The titled complainant Yogesh Kumar Mahajan has filed the present complaint against the titled opposite parties (for short, the OP1 Financiers & the OP2 & 3 Insurers) being hurt at their alleged arbitrary acts of omissions and commissions that have allegedly infringed his statutory consumer rights. He proceeds to explain that he on 27.09.2018 had availed of Rs.15 Lac as Housing Loan from the OP1 Financiers in his Loan A/c # 635612019; And, the OP1 in order to insure the said housing loan had got him (Complainant) insured against major medical illnesses (and other factors) with the OP2/3 insurers vide policy no.2918202427817100000 valid w.e.f. 27.09.2018 to 26.09.2023 (i.e. for term of the loan) for Sum Insured as par with the Loan Amount on reducing balance basis at a total premium @ Rs.1,78,402/- to the debit of the 2nd Loan Account of the complainant, for the purpose.
2. The complainant has been regularly paying the determined EMI (Equated Monthly Installment) in both his loan accounts till he fell critically ill in January' 2020 and had to be admitted for medical-treatment on 14.01.2020 in Shrimann Super-specialty Hospital at Jalandhar from where he was discharged on 18.01.2020.
3. Further, in terms of the policy, the entire outstanding loan amounts were to be paid/ borne by the OP2/3 insurers at the borrower complainant contacting a major illness out of the listed major illnesses w e from the date of insurance-event which shall be the date when the insured gets diagnosed with the critical illness. Here, the complainant in the super specialty hospital was diagnosed with seven nos. of diseases including the 'Chronic Kidney' at its End Stage Renal Failure for which he will be needing regular 'blood-dialysis' twice a week throughout the balance of his life. As the Chronic Kidney disease has been duly listed in 'List of Major Illnesses' of the related policy, the complainant on 20.01.2020 approached the OP2/3 insurers, through his family members, who submitted the related insurance-claim for liquidation of the loan amounts w e from the date of 'insurance-event' i.e. 14.01.2020 the date of diagnosis of the critical Chronic Kidney disease.
4. Somehow, the OP2/3 insurers kept on deferring/lingering the insurance claim and finally repudiated the same sans assignment of any valid/reasonable grounds and thus the present complaint accompanied by the complainant's affidavit Ex.C1 along with the other documents Ex.C2 to Ex.C9 + written arguments put forth in evidence seeking directives to the OP2/3 insurers to pay the amounts outstanding with interest @12 % PA in the two loan accounts as on the date of the insurance event i.e. 14.01.2020 besides Rs.20,000/- as compensation plus any other relief that the forum may deem fit.
5. The titled opposite party financier (the OP1), in response to the commission’s summons appeared through their counsel and filed their written reply stating therein preliminary as well as the other (on merits) objections as:
6. The complaint is not maintainable as there have been disputed questions of fact that cannot be adjudicated under the summary procedure prescribed here. There has been no compulsion upon the complainant to get the loan insured and he got it insured at this own and premium amount was financed by the OP2 who being the one secured creditor has every right to recover the loan(s) outstanding. Again, on merits, the OP financiers in their written statement have either denied or shrugged the contents of the complaint addressing these as matters of records etc.; but the main contention of the OP financiers throughout have been that the matter of claim-settlement has been between the complainant and the OP insurers and thus complaint deserves dismissal against them. In support of their version opposite party No.1 has filed affidavit of Sh.Aditya Kochar Deputy Manager and authorized representative Ex.OPW-1/A alongwith copies of documents Ex.OP-1/1 and Ex.OP-1/2.
7. Similarly, the titled opposite party insurers (the OP2 and OP3), in response to the commission’s summons appeared through their counsel and filed their written reply stating therein preliminary as well as the other (on merits) objections as:
8. The complaint has been pre-mature as the claim has not been finally settled but has been on hold kept as 'no-claim' on account of non-submission of proper information given to the queries raised by them pertaining to the claim. Finally, the OP insurers have sought dismissal of the complaint being bereft of merit and also for want of cause of action, in the interest of justice, equity and fair play. The claim was not repudiated but only closed being immature as reply to the related queries was awaited. The complainant has not replied exhaustively to the OP queries in spite of the repeated reminders. The benefits of the policy are subject to terms and conditions governing the policy hence the queries do warrant proper replies by the complainant along with submission of related documents.
9. Again, on merits, the OP insurers in their written statement have either denied or shrugged the contents of the complaint addressing these as matters of records etc.; but the main contention of the OP insurers throughout have been non-submission of proper replies to the queries raised by them pertaining to the claim.
10. Finally, the OP insurers have sought dismissal of the complaint being bereft of merit and also for want of cause of action, in the interest of justice, equity and fair play.
11. The OP insurers in support of their version and pleadings in defense have produced the following documents in evidence: Ex.OP2,3/1 - Self declaration by the Legal Manager Manoj Prajapati; Ex.OP2,3/2 - Power of Attorney favoring the Manager Legal (claims); Ex.OP2,3/3 - Certificate of Insurance; Ex.OP2,3/4 - Policy Wording; Ex.OP2,3/5-Deficiency Letter; Ex.OP2,3/6 to Ex.OP2,3/11–Additional Documents; Ex.OP2,3/12–Discharge Summary; Ex.OP2,3/13–Claim form; Ex.OP2,3/14–Closure Claim Letter;
12. We have examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective litigants. We find that the present dispute has arisen on account of the impugned ‘non-settlement’ of insurance-claim pertaining to the insured loan accounts of the complainant, by the OP2/3 insurers who allege non-reply of their queries in spite of their repeated reminders. We have minutely examined the documents produced in evidence by the complainant, the insured's Hospital and also by the OP insurers as produced and as collected by them during the course of their investigations and find that there's neither any chance nor scope of any OP query still having left unanswered/ unresolved, by the time.
13. The list of major illnesses, in terms of the related policy, comprised of the ailments as: (Ex.OP2,3/4) (Policy Wording: Section3 a): Major Medical Illness & Procedures:
1. Cancer of …...
2. Kidney Failure requiring regular dialysis;
3. Multiple ….......
4. Benign Brain …...
5. Parkinson's Dis.......
6. Alzheimer's Dis.…...
7. End stage Liver Dis.....
14. The complainant vide his Hospital Discharge Summary (Ex.C7) has been diagnosed on 14.01.2020 as having suffered from Chronic Kidney disease on HD (along with six others) requiring dialysis twice a week on regular basis throughout the rest of his life.
15. We find that the complainant has successfully proved his entitlement to the related policy proceeds and the same need to have been made available to him by the OP insurers w e from the date of the insured-event i.e. 14.01.2020.
16. Somehow, we do not concur with the logic of the herein impugned 'nos-resolve' of the hospitalization-claim and are inclined to examine the validity and legality of the same in the back-drop of the preceding and also the succeeding acts and events in the light of the facts on records and current law on the consumer proposition’s subject matter, in issue. We observe that the impugned non-resolve of the insurance-claim has been the result of the OP2/3 insurers' resolve in their endeavor to somehow repudiate the same. Finally, in the matter pertaining to the present complaint and in the light of the all above, we find and address the intentional 'non-resolve' and 'delay' at the OP insurers' end as ‘deficiency in service' and 'unfair-practices' at play and that places the OP2/3 insurers on the adverse side of the statutory award under the applicable statute here.
17. Thus, we ORDER the OP2/3 insurers to pay the insurance claim, in full, to the complainant, in terms of the related policy i.e. by crediting/liquidating the entire outstanding balance in both the loan accounts as on the date of insured-event(14.01.2020) and further ORDER the OP1 financier to reverse all the debit entries of whatsoever in both the loan accounts and refund all the credit entries in these two accounts made as on/after 14.01.2020 be paid with interest @ 6% PA to the complainant besides to pay Rs.15,000/- in lump sum as cost and compensation within 45 days of receipt of the certified copy of these orders otherwise the award shall attract additional interest @ 3 % PA from the date of the complaint till actually paid.
18. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.
19. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President.
ANNOUNCED: (R.S.Sukhija)
NOV. 16, 2022. Member.
YP.
