Complainant Gurbir Singh has filed the present complaint against the opposite parties U/S 12 of the Consumer Protection Act (for short, C.P.Act.) seeking necessary directions to the opposite parties to pay Rs.1,40,000/- alongwith interest @ 24% P.A. from the date of due till realization. Opposite parties be further directed to pay Rs.50,000/- as mental and  physical harassment alongwith Rs.20,000/- as litigation expenses, in the interest of justice.

2.       The case of the complainant in brief is that he took insurance policy from opposite parties namely Health Suraksha SILVER PLAN bearing Policy No.2828 1004 0003 6100 000 for Rs.3,00,000/- which was valid w.e.f. 03.1.2019 12:23 Hrs to 01.01.2020 midnight. Thus, he is consumer of the opposite parties. He has further pleaded that at the time of taking the abovesaid policy, the officials of opposite parties assured him that pre-hospitalization of 60 days and post-hospitalization of  90 days for indoor patient shall be free upto the limit of Rs.3,00,000/- and many other benefits were also covered under the said policy. The opposite party also issued Cashless Card to him. He has next pleaded that on 16.05.2019 he slipped near Post Office Chowk, Gurdaspur and as a result of which blood started coming from his nose and right ear. He also received Head Injury, Linear Fracture of Right Parietal Bone, Right Temporal Bone and Mastoid. He was firstly taken to Civil Hospital, Gurdaspur where suturing of scalp wound was done and then he has been brought to Ajit Hospital. The Brain Spine and Trauma Centre at 309, Green Avenue, Circular Road, Amritsar on the same day and necessary intimation was also brought into the notice of opposite parties. He remained admitted in the abovesaid Hospital from 16.05.2019 to 29.05.2019 and more than Rs.1,40,000/- were spent on his treatment and when he gave his Cashless Card to the Hospital authority to pay the bill amounts, but to the utter surprise, the Cashless Card could not be accepted by the Hospital authorities. He was discharged from the Hospital on 29.05.2019 and after discharging, he moved application to the opposite party claiming the expenditure spent on his treatment, but the opposite parties gave false and frivolous reply to the said application and repudiated his claim on flimsy ground. This is the second complaint on the cause of action as earlier he filed similar complaint before this Ld.Commission against opposite party no.1 on 6.9.2019 which was dismissed, in default, on 2.12.2019 due to non-appearance of complainant. Hence, this complaint.

3.          Notice of the complaint was issued to the opposite parties. Opposite party no.1 and 3 appeared through their counsel and filed their joint written reply taking preliminary objections that the complainant has concealed the true and material facts from this Hon'ble Commission; the complainant was covered under Health Surakhsa Policy having Policy No. 2828 1004 0003 6100 000 which was valid from 03.01.2019 to 02.01.2020.The policy was issued subject to the terms and conditions and therefore in case any liability arises under the policy, the same shall be restricted by and subject to the terms and conditions of the policy; both the parties are bound with the terms and conditions of the policy, which are duly supplied to the complainant and no claim can be passed beyond the terms and conditions of the policy; the present complaint has been filed without any cause of action against the opposite party, therefore, the present complaint is liable to be dismissed; the complainant is stopped by his own act and conduct from filing the present complaint and the complainant has no locus standi to file the present complaint. On merits, it was submitted that as per the statement given by the complainant himself, the complainant had fallen after suffering from an episode of Vertigo and not as a result of slipping. That after receiving the intimation regarding the claim, as per the documents submitted, patient was admitted on 16.05.2019 for treatment of head injury secondary to Hypertension. On verification, it was established that patient is a known case of Hypertension before the first inception of policy. As there is history of Hypertension for the last 5 years thus the disease is pre-existing in nature. The date of first inception of policy bearing 03.01.2019, the claim of the insured was repudiated under Section 9 A iii of the policy terms and conditions which state as "Any pre-existing disease/illness/injury will not be covered until 48 months of continuous coverage have elapsed since inception of first health Suraksha Policy with us" Also insured had not disclosed the ailment while purchasing the policy. Hence there is non disclosure of material facts therefore the claim was repudiated under section 10 r ii of policy terms and conditions. This fact is also clear from the certificate issued by Dr.B K Mahajan,  family doctors of insured.  It was next submitted that the opposite party is bound to settle the claim only as per terms and conditions of the policy, but in this case the complainant has violated the terms and conditions of the policy and has deliberately concealed the facts regarding pre-existing disease of the insured, therefore, he is not entitled for any claim. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.      Opposite party no.2 had been served through dasti summon. Case called several times but none had appeared on behalf of opposite party no.2 despite repeated calls. Hence, opposite party no.2 was ordered to be proceeded against exparte vide order dated 4.12.2020.

5.       Alongwith the complaint, complainant has filed his own affidavit  alongwith other documents Ex.C-1 to Ex.C-5.

6.     Alongwith the written statement ld.counsel for the opposite party no.1 and 3 has filed affidavit of Shweta Pokhriyal, Manager-Legal Claims Ex.OP-1,3/1 alongwith documents Ex.OP-1,3/2 to Ex.OP-1,3/8.

7.        Rejoinder filed by the complainant.

8.         Written arguments have been filed on behalf of opposite party.

9.        We have carefully gone through the pleadings of counsel for the complainant; oral arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsel for the complainant for the purposes of adjudication of the present complaint.

10.     In the present complaint Gurbir Singh complainant had got himself insured under Health Suraksha SILVER PLAN  of HDFC Ergo General Insurance Company bearing Policy No.2828 1004 0003 6100 000 for a sum assured of Rs.3,00,000/-  for the period 03.1.2019  to 01.01.2020.

11.    The complainant has complained that he slipped and suffered injuries and consequently sought treatment at Civil Hospital, Gurdaspur and was later got admitted to Ajit Hospital, The Brain Spine and Trauma Centre at 309, Green Avenue, Circular Road, Amritsar. Complainant remained in the hospital for the period 16.5.2019 to 29.5.2019. During the course of his treatment his Cashless card against the aforesaid policy was not entertained by hospital. His claim for reimbursement for the said treatment was also repudiated by opposite party on the contention that the complainant is suffering from Hypertension for about five years and he had concealed the facts and thus U/s 9A (iii) of the terms of the policy, "Any pre-existing disease/illness/injury will not be covered until 48 months of continuous coverage have elapsed since inception of first health Suraksha Policy with us"

12.     We are of the considered opinion that in the present case complainant suffered an injury on 16.5.2019 as he fell down and as a result of it had bleeding from his nose and ear and also received head injuries. The head Injury included Linear Fracture of Right Parietal Bone, Right Temporal Bone and Mastoid.

13.    After receiving the treatment from Civil Hospital, Gurdaspur complainant was admitted to Ajit Hospital, Amritsar for the period 16.5.2019 to 29.5.2019.

14.    Denial of claim by opposite party merely on the basis of complainant being hypertensive is not a valid point in the present case as he suffered injury consequential to a fall. Hence allegation of concealment of pre-existing disease has no direct tangible relationship for the denial of claim in the present case.

15.     Based on the facts and circumstances narrated above, the present complaint is partly allowed. Opposite party is directed to pay a sum of Rs.1,40,000/- to the complainant for the hospital bills submitted by him for his treatment at Ajit Hospital for the period from 16.5.2019 to 29.5.2019. Further, opposite party is also directed to pay an interest @ 6% P.A. on the said amount from the date of institution of this complaint. Opposite party shall also pay a sum of Rs.5,000/- on account of litigation expenses to the complainant.

16.        The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.

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

                                                                     (NaveenPuri)                                                                                                                                                  President   

Announced:                                                   (Ragbir Singh Sukhija)

August 24, 2022                                                  Member

*MK*