Nidhi Verma, Member

1        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 35 and 36 against the opposite parties on the allegations that complainant took insurance policy from the opposite parties for a sum of Rs.5,00,000/- bearing policy No.11704619 on dated 27.10.2017 which was to expire on midnight 26.10.2018 and paid premium of Rs.16,463/-. After the expiry of above policy the complainant again took policy on dated 8.10.2018 from the opposite parties and the policy period was to expire on 7.12.2019 and paid premium of Rs.17,150/- and the complainant was allotted new policy No.13403090. After the expiry of above policy No.13403090, the complainant again renewed the above said policy on dated 20.12.2019 and the policy period was to expire on 19.12.2020 and paid premium Rs.19,471/- and the complainant was allotted same policy No.13403090. After the expiry of above said policy on 19.12.2020 the complainant again renewed the above said policy on dated 28.3.2021 and the policy period i.e. to expire on 27.3.2022 and paid premium Rs.20,405/- and the complainant was allotted same policy no.13403090. Through the above said policies, the policy holder i.e. complainant and his full family were covered for the health risk. The above said policies were finalized at the house of the complainant through opposite parties No.3 i.e. agent of opposite parties No.1 & 2. The opposite parties No.3 also took premium amount of the above said policies 1. Ex-C1 to C4 from the complaint from his house and also got his signatures on various papers and hence this commission has got jurisdiction to try and decide the present complaint as the contract was finalized at the house of complainant and premium amount was also paid at the house of complainant which is located within District Tarn Taran. The complainant suffered from Atypical Pneumonia/DM (COVID Negative) i.e. having difficulty in breathing, chest spasm, desaturated and G weakness and was admitted to Medic Aid Hospital on 16.8.2020 and was discharged on 31.8.2020 in a satisfactory Condition. After the discharge from hospital complainant also took post hospital treatment as advised by the Medic Aid Hospital. The complainant submitted his claim for sum of Rs.301745 with the opposite parties for the hospital charges including medicines as on 3.10.2020 but the opposite parties denied that claim of the complainant stating that he had not disclosed at the time of taking policy i.e. on 27.10.2017 that he was suffering from Diabetes. The complainant was not suffering from any kind of diabetes when he first took the policy from the opposite parties and also disclosed his true state of health and secondly when he was admitted in the hospital on 16 August 2020 he was suffering from Chest Infection i.e. pneumonia and was not suffering from diabetes. The complainant was treated for chest infection only by the Medic Aid Hospital but the opposite parties falsely and wrongly denied that claim of the complainant. The complainant first time got his Sugar level checked on 26.11.2019 in a routine checkup from Anand Hospital and health care centre Amritsar and that time came to know that his sugar level is little high. After that complainant took all his precautions and never took Extra Sugar in his diet and also did regular exercise. Even the Medic Aid Hospital gave the report on 2.2.2021, that complainant first consultation for diabetes was taken from Anand Hospital on 26.11.2019. Even the Medic Aid Hospital also admitted its mistake that in the pre authorized form the history of T-11-diabetes was mentioned by mistake from 03 years, whereas the T-11 diabetes of the complainant was first deducted as on 26.11.2019. Even the Anand hospital gave its statement that complainant was detected diabetes as on 26.11.2019 on routine checkup. All the above said documents were submitted with the opposite parties including the affidavit of the complainant and request made to the opposite parties to pay the hospital and other expenses incurred by the opposite parties on his treatment i.e. post hospital charges as per insurance policy but the opposite parties wrongly and falsely denied the claim of the complainant. As per the terms of the insurance policy complainant is entitled for the hospital charges including the medicine and also entitled for the post treatment charges which he incurred i.e. hospital charges total 3,01,745/- and post hospital charges i.e. Rs.12,600/- & Rs. 21,000/- which he took from homecare services and as such complainant is entitled for total some of Rs. 3,35,345/- from the opposite parties. It was assured by the opposite party to the complainant that once his claim for hospital charges is cleared thereafter he can submit his claim for post hospital charges but the opposite parties refused to pay the hospital charges to the complainant falsely and wrongly and as such the post hospital charges bill was not submitted by the complainant with the opposite parties for which he is also entitled as per the insurance policy given by the opposite parties. The opposite parties renewed the insurance policy of the complainant on the same terms even after denying the claim of the complainant. The complainants requested the opposite parties to admit his claim, but they refused and declined his requests. The complainant is within time from the final refusal by the opposite parties on 23-03-2021 and prayed that the opposite parties may be directed to pay health claim (Hospital and medicine charges) of Rs. 3,35,345/- with other benefits as mentioned in the policy No. 13403090 alongwith interest @ 12% P.A. from the date of final refusal by the opposite parties till final payment and the complainant has also prayed Rs. 50,000/- as compensation and Rs.50,000/- as costs of litigation. Alongwith the complaint, the complainant has placed on record his affidavit Ex. C-1/A, Self attested copy of Policy bond No. 11704619 Ex. C-1, Self attested copy of Policy bond No. 13403090 Ex. C-2, Self attested copy of Policy bond No. 13403090 Ex. C-3, Self attested copy of Policy bond No. 13403090 Ex. C-4, self attested copy of discharge summary  Ex. C-5, Attested copy of claim form Ex. C-6,  Attested copy of Hospital Charges Bill Ex. C-7, Attested copy of medicine bill of Medic Aid Hospital Ex. C-8, Original Medicine Bill issued by Gurmail Medi Shop Ludhiana Ex. C-9, self attested copy of report given by Anand Hospital dated 26.11.2019 Ex. C-10, Self attested copy of report given by Anand Hospital dated 2.2.2021 Ex. C-11, Original certificate issued by Medic Aid Hospital dated 29.12.2020 Ex. C-12, Self attested copy of statement given by Anand Hospital  dated 8.1.2021 Ex. C-13, Self attested copy of affidavit of Sarabjit Singh Ex. C-14, Self attested copy of refusal letter dated 23.3.2021 issued by the opposite parties  Ex. C-15, Original Post Hospital Charges bill issued by Home Care service Ex. C-16, Original Post Hospital charges bill issued by Home Care service Ex. C-17.

2        Notice of this complaint was issued to the opposite parties and opposite parties No. 1 and 2 appeared through counsel and filed written version by interalia pleadings that the opposite parties No. 1 and 2 issued a Policy under the Plan namely "Care - Floater" bearing Policy No. 13403090 in favour of the complainant Mr. Sarabjit Singh (hereinafter referred to as "insured") for providing policy coverage to the complainant, his spouse, daughter and a son. The said policy was issued w.e.f. 08.12.2018 till 07.12.2019 for a sum insured of Rs. 5,00,000/- subject to Policy Terms & Conditions. The said policy has been further renewed on annual basis with the latest policy effective from 28.03.2021 till 27.03.2022. The complainant has concealed the true and material facts from the knowledge of this Commission, therefore, not entitled for any claim. A cashless facility request was received from the hospital on behalf of the insured as he was to be admitted to Medicaid Hospital, Amritsar on 16.08.2020 with complaints of difficulty in breathing with cough and was provisionally diagnosed with Atypical pneumonia with Covid Negative with Type 2 DM. On that the opposite parties No. 1 and 2 triggered an investigation in order to check the veracity of cashless request and a query was raised by the opposite parties No. 1 and 2 to the treating hospital vide Deficiency Letter dated 17.08.2020 seeking following information and documents as under: -

KINDLY PROVIDE

(i)      EXACT DURATION AND PAST HISTORY OF PRESENT AILMENT WITH 1ST CONSULTATION PAPER AND ALL PAST TREATMENT RECORDS. DIABETES

(ii)     INVESTIGATION REPORT SUPPORTING DIAGNOSIS. WITH X-RAY REPORT

(iii)    PRE HOSPITALISATION OPD TREATMENT RECORD.

A reply was received from the hospital against the aforesaid query and upon perusal of the medical documents received along with pre-authorization and additional documents procured during investigation, the opposite parties No. 1 and 2 came up forefront with the following findings:-

1. As per pre-authorization form received from treating hospital, the insured is marked with past history of Diabetes since 3 years.
2. As per Letter dated 18.08.2020 received in query reply from the treating hospital, the insured is stated to have history of Diabetes since 2.5 years.
3. As per History Sheet document of treating hospital, the insured is marked with history of DM with known Type II DM (on Rx i.e., medication)

In view of the above findings, the opposite parties No. 1 and 2 rejected the cashless facility request on grounds of non-disclosure of Diabetes at the time of proposal and the same was intimated to the treating hospital vide Denial Letter dated 18.08.2020. Thereafter, the complainant approached the opposite parties No. 1 and 2 with request to reimbursement of claim along with post hospitalization expenses as the insured was admitted to Medic Aid Hospital, Amritsar from 16.08.2020 till 31.08.2020. As per the medical documents and discharge summary, the insured was finally diagnosed with Atypical Pneumonia/DM (Covid Negative). The said claim form was received by the opposite parties No. 1 and 2 on 05.10.2020. An investigation was triggered by the opposite parties No 1 and 2 to ensure the veracity of the claim. Henceforth, the opposite parties No. 1 and 2 raised queries vide Deficiency Letter dated 11.10.2020 followed by Reminder Letters dated 21.10.2020 and 31.10.2020 seeking additional information/documents as under:-

(i)      Exact duration and past history of present ailment with 1st consultation paper and all past treatment records. Diabetes

(ii)     Original cash paid receipt against final bill.

(iii)    Pre hospitalisation OPD treatment record.

(iv)    Complete indoor case papers with admission notes, history sheet, doctor's notes, nursing notes and vital chart.

Since insufficient query was received from the insured, the opposite parties No. 1 and 2 received another query vide Deficiency Letter dated 25.01.2021 followed by Reminder Letters dated and 31.01.2021 seeking further documents 28.01.2021 and like supportive investigation reports along with 1st consultation paper for Diabetes.  The complainant did not submit requisite documents sought in the above query, another query was raised by the replying opposite parties vide Deficiency Letter dated 12.02.2021 followed by Reminder Letters dated 15.02.2021 and 18.02.2021 seeking supportive investigation reports along with 1st consultation paper for Diabetes.       The complainant did not reply the same and thereafter, upon perusal of the documents received with the claim form and those additional documents procured during investigation, the opposite parties No. 1 and 2 came up forefront with the following findings:-

1. As per Discharge Summary dated 31.08.2020, the insured was been mentioned with past history of DM.

In view of the above findings and those additional findings concluded during cashless request above, the opposite parties No. 1 and 2 repudiated the claim vide Denial Letter dated 23.03.2021 on the following grounds:-

(i) Claim repudiated: non disclosuer of material facts/pre-existing ailments at time of proposal (diabetes)

The claim of the complainant was repudiated as per terms and conditions of the policy. The relevant clause pertaining to Non- disclosure and policy cancellation are reproduced herein: -

"Clause 7.1- Disclosure to Information Norm

If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particulars or any material information having been withheld, or if a Claim is fraudulently made or any fraudulent means or devices are used by the Policyholder or the Insured Person or any one acting on his/ their behalf, the Company shall have no liability to make payment of any Claims and the premium paid shall be forfeited ab- initio to the Company."

The policyholder/complainant had the opportunity to disclose the History of DM at the time of proposal. However, the said pre- existing disease was deliberately not disclosed by the complainant for the reasons best known to him. The following questions were asked during the proposal where mis-declarations has been made under the heading "Medical/Lifestyle Related Information" as under:-

Does any proposed insured currently or in past Diagnosed/ suffered/ treated/ Taken Medication for any of the following conditions: if yes, please provide details in additional information section below:

6.       Diabetes Mellitus/ High Blood Sugar/ Diabetes on Insulin or Medication

The contract of insurance is contract of uberrimae fidei, and by not declaring correct and accurate information at the time of proposing for the referred Policy, the complainant has acted in breach of the principle of utmost good faith. Therefore, the opposite party company has rightly rejected the claim in accordance with Clause 7.1 of the Policy Terms and Conditions. Had the correct details of pre-existing ailments been disclosed at the time of proposal, the policy would not have been issued to the complainant. The Insurance Regulatory and Development Authority of India (IRDAI) (Protection of Policy Holder's Interest) Regulations, 2017 under Clause 19(4) enumerating the "General Principles" casts an absolute duty to disclose all material facts to the Insurer in order to assess the risk as per it's capacity. The same is reproduced herein for your reference:-

"The policyholder shall furnish all information that is sought from him by the insurer, either directly or through the distribution channels which the insurer considers as having a bearing on the risk to enable the insurer to assess properly the risk covered under a proposal for insurance."

The Policy Holder/ Complainant herein is not only acting in breach of the Policy Terms and Conditions governing the Policy, but also has acted in blatant violation of the above stated Principles and Regulations. Both the parties are bound with the terms and conditions of  the policy and in this case the complainant has not complied with the terms and conditions of the policy as he has not filed, supplied or delivered required documents related to the alleged claim. The terms and conditions of the policy were duly supplied to the complainant at the time of issuance of policy. The complainant never complained regarding non-supply of terms and conditions, now the complainant has denied regarding receiving the terms and conditions, just to take undue benefits. The present complaint has been filed without any cause of action against the opposite parties, therefore, present complaint is liable to be dismissed. The complainant is estopped by his own act and conduct from filing the present complaint. The complainant has no locus standi to file the present complaint. The present complaint is not maintainable and liable to be dismissed.
The opposite parties No. 1 and 2 have denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite parties No. 1 and 2 have placed on record affidavit of Lakshay Juneja Manager legal Ex. OP1,2/1, Self attested copy of authority letter Ex. OP1,2/2, Self attested copy of policy Ex. OP1,2/3, Self attested copy of terms and conditions Ex. OP 1,2/4, Self attested copy of proposal form Ex. OP 1,2/5 self attested copy of claim form Ex. OP 1,2/6, self-attested copy of Deficiency Letter dated 17.08.2020 Ex.OP1,2/7, self-attested copy of reply of Medicaid Hospital dated 18.08.2020 Ex.OP1,2/8, self-attested copy of pre-authorization form received from treating hospital showing past history of Diabetes since 3 years Ex.OP1,2/9, self-attested copy of History Sheet document of treating hospital, the insured is marked with history of DM with known Type II DM (on Rx i.e., medication) Ex.OP1,2/10, self-attested copy of cashless rejection vide Denial Letter dated 18.08.2020 Ex.OP1,2/11, self-attested copy of discharge summary (including indoor case papers and treatment chart) Ex.OP1,2/12, self-attested copy of Deficiency Letter dated 11.10.2020 Ex.OP1,2/13, self-attested copy of Reminder Letters dated 21.10.2020 and 31.10.2020 Ex.OP1,2/14 and Ex.OP1,2/15, self-attested copy of query reply dated 14.08.2020 (Ohri Hospital Chest & Critical Care including reports and x-ray) Ex.OP1,2/16, self-attested copy of Deficiency Letter dated 25.01.2021 Ex.OP1,2/17, self-attested copy of Reminder Letters dated 28.01.2021 and 31.01.2021 Ex.OP1,2/18, Ex.OP1,2/19, self-attested copy of Deficiency Letter dated and 12.02.2021 Ex.OP1,2/20, self-attested copy of Reminder Letters dated 15.02.2021 and 18.02.2021 Ex .OP1,2/21 & Ex.OP1,2/22, self-attested copy of claim Denial Letter dated 23.03.2021 Ex.OP1,2/23, self-attested copy of investigation report is Ex.OP1,2/24, self-attested affidavit of investigator Ex.OP1,2/25.

3        Notice of this complaint was sent to the opposite party No. 3 but no one appeared on behalf of opposite party No. 3 consequently, the opposite party No. 3 was proceeded against exparte by this commission. 

4        In the present complaint, the complainant purchased the insurance policy from the OP ,in which complainant and his full family was covered for the health insurance on dated 27/10/2017 , after the expiry of 1^st policy, he again purchased the insurance policy on dated 08/10/2018 , after the expiry of the 2^nd policy he again purchased the policy on dated 07/12/2019 and continue to renew the policy every year ,he renewed policy on dated 20/12/2019 and the policy period was to expire on 19/12/2020 (Ex.C3) he last renew the policy on dated 28/03/2021 (Ex.C 4) .

5        The complainant suffered from Atypical Pneumonia i.e having difficulty in breathing, chest spasm, desaturated and G weakness and was admitted to Medic Aid Hospital on 16/08/2020 and was discharged on 31/08/2020 . The complainant submitted his claim for sum of Rs 3,01745/- with the OP for the hospital charges including medicines as on 13/10/2020. But the OP denied that claim of the complainant stating that he had not disclosed at the time of taking policy i.e on 27/10/2017 that he was suffering from diabetes(Ex.C15)

6        It is pertinent to mention over here that complainant was not suffering from any kind of diabetes when he first took the policy from the OPs and the complainant first time got his sugar level checked on dated 26/11/2019 on a routine check-up from Anand Hospital , Amritsar and at that time came to know that his sugar level is little high (Ex.C10), even the Medic Aid Hospital  gave the report on 2^nd February 2021 that complainant first consultation for diabetes was taken from Anand Hospital on 26^th November 2019 ( Ex.C11). The Medic Aid Hospital also admitted its mistake as per Ex.C12 ,that in the pre authorized form of the history of T- 11 diabetes was mentioned by mistake from 3 years whereas the T- 11 diabetes of complainant was first detected as on 26^th November 2019.  Even the Anand Hospital gave it's statement that complainant was detected diabetes as on 26^th November 2019 on routine check-up (Ex.C 13) . All the above said documents were submitted with the claim form but OPs wrongly and falsely denied the claim of the complainant.

7        OP No 1 & 2 stated in their written version that a cashless facility request was received from the hospital on behalf of the insured on dated 16.08.2020, On that the opposite parties triggered an investigation in order to check the veracity of cashless request and a query was raised by the opposite parties to the treating hospital vide deficiency letter dated 17 August 2020 seeking following information and document as under:-

• Exact duration and past history of present ailment with first consultation paper and all past treatment records. Diabetes
• Investigation report supporting diagnosis with X ray report.
•  pre hospitalisation pre hospitalisation OPD treatment record.

After the reply was received from the hospital, the OP Nos. 1 and 2 came up forefront with the following findings:-

• As per pre authorization form received from treating hospital, the insured is marked with past history of diabetes since 3 years.
• As per letter dated 18.08.2020 received in query reply from the treating hospital, the insured is stated to have history of diabetes since 2.5years.
• As per history sheet document of treating hospital, the insured is marked with history of DM with known type II DM.

8        In view of above finding, the O.P No. 1 & 2 rejected the cashless facility request on ground of non disclosure of diabetes at the time of proposal. Thereafter, the complainant approached the O.P No. 1 & 2 with reimbursement of claim along with post hospitalization expenses. Thereafter, the OP No. 1 & 2 raised queries vide deficiency letters dated 11.10.2020, 21.10.2020 and 31.10.2020 seeking additional information as under :-

• Exact duration and past history of present ailment with 1^st consultation paper and all past treatment records .
• Original cash paid receipt against final bill.
• Pre hospitalization OPD treatment record.
• Complete indoor case papers with admission notes, history sheet , doctor notes, nursing notes and vital chart.

But the complainant did not submit requisite documents sought in above query after number of reminder letters sent on dated 25.01.2021 , 28.01.2021, 31.01.2021 , 12.02.2021 ,15.02.2021 and 18.02.2021 . The complainant did not reply the same and thereafter, the O.P No. 1 & 2 repudiated the claim vide letter dated 23.03.2021 :- “ claim repudiated: Non disclosure of material facts /pre-existing ailments at time of proposal (diabetes).”

9        However, after gone through the facts and circumstances of the case we are of the considered opinion that the Ld. Counsel for the complainant has submitted that the main controversy involved in the present case is that the O.P No. 1 & 2 had repudiated the claim on the ground of non disclosure of material facts/pre-existing ailments (diabetes) , which was mentioned by mistake in the history of T-11 diabetes from 3years by the Medic Aid Hospital in the pre authorization form. To prove this fact the complainant placed on record the document of  justification for clerical mistake (Ex.C12) from the Medic Aid Hospital stated that “ in pre authorization form the history of T 11 diabetes was mentioned by mistake from 3years whereas the T 11 diabetes had first detected on 26.11.2019.”

10      Further the complainant placed on record the document from the Anand Hospital stated that “the complainant was detected diabetes as on 26/11/2019 on routine check up” (Ex.C13) on other hand O.P No. 1 & 2 stated that after the complainant approached for reimbursement of the claim , OP No. 1 & 2 raised queries and seeking additional information/documents from the complainant and in this regard send the deficiency letter and number of reminder letters to submitted the required documents but the complainant did not reply the same and as per discharge summary they repudiated the claim . However, the OP No. 1 & 2 placed on the record the deficiency letters send on particular dates to the complainant but failed to provide the postal receipts for the same and which cannot prove their point that they dispatched the same deficiency letters to the complainant and same is received by the complainant.

11      Moreover, complainant admitted to Medic Aid Hospital on dated 16.08.2020 having difficulty in breathing, chest spasm, desaturated and G weakness i.e. suffered from Atypical Pneumonia , which have no concern with  diabetes. Diabetes is not a disease . The non disclosure of diabetes is not a ground to repudiate the claim on the ground that the insured intentionally suppressed the material disease. The burden is upon the OP No. 1 & 2 to prove that the complainant intentionally suppressed the previous disease at the time of obtaining the 1^st policy . The 1^st policy was issued on 27.10.2017 . The test were conducted after almost 2 years i.e. on dated 26.11.2019 on routine check up. As per the contents mentioned in the written version the complainant was diabetic prior to 2017 which was not disclosed by the complainant. But there is no documentary proof or evidence before the court to show that the complainant was suffering from diabetes prior the policy . however, the OP No. 1 & 2 repudiated the claim on the ground as per discharge summary dated 31.08.2020 (Ex.Op1,2/12) , regarding this the complainant placed on the record the letter from the Medic Aid Hospital on dated 29.12.2020 related to clerical mistake for his past medical history (Ex.C12). Further , the complainant clarified that the first consultation for diabetes was taken from Anand Hospital on dated 26.11.2019 (Ex.C-10, C-11,C-13) . Without considering the above documents, repudiated the claim on the ground of discharge summary by OP No. 1 & 2 is not valid and  genuine.

12      The OP No. 1 & 2 also failed to prove that the complainant was suffering from diabetes prior to 2017. Even If the complainant was suffering from diabetes, it is not a disease as per the judgement reported in 2008 Delhi 29 Hariom Agarwal Versus Oriental Insurance Company Limited, more than 15% of the people are suffering from diabetes the opposite parties failed to prove that the complaint was suffering from diabetic prior to obtaining the policy even if the complainant was suffering from diabetes is not a disease. Diabetes was a condition at the time of submission of proposal it can lead to cardiac diseases presumption arises that exclusion clause would not cover such an unforeseen ailment- refusal by insurer to process and reimburse .The hypertension and diabetic can lead to a heart ailment such a stroke - cardiac disease, renal failures, lever complication etc, depending upon variety factors that implies that there is probability of such ailment equally that can arise in diabetic are those without hypertension in view of above judgment diabetic is not disease, the non disclosure of diabetic is not a ground to reject the claim on the ground that the insured intentionally suppressed the material disease. Similar view has been taken in II 1197 C.P.J-I(N.C)=1997(2)C P.R21 New India Assurance Company Limited Versus DP Khanna wherein it has been specifically held that it is the duty of the insurance company to prove the fact of actual illness and after the revival of the policy the insurance company cannot escape from the liability merely by saying that the insured has not disclosed the true facts. In II (1997) C.P.J 137 Hariyana State Consumer Dispute Redressal Commission, Chandigarh in L.I.C Of India Vs Rampati it has clearly held that claim could not be repudiated as insured suffering from diabetes and the said facts not disclosed as the diabetes is not a serious ailment such a repudiation is arbitrary and also observed by the State Commission that there was no misstatement or suppressed of any material fact as the same insured person was before the insurer – LIC who had been subjected to medical checkup and examination by the LIC doctor even if the medical examination of the decreased conducted by the doctor of LIC was not to be treated as authentic as contended by the Learned Council for the LIC, yet diabetes was not such a serious ailment which was necessary for the insured to bring to the notice of the insurance corporation .For these reasons the repudiation of the claim by LIC was wholly arbitrary and without any cogent or convincing reason. Moreover, The insurance companies collect the premium from the insured and find ways to decline the claims without any valid reasons. This fact is settled by Honble Punjab and Haryana High Court at Chandigarh in case titled as New India insurance company limited versus Smt. Usha Yadav and others reported in 2008(3)RCR(Civil) Page 111 held as under:- It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline the claims. All conditions which generally are easily understood by a person at the time of buying any policy. The insurance companies in such cases rely upon clauses of the agreement which a person is generally made to sign on dotted lines at the time of obtaining policy.

13      Having regard to overall consideration, there is no hesitation to hold the OP No. 1 & 2 have miserably failed to substantiate that the complainant before taking the policy or at the time of submitting proposal form suppressed material information about diabetes. Further, the complainant purchased the policy 1^st on dated 27/10/2017 which was expired on 26/10/2018 after the expiry of the above policy the complainant again took the policy on dated 08/10/2018 which was expired on 07/12/2019 . Again after the expiry of the above policy he renewed the above said policy on dated 20/12/2019 which was expired on dated 19/12/2020. Again after the expiry of above said policy same was renewed on dated 28/03/2021 (Ex.C1,C2,C3,C4 respectively) this seems the OP No. 1 & 2 have no problem in issuing/renewing the insurance policies and only interested in earning the premium every time but when question arises for reimbursement of the claim , OP No. 1 & 2 come forward to find the ways to decline the claim which is not genuine. It’s totally fine that after getting required information/documents from the hospital regarding past history,  OPD treatment, etc. OP No. 1 & 2 rejected the cashless facility request but after receiving the reimbursement of claim along with all required documents ( clerical mistake by hospital, 1^st consultation for diabetes,etc) OP No. 1 & 2 rejected the claim  on the ground of the discharge summary is not valid and genuine. Therefore in these circumstances the repudiation of the claim by the OP No. 1 & 2 is arbitrary, unreasonable and unjust and amount to deficiency of service on their part.

14      In view of our above discussion, we find that rejection of insurance claim of the complainant by O.Ps No. 1 and 2 is not valid . Therefore, we allow the complaint of the complainant and O.Ps No. 1 and 2 are directed to pay Rs. 3,35,345/- to the complainant. The complainant has been harassed by the opposite parties No. 1 and 2 unnecessarily for a long time. The complainant is also entitled to Rs. 20,000/- as compensation on account of harassment and mental agony and Rs. 11,000/- as litigation expenses. The present complaint against the opposite party No. 3 is dismissed. Opposite Parties No. 1 and 2 are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission and due to COVID-19. Copies of the order be furnished to the parties as per rules. File is ordered to be consigned to the record room.

Announced in Open Commission

25.05.2023