Nidhi Verma, Member
1 The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.
2 The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 11 and 12 against the opposite party on the allegations that the complainant had purchased Health Policy from the opposite party under the name of Health Suraksha Policy (Silver Plan) for himself and his wife namely Shifali Arora and his two minor sons namely Isha Aroa and Reyansh Arora. The complainant had paid the premium amount and the opposite party had issued only the cover note and never issued any document alongwith policy containing the terms and conditions. The policy was obtained/ purchased by the complainant from the opposite party bearing Policy No. 28251001099459300000 dated 7.4.2016 till 6.4.2018 for which premium of Rs. 16,210/- was paid by him. Thus the complainant having hired the services of the opposite party for due consideration, is covered under the definition of Consumer as defined under the Consumer Protection Act, 1986. During the validity of the aforesaid policy, the complainant felt some deviation in the right eye of his minor son Reyansh Arora. On 1.9.2016 the complainant alongwith his son went to Om Parkash Eye institute (P) Ltd. 117-A, The Mall, Amritsar for checkup of his son in order to clear his doubt regarding the above said disease. Various test have been conducted by the hospital authorities in order to clear the doubt. The hospital authorities created a doubt that the son of the complainant is suffering from Retinoblastoma but this disease can be verified after some more tests. So the complainant in order to take expert opinion decided to consult another document. The complainant paid an amount of Rs. 250/- on various test and diagnostic charges. The complainant decided to take the advise from the doctors of P.G.I. Chandigarh so he went to PGI Chandigarh alongwith his son. The son of the complainant was admitted to PGI on 5.9.2016. On 6.9.2016, the doctors had advised the son of the complainant for M.R.I which was accordingly done by hospital authorities. Later on the doctors confirmed that the son of the complainant was suffering from Retinoblastoma. So accordingly, they started the treatment of the son of the complainant and in that the complainant paid an amount of Rs. 24,332/- with the hospital authority. The opposite party was duly informed about the admission of his son in the hospital by the complainant. After the start of the treatment, the complainant alongwith his son came back to Amritsar. Suddenly, on 11.9.2016 the son of the complainant fell sick due to high fever, so he immediately rushed to Parvati Devi Hospital at Ranjit Avenue, Amritsar. They admitted the son of complainant and started his treatment. The son of the complainant was discharged from the hospital on 14.9.2016. the complainant spent an amount of Rs. 25,061/- on account of treatment of his son. On the operation and the follow up treatment, the complainant had spent Rs. 38,858/- on the treatment and operation of his son. The opposite party was duly informed regarding all these facts from time to time. For the operation, tests, medicines etc. the hospital authorities charged a total sum of Rs.88501/- (24,332+25061+38858) from the complainant which he paid. Accordingly, in order to get the claim from the opposite party regarding the expenses incurred by the complainant on the treatment of his son, he approached the opposite party, submitted claim form alongwith all the relevant documents to them and requested them to make the payment of said amount of Rs. 88501/- covered under the said policy and he was assured for the reimbursement by the opposite party. He visited the office of the opposite party number of times for the reimbursement of his claim amount but they put off the matter on one pretext or the other. Ultimately, they illegally, malafidely, unlawfully and arbitrary repudiated the claim of the complainant by issuing a repudiation e-mail dated 2.6.2017 on the flimsy grounds. The repudiation of claim of the complainant on the part of the opposite party is totally wrong, illegal, malafide, arbitrary, unjust, against the law, rules and principle of natural justice because the opposite party wants to grab the huge amount of the insurance claim of the complainant which he had incurred and paid on the treatment of his son. He is legally entitled to get the aforesaid entire amount alongwith interest on it and opposite party is legally liable to pay the same. The terms and conditions of the policy in question is concerned, it is submitted that the that the opposite party did not issue any document alongwith the policy which contained the terms and conditions and rather, they issued the cover note to the complainant and as such, the alleged terms and conditions contained in the repudiate letter are not at all applicable to this case nor the complainant is bound by the same. Even till date, they have not supplied the terms and conditions of the policy in question to the complainant and they have malafidely repudiated the claim of the complainant on flimsy grounds which are not tenable. The opposite party may be directed to produce the complete claim file of the complainant and also to submit the proof of the supply of the alleged terms and conditions to the complainant at the time of issuing of the policy in question. The complainant has prayed the following reliefs.
(a) The opposite party may be directed to make the payment of Rs. 88,501/- being the claim amount which he had incurred on treatment of his son and paid to the hospital alongwith interest on it @ 18% p.a. from the date of payment to the hospital till realization.
(b) Compensation of Rs. 20,000/- may be awarded to him on account of suffering mental pain, agony, harassment, inconvenience at their hands due to deficiency in service.
(c) Costs of proceedings of Rs. 10,000/-
3 After formal admission of the complaint, notice was issued to Opposite Party and opposite party appeared through counsel and filed written version and contested the complaint by interailia pleadings that the complaint pertains to hospitalization claim of Reyansh Arora who is the dependent son of the complainant and was insured under Health Suraksha Policy having policy vide No. 2825 1001 0945 9300 000 for the period from 7.4.2016 to 6.4.2018, subject to policy terms and conditions, which were never disputed by the complainant. The opposite party processed the claim of the opposite party and perused the documents filed by the complainant. The first consultation paper of Dr. Om Parkash Eye Institute dated 1.9.2016, apparently mentions that “C/o (OD) Eye deviation upward mother feels x 5-6 months age” The date of birth of the child is 7.2.2015. Thus it becomes an establish fact that the ailment for which the minor was treated was pre-existing in nature as the policy inception date is 7.4.2016. As pert he terms and conditions of the policy, the claim has been repudiated under Section 9A iii, which say “ any pre-existing disease/ illness/ injury will not be covered until 48 months of continuous coverage have elapsed since inception of the first Health Suraksha Policy with us”. Thus the present case where the ailment was present even prior to the policy inception date, the coverage for Retinoblastoma and related symptoms would not be covered for the first 48 month and for this reason as well as claim of the complainant is not maintainable and has rightly been denied. There has been no deficiency in service on the part of the opposite party because on receipt of request from the complaint for reimbursement of the claim, the same was verified with respect to the coverage under the terms and condition of the insurance policy plan and only after due process, the claim was repudiated as per policy terms and conditions. The letter dated 2.6.2017 in this regard regarding repudiation of the claim was sent to the complainant. Hence the complaint is liable to be dismissed. In order to prove its case, the opposite party will have to lead evidence and examine its witnesses and expert evidences. The complainant is estopped by his own act and conduct from filing the present complaint. The complainant has filed the present complaint without any cause of action against the opposite party, therefore, liable to be dismissed. On merits, it was pleaded that as per documents provided, it has been found that the minor was having symptoms of Retinoblastoma from the age of 5-6 months and this fact has been concealed by the complainant at the time of taking policy. The opposite party has denied the other contents of the complaint and prayed for dismissal of the same.
4 In order to prove his case, Ld. counsel for the complainant has tendered in evidence affidavit of complainant Ex. C-1, copy of claim repudiation letter Ex. C-2, copy of policy Ex. C-3, copy of cover note Ex. C-4, copy of discharge card of Om Parkash Eye Hospital Ex. C-5, copy of the payment receipts Ex. C-6 to Ex. C-9, copy of discharge bill of Parvati Devi Hospital Ex. C-10, payment receipt Ex. C-11, copy of ID Card issued by the opposite party Ex. C-12, copies of payment receipts ex. C-13 to Ex. C-30, copy of out patient card of PGI Ex. C-31, copy of the payment receipt/ bills Ex. C-32 to C-45 and closed the evidence. On the other hands, Ld. counsel for the opposite party tendered in evidence affidavit of Pankaj Kumar Ex. OP-1, copy of policy Ex. OP-2, copy of terms and conditions Ex. OP-3, copy of repudiation letter Ex. OP-4 and closed the evidence.
5 We have heard the ld. Counsels for the parties and have carefully gone through the record.
6 In the present complaint , the complainant Amit Arora had purchased Healthy Policy from the OP under the name of Health Suraksha Policy (Silver Plan) policy No. 2825100109459300000 dated 7.4.2016 till 6.4.2018 and premium paid Rs16,210/- for himself and his family i.e. his wife Shifali Arora and his two minor sons namely Ishan Arora and Reyansh Arora . The OP had issued only the cover note and never issued any document along with policy containing the terms and conditions. On dated 1.9.2016 complainant felt some deviation in the right eye of his mirror son Reyansh Arora. He went to Om Parkash Eye Institute, Amritsar to clear his doubt regarding the above disease. The hospital authorities created a doubt that the son of the complainant is suffering from Retinoblastoma, complainant in order to take expert opinion decided to consult another doctor. On dated 5.9.2016 he took his son to P.G.I and hospital authorities advised for M.R.I and later on the doctor confirmed that the son of the complainant was suffering from Retinoblastoma, so accordingly they stared the treatment of the son of the complainant and in that the complainant paid an amount of Rs 24,332/- with the hospital authority. The OP was duly informed about the admission of his son in the hospital by the complainant.
7 Suddenly on 11.9.2016 the son of the complainant fallen sick due to high fever, so he immediately rush to Parvati Devi Hospital, Amritsar . The son of the complainant was discharged from the hospital on 14.09.2016. The complainant spent an amount of Rs 25,061/- on account of treatment of his son. On the operation and follow up treatment, the complainant had spent 38,858/- and duly informed regarding all these facts to OP from time to time.
8 As per complainant the operation, tests, medicines etc. the hospital authorities charged a total sum of Rs 88,501/- (24332 +25061+38858) which he paid. The complainant submitted the claim form along with all the relevant documents to OP and requested them to make the payment of said amount of Rs 88,501/- . The complainant visited the office of the OP number of times for the reimbursement of his claim amount but they put off the matter on one pretext or the other. Ultimately they repudiated the claim of the complainant on dated 02/06/2017.
9 As per the written version of the OP , the complainant submitted that the first consultation paper of Dr. Om Parkash Eye Institute dated 01/09/2016 , apparently mentions that “C/O (OD) Eye deviation upward mother feels x 5-6 months of age” (Annexure 2) .The DOB of the child is 07/02/2015 . Thus, it becomes an establish fact that the aliment for which the minor was treated was pre existing in nature as the policy inception date is 07/04/2016 . As per the terms and conditions of the policy, the claim has been repudiated under section 9 A iii, which says “any pre existing disease/illness/injury will not be covered until 48 months of continuous coverage have elapsed since inception of the first hearth suraksha policy with us” .
10 Further , OP denied that the son of the complainant fallen sick due to high fever and he immediately rushed to Parvati Devi Hospital. OP also denied that the complainant spent Rs 25061/- on account of treatment of his son. Moreover the OP also denied that the complainant spent Rs. 38858/- on the treatment and operation of his son. Moreover, OP stated that at the time of issuance of policy , complete set of policy including terms and conditions were supplied to the complainant (Ex. OP2 and Ex. OP3)
11 Reading the pleading of the documents on record it is an undisputed fact that the complainant had purchased health policy from the OP under the name of Health Suraksha Policy for himself and his family in 2016. It is also an admitted fact that the complainant admitted his son for treatment and operation from 01/09 /2016 ( all the bills and discharge bills and other bills are attached as Ex. C6 to C45) . The OP has relied upon condition 9A iii ,which according to them related to pre existing disease . Unfortunately the OP has not placed on record the evidence of supply of the terms and conditions to the insured at the time of execution of contract of insurance. It is now well settled law that if the terms and conditions do not form part of the insurance policy or they were not furnished subsequently to the insured, the company cannot rely on the said terms and conditions for repudiation of the claim filed by the complainant.
12 The statement of Dr. Sukanta Mondol from Om Parkash Eye Hospital, Amritsar on dated 23.08.2018 regarding “Eye deviation upward mother feels x 5-6 month of age”., The statement of Dr.Rajan Bhatia of Dr.Om Parkash Eye Institute, Amritsar on dated 21.08.2018 regarding the treatment of Master Rayansh Arora on particular dates. Clearly stated that the son of the complainant having some problem for which they submitted the claim for reimbursement . In Modern Insulators Ltd. vs. Oriental Insurance Company Limited” (2000) 2 SCC 734, it has been held as under:-
“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 cannot claim the benefit of the said exclusion clause. Therefore, the finding of the National Commission is untenable in law.”
The complainant admitted his son on 11/09/2016 to Parvati Devi Hospital Amritsar, as his son fallen sick due to high fever as an evidence he attached the bills and discharge detail on dated 14/09/2016.(Ex. C6 to Ex. C10) and the complainant spent an amount of Rs 25,061/- . The OP denied in their written version that the complainant’s son fallen sick due to high fever and he immediately rushed to the Parvati Devi Hospital, but OP failed to provide any evidence against this , as it’s very much cleared from the bills that minor Reyansh Arora was admitted on dated 11.09.2016 to 14.09.2016 and fallen sick is not considered as preexisting disease. After receiving the premium and making attractive offers usually the Insurance Company are rejecting the benefits on unreasonable grounds. It is not fair . Ext. Attached by the complainant shows the medicines are taken by his son as well as he was under treatment by hospital authorities. The insurance is being taken for financial assistance and if it is rejected on unreasonable grounds , the purpose will be futile. So the petitioner is entitled for the insurance benefits. If any how according to the first consultation paper ,the illness is not payable in first two years as per the terms and conditions. OP must check the claim form efficiently as son of the complainant admitted to the hospital on dated 11.09.2016 for the reason of high fever which OP failed to prove that it is because of the first consultation. Thus just repudiated the claim on one pretext and ignoring the rest , proves the deficiency in service on the part of the OP. The Hon’ble High Court of Madhya Pradesh in “Life Insurance Corporation of India v. Ambika Prasad Pandey” AIR 1999 MP 13 has held that there is a common practice of the Insurance Companies to repudiate the claim on flimsy grounds without any justification. Similar view was taken by the Hon’ble High Court of Orissa in “Life Insurance Corporation of India v. Narmada Agarwalla” AIR 1993 Ori 103. Hon’ble Supreme Court in case of “Dharmendra Goel v. Oriental Insurance Co. Ltd.” 2008(3) CPJ 377 (SC) has held as under:-
“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 First Appeal No.20 of 2019 14 “take it or leave it‟, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.”
13 We are of the considered view that the OP has wrongly repudiated the claim of the complainant, this is deficiency in service on the part of the opposite party. Hence the complainant is entitled to get the claim equal to the expenses incurred by them on the treatment of his son . The complainant to prove the amount spent on his son’s treatment placed on file Ex. C5 to Ex. C10 , C13 to C22, C27 to C38. And lodged the claim for Rs 88501/-(24332+ 25061+38858).
14 Therefore in view of what has been discussed above this complaint is partly allowed as per the bills attached we found Rs. 24,332/- and Rs. 25,061/- , complainant spend on the treatment of his son (out of which some bills are attached twice and some are of 2017) and failed to submitted the bills of amount Rs 38,858/- . So the complainant is entitled to get a total sum of Rs. 48,308/-. The complainant has been harassed by the opposite party for a long period. Therefore, the complainant is also entitled to Rs.5,000/-(Rs. Five Thousand only) as compensation on account of harassment and mental agony and Rs 4,000/- (Rupees Four Thousand only) as litigation expenses. Opposite Party is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation. Copy of order be supplied by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar.
Announced in Open Commission
07.09.2022
