Complainant Nishan Singh has filed the present complaint against opposite parties (for short O.P.) U/S 12 of the Consumer Protection Act, 1986 with a prayer that opposite parties may be ordered to make payment of Rs.2,79,851.14 alongwith interest @ 22% P.A. from the date of commencement of the treatment of his wife. Opposite parties be also directed to pay Rs.1,00,000/- as compensation on account of mental agony and harassment suffered by him on their part alongwith  litigation expenses.

2.     The case of the complainant in brief is that he and his wife Kulwinder Kaur have opened a joint Saving Bank Account in the HDFC Bank Amritsar Road, Batala and as such both of them are on visiting terms in the Bank for the operation of their joint account in the Bank. On the allurement of the Branch Manager, he and his wife purchased an Insurance Policy (Health Surksha Policy Silver Plan) bearing No.2952 2008 8134 2100 000 dated 15.10.2012 for a sum of Rs.3,00,000/-. The said policy has been continued year after year and hence the validity is extended upto 17.10.2015 Midnight. He has further pleaded that his wife suffered from Heart ailment and she started her treatment from Tagore Hospital and Heart Care Centre Private Ltd. Banda Bahadur Nagar Mahavir Marg Jalandhar. She was admitted as indoor patient in this hospital on 3.12.2014 and was discharged on 20.12.2014. He revealed the trouble of Hypertension suffered by his wife to the opposite party and they assured him that in case of any problem, first go for treatment and then submit the bill for reimbursement. He submitted the bills of reimbursement No.14007100 dated 22.12.2014 for a sum of Rs.2,20,000/- of Tagore Hospital and Bill No.1588/R1/14-15 dated 5.12.2014 of GEENESEE MEDICALS  for Rs.50,000/- and other small bills of different dates worth Rs.9451.14. Thus total bills summing upto Rs.2,79,851.14. The opposite parties induced him and his wife at the first instance that the Insurance Claim is Cashless but when the bills were submitted he was directed to pay the bill and it will be reimbursed subsequently, but later on the opposite parties did not make the payment of the Medical claim to his wife. Thus there is deficiency in service on the part of the opposite parties. Hence this complaint.

3.      On notice, opposite parties appeared through their counsel and filed their joint contested written statement taking the preliminary objections that the complainant has no cause of action to file the present complaint; the insurance is a contract and the liability of any of the parties arise subject to the terms and conditions of the insurance contract. Thus the terms of the contract is the sine-qua-non of any claim and is to be strictly adhered with while deciding any claim. As such opposite parties have rightly evaluated the claim on the basis of terms and condition and repudiated the claim due to violation of terms; there is no deficiency in service on the part of the opposite parties. The claim of the complainant has rightly been repudiated due to breach of the terms and conditions of the policy. The claim is repudiated as the claim was found to be manipulated, misrepresented and there was concealment of material medical facts. On verification, it was found that patient was suffering from ailment before taking the policy i.e. pre-existing ailment and insured concealed the facts at the time of policy. As per policy terms and conditions if any claim in any manner found dishonest or fraudulent or is supported by any dishonest or fraudulent means, whether by insured person or anyone acting on behalf of insured person, then the policy shall be void and all the benefits paid under it shall be forfeited so the claim has been repudiated as per terms and conditions of the policy. The repudiation letter dated 28.05.2015 has been duly sent. The claim has been repudiated after sending many reminder letters to explain the abovesaid reason, but the complainant failed to give any reply due to which the claim has been repudiated.  On merits also, the same pleadings have been repeated and dismissal of the complaint has been prayed.

4.         Complainant tendered into evidence his own affidavit Ex.C-I and of Kulwinder Kaur Ex.C2, along with the other documents exhibited as Ex. C3 to Ex.C42 and closed the evidence.

5.     On the other hand, counsel for the opposite parties tendered into evidence affidavit of Sh.Pankaj Kumar Authorized Signatory Ex.OP1, alongwith the other documents Ex.OP2 to Ex.OP21 and closed the evidence

6.         We have carefully examined all the documents/evidence produced on record and have also judiciously considered and perused the arguments duly put forth by the learned counsels along with the incidental scope of adverse inference for some documents that have been somehow ignored to be produced by the contesting litigants. We observe that the prime dispute has prompted from the OP’s claim repudiation of 28.05.2015 (Ex.C6) in response to the complainant’s insurance claim(s) of Rs.2,79,851/79 p (Ex.C4 & C5) for reimbursement of the hospitalization expenses incurred by him upon medical treatment of his insured wife Kulwinder Kaur. Further, the OP insurers have duly admitted in the written statement & also in its affidavit (Ex.OP1) that the impugned insurance claims was repudiated in terms of Ex.OP6 (28.05.2015): “The claim is repudiated as the claim was found to be manipulated, misrepresented and there was concealment of medical facts. On verification, it was found that the patient was suffering from the ailment before taking the Policy but insured concealed the facts. As per policy terms and conditions if any claim is in any manner dishonest or fraudulent or is supported by any dishonest of 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 U/c 10 r ii & 9 A iii.”; whereas these read as: “9. Exclusions: A. Waiting Periods: All claims will be subject to the waiting periods specified below: iii) 48 months waiting period for all Pre-existing Conditions declared and/or accepted at the time of application. 10. General Conditions: r: Termination: ii)

We may terminate this policy on grounds of misrepresentation, fraud, non-disclosure of material facts or non-cooperation by you or any insured Person or anyone acting on Your behalf or on behalf of an Insured Person. Such termination for the Policy shall be from the inception date or the renewal date (as the case may be) upon 30 days notice and by sending an endorsement in this regard at your address shown in the schedule without refund of any premium”. We further find that the complainant has duly provided all the requisite information as desired in the claim formats and the information(s) sought by the OP insurers vide Ex.OP3 (04.02.2015), Ex.OP4, Ex.OP5 & Ex.OP6 (26.11.2014) were already available with them (vide the related proposal form(s) etc) and otherwise also vide the documents accompanying the impugned (Ex.OP7 to OP10) insurance claims and its enclosures (Ex.OP10 to OP16). The OP insurers have somehow not produced the proposal/subsequent renewal forms and these should also contain more information etc. To sum it up all, the OP insurers have failed to produce any cogent evidence to support the above grounds/basis of repudiation and in its absence these shall amount to ‘bald’ statements, only. Even, there is no evidence of ‘other conditions (including the 30 days notice) mandatorily required by the OP own quoted 10 r ii & 9 A iii’. It is not proved on record that the complainant and/or the patient did conceal any pre-existing ailment at the time of purchase of the Health Policy. The OP insurers’ reference to Ex.C8 (13.04.2015) during the course of arguments is still the more unfounded as the letter is addressed to the insurers by an RMP doctor (sans any context and/or locus-standi) claiming to have diagnosed the patient for Hypertension in the year 2010 (cured in 2 months time only) with further diagnosis of RHD (Rheumatic Heart Disease) in August’ 2012 through Bhalla Lab, Batala; since the same is neither supported by any ‘deposition’ nor the Lab report etc. Thus, the OP insurers’ impugned repudiation of the insurance claim does not entail legality under the applicable law and need be set-aside.     

7.       In the light of the all above, we partly allow the present complaint and thus ORDER the OP insurers to pay the impugned insurance med-claim(s) with full Hospitalization Benefits as applicable under the related Policy to the complainant besides Rs.5,000/- as compensation (for the harassment inflicted) and Rs.3,000/- as cost (of litigation) within 30 days of the receipt of the copy of these orders otherwise the aggregate awarded amount shall attract interest @ 9% PA from the date of filing of this complaint till actual payment. 

8.       Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to records.

                          (Naveen Puri)

                                                                                             President      

ANNOUNCED:                                                                   (Jagdeep Kaur)

May 05, 2016                                                                       Member

*MK*