DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

C.C. No.306/2020

Date of Institution: 16.12.2020

Judgment Reserved on: 09.10.2023

Judgment Passed on: 31.10.2023

COURUM:

Sh. S.S. Malhotra (President)

Ms. Rashmi Bansal (Member)

Sh. Ravi Kumar (Member)

Judgment By: Ms. Rashmi Bansal (Member)

JUDGMENT

By the present judgment this Commission is disposing off the complaint of the complainant alleging deficiency of service on the part of OP in repudiating  his mediclaim despite there being a valid policy.

1. It is the case of the complainant that he has taken a medical insurance policy. “Health Suraksha Policy, Silver Plan” and it was renewed from time to time as per following table:

2. Complainant submits that the policy at serial number 1–6 were purchased from OP and Policy S.No. 7 to 8, from Apollo Munich Health Insurance Limited, which now has been taken-over by the group companies of OP namely HDFC Ergo, Health-Insurance Company and subsequently merged into OP company and as such the cause title is being depicted as such.
3. Complainant submits that on 02.11.2019, he suffered high fever, and upon consultation with Doctor he was diagnosed with dengue, fever and on his advice was hospitalised in Max Super Speciality Hospital, Patparganj on 03.11.2019. On his request for cashless, a surveyor had visited the hospital and recorded the statement of the wife of the complainant but on 06.11.2019 the cashless request of the complainant was declined by OP and because of which he had to pay Rs.3,71,225/- to the hospital against the bill dated 11.11.2019. The complainant being not satisfied with the treatment wished to be shifted to another hospital i.e. Max Super Speciality Hospital, Vaishali and was admitted there on the same day and his request for cashless was again declined by OP on 12.11.2019 on the false and baseless grounds. It is further submitted that after the treatment he was discharged on 21.11.2019 and a total bill of Rs.8,11,236/- was paid, by the complainant in this hospital by taking loans and disposing off the jewellery of his wife.
4. Complainant further submits that he has also spent Rs.6,16,962/- in pre-and post hospitalisation expenses which were also covered in the policy. Therefore, the aggregate amount of Rs.17,99,423/- has been incurred by him and the entire treatment is covered in the two policy years/period, i.e. for the period 15.12.2018–14.12.2019 and 15.12.2019–14.12.2020, and therefore he is entitled to receive entire expenses of Rs.17,99,423/- as a reimbursement under the said policies of two years. He further stated that he has not been provided with any terms and conditions at the time of issuance of the policies, not even afterward.
5. It is further submitted that he has submitted the duly filled, claim from along with all the relevant bills, payment receipts, discharge summaries, and other relevant documents with OP along with the legal notice to settle the claim, however, OP has not settled/reimbursed the claim of the complainant and on the contrary has issued a repudiation letter dated 07.12.2020 through email rejecting his claim on the ground that the treatment comes under two years condition i.e. treatment of PIVD is excluded from the policy, if admitted within two years of policy inception date. Complainant submits that his claim was rejected on the frivolous and baseless grounds and OP is indulged in unfair trade practice and also deficient in its service because of which he has suffered lots of physical, financial harassment and mental agony, and therefore he is entitled for the claim amount of Rs.17,99,423/-, compensation of Rs.5,00,000/- for causing him a great amount of physical and mental harassment and Rs.2,20,000/- towards the cost of litigation.
6. OP has filed written statement but failed to appear ot the stage of evidence and as such was proceeded ex parte on 13.10.2022. This is settled principle of law that the pleadings, howsoever strong may be, cannot take place of proof in the absence of evidence. To prove its case, OP has not taken any steps as averred in the written statement. Since it has not come forward to file its evidence by way of affidavit, therefore, the written statement filed by the OP also cannot be read for the purpose of its defence, except to such extent & facts which are admitted by it.
7. The OP has filed an application for setting aside the ex-parte order dated 13.10.2022 which was dismissed vide order dated 11.01.2023.
8. Complainant has filed its evidence along with all the documents on record. In support of his case, he filed copy of the policy, schedules and certificates, copy of the prescription dated 02.11.2019, copy of document prepared by surveyor, copy of letter dated 6.11.2019 of OP, copy of the bills, payments receipts and discharge summary dated 11.11.2019, copy of letter dated 12.11.2019 of OP, copy of the bills, payment receipt and discharge summary dated 21.11.2019, the documents related with expenses incurred by the complainant along with claim form, copy of legal notice, copy of repudiation letter of OP.
9. The Commission has heard the arguments and perused the documents available on record.
10. The details as provided by the complainant in the tabular form clearly shows that though the  complainant has renewed his insurance policy from 04.09.2011 till 14.12.2021, however, there is a break from 29.09.2017 to 15.12.2018, i.e. a gap of about 1 year and 3 months approximately.
11. Complainant has filed all the policies on record and it is observed that all the policies are only single page policy without any terms and conditions annexed there to.
12. The preliminary-issue for determination is whether the terms and conditions were supplied to the complainant by the OP with respect to polices and whether his case falls under the exclusion clause? It is the specific contention of the complainant that exclusionary condition in the policy document have not been communicated by the OP to him as a result of which the terms and conditions of the exclusion clause were never binding on him. The issuance of policy has never been in dispute. Therefore, in order to decide whether the exclusion clause were communicated to the complainant by OP or not, OP had to prove the same by cogent evidence which it did not file, and nothing is found on record to establish that the complainant has received the copy of the terms and conditions of the policy and he himself has filed single page policy documents. OP admitted issuance of polices but not established that the terms and condition of this policy were even served upon the complainant.  The Commission is unable to find any document which may show the proof of receipt of the terms and conditions of the policy by the complainant and hence they are not binding upon the complainant. As per settled law in Bharat Watch Company through its partner versus National Insurance Co. Ltd., 2019 (6) SCC 212, it is clear that unless the insured is duly informed about the terms and conditions of the policy, the exclusion clauses of the policy cannot be made applicable upon him. Since OP failed to file its evidence as well as any document  to show that copy of the said policy has been supplied to the complainant along with terms and conditions, this cannot be said that exclusionary clause in the said policy is applicable upon the complainant and therefore OP was wrong in denying the claim of the complainant.
13. The another issue for decision is whether complainant is entitled for the whole amount of Rs.17,99,423/- in all, as claimed? The documents on record show that the treatment of the complainant started when policy starting from 15.12.2018 to 14.12.2019 was in force since he was discharged on 21.11.2019 from the second hospital. The entire claim therefore, is limited to and would be governed by the policy which was in force for the year/period from 15.12.2018 to 14.12.2019 only. Moreover, second policy from, 15.12.2019 to 14.12.2020, is the renewal of the previous policy, which was renewed after the lapse of the first policy on 14.12.2019 and no ailment happened when the policy of successive year was in force. By no stretch of imagination, it can be considered that previous policy of Rs.10,00,000/- insurance would merge with policy of successive year carrying insurance of Rs.10,00,000/- and the total insured amount would be of Rs.20,00,000/-. There is no such procedure/system by which the document policy for successive year can be merged with the policy of previous year, so as to make the insurance amount double for one year policy. This is a non-est concept of merging the insurance of two successive year policies.   Therefore, complainant‘s claim is limited to Rs.10,00,000/- only i.e. within previous year’s policy which was for the period from 15.12.2018 to 14.12.2019. Ld. Counsel for complainant during arguments has also conceded that he is restricting its claim to only one year’s existing policy. Complainant had submitted a claim of Rs.3,71,225/- from Max Super Speciality Hospital, Patparganj and an amount of 8,11,236/- from Max Super Speciality, Hospital, Vaishali and also has submitted pre-and post medical expenses of Rs.6,16,692/-, total amounting to Rs.17,99,423/-. Since, the insured value of the policy is of Rs.10,00,000/- only therefore complainant would be entitled for the policy amount of Rs.10 lakhs, if he is able to prove the deficiency on the part of OP. The complainant has a valid policy for the relevant year, the Commission has above held that the terms and condition of policy were not supplied to the complainant and despite that the claim has been rejected by the OP, and in the considered opinion of the Commission such act, on the part of OP, amounts to deficiency in service.  Therefore, the repudiation of the claim of the complaint is bad as per established principles of law and hence OP is directed to pay the insurance amount to the complainant of Rs.10,00,000/- along with an interest @6% p.a. from the date of filing of the complaint i.e. 16.12.2020, a compensation of Rs.30,000/- and litigation cost of Rs.20,000/-.
14. The above stated order be complied with by the OP within 30 days from the date of receipt of the order, failing which the entire amount i.e. Rs.10,50,000/- shall carry an interest at the rate of 9% per annum from the date of filing of the complaint 16.12.2020 till its final realisation by the complainant.
15. The file be consigned to record room after delivering the copy of the order to both the parties as per CPA rules.
16. Order contains 08 pages each bears our signature.
17. Pronounced on 31.10.2023.