Order by:
Sh.Amrinder Singh Sidhu, President
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that complainant has purchased a Medi Claim health insurance Policy from opposite parties vide policy No.18309703 with effect from 24th September 2020 to 23rd September 2021 for which complainant had paid premium of Rs.16,204/-. Unfortunately, health of the complainant became deteriorated as he was suffering from COVID-19 in the month of December 2020 and was got admitted in Harbans Nursing Home and Maternity Hospital, Kot-Ise-Khan, District Moga, under the observation of Dr. Harjot Kaur Kamboj, from 15.12.2020 to 29.12.2020 for which complainant had spent Rs.1,94,638/- vide bill dated 29.12.2020. The complainant informed the opposite parties regarding his treatment and deposited the requisite documents as required by opposite parties and opposite parties assured complainant that the insurance company will pay the whole expenses. However, complainant was astonished when he received the letter from the opposite party No.1 dated 13.06.2021 in which the claim of the complainant was repudiated with a reason that “Discrepancy in Medical Documents”. The complainant some how arranged the amount of Rs.1,94,638/- and got deposited the said amount in the hospital vide bill dated of 29.12.2020. Thereafter, the complainant approached opposite parties with a request to pay the amount but with no effect. The opposite parties have not paid the said amount to the complainant and linger the matter on the pretext or one and another and lateron flatly refused to pay any amount. Hence this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to pay a sum of Rs.1,94,638/-.
b) To pay an amount of Rs.1,00,000/- as compensation on account of mental tension, harassment and deficient services.
c) To pay an amount of Rs.50,000/- as costs of 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 appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complaint filed by the complainant is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead the Commission. The present complaint is not maintainable in the present form as the complaint involves disputed question of facts which cannot be determined in summary jurisdiction of consumer commission. The present complaint filed by the complainant with the mala-fide intention and has not come before this Commission with the clean hand. Prima facie no cause has arisen in favour of the Complainant's to file the present Complaint, as the complainant claim is not fall within the Insurance as granted by the replying opposite party. Intricate questions of law and facts are involved in the matter in issue and parties should have to lead evidence by examining the witnesses and the other party should have to cross examine the witnesses and the matter involved in this case cannot be decided in summary manner and the complainant, if so advised, may approach the Civil Court. The complaint is false, frivolous and vexatious in nature, as such the complainant is liable to pay penalty under the Act to the opposite party. 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 complainant is devoid of any material particulars, and has been filed merely to harass and gain undue advantage and unjustified money from the Opposite Party, and hence the complaint deserves to be dismissed in limine. The complaint has been filed with ulterior motive malafide intention, to cause harassment and prejudice to opposite party, which is a company of long standing and high repute, and to extract money from it without just cause or valid reason. This 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. The Commission cannot pass any order in contravention to the terms and conditions of the policy contract. The complainant has not acted in good faith with respect to subject of this complaint and has approached the Commission with unclean hands. The insurance is a contract of utmost good faith and that the contract of insurance is base on Doctrine of Uberrima Fides and even if any due diligence is done by the insurance company, it does not change the basic element of an insurance contract. The complaint is devoid of any material particulars, and has been filed merely to harass and gain undue advantage and unjustified money from the replying opposite party, and hence the complaint deserves to be dismissed in limine. The claim made by the complainant was repudiated by the opposite party on the ground of that the Assured failed to disclose correct health status at the time of treatment rather he conceal true facts from the replying opposite party, so no benefits are payable under the policy. The complainant has sought a relief from this Commission which he is not entitled to get under the terms and conditions of the subjected Life Insurance Policy and as such no deficiency in services on the part of the opposite party have been demonstrated by the Complainant. The complainant has sought relief on the basis of allegations which are not supported by any documentary evidence to substantiate the same. Therefore, the complaint does not deserve any consideration by this Commission and merits dismissal at the threshold. 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, accordingly present complaint ought to be dismissed against the opposite party. The complaint being frivolous and vexatious is liable to be dismissed under Consumer Protection Act. Further alleges that replying opposite party had issued health insurance policy vide policy number 18309703 covering the Complainant (Policy Holder), his spouse and a son with effect from 24.09.2020 to 23.09.2021 for a Sum Insured of Rs.5,00,000/- subject to policy terms and conditions. The copy of Schedule bearing relevant details of the Policy along with policy bond having terms and conditions were duly sent and delivered to the Proposer. Further, no assurance was given to the Complainant beyond the terms and conditions of the Policy. Replying Opposite Party Company further submits that the Policy kit containing all relevant documents was duly delivered to the Complainant, thereby giving an opportunity to the Complainant to verify and examine the benefits, terms and conditions of the Policy taken by the Complainant. Further alleges that the Complainant never approached the Opposite Party Company stating that any information given in the Policy Schedule was incorrect. The Complainant approached the replying opposite parties with a Reimbursement Claim vide Claim No. 91605652 with respect to the hospitalization of the Complainant at Harbans Nursing Home & Maternity Hospital, Moga w.e.f. 15.12.2020 till 29.12.2020. The total reimbursement claim amount to Rs. 1,94,638/-. Upon receipt of the claim the Respondent Company triggered an investigation to check the veracity of the claim. That upon investigation the following points came to light:
i) As per insured, patient having fever, cough and burning urination in initial 3-5 days of hospitalization but as per nursing note patient has fever only at the day of admission.
ii) All the vital till 24.12.2020 are monitored in day time, no night vital are monitored.
iii) After 25.12.2020 night vital of the patient are monitored and entire nursing note in the ICP seems single stretched.
iv) No treatment chart of the patient and progress noted are provided with the ICP.
v) As per pharmacy bill multiple medicine are maintained but no record of administrating of same medicine noted in the ICP.
vi) No diagnostic investigation and COVID-19 test advice by the doctor as no record of consultation for same present in the ICP.
vii) As per doctor advice patient underwent COVID-19 test on dated 1712-2020 and also advice to undergo for chest-CT and X-ray on same day but no X-ray and Chest-CT report provided by the patient and provided in the ICP.
viii) Final bills of patient hospitalization are maintained on the OPD slip of the hospital.
ix) Patient did not provide carbon copy of the final bill of hospitalization.
x) Vicinity of the insured address has been made and no confirmation of the insured hospitalization and COVID-19 diagnosis confirmed by neighbors.
In light of the fact the Complainant has seemingly played fraud on the Opposite Party Company. Opposite Party Company rejected the Claim of the Complainant on the ground of this point alone vide Letter dated 13.06.2021. The relevant clause of Policy Terms and Conditions is reproduced herein below:
"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."
In the light of above, the complaint is not at all maintainable, hence, there is no deficiency in services on part of replying opposite parties and hence the present complaint is liable to dismissed forthwith. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint is made.
3. To prove his case, complainant tendered in evidence his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C7.
4. To rebut the evidence of complainant, Opposite Parties tendered in evidence copies of documents Ex.OPs1 & 2/1 to Ex.OPs 1 & 2/9 and affidavit of sh.Saurav, Authorized Signatory of Care Health Insurance Ltd. Ex.OPs1 & 2/10.
5. During the course of arguments, ld. counsel for complainant has mainly reiterated the same facts as narrated in the complaint. He further contended that complainant has purchased a Medi Claim health insurance Policy from opposite parties vide policy No.18309703 with effect from 24th September 2020 to 23rd September 2021 for which complainant had paid premium of Rs.16,204/-. Unfortunately, health of the complainant became deteriorated as he was suffering from COVID-19 in the month of December 2020 and was got admitted in Harbans Nursing Home and Maternity Hospital, Kot-Ise-Khan, District Moga, under the observation of Dr. Harjot Kaur Kamboj, from 15.12.2020 to 29.12.2020 for which complainant had spent Rs.1,94,638/- vide bill dated 29.12.2020. The complainant informed the opposite parties regarding his treatment and deposited the requisite documents as required by opposite parties and opposite parties assured complainant that the insurance company will pay the whole expenses. However, complainant was astonished when he received the letter from the opposite party No.1 dated 13.06.2021 in which the claim of the complainant was repudiated with a reason that “Discrepancy in Medical Documents”. The complainant some how arranged the amount of Rs.1,94,638/- and got deposited the said amount in the hospital vide bill dated of 29.12.2020. Thereafter, the complainant approached opposite parties with a request to pay the amount but with no effect.
6. Ld. counsel for the Opposite Parties have filed written arguments, in which, he has mainly reiterated the same facts as narrated in the written reply. He further contended that opposite parties had issued health insurance policy vide policy number 18309703 covering the Complainant (Policy Holder), his spouse and a son with effect from 24.09.2020 to 23.09.2021 for a Sum Insured of Rs.5,00,000/- subject to policy terms and conditions. The copy of Schedule bearing relevant details of the Policy along with policy bond having terms and conditions were duly sent and delivered to the Proposer. The Complainant approached the opposite parties with a Reimbursement Claim vide Claim No. 91605652 with respect to the hospitalization of the Complainant at Harbans Nursing Home & Maternity Hospital, Moga w.e.f. 15.12.2020 till 29.12.2020. The total reimbursement claim amount to Rs. 1,94,638/-. Upon receipt of the claim the Opposite Parties triggered an investigation to check the veracity of the claim. That upon investigation the following points came to light:
i) As per insured, patient having fever, cough and burning urination in initial 3-5 days of hospitalization but as per nursing note patient has fever only at the day of admission.
ii) All the vital till 24.12.2020 are monitored in day time, no night vital are monitored.
iii) After 25.12.2020 night vital of the patient are monitored and entire nursing note in the ICP seems single stretched.
iv) No treatment chart of the patient and progress noted are provided with the ICP.
v) As per pharmacy bill multiple medicine are maintained but no record of administrating of same medicine noted in the ICP.
vi) No diagnostic investigation and COVID-19 test advice by the doctor as no record of consultation for same present in the ICP.
vii) As per doctor advice patient underwent COVID-19 test on dated 1712-2020 and also advice to undergo for chest-CT and X-ray on same day but no X-ray and Chest-CT report provided by the patient and provided in the ICP.
viii) Final bills of patient hospitalization are maintained on the OPD slip of the hospital.
ix) Patient did not provide carbon copy of the final bill of hospitalization.
x) Vicinity of the insured address has been made and no confirmation of the insured hospitalization and COVID-19 diagnosis confirmed by neighbors.
In light of the fact the Complainant has played fraud with the Opposite Parties. We have perused the final bill of the patient (Ex.C-3) and the same are maintained on the OPD slip, which creates doubt. Moreover, Opposite Parties have taken the plea that all the vital till 24.12.2020 are monitored in day time, no night vital are monitored and to prove this fact he brought our notice to the Vital Sign Chart attached with Ex.OPs1 & 2/6. We have perused the said document Ex.OPs1 & 2/6, it proves the averment of the Opposite Parties true, till date 24.12.2020 monitored in day time and not night vital are mentioned. So, we are of the view that since the disputed questions of facts are involved in the present complaint which can only be decided by the Civil Court after leading cogent evidence and therefore, the present complaint is not maintainable.
7. In view the aforesaid facts and circumstances and matter regarding fraud allegedly committed by the complainant regarding suppression of facts and since the complainant has failed to prove his case by filing any cogent and convincing evidence on the record, we are of the view that intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure under the Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court. Not only this, the nature of the dispute, in the present complaint, is squarely covered by the law laid down by their lordships of the Hon'ble Supreme Court in various judgements. Further in case Oriental Insurance Company Ltd. Vs. Munimahesh Patel 2006(IV) CPJ page 1, wherein the Hon'ble Supreme Court has held that :-
“Proceedings before the commission are essentially summary in nature and adjudication of issues which involve disputed factual questions should not be adjudicated. It is to be noted that commission accepted that insured was not a teacher. Complainant raised dispute about genuineness of the documents (i.e. proposal forms) produced by the appellant.”
Their lordships have further held that :-
“The nature of the proceedings before the commission as noted above, are essentially in summary nature. The factual position was required to be established by documents. Commission was required to examine whether in view of the disputed facts it would exercise the jurisdiction. The State Commission was right in its view that the complex factual position requires that the matter should be examined by an appropriate court of Law and not by the Commission.”
A similar view has been taken by the Hon'ble National Consumer Disputes Redressal Commission in 1(2004) CPJ page 101 wherein it has been held by the Hon'ble National Commission in a revision petition titled as R.D. Papers Ltd. Vs. New India Assurance Co. Ltd. & Ors. in para No.7 of the judgement which reads as under:-
“After going through the complaint and the written version, it appears to us that the complaint raises complicated questions of facts which cannot be decided by us in our summary jurisdiction.”
8. Keeping in view the aforesaid facts and circumstances of the case, the instant complaint is not maintainable in this District Consumer Commission for its proper adjudication and the same stands dismissed. However, the complainant can get redressal of her grievance from the Civil Court/ or any other competent authority, in accordance with law, for which the time spent before this District Commission shall stand excluded under Section 14 of the Limitation Act in the light of the judgment of the Hon'ble Supreme Court in case titled 'Lakshmi Engineering Works vs PSG Industrial Institute reported in 1995(3) SCC 583'. However, keeping in view the peculiar circumstances of the case, the parties are left to bear their own costs. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Commission.
