Order by:

Smt.Priti Malhotra, President

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that the complainant is the account holder of opposite party no.1-bank having account no.100008573891. In the month of March 2021, opposite party no.1 offered a group assurance health plan of Opposite Party No.2 to the complainant, which was accepted by him  and opposite party no.1 deducted the amount of Rs.5822/- from the account of complainant as premium of the policy. After that opposite party no.2 issued a policy as well as identity Card to the complainant. In this way, the complainant was insured with Insurance Company known as HDFC Ergo vide 2811204100697900000 dated 31.03.2021 and the opposite party no.1 handed over policy issued to the complainant. Unfortunately, complainant suffered from breathlessness cough and fever etc. The family members of the complainant got her admitted in Harbans Nursing Home & Maternity Hospital, Kot Ise Khan District Moga for treatment. H.R.C.T. Test of the complainant was got done at Jaiswal Diagnostic Centre, Moga on 11-52021. Lateron Rapid Antigen sample was collected by the concerned doctor/staff and complainant was advised to isolate herself till the sample is tested and complainant was found Corona +ive. Due to the Covid-19 disease, the complainant remained under regular treatment form 11.05.2021 to 19.5.2021 in Harbans Nursing Home & Maternity Hospital. The complainant spent Rs.4,00,000/- on her treatment. After recovery the complainant approached the Opposite Parties and requested them to pay the amount incurred by her on the treatment. Opposite Party No.1 demanded the entire record regarding the treatment and complainant furnished the same to Opposite Party No.1. Accordingly claim filed by the complainant was duly registered with Opposite Parties. But however, the Opposite Parties vide its letter dated 20.09.2021 repudiated the claim of the complainant on the ground of fraud instituted against the company by producing forged documents. Lateron vide letter dated 21.09.2021, the Opposite Parties issued notice of cancellation of policy in question. However, the complainant has not played any fraud with the Opposite Parties in any manner. Due to the acts of the Opposite Parties, complainant 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 pay an amount of Rs.4,00,000/-  along with upto date interest @ 18% p.a. on the basis of policy no.2811204100697900000 dated 31.03.2021.

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

c)       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 Party No.1 appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present complaint is not maintainable, as there is no relationship of consumer and service provider between the parties. The insurance policy has been purchased by the complainant from HDFC Ergo General Insurance Company limited/Opposite Party No.2. The complainant has no cause of action to file the present complaint against the answering Opposite Parties. The complainant has not come to this commission with clean hands and has tried to misled this Commission by stating wrong facts. No claim has been submitted by the complainant before the answering Opposite Party. The answering Opposite Party came to know about the said claim of complainant from Opposite Party No.2 and after that answering Opposite Party thoroughly verified the facts from Opposite Party No.2 and came to know about the filing of this false complaint. Further alleged on 20.06.2021, Opposite Party No.2 received a Reimbursement claim which was registered vide claim no.RP-HS21-12378394 for complainant who admitted in Harbans Nursing Home & Maternity Hospital with date of admission as 11.05.02021 and date of discharge as 19.05.2021 for the claimed amount of Rs.375882/-. In the investigation done by Opposite Party No.2 through an independent investigator and noted that patient is not having the covid positive report and confirmatory SMS. The lab register was verified and no test entry for covid-19 was seen in the lab register. The vital are prepared in the single stretch and no treatment sheet and intake and output charting was found in icp. No notes for the patient saturation by oxygen inhalation were found in the icp. As per the treating doctor the patient has made the request for the inflation in the bills for the adjustment of other expenses, hence manipulation of fact noted. As per the treating the patient was on the day care treatment from 16.05.2021 to 19.05.2021 and inflated the bills for an amount of Rs.1,90,000/- to adjust her expenses. Thus, there is no deficiency in service on the part of answering Opposite Party. So, in view of the above mentioned misrepresentation by the complainant, the claim was rightly rejected. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       Opposite Party No.2 appeared through counsel and filed written reply taking preliminary objections therein inter alia that the complaint filed by the complainant is in entirety vague, false, vexatious and frivolous without merits and is an abuse of Consumer Protection Act. The complainant had with malfide and dishonest intention not only concealed the material facts but had also twisted and distorted the same to suit his convenience and to mislead this Commission. The present complaint does not disclose any cause of action against answering Opposite Party. The complainant has miserably failed to demonstrate any deficiency in service nor have attributed any fault, imperfection, shortcoming or inadequacy in the quality, nature and manner of performance, which is required to be maintained in pursuance of a contract. In the present case, as per the submitted documents misrepresentation of facts was noted in the claim documents. In the investigation done by Opposite Party No.2 through an independent investigator during investigation it was found that the patient is not having the covid positive report and confirmatory SMS. The lab register was verified and no test entry for covid-19 was seen in the lab register. All other averments have been reiterated as have been mentioned in the reply by Opposite Party No.1. It is claimed that there is no deficiency in service on the part of answering Opposite Party while rendering the services to the insured nor were the Opposite Party indulged into any unfair trade practice while rejecting the claim. Further alleges that the Policy of Insurance is a contract between the Insured and the insurer and the terms and conditions of the Policy of Insurance are binding upon the Parties. Terms and conditions are required to be read with reference to the stipulations contained in the Policy. Non observance of the terms and conditions vitiates the Policy and absolve the Insurance Company of its liability to indemnify the Complainant. In the present case, there was a breach of Policy conditions done by the policy holder. Further alleged that gross discrepancies and misrepresentation were noted between the statement of the insured and the claim documents. Since there was a breach of the fundamental conditions of the Policy, the answering Opposite Party is justified in rejecting the Claim of the Complainant. Further alleges that this Complaint has been filed with an intent to claim relief which are in complete contravention of the terms and conditions of the contract of insurance between the parties, the Complaint being fully aware about the said factual situation regarding the consequences of fraudulent claim has prayed for relief's in the present Complaint which travels beyond express terms of subject policy, thus the present Complaint is nothing but gross abuse of process of law and deserves to be dismissed with exemplary cost. In the present case as well, in accordance with Clause 6 (2) of the Insurance Regulatory and Development Authority (Protection of Policyholders' Interest) Regulations 2002 the answering Opposite Party had dispatched the Policy documents to the Policyholder. The said Policy document was duly received by him. Further alleged that the insured never approached the answering Opposite Party alleging any discrepancy or any grievance relating to the Policy or its terms and conditions during freelook period, implying that the Policyholder had agreed to the contents in the application form, Policy and their terms and conditions and were in order. The answering Opposite Party on 20.06.2021 received a Reimbursement claim which was registered vide Claim No. RR-HS21-12478394 for Complainant who got admitted in Harbans Nursing Home & Maternity Hospital with date of admission as 11.05.2021 and Date of Discharge as 19.05.2021 for the claimed amount as Rs. 3,75,882/-. That Complainant submitted claim form, discharge summary and other medical documents with opposite party. The claim was sent for Investigation and from the Investigation misrepresentation was noted. The following the discrepancies noted by the Opposite Party Company:-

i)       As per the treating doctor the patient has inflated the bill for an amount of 190000/- one lacs ninety thousand to adjust the expenses.

ii)      The patient is not having the covid positive report and confirmatory sms.

iii)     The lab register was verified and no test entry for covid 19 was seen in the lab register.

iv)     The vitals are prepared in the single stretch, and no treatment sheet and intake and output charting was found in the icp. No icu notes / doctor/ consultant notes were found in the icp, no notes for the patients saturation or oxygen inhalation were found in the icp.

v)      As per the treating doctor the patient has made the request for the inflation in the bills for the adjustment of other expenses.

vi)     As per the treating the patient was on the day care treatment from 16/05/2021 to 19/05/2021 and inflated the bills for an amount of 190000 to adjust her expenses.

          In view of the above submission, the claim was found to be misrepresented. As per the policy terms and conditions, if any claim is in any manner dishonest or fraudulent, or is supported by any dishonest or fraudulent means or devices, whether by insured person or anyone acting on behalf of an insured person, then this policy shall be void and all benefits paid under it shall be forfeited. Hence this claim is being repudiated under policy terms & conditions and policy was also cancelled. On merits, all other allegation made in the complaint are denied and a prayer for dismissal of the complaint is made.

4.       Complainant also filed replication to the written reply of Opposite Parties, denying the objections raised by the Opposite Party no.2 in their written reply.

5.       In order to prove his case, complainant tendered in evidence his affidavit Ex.CW1/A alongwith copies of documents Ex.C1 to Ex.C23.

6.       To rebut the evidence of the complainant, Opposite Party No.1 tendered in evidence affidavit of Smt.Deepika Legal Manager, Equitas Small Finance Bank Ex.OP1/1. Whereas, Opposite Party No.2 tendered in evidence affidavit of Sh.Manoj Kumar Prajapati, Manager-Corporate Legal, HDFC Ergo General Insurance Co. Ltd. Ex.OP2/1 along with copies of documents Ex.OP2/2 to Ex.OP2/5.

7.       We have heard the counsel for the complainant and gone through the documents placed on record.

8.       There is no dispute with regard to the policy namely Group Personal Accident Insurance bearing no.3318204100698000000 for the period 31.03.2021 to 30.03.2022 purchased by the complainant from the Opposite Parties by paying a premium of Rs.5822/-. Moreover, the hospitalization of the complainant for the period 11.05.2021 to 19.05.2021 is also not disputed. It is matter of record that the complainant suffered covid-19 and taken treatment for the same. This factum is also proved by statements given Dr.Aniljit Singh Kamboj and Dr.Harjot Kamboj (treating doctors) who were called as witnesses before this Commission. The claim raised for the reimbursement of the expenses incurred by the complainant was declined by the Opposite Parties, vide letter dated 20.09.2021 Ex.OP2/5on the ground that “as per the documents submitted, the claim was found to be misrepresented. As per the policy terms and conditions, if any claim is in any manner dishonest or fraudulent, or is supported by any dishonest or fraudulent means or devices, whether by insured person or anyone acting on behalf of an insured person, then this policy shall be void and all benefits paid under it shall be forfeited. Hence this claim is being repudiated under Section 8 of the policy terms and conditions. Furthermore, as the policy is under process of cancellation, no further claim will be entertained.” Perusal of the record shows that the statements given by Dr.Aniljit Singh Kamboj and Dr.Harjot Kamboj clinches the whole issue and negates the alleged factums qua the complainant not suffered from Covid-19 and approached the said doctors for inflation in bills. The statement suffered by Dr.Aniljit Singh Kamboj and Dr.Harjot Kamboj are reproduced as under:-

“Stated that complainant Amarjit Kaur wife of Rashpal Singh, resident of House No.47, Kot Ise Khan, Tehsil Dharamkot, District Moga was admitted in my hospital on 11.05.2021 suffered from breathlessness, cough and fever etc. Patient was treated conservatively then revived antibiotics antipyretic and antiviral medicines. Patient was remained on oxygen with HFNC and ventilator. Patient discharged on 19.05.2021. He was suffered from Covid-19. Reports already in the Court file are Ex.C8 and Ex.C9. I have seen the bills Ex.C10 to Ex.C17 which are duly issued by our lab in the hospital and chemist shop situated in my hospital. I have seen the  discharge card in the court file Ex.C18 which is duly issued by me. I have seen the bill Ex.C19 in the court file which is duly issued by me. I have also brought my hospital record today i.e. final bill and lab bill and chemist shop bill issued to the patient,  the copies of the same are Mark-A, Mark-B,  Mark-C, Mark-D and Mark-E. I never inflated the bill at the request of the patient as alleged by the opposite parties in their written statement. Opposite Parties himself written without my permission above the already bills signed and sealed by me.”

From the aforesaid statement, it is proved that the complainant suffered from Covid-19 and was given the treatment of the same and he never ever approached the doctors concerned for inflation in bills. So, in view of the aforesaid statement of the doctors concerned, the investigation report relied upon by the Opposite Parties for repudiating the genuine claim of the complainant is not justified. 

          In the given circumstances, the repudiation made by the Opposite Party-Insurance Company regarding genuine claim of the complainant has been made without application of mind. It is usual with the insurance company to show all types of greener pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these 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. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

In view of the above discussion, we partly allow the complaint of the complainant against Opposite Party No.2 and direct the Opposite Party No.2 to pay an amount of Rs.3,75,882/- incurred by him on her treatment, as per bill Ex.C19 produced on record by the complainant. Complaint against Opposite Party No.1 stands dismissed. Opposite Party No.2 is also directed to pay compository amount of Rs.25,000/- (Rupees Twenty Five Thousand only) towards compensation and litigation costs to the complainant. The compliance of this order be made by the Opposite Party within 30 days from the date of receipt of copy of this order, failing which, the Opposite Party No.2 is burdened with additional amount of Rs.20,000/- (Rupees Twenty Thousand only) to be paid to the complainant. 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