Complainant Vimalpreet 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 pay Rs.3,00,000/- and the opposite parties be further directed to pay Rs.50,000/- for mental and physical harassment alongwith Rs.15,000/- as litigation expenses to him, in the interest of justice.
2. The case of the complainant in brief is that he took insurance policy from the opposite parties namely Health Suraksha Policy bearing policy No.2825100110482500000 for the sum assured of Rs.3,00,000/- valid from 13.4.2016 to 12.04.2017 in the name of Vimal Preet Singh, Davinder Kaur his wife and Gursehaj Singh his son. His wife due to complaints of bleedings while giving call of nature consulted Dr.Vikas Gupta, Consultant Gastroenterologist, Amritsar first time on 9.9.2016. Then Dr. Vikas Gupta prescribed her medicine for 3-4 days and advised for colonoscopy, if the problem remains the same. On 15.09.2016, her problem remain same and colonoscopy was conducted and after seeing the report doctor advised her for CT Scan and after the Histopathology report, doctor detected Adeno carcinoma (Cancer). After receiving Histopathology report, he took his wife for surgical treatment at Medanta Medicity Hospital, Gurgaon and doctor advised his wife for the surgery and in this regard on 22.9.2016 he submitted his claim form to the opposite parties for pre approval. Her wife’s operation was done on 23.09.2016 and thereafter opposite party sent the approval for the amount of Rs.2,00,000/- and further told that the rest of the claim will be finalized after the final bill. He has next pleaded that inadvertently and due to typographical mistake, the staff of the abovesaid Hospital at Gurgaon has wrongly mentioned the duration of complaint of bleedings of Davinder Kaur as 11 months instead of 4 months in their online claim form, but this was clearly rectified by the Hospital by issuing letter dated 27.09.2016 issued by the Chairman, Medanta Hospital, Gurdaspur where they have admitted their mistake. This thing is also clear from the discharge slip of Davinder Kaur but the opposite parties acting arbitrary, illegally and without giving satisfactory reason repudiated his claim vide letter dated 24.12.2016. He approached the opposite party no.2 and submitted all the legal formalities required by the opposite parties and he has also submitted the original documents by meeting Mr.Vaneet Julka, Manager of opposite party no.2 but of no use. Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint. 3. On notice, opposite parties appeared through their counsel and filed their joint contested written statement taking the preliminary objections that the complainant has no cause of action to file the present complaint; there is no deficiency in services on the part of the opposite parties; it is settled law that the contract of insurance is based on the Utmost good faith; insurance is a contract and both the parties bind by the terms and conditions of the policy and the present complaint is not maintainable as there is no deficiency in services on the part of the opposite parties. On merits, the claim has been raised for patient Davinder Kaur for disease Malignant Neoplasm of rectum. The documents submitted have been duly scrutinized and from the documents submitted, it becomes clear that patient was admitted on 22.9.2016 with the diagnosis of Adenocarcionoma-Mid Rectum and was treated for the same. As the date of inception of policy is 13.4.2016 and the patient was symptomatic since 2015, as such the ailment is preexisting in nature. Hence the claim is repudiated under section 9-A (iii). Moreover, the claim was found to be misrepresented. As per policy terms and conditions if any is in any manner dishonest or fraudulent or is supported by any dishonest or fraudulent or is supported by any dishonest or fraudulent means or devises, whether by a insured person or anyone acting on behalf of an insured person, then this policy shall be void and all benefits paid under it shall be forfeited. Hence, this claim is being repudiated under section 10. So, this claim is being repudiated under section 10. So, there is no deficiency in services on the part of the opposite parties. It was further submitted that the claim was found to be misrepresented. As the medical paper of Medanata Hospital, in itself states that the patient started the symptoms about 4 months back (while 3rd trimester of pregnancy). The medical paper clearly shows that there is overwriting in mentioning the months from 11 months to 4 months. Also the medical paper on record of Medananta Hospital is for the month of September and the patient delivery the baby in the month of December. Therefore, when the ailment started in 3rd trimester of the pregnancy then it cannot be 4 months, if we calculate it from the month of September, it has to be 11 months if the ailment started in 3rd trimester of the pregnancy. Hence, an inference can be drawn that the month from 11 months was changed into 4 months, best known to the hospital authority. All other averments made in the complaint have been denied and dismissal of the complaint has been prayed.
4. Counsel for the complainant tendered into evidence affidavit of complainant Ex.C-I , along with the other documents exhibited as Ex. C2 to Ex.C12 and closed the evidence.
5. On the other hand, counsel for the opposite parties tendered into evidence affidavit of Sh.Pankaj Kumar Authorized Signatory Ex.OP6, alongwith the other documents Ex.OP1 to Ex.OP5 and closed the evidence
6. We have thoroughly 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 contestants. We find that the present dispute has arisen at the impugned ‘repudiation’ of 21.12.2016 (Ex.OP1,2/5) and notice of policy cancellation of 24.12.2016 (Ex.C5) at the filing of insurance-claim (Ex.C3) dated 20.09.2016 pertaining to the complainant’s wife’s hospitalization-expenses for Rs. 3,00,000/- the full sum insured per the applicable policy (Ex.C2) on the grounds of non-disclosure of pre-existing ailment amounting to fraud, misrepresentation etc by producing forged documents at the time of purchase of the policy in question.
7. We find that the titled opposite party insurers (hereinafter for short ‘the OP insurers’) have duly admitted the repudiation through their written statement and accompanying affidavit (Ex.OP6) but have failed to prove the allegations vide some cogently reliable evidence and that turn these to mere ‘bald’ statements. The OP insurers have based the impugned ‘repudiation’ on mere presumptions and conjectures etc and have not produced any documentary evidence of past history/continuation of the allegedly pre-existing ailment. The presence of traces of and passing of non-recurrent recto-blood during pregnancy does not in itself prove the malignant growth and in all probability the patient herself could not have known its nature till the time (09.09.2016) she first sought medical advice on the same and was herself unaware of the same. However, on the other hand, the complainant has successfully proved the contents of his complaint pertaining to purchase of the health policy, being unaware of the pre-existing ailment, the subsequent hospitalization/ surgery, medical treatment expenses incurred and filing of the related claim with its repudiation etc vide evidentiary documents exhibited hereinabove as: Ex.C1 to Ex.C12.
8. The OP insurers, in rebuttal, have filed Ex.OP1 to Ex.OP6 (affidavit) comprising of the related Policy Ex.OP1/impugned repudiation Ex.OP5 and others etc and that does not prove the alleged presence of some pre-existing ailment and/or its intentional non-disclosure etc and that in turn also proves adoption of ‘unfair trade practice’ to turn down an otherwise a routine and valid claim.
9. Lastly, the OP insurers must realize that their administrative decisions in settling insurance claims are open to judicial reviews and thus need be taken with due application of mind and not arbitrarily and these should also be speaking in nature duly explaining the reason and logic of the decision as to how the same has been reached. All the facts in issue need be appreciated while awarding sanctity to the current applicable law. The duty of settlement of insurance claims shall not be, in routine, delegated to the technical team who shall simply provide assistance on technical issues pertaining to the same.
10. In the matter pertaining to the present complaint and in the light of the all above, we set aside the OP’s impugned repudiation being arbitrary (contra to laws of natural justice) amounting to ‘deficiency in service’ etc. Thus, we ORDER the OP insurers to pay the impugned ‘insurance claim’ pertaining to the Policy in question with full accrued benefits etc (if any), along with Rs.5,000/- as compensation for the undue harassment inflicted besides Rs.3,000/- as cost of litigation; within 30 days of the receipt of the copy of these orders, otherwise the entire awarded amount shall attract interest @ 9 % PA form the date of the orders till actually paid.
11. 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)
January 17, 2018 Member
*MK*
