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 deceased husband of the complainant namely Purusharath Garg purchased health insurance policy bearing no.P/211222/01/2022/007124 for the period from 08.12.2022 to 07.12.2023, Basic Floater Sum Insured Rs.5,00,000/- from Opposite Parties covering self as well as complainant. Unfortunately on 30.12.2022, the husband of the complainant fell ill and got admitted firstly in Delhi Heart Hospital, Moga and thereafter got admitted in DMC, Ludhiana on 30.12.2022 and got discharged on 07.01.2023. Alleged that on 12.01.2023, the husband of the complainant again felt ill and got admitted in Sidhu Hospital, Moga and on the same day doctor of Sidhu Hospital referred him to DMC, Ludhiana and he admitted in DMC Hospital, Ludhiana on 12.01.2023. Thereafter died on 13.01.2023. Alleged further that at the time of treatment, the complainant requested the Opposite Parties to provide cashless facility, but they have not provide cashless facility and promised that they will pay the whole amount at the time of reimbursement of the claim, so in these circumstances, the complainant has to pay the whole amount from his pocket. Alleged further that after the death of husband of complainant, the complainant lodged the claim with Opposite Parties and submitted all the medical record alongwith required documents with them and also furnished self declaration for the satisfaction of the query of Opposite Parties, as per demand, but despite that the Opposite Parties have not paid any amount to complainant in lieu of medical expenses and repudiated the claim vide letter dated 24.06.2023. Alleged that complainant spent Rs.2,22,341/- on the treatment of his husband. Due to such act and conduct of Opposite Parties, the complainant has suffered mental tension and harassment.  Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite parties may be directed to release the amount of Rs.2,22,341/-(Rs.13,900/-  paid to Delhi Heart Hospital, Moga, Rs.1,60,971/- paid to DMC Ludhiana, Rs.8500/- spent at Sidhu Hospital, Moga and Rs.4980/- paid to DMC, Ludhiana and Rs.33,990/- other expenses) incurred on the treatment of husband of the complainant alongwith interest @24% p.a. till its realization.

b)      To pay Rs.50,000/- as compensation on account of mental tension and harassment.

c)       To pay Rs.33,000/- 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 appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the 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 summary procedure under C.P. Act and appropriate remedy, if any, lies only in the Civil Court; the complainant has concealed material facts and documents from this Commission as well as from the opposite parties, therefore, the complainant is not entitled to any relief. Further averred that deceased husband of the complainant namely Pursharath Garg availed the ‘Family Health Optima Insurance Plan’ Policy No.P/211222/01 /2023/008778 for the period 08.12.2022 to 07.12.2023 and under this policy, husband of the complainant Pursharath Garg and his spouse Veena Kumari  were insured for an amount of Rs.5,00,000/-. Further submitted that the terms and conditions of the policy were explained to the complainant at the time of proposing the policy and same were served to the complainant alongwith policy schedule. Further submitted that policy is contractual in nature and the claims arising therein are subject to terms and conditions forming part of the policy. Averred that policy in question in continuation since 08.12.2020 and the claim was registered vide claim no.CIR/2023/211222/1294299. Further it is averred that insured requested for cashless and submitted the documents for hospitalization on 30.12.2022 in Dayanand Medical College and Hospital, Ludhiana towards the treatment of Right Temporal SDH with Seizure Disorder and cashless was rejected on 06.01.2023 with the reason that Opposite Party is not able to ascertain the duration of the disease based on the documents/details submitted by the hospital and it requires further evaluation. After this subsequently insured has submitted the claim documents in the present case regarding the medical reimbursement expenses towards the treatment of husband of complainant taken by him at DMC & Hospital, Ludhiana from 30.12.2022 to 07.01.2023 with disease named above and claimed Rs.2,18,881/-. On perusal of submitted record, medical team of Opposite Parties demanded documents and after scrutinizing the record it was found that as per the discharge summary of the hospital the insured patient had Cerbrovascular Accident from the year, 2011, which is prior to inception of the policy in question and the same has not been disclosed at the time of taking medical policy in question and the above said history/health details of the insured patient not mentioned in the proposal form which is clear cut violation of the terms and conditions of the policy in question and came under the exclusion clause. Averred that as per condition no.1 of the policy issued to the complainant or her husband on the conditions that if there is any misrepresentation made by whether the insured person or on behalf of the insured person, the insurance company is not liable to pay any claim, hence the claim was rejected vide repudiation letter dated 24.06.2023 and duly informed to the complainant. Averred further that the present complaint has been filed for claiming the amount of Rs.2,22,341/- as mentioned in the complaint regarding the treatment taken from said hospital, but as per the alleged claim form the amount was claimed only Rs.2,18,881/-, so the complaint is liable to be dismissed on this ground alone being filed by violating the terms and conditions of the policy and even not disclose any pre-existing disease at the time of taking the policy in question. Averred further that in this case insured availed policy through online and has deliberately answered ‘None’ to the query raised in the online proposal form regarding declaration of health histories which is clearly proved from the proposal form, from where it is clear that he intentionally not disclosed the same, so he is not liable to any claim. Further averred that the complainant is not the consumer of Opposite Parties and the complaint is liable to be dismissed; the complainant has no locus standi or cause of action to file the present complaint against Opposite Parties; the complaint is not maintainable in the present form; the complainant has violated the terms and conditions of the policy. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       In order to prove his case, the complainant has placed on record her affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C10.

4.       To rebut the evidence of complainant, Opposite Parties have placed on record copies of documents Ex.OP1 to Ex.OP14 and affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP15.

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

6.       It is admitted case of the complainant that husband of the complainant namely Purusharath Garg (now deceased) availed health insurance policy for the period from 08.12.2022 to 07.12.2023, Basic Floater Sum Insured Rs.5,00,000/- from Opposite Parties covering self as well as his wife Veena Kumari i.e. present complainant. Unfortunately on 30.12.2022, the husband of the complainant fell ill and got admitted firstly in Delhi Heart Hospital, Moga and thereafter got admitted in DMC, Ludhiana on 30.12.2022 and got discharged on 07.01.2023. Thereafter on 12.01.2023, the husband of the complainant again felt ill and got admitted in Sidhu Hospital, Moga, where he was referred to DMC Hospital, Ludhiana. Accordingly, the husband of the complainant got admitted in DMC Hospital, Ludhiana on 12.01.2023 and discharged on the same day. Unfortunately, the husband of the complainant died on 13.01.2023. However, the main grievance of the complainant is that the claim lodged for the reimbursement of the expenses incurred on the treatment of the deceased husband of the complainant was repudiated by the Opposite Parties. Now, the question is to be decided is that whether the repudiation of the claim by the Opposite Parties is genuine or not?

7.       Perusal of the record reveals that firstly the Opposite Parties repudiated the claim vide letter dated 24.06.2023 on the ground that ‘it is observed from the discharge summary of the above hospital that insured patient had cerebrovascular accident from the year, 2011, which is prior to inception of medical insurance policy. At the time of inception of policy which is from 08.12.2020 to 07.12.2021, the above mentioned medical history/health details of the insured-person were not disclosed in the proposal form which amounts to misrepresentation/ non disclosure of material facts’. The ground so taken for repudiation of the claim of the complainant is not sustainable, as it is the duty of the insurance company to get medically examined the person before issuing of the policy. If the complainant was suffering from any disease prior to issuance of the policy, in question, the same must not have escaped from the notice of the empanelled doctors of the Insurance Company. In case Bajaj Allianz Life Insurance Co. Ltd. & Ors. Vs. Raj Kumar III (2014) CPJ 221 (NC), it was held by the Hon’ble National Commission that usually, the authorized doctor of the Insurance Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. It was held that the Insurance Company wrongly repudiated the claim of the complainant.

8.       Furthermore, as per the policy document Ex.C2 placed on record by the complainant reveals that the life assured has duly mentioned his age as 59 years and date of inception of first policy is mentioned as 08.12.2020 (meaning thereby at the time of availing the policy, the age of the deceased life assured was more than 45 years), so it was the bounden duty of the Opposite Parties-Insurance Company to get the life assured medically examined before issuing the policy in his name who was above the 45 years of age. In this regard, we are well guided by Rules and Instructions of I.R.D.A.I with regard to thorough medical examination if the insured is more than 45 years which is reproduced as under:-

“As per instructions issued by the Insurance Regulatory and Development Authority of India (IRDAI), it was bounded duty of the insurer to put insured to thorough medical examination in case Mediclaim insured was more than 45 years and if insurance company failed to do so then insurance company has no right to decline the insurance claim on account of non disclosure of the facts of pre existing disease when the policy was taken. The above observations is supported by law cited in SBI General Insurance Company Limited Vs. Balwinder Singh Jolly” 2016(4) CLT 372 of the Hon’ble State Commission, Chandigarh.”

The Opposite Parties-Insurance Company has not placed on record any evidence showing that before issuing the policy they ever got medically examined the insured. So the abovesaid law squarely covers the case of the complainant that it was the duty of the insurer to get insured medically examined, while issuing the policy.

9.       Now come to the quantum of amount to be awarded to the complainant. Vide instant complaint, the complainant claimed the amount of Rs.2.22,341/- i.e. Rs.13,900/- paid to Delhi Heart Hospital, Moga, Rs.1,60,971/- paid to DMC Ludhiana, Rs.8500/- Sidhu Hospital, Moga, Rs.4980/- paid to DMC Ludhiana and Rs.33,990/- other charges. However perusal of the record reveals that vide Ex.OP-14, the Opposite Parties assessed the final admissible amount of Rs.1,68,875/- after deducting the amount of Rs.13,444/- as already been paid, but the Opposite Parties have not placed on record any document, which shows that amount of Rs.13,444/- has already paid to the complainant. Hence we allow the admissible amount of Rs.1,68,875/-  plus Rs.13,444/- totaling Rs.1,82,319/-.

10.     From the above discussion, we partly allow the complaint of the complainant and direct the Opposite Parties to pay an amount of Rs.1,82,319/- (Rupees One Lakh Eighty Two Thousand Three Hundred Ninety only) to the complainant. Opposite Parties are also directed to pay compository costs of Rs.15,000/-(Rupees Fifteen Thousand only) as compensation and litigation expenses to the complainant. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Parties within 45 days from the date of receipt of copy of this order, failing which, the Opposite Parties are further burdened with additional cost of Rs.10,000/-(Rupees Ten Thousand only) to be paid to 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