Order by:

Smt.Aparana Kundi, Member

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that the complainant is having an account with opposite party no.3/ Punjab Gramin Bank and in the month of May 2022, the complainant alongwith her son went to operate her account in the bank. At that time the employees of the opposite party no.3/Punjab Gramin Bank has told the complainant and her son that the opposite party no.3 has tie up with the opposite party no.1 & 2 regarding providing medical insurance to the account holders of the Punjab Gramin Bank/opposite party no.3. The employees of the opposite party no.3 convinced the complainant and her son to purchase the medical insurance policy. So on the allurement of employee of Opposite Parties no.1 & 2, the complainant purchased the policy for the period 20.05.2022 to 19.05.2023 from the Opposite Parties No.1 & 2. Alleged that in the third week of April 2023, the complainant fell ill and suffered from dry cough, pain in abdomen alongwith breathing problem and got admitted in Sidhu Hospital & Diagnostic Centre on 21.04.2023 and got discharged from the hospital on 26.04.2023. The doctor advised the complainant for regular follow up and medication. Alleged further that the complainant spent Rs.45,986/- on her treatment. After recovering from the illness, the complainant went to opposite parties and requested them to reimburse the amount Rs.45,986/- as assured by the opposite parties. The opposite parties then told the complainant to lodge claim online through mobile application of opposite parties namely Care Health Insurance. Then complainant has lodged the claim on mobile application and uploaded all the relevant documents on application thereafter claim no. 93195756 dated: 12.05.2023 generated on mobile application. Thereafter, the complainant visited the office of the opposite parties many times for the reimbursement of medical expenses but the opposite parties told the complainant that the claim is under process and advised to check online on mobile application. Thereafter, on 21.05.2023, complainant checked online through mobile application, where claim of the complainant was shown as closed and Repudiation/non registration of claim dated: 21.05.2023 was uploaded for reference. Then complainant download the letter and shocked to see that her claim was not registered, hence denied by the opposite parties. Alleged further that the opposite parties have illegally not paid the genuine and legal claim of the complainant taking false and frivolous ground. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to pay an amount of Rs.45,986/- on account of medical expenses incurred by the complainant alongwith interest @ 12 % per annum from the date of filing of the complaint till realization.

b)      To pay Rs.1,00,000/- as compensation on account of mental tension and harassment. 

c)       To pay Rs.11,000/- as litigation expenses.

d)      And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite Parties No.1 & 2 appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complainant has attempted to misguide and mislead this Commission; the complaint involves disputed question of facts which cannot be determined by this Commission; the present complaint filed by the complainant with the mala-fide intention and has not come before this Commission with the clean hand; the claim of the complainant does not fall within the purview of the Insurance as granted by the replying opposite party, hence the complainant is not entitled for any claim under the policy; the complaint is false, frivolous and vexatious in nature; the complainant is estopped from filing the present complaint by his own acts, conduct, omissions and acquiescence; the complainant has tried to challenge the veracity of decision of the opposite party to repudiate the claim. The Company has repudiated the claim under the said policy by a speaking order, which lists out the specific reasons for the decision. By no stretch of imagination the said decision can be brought under the umbrella of 'Deficiency in Services'. The Complainant should approach the Civil Courts in order to challenge the veracity of the decision of the opposite party company to repudiate the claim; the complainant is devoid of any material particulars, and has been filed merely to harass and gain undue advantage and unjustified monies from the Opposite Party; this Hon'ble Commission has no jurisdiction to entertain the present complaint. The complainant has failed to demonstrate any deficiency in service on the part of the Opposite Party; there is no deficiency in service rendered by the opposite party in the present case, and the opposite party is not a necessary or a proper party to present dispute.

          Averred that the replying opposite party company issued a health insurance policy namely "Group Care 360 (Scheme 1 for PGB)" bearing Policy No. 18348790 with Certificate of Insurance Number 42697324 being issued to Ms. Krishna Rani (hereinafter referred to as the complainant) from 20-05- 2022 till 19-05-2023 for a sum insured up to Rs.5,00,000/- subject to policy terms and conditions. Believing the information and details provided by the Proposer including the medical history to be true and correct in all respect and giving due credence to the under writing norms of replying opposite party Company, a Policy issued. The replying opposite party Company further submits that the Policy kit containing all relevant documents was duly delivered to the Complainant from time to time, thereby giving an opportunity to the Complainant to verify and examine the benefits, terms and conditions of the Policy taken by the Complainant. The Complainant never approached the replying Opposite Party Company stating that any information given in the Policy Schedule was incorrect. Thereafter, the replying opposite party received a claim filed for the hospitalization of the complainant from 21.04.2023 till 26.04.2023 in Sidhu Hospital & Diagnostic Centre for the diagnosed case of Diabetes Mellitus II, Coronary Artery Disease, Left Ventricyular Dysfunction, Nephropathy. Averred further that the heart related ailments that the complainant went through are covered under Cardio-myopathy. Therefore the opponent sent a letter dated 21-05-2023 to the complainant wherein the claim was informed to have not been registered for the following reasons:

i.        NON-REGISTRATION- 1 YEAR WAITING PERIOD APPLICABLE FOR CARDIOMYOPATHY

ii.       WAITING PERIOD APPLICABLE TO THE CLAIM

As per the policy certificate, in the Annexure D a list has been mentioned wherein the mentioned diseases will have a 12 month wait period. The Cardiomyopathies have been mentioned therein. In the light of above, the complaint is not at all maintainable since the complainant himself violated the terms and conditions of the policy and there is no deficiency in services on part of replying opposite party. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       Upon service of notice, none appeared on behalf of Opposite Party No.3, hence Opposite Party No.3 was proceeded against exparte.

4.       Ld. counsel for the complainant has also filed replication to the written reply of Opposite Parties No.1 & 2 denying the objections raised by them in their written reply.

5.       In order to prove the case, ld. counsel for the complainant has placed on record affidavit of Krishna Rani as Ex.C1 alongwith copies of documents Ex.C2 to Ex.C9, affidavit of Dr.Devender Singh Sidhu as Ex.C10, copy of aadhar card Ex.C11 and copy of passbook Ex.C12.

6.       On the other hand, ld. counsel for Opposite Party No.1 has placed on record affidavit of Smt.Shruti Saxena, Authorized Signatory of Care Health Insurance Co. Ltd. Ex.OP1,2/1 alongwith copies of documents Ex.OP1,2/2 to Ex.OP1,2/8.

7.         We have heard the ld. counsel for both the parties and also gone through the record.

8.       It is pertinent to mention here that during the pendency of the complaint, complainant Krishna Rani expired, thereafter ld. counsel for the complainant has moved an application for impleading the LRs of the complainant/deceased and vide separate statement, ld. counsel for the Opposite Parties No.1 & 2 has given no objection to the said application. Hence, vide order dated 30.01.2024, the application stands allowed and ld. counsel of the complainant was directed to file amended complaint. Thereafter, ld. counsel for the complainant has filed amended title of the complaint after impleading LRs of the complainant/deceased as party to the present complaint.

9.       There is no dispute that the complainant purchased an insurance policy for the period 20.05.2022 to 19.05.2023 from the Opposite Parties No.1 & 2. During the policy period, the complainant suffered abdomen pain, dry cough and breathing problem and got admitted in Sidhu Hospital & Diagnostic Centre on 21.04.2023 and discharged on 26.04.2023. It is also not disputed that after discharge from the hospital, the complainant lodged the claim with Opposite Parties, but the claim of the complainant not registered/denied by Opposite Parties No.1 & 2.

10.     The perusal of the record reveals that Opposite Parties no.1 & 2 denied the claim of the complainant, vide letter dated 21.05.2023 and placed on record copy of said letter as Ex.OP1,2/8 (Non-Registration of Claim). The contents of said letter are reproduced as under:-

We have received the documents (CL No.93195756-00 in the name of Krishana Rani) filed by you pertaining to Health Insurance Policy (42697324).

We hereby inform you that we are not registering your claim since the present ailment (Chronic ischaemic heart disease) for which admission has been done.

For ease of your perusal we have listed the reason for denial below:-

1 year waiting period applicable for Cardiomyopathy

Waiting period applicable to the claim.

The perusal of aforesaid repudiation letter reveals that Opposite Parties have taken the plea that complainant is suffering from ‘Chronic ischemic heart disease’ and 1 year waiting period applicable for ‘Cardiomyopathy’, so as per terms and conditions of the policy, the complainant is not entitled for the claim as claimed.  But the Opposite Parties could not produce  any evidence to prove that terms and conditions of the policy were ever supplied to  the complainant insured, when and through which mode? It has been held by Hon’ble National Commission, New Delhi in case titled as The Oriental Insurance Company Limited Vs. Satpal Singh & Others 2014(2) CLT page 305 that the insured is not bound by the terms and conditions of the insurance policy unless it is proved that policy was supplied to the insured by the insurance company. Onus to prove that terms and conditions of the policy were supplied to the insured lies upon the insurance company. From the perusal of the entire evidence produced on record by the Opposite Party, it is clear that Opposite Party  has failed to prove on record that they ever did supply the terms and conditions of the policy to  the complainant insured. As such, these terms and conditions, particularly the exclusion clause of the policy is not binding upon the insured.

11.     Further perusal of the record reveals that the complainant availed the policy in question for the period 20.05.2022 to 19.05.2023 and complainant took the treatment of her ailment on 21.04.2023. Then under the given set of circumstances, the rejection of the claim of the complainant solely on the basis that one year waiting period had not elapsed does not appears to be genuine. The policy was in operation till 19.05.2023 and the complainant availed the treatment of her ailment on 21.04.2023, which means that less than a month was there to complete one year. There is nothing on record by the Opposite Parties that there was any malafide on the part of the complainant or there was any concealment of facts by the complainant. Otherwise the very purpose of purchasing the policy by the complainant will get defeated. Therefore while taking a merciful view in favour of the complainant, finding her claim to be genuine and based upon necessity, needs to be allowed.

12.     Vide instant complaint, the complainant claimed the amount of Rs.45,986/-, which is fully proved on record vide medical bills Ex.C4 to Ex.C7. Hence, we allow the said amount.

13.     In view of the above discussion, the instant complaint is allowed in part and Opposite Parties No.1 & 2 are directed to pay Rs.45,986/-(Rupees Forty Five Thousand Nine Hundred Eighty Six only) to legal heirs of the complainant in equal share. Further Opposite Parties No.1 & 2 are directed to pay Rs.4000/-(Rupees Four Thousand only) as litigation expenses to the legal heirs equally. The complaint against Opposite Party No.3 stands dismissed. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Parties within 30 days from the date of receipt of copy of this order, failing which, the Opposite Parties No.1 & 2 are further burdened with additional cost of Rs.5,000/- (Rupees Five Thousand only) to be paid to the legal heirs of the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced on Open Commission