 to 27.08.2016. The complainant incurred an amount of Rs.69,214/- on the treatment of his wife. Thereafter, the complainant filed claim for the said amount with OPs along with all documents such as case history, treatment given, investigation and original payment receipts etc. The OPs assured the complainant that needful will be done within 5-6 days from the date of filing of the claim. The complainant made various visits on many occasions to request OPs for releasing the claim amount but to no effect. Thereafter, the complainant filed a consumer complaint No.3 of 2017 in this Forum and vide order dated 12.01.2017, the OPs were directed to decide the claim of the complainant within a period of 30 days. The complainant also filed fresh online claim on 15.01.2017 but he did not receive any reply/intimation regarding his claim. The complainant also served a legal notice dated 07.11.2016 upon OPs to pay claim amount along with compensation and interest, but all in vain. The act and conduct of the OPs amounts to deficiency in service on their part. Hence, this complaint for giving directions to the OPs to pay an amount of Rs.69,214/- on account of lawful medical claim and Rs.1,00,000/- as compensation for mental tension, pain, agony, undue and unnecessary harassment suffered by the complainant. Notice of the complaint was issued to the OPs but OPs No. 1 & 2 chose not to appear to contest this complaint. Hence, OPs No.1 & 2 were proceeded against exparte. The complaint is contested by OP No.3 and later on OP No.1 joined the proceedings at evidence stage. In reply to complaint, OP No.3 raised certain preliminary objections, inter alia, that the present complaint is not maintainable; the complaint is misuse and abuse of the process of the law; the complaint is false, frivolous and vexatious; the complainant has not come to this Forum with clean hands; the complainant has got no cause of action to file the present complaint and this Forum has got no territorial jurisdiction to try and decide the present complaint. As regards the facts of the complaint, OP No.3 stated that the complainant has purchased policy from OPs No. 1 & 2 and the premium was paid by the complainant through Axis Bank Branch Hansali. No claim was filed by the complainant with it, so there is no question of releasing the same by it. The claim, if any, has to be released by OP No.1 and 2. There is no deficiency in service on their part. After denying the other averments made in the complaint, OP No.3 prayed for dismissal of the complaint qua it. In order to prove his complaint, the complainant tendered in evidence copies of documents Ex. C-1 to Ex.C-13 and his affidavit Ex. C-14 and closed the evidence. In rebuttal OP No.1 tendered in evidence affidavit of Vidula Kaushik Ex. OP1/1,true copies of documents Ex. OP1/2 to Ex. OP1/7 and closed the evidence. OP No.3 tendered in evidence affidavit of Ramesh Jamwal and closed the evidence. The Ld. counsel for the complainant argued that the Medi Prime Policy was purchased by the complainant for himself and his wife Smt. Gita Rani in respect of any medical treatment/expenses from the OPs on 10.06.2016, which was valid upto 09.06.2017 and the amount insured was Rs.2,00,000/-. Complainant's wife Smt. Gita Rani had to undergo medical treatment w.e.f.19.08.2016 to 27.08.2016 for some abdominal ailment and incurred expenses to the tune of Rs.69,214/-. Inspite of filing the medical claim with the OPs, the OPs repudiated the claim of the complainant. Hence, he pleaded for acceptance of the complaint. On the other hand, Ld. counsel for OP No.3 argued that the Bank has nothing to do with the claim. The refund if any, has to be given by OPs No.1 & 2 only. The complainant had only made the payment through the bank. The Ld. counsel for OP No.1 argued that the claim of the complainant was repudiated correctly because the wife of the complainant had been having a disease prior to the purchase of policy. He argued that as per the admission report of the hospital (Ex. OP1/5), wife of the complainant was admitted to hospital on 19.08.2016 with complaints of diffuse pain abdomen/ loose motions since 3-4 months. So, accordingly if existence of disease is presumed to be 3 months, then the period of occurrence of disease comes out to be 19.05.2016, which is prior to the purchase of policy. Hence, he argued that she was having a pre-existing disease and as per terms of the policy(Ex.OP1/6), pre-existing conditions are not covered. The counsel for OP No.1, therefore, prayed for dismissal of the complaint. After hearing the Ld. Counsel for the parties and going through the pleadings, evidence produced by the parties and the oral arguments and written submissions, we find that there is force in the plea of the ld. counsel for OP No.1. It is established from Ex. OP1/5, wherein it is mentioned as " Brief History of Present Illness: A 37 years old female non-diabetic, normotensive presented with complaints of diffuse pain abdomen admitted with loose motions since last 3-4 months admitted with weight loss of 7 kg. Now, admitted here for further evaluation and proper management", which shows that the disease was pre-existing from the date of inception of Medi-Prime Policy and this is not covered under the terms and conditions of the policy Ex. OP1/6, which reproduced as under:- " Pre-existing conditions will not be covered until 48 months of continuous coverage have elapsed, since inception of the first retail health insurance policy with the Indian non life Insurer?????" Accordingly, in view of above discussion, the present complaint is hereby dismissed. Parties to bear their own cost. The arguments on the complaint were heard on 30.01.2018 and the order was reserved. Now the order be communicated to the parties. Copy of the order be sent to the parties free of cost and thereafter the file be consigned to the record room. Pronounced Dated:06.02.2018 (A.P.S.Rajput) President (Inder Jit) Member