Complainant Gurkirat 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 kindly be ordered to reimbursement claim of Rs.1,68,324/- to him and also to pay Rs.20,000/- as compensation for unnecessary harassment, physical pain and mental agony suffered by him from the hands of the opposite parties. Opposite parties be further directed to pay Rs.10,000/- as litigation expenses.

2.     The case of the complainant in brief is that he had taken Health Suraksha Policy Silver Plan No.2828 1001 1140 1900 000 from opposite party no.1 which was valid from 20.04.2016 to 19.04.2017 on the asking of opposite party no.2, where he is having his Account No.50100043440655. The sum insured was Rs.5,00,000/- and premium was Rs.5688/-. He had paid only one premium of Rs.5688/- to the opposite party no.1 which amount was transferred from his account through opposite party no.2. He met with an accident on 21.4.2016 and remained admitted in Amandeep Hospital and Clinics, G.T.Road, Amritsar from 22.04.2016 to 03.05.2016 and spent more than Rs.1,68,324/- on his medical treatment. He submitted his reimbursement claim of Rs.1,68,324/- to the opposite party no.1 but his claim was repudiated by the opposite party no.1, illegally and without any sufficient cause or reason. He approached the opposite parties with the request to make payment of reimbursement claim of Rs.1,68,324/- to him as per terms and conditions of the policy, but all in vain. Thereafter, he also served a legal notice upon the opposite parties but of no use. Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint.

3.      On notice, opposite party no.1 and 3 appeared through their counsel and filed their joint written statement taking certain preliminary objections. On merits, it was submitted that the inception date of which is 20.4.2016 has been taken by the complainant. Actually, the claim of the complainant has been repudiated vide letter dated 5.8.2016. The claim has been filed by the complainant and the documents in support of the claim submitted by the complainant. As per the submitted documents, the complainant was admitted on 22.4.2016 with the diagnoses of gunshot injury and was treated for the same. As the date of inception of policy is 20.4.2016 and on verification it was found that patient had a gunshot injury in  right thigh 6 days prior to the date of admission which indicates that the injury is pre existing one. Hence this claim is being repudiated.  All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.          On notice, opposite party no.2 appeared through their counsel and filed their written statement taking the preliminary objections that the opposite party no.2 Bank has been wrongly made party in this complaint. OP2 has no role to play in the transaction between the complainant and OP1 & OP3. Opposite party no.2 is totally separate entity from HDFC ERGO General Insurance Company. Opposite party no.2 Banking Company doing Banking Business only. OP1 and OP3 is Insurance Company doing business of Insurance. So this complaint deserve outright dismissal against OP2 (HDFC Bank). On merits, it was submitted that the liability, if any, is of HDFC ERGO General Insurance Company only i.e. OP1 and OP3. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

5.        Complainant tendered into evidence his own affidavit Ex.CW-I , along with the other documents exhibited as Ex.C1 to Ex.C6 and closed the evidence.

6.     On the other hand, counsel for the opposite party no.1 and 3 tendered into evidence affidavit of Sh.Pankaj Kumar Ex.OP-1,3/1, alongwith the other documents Ex.OP1,3/2 to Ex.OP-1,3/25 and closed the evidence.

7.     Counsel for the opposite party no.2 tendered into evidence affidavit of Sh.Amit Chatrath Branch Manager, HDFC Bank Ex.OP-2/1 and closed the evidence.

8.      We analytically observe with the judicial precision and find that the OP insurers have arbitrarily repudiated (Ex.OP1,3/2) on 05.08.2016 the complainant’s hospitalization medical-treatment claim (Ex.OP1,3/8) filed on 12.05.2016 for reimbursement of an amount of Rs.1,68,324/- pertaining to his (Ex.C3) Health Suraksha Policy purchased on 20.04.2016. Somehow, the present dispute has arisen on account of the impugned repudiation of the complainant’s insurance claim for Rs.1,68,324/- by the OP insurers pertaining to ‘hospitalization’ of the complainant for treatment of an accidental gun-shot injury allegedly received on his right leg thigh on 21.04.2016 while cleaning his licensed pistol; on the pretext-allegation of gun-shot injury having occurred on 16.04.2016 prior to purchase of policy on 20.04.2016 and thus being a pre-existing injury/ situation was not covered under the related policy.

9.       The OP insurers have based their above repudiation decision solely on the ‘Admit-Treatment-card’ (Ex.OP1,3/15) wherein the gun shot injury has been referred to as have been sustained on 16.04.2016. We find that such information is procured by the present junior doctors/ nurses from the patient’s attendants and thus shall not be authentic enough to place exact reliance upon the same. These are legally equated to mere hearsay evidence and shall require some independent corroboration. We find that there has been no other evidentiary document as available on the record of the proceedings indicating 16.04.2016 as the date of the gun-shot injury rather there are many other documents like the complainant’s deposition and the first Hospital’s treatment record proving 21.04.2016 as the date of gunshot injury. We also find that the OP2 Bank has neither any prescribed active part to play in the current adjudicatory nor the complainant has sought any relief against him and thus he gets absolved of all statutory liability, hereinafter, in the present case.    

10.     Thus, the alleged misrepresentation/concealment/non-disclosure of material facts etc do not stand proved. In such like repudiations the o. n. p. (onus of proof) always lay heavily upon the insurers but here they have miserably failed to legally discharge the same successfully. We are strengthened in our above proposition by virtue of the valuable comments as made out by the honorable Punjab State Commission in the FA # 537 of 2008 titled: LIC of India vs. Priya Sharma & ors., as: “…. in this case, there is no evidence on record to prove that the deceased life assured was suffering from any pre-existing disease at the time of purchasing the policy. …. There is no evidence to prove that the deceased was ever admitted or took any treatment from any hospital or the doctor regarding the alleged pre-existing disease. …”. Lastly, we find that the there has been no evidence on the proceeding’s records that the ‘terms and conditions’ of the applicable policy were ever communicated to the present complainant and as such these including its exclusion clauses cannot be made applicable to the detrimental settlement of the impugned claim.

11.     In the light of the all above, we are of the considered opinion that the OP insurers have blatantly bruised the consumer rights of the present complainant by employing ‘unfair trade practice’ amounting to ‘deficiency in service’ (on their part) and that lines them up for an adverse statutory award under the applicable Consumer Protection Act’ 1986. We, therefore,  partly allow the present complaint and thus ORDER the OP insurers to pay the impugned ‘insurance-claim’ by taking the determined prospective date of ‘gunshot-injury’ as 20.04.2016 as per the governing ‘terms’ of the applicable Health Insurance Policy (to its full benefits) but strictly in accordance with the IRDA guidelines on ‘settlement of claims’ to the present complainant besides to pay him Rs.10,000/- as cost and compensation within 30 days of receipt of the copy of the present orders otherwise the aggregate award amount shall attract interest @ 9% PA from the date of the filing of this complaint till actual payment.

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

                        (Naveen Puri)

                                                                                       President      

ANNOUNCED:                                                                   (Jagdeep Kaur)

June 27, 2018                                                                      Member

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