The complainant Sandeep Kumar, the holder of Aadhar (Ex.C1) and the nominee son of Late Sh. Surinder Singh has filed the present complaint against the titled opposite parties (for short, the OP1-2 insurers and the OP3 bank ) being hurt at their arbitrary acts of omissions and commissions that have allegedly infringed his statutory consumer rights. He proceeds to explain that the his late father Surinder Singh had purchased on 03.12.2016 the Suraksha Policy Silver Plan (Ex.C2) with Rs.3.0 Lac as Sum Assured and Rs.30,000/- as the CB (Cash Back) had been extending the same by paying its annual premiums regularly (Ex.C3, Ex.C4 and Ex.C5) till his demise on 14.10.2019. The last premium of Rs.10,498/- was paid on 13.02.2019 for the policy to stay valid till 12.02.2020.
2. The complainant further states that his late father during his life-time had suffered medical emergency on 18.02.2019 and was hospitalized at Rapha Care Hospital, Dasyua for medical-treatment of the diagnosed ailments Hypertension, Type II Diabetes Mellitus and Respiratory cum Urinary Tract Infections and was discharged (Ex.C6/Ex.C7) on 23.03.2019 having paid Rs.313,778/- (Ex.C8 to Ex.C30) as the hospital-fee cum cost of medicines etc. And, issued a requisition letter dated 08.08.2019 seeking some vague information/queries (Ex.C31) from the insured that were already available with insurers as collected at the time of sale of the insurance and moreover it was the deceased insured who was hospitalized and not the nominee complainant so how he could have known and answered the queries pertaining to the hospitalization etc. In the meantime, the insured breathed his last, still in wait for settlement of his valid insurance-claim. The death certificate and Aadhar card of the insured are exhibited here as Ex.C32 and Ex.C33, respectively. The complainant had also got one legal-notice (Ex.C34) served upon (Ex.C35 & Ex.C36) the OP insurers but even that failed to move them to review/revise the repudiation and thus prompted the present complaint accompanied by his affidavit Ex.CW1/A seeking directives to the opposite parties to pay the complainant insured sum of Rs.3.0 Lac with interest @18 % PA from the date of hospitalization of the insured besides Rs.1.0 Lac as compensation in addition to any other relief that the forum may deem fit alongwith rejoinder.
3. The titled opposite party insurers (OP1 & OP2), in response to the commission’s summons appeared through their counsel and filed their written reply stating therein preliminary as well as the other (on merits) objections as:
4. The complaint has not been filed by a competent person as it should have been filed by all the legal heirs of the deceased Surinder Singh. The claim was not repudiated but only closed being immature as reply to the related queries was awaited. The complainant has not replied exhaustively to the OP queries in spite of the repeated reminders. The benefits of the policy are subject to terms and conditions governing the policy hence the queries do warrant proper replies by the complainant along with submission of related documents.
5. Again, on merits, the OP insurers in their written statement have either denied or shrugged the contents of the complaint addressing these as matters of records etc.; but the main contention of the OP insurers throughout have been non-submission of proper replies to the queries raised by them pertaining to the claim. Finally, the OP insurers have sought dismissal of the complaint being bereft of merit and also for want of cause of action, in the interest of justice, equity and fair play.
6. The OP insurers in support of their version and pleadings in defense have produced the following documents in evidence:
Ex.OPW1,2/1 Self declaration by the Legal Manager Shweta Pokhriyal;
Ex.OP1,2/2 Power of Attorney favoring the Manager Legal (claims);
Ex.OP1,2/3 Certificate for the purpose of S-80D of the I.T. Act;
Ex.OP1,2/4 Policy Wording;
Ex.OP1,2/5 Deficiency Letter;
Ex.OP1,2/6 Delivery Letter;
Ex.OP1,2/7 Reminder Letter dated 08.09.2019;
Ex.OP1,2/8 Doctor Certificate;
Ex.OP1,2/9 Doctor Questionnaire;
Ex.OP1,2/10 Insured/Complainant Questionnaire;
Ex.OP1,2/11 Insured/Complainant Questionnaire (Contd.);
Ex.OP1,2/12 Hospital Admission Records;
Ex.OP1,2/13 Hospital Discharge Records;
Ex.OP1,2/14 & 15 Hospital Expenses (item-wise).
Written Arguments – by the OP1,2 insurers.
7. The OP3 Bank did not appear in spite of service of summons/notice and were thus ordered to suffer ex-parte proceedings.
8. We have examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective litigants. We find that the present dispute has arisen on account of the impugned ‘non-settlement’ of insurance hospitalization-claim pertaining to the insured father (Late Sh. Surinder Singh) of the complainant, by the OP1,2 insurers who allege non-reply of their queries in spite of their repeated reminders. We have minutely examined the documents produced in evidence by the complainant, the insured's Hospital and also by the OP insurers as produced and as collected by them during the course of their investigations and find that there's neither any chance nor scope of any OP query still having left unanswered/ unresolved, by the time.
9. Somehow, we do not concur with the logic of the herein impugned 'nos-resolve' of the hospitalization-claim and are inclined to examine the validity and legality of the same in the back-drop of the preceding and also the succeeding acts and events in the light of the facts on records and current law on the consumer proposition’s subject matter, in issue. We observe that the impugned non-resolve of the insurance-claim has been the result of the OP insurers' resolve in their endeavor to somehow repudiate the same.
10. Finally, in the matter pertaining to the present complaint and in the light of the all above, we find and address the intentional 'non-resolve' and 'delay' at the OP insurers' end as ‘deficiency in service' and 'unfair-practices' at play and thus ORDER the OP insurers to pay the hospital-claim, in full i.e. Rs.Three lacs, to the nominee complainant, in terms of the related policy with interest @ 6% PA from the date of hospitalization (as the OP insurers had also arbitrarily disallowed cash-less medical-treatment at the hospital) till paid, in full, besides to pay Rs.10,000/- in lump sum as cost and compensation within 45 days of receipt of the certified copy of these orders otherwise the award shall attract additional interest @ 3 % PA from the date of the complaint till actually paid.
11. 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.
12. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President.
ANNOUNCED: (B.S.Matharu)
SEP. 16, 2022. Member.
YP.
