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 on the assurance of the agent of the Opposite Parties, the complainant purchased the health insurance policy for his entire family from the Opposite Party. Complainant no.2 is the father of the complainant no.1 who is covered under the policy. This health insurance policy was cashless and valid from 26.12.2019 to 25.12.2020. During the policy period, the complainant no.2 fell ill due to abdomen pain and he remained hospitalized in DMC, Ludhiana for his treatment from 05.09.2020 to 17.09.2020, where he spent a sum of Rs.3,50,000/- on his medical treatment. At the time of admission in the hospital, the complainant no.1 showed the insurance policy issued by Opposite Party for cashless facility, but the officials of the Opposite Party replied that it will take time to get authorization from their panel doctors. At the time of discharge from the hospital on 17.09.2020, the complainant no.1 again made a request to the Opposite Party to make the payment of the hospitalization bills, but the Opposite Party failed to do the needful and hence complainants were compelled to make the payment of Rs.3,50,000/- to the treating hospital from his own pocket. At the time of purchasing the policy, the complainants and their family members were got medically checked up by the Opposite Party from their own doctors and after their full satisfaction, the Opposite Party issued the policy. The Opposite Party illegally repudiated the genuine and legal claim of the complainant giving the false and frivolous ground. The Opposite Party repudiated the claim of the complainant vide letter dated 17.09.2020. Hence this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to reimburse the medical claim of the complainants amounting to Rs.3,50,000/- as per bills alongwith interest @ 12% per annum from the date of payment till its actual realization.

 b)     To pay an amount of R.50,000/- as compensation on account of mental tension, harassment and agony.

c)       To pay an amount of Rs.25,000/- 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 Party appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present complaint is filed without any cause of action. The present complaint pertains to insurance claim under Future Health Suraksha-Family Floater Policy bearing No.FHR-63-197022245-00-000 valid from 26.12.2019 to 25.12.2022 covering the complainant self and his father Amrik Singh Dhaliwal and mother Jasveer Kaur i.e. for a sum of Rs.5,00,000/-. However the aforesaid insurance policy was issued to the insured by the answering Opposite Party subject to the terms and conditions of the insurance policy. The said terms and conditions were handed over and supplied to the insured at the time of the contract. Moreover, the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same were served to the complainant along with policy schedule. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Therefore it is submitted that in case if any liability would arise against the answering Opposite Party, then it would be subject to the terms and conditions of the insurance policy. The insured requested for a cashless authorization for the treatment of bleeding PR internal hemorrhoids on dated 05.09.2020 and he got admitted in Dayanand Medical College and Hospital, Ludhiana and submitted claim for Rs.64600/- on initial basis as estimated amount only which could increase or decrease subsequently till the discharge of the patient. On scrutiny of the cashless claim documents as provided by the insured, it was found and observed by the answering Opposite Party that the insurance was not able to ascertain the duration of the disease based on the documents/details received by it and it requires further evaluation and thus the Opposite Party insurance company vide letter dated 05.09.2020 requested the insured to submit certain documents and information for the processing of the claim further. Hence cashless claim was rejected vide letter dated 17.09.2020. On scrutiny of claim documents the medical team of the answering company observed from the indoor case records of the treating hospital that the insured patient has undergone treatment of internal hemorrhoids. Based on these finding, the cashless claim was denied as according to the Exclusion 1 of the policy and it was conveyed to insured. The instant complaint is neither maintainable in law nor on facts. No deficient services have been rendered by the answering Opposite Party as alleged by the complainant. The complaint being pre-mature and false is not maintainable. The complainant has not come with clean hands. He has not disclosed the entire true facts. The complainant has also suppressed the material facts from this Commission as well as from the answering Opposite Party. Further alleged that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the Proposal form. 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, complainant tendered in evidence his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C6.

4.       To rebut the evidence of the complainant, Opposite Party No.2 tendered in evidence affidavit of Sh.Masiruddin Shaikh, Assistant Manager-Legal Ex.OP/A along with copies of documents Ex.OP/1 to Ex.OP/7.

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

6.       All the facts as narrated by the complainant in the complaint are admitted, but the only plea raised by Opposite Party is that the complainant has violated the terms and conditions of the policy in question and as per the terms and conditions of the policy, the complainant is not entitled to the claim as claimed.  The opposite party is not liable to make payment under the policy, as the treatment of Bleeding PR Internal Hemorrhoids is not covered for the first two years from the policy start date. Further the plea has been taken by the Opposite Party is that terms and conditions were handed over and supplied to the insured at the time of the contract and the same were served to the complainant alongwith policy schedule. But the Opposite Party could not produce any evidence to prove that terms and conditions of the policy were ever supplied to the complainant i.e. 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 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. Reliance in this connection can be placed on Modern Insulators Ltd.Vs. Oriental Insurance Company Limited (2000) 2 SCC 734, wherein it is held that “In view of the above settled position of law, we are of the opinion that the view expressed by the National Commission is not correct. As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclosed to the appellant, the respondent can not claim the benefit of the said exclusion clause. Therefore, the finding of the National Commission is untenable in law.” 

          Being guided by the above findings it has been observed that the Opposite Party failed to discharge its burden to prove that the complainant was duly supplied with the terms and condition of the policy in question. In the given circumstances, the non-payment of the genuine claim of the complainant not only amounts to deficiency in service on the part of the Opposite Party, but further amounts to unfair trade practice resorted to by the Opposite Party. Moreover, the judgement so relied upon by the Opposite Party is not applicable to the facts and circumstances of the present complaint. 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.

7.       From the discussion above, the deficiency in service on the part of the Opposite Parties is proved and the Opposite Parties are held liable to make good the loss of the complainant i.e. to pay the genuine claim which has unjustifiably been repudiated. Vide instant complaint, the complainant has claimed the amount of Rs.3,50,000/- for his treatment alongwith compensation and litigation costs. But the complainants failed to prove that they have spent Rs.3,50,000/- on treatment of complainant no.2. They only placed on record copy of bill dated 17.09.2020 Ex.C4, which shows that during the period from 05.09.2020 to 17.09.20220, complainant spent only Rs.1,58,108.53/-Hence, we allow the same.

8.       In view of the above facts and circumstances, we party allow the complaint of the complainant and direct the Opposite Party to pay an amount of Rs.1,58,110/- spent by the complainants (Rupees One Lakh Fifty Eight Thousand One Hundred Ten (round off) only). Opposite Party is also directed to pay compository amount of Rs.10,000/- (Rupees Ten 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 Parties are further burdened with 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