Order by:

Sh.Amrinder Singh Sidhu, President

1.       The  complainant  has filed the instant complaint under section 35 of Consumer Protection Act, 2019 on the allegations that on the allurement of agent of Opposite Party No.2- HDFC Life Insurance, the complainant purchased HDFC Life Group Health Shield Credit Master Policy bearing No.HC000101, with Commencement of Risk 22.02.2020 with expiry dated 21.02.2025 for cover term 60 months for a sum of Rs.2 lakhs against paid up premium of Rs.13,103/-.  This policy was purchased through Bajaj Finance Limited-Opposite Party No.3, the Master Policy Holder, under the group insurance scheme administered by Bajaj Finance Limited under Group Master Policy No. HC000101  issued by Opposite Parties No.1 & 2-HDFC Life Insurance Company Limited. Further alleges that   at the time of purchasing the policy in question, the policy holder complainant Niranjan Gill was fully medically got checked up by the  Opposite Parties from their own panel doctors and after full satisfaction, the Opposite Parties issued the policy cover note by getting the premium amount from the policy holder. As per the policy terms, all types of medical treatment was covered in the policy  during the policy tenure. Further, during the policy period i.e. on 02.09.2021 the complainant felt pain and he was  immediately brought to nearest hospital Dr.Deepak Heart Centre, Akalsar Road, Moga where the complainant was diagnosed as CAD-ACS-US, TMT+VE  where Proximal LAD Predilated & then stented with 3.00 mmx22 mm Koronar Des was done and remained upto 04.09.2021 in said hospital.  Again, on 25.09.2021 the complainant felt uneasiness and he again brought to Deepak Garg Hospital and again he remained admitted there till 27.09.2021. That again the complainant remained admitted in SPS Hospital, Ludhiana from  1.10.2021 to 07.10.2021, then from 12.10.2021 to 14.10.2021 again from 29.11.2021 to 02.12.2021 and lastly discharged on 02.12.2021.  However, the medical reimbursement of the hospital of Deepak Heart Centre, Moga has not been claimed by the complainant from the Opposite Parties as these medical bills have been got reimbursed through Prime Minister Yojna scheme, though the complainant could claim these bills from the Opposite Parties, but he did not claim the said amount. After discharge from SPS Hospital, Ludhiana the complainant lodged the claim for the reimbursement of his medical bills for Rs.3,05,193/- under the policy  and completed all the formalities as required by the Opposite Parties, but initially, the Opposite Parties lingered on the matter on one pretext or the other and at last refused to make the rightful and lawful claim of the complainant on the false and frivolous ground that as per the policy terms and conditions, said ailment does not fulfill the definition of first heart attack of specific severity listed under critical illness. But the aforesaid allegations leveled by the Opposite Parties are totally incorrect.  The complainant has not concealed any fact as alleged by the Opposite Parties. Moreover, it is otherwise the duty of the Insurance Company to verify the health status of an individual specifically when the Policy is sold which was done in the instant case. Rather it is a common practice of the Insurance Companies to repudiate the claim on flimsy grounds without any justification. Since the policy purchased by the complainant covers the claim maximum upto the extent of Rs.2 lakhs, so the complainant claims the amount of medical reimbursement upto the extent of Rs.2 lakhs against the medical paid up bills of Rs.3,05,193/-. It is further submitted that  at the time of issuing the policy in question as mentioned above, alongwith this cover note, the Opposite Parties never issued any terms and conditions of the policy documents. As such, the alleged  terms and conditions, particularly the exclusion clause of the policy in question is not binding upon the insured.  The complainant approached the Opposite Parties time and again for the insurance claim, but  the Opposite Parties  flatly refused to make the insurance claim of the complainant, as such, there is deficiency in service on the part of the Opposite Parties.  Vide instant complaint, the complainant has sought the following reliefs.

a)       The Opposite Parties may be directed to make the insurance claim of Rs.2 lakhs on account of medical treatment of the complainant under the policy which covers the medical reimbursement upto the extent of Rs.2 lakhs  alongwith future interest  @ 12 % per annum from the date of discharge from the hospital  till its actual realization.

 b)     The amount of Rs.2,00,000/- be allowed to be paid by the opposite parties on account of compensation due to mental tension and harassment caused by the complainant.

c)       The cost of complaint amounting to Rs.20,000/- may please be allowed.

d)      And any other relief to which this  Consumer Commission, Moga may deem fit be granted in the interest of justice and equity.      

2.       Opposite Parties No.1 and 2  appeared through counsel and contested the complaint by filing  the written version taking preliminary objections therein inter alia that the complaint filed by the complainant is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead this District Consumer Commission.  Brief facts are that on 19.01.2022 the Opposite Parties No.1 and 2 received claim from the complainant for an amount of Rs.1,50,000/- wherein it was stated that he was admitted in SPS Hospital Ludhiana on 29.11.2021 and was discharged on 02.12.2021  and said claim was  raised towards Critical illness Mycocardial Infarction (First Heart Attack of Specific Severity) under clause 2.2.6 (a) of the policy. After that, the answering Opposite Parties  asked for certain documents which were required to adjudicate the matter, however the complainant submitted all the documents on 11.02.2022. Thereafter, the answering Opposite Parties thoroughly studied the medical record  of the treating hospital and come to the conclusion that the definition of a First Heart Attack of Specific Severity was given by the IRDAI in the Guidelines of Standardization in Health Insurance, 2016, but  in the instant case out of the three  requirements, one has been met but since required documents have not been provided by the complainant, therefore, the said claim has been rightly denied by the Opposite Parties. As per the medical record, the LA was diagnosed with Coronary Artery Diseases which is the exclusion as per the policy terms and conditions, therefore, the answering Opposite Parties repudiated the claim of the complainant.  On merits, Opposite Parties No.1 and 2 took  up almost same and similar pleas as taken up by them in the preliminary objections and hence no illegality has been committed by the Opposite parties while repudiating the claim of the complainant and the complaint may be dismissed with costs. 

3.       Opposite Party No.3-Bajaj appeared through counsel and filed separate written reply contesting the same by taking preliminary objections inter-alia that the complainant has sought the relief only against Opposite Parties No.1 and 2, whereas answering Opposite Party has only provided the loan for the payment of the premium and the same has  been paid and the complainant has already paid the installments of the loan and the loan has closed and that further in the absence of any specific relief claimed against Opposite Party No.3, the answering Opposite Party is not a necessary party to the complaint and hence the instant complaint is not maintainable against the Opposite Party No.3. Moreover, there is no privity of contract with the Finance Company and the Opposite Party No.3 has no role to play in the insurance claim of the complainant and there is no cause of action against Opposite Party No.3 and the present complaint is liable to be dismissed against Opposite Party No.3.  On merits, Opposite Party No.3 took  up almost same and similar pleas as taken up by them in the preliminary objections and the complaint may be dismissed with costs against Opposite Party No.3.       

4.       In order to  prove  his  case, the complainant has tendered into  evidence his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C14 and  closed the evidence on behalf of the complainant.

5.       On the other hand,  to rebut the evidence of the complainant,  Opposite Parties No.1 and 2 also tendered into evidence the affidavit of  Sh.Arpit Higgins Manager Legal Ex.Ops1 & 2/1 alongwith copies of documents Ex.OP1,2/2 to Ex.OP1,2/9. Similarly, Opposite Party No.3-Bajaj tendered into evidence the affidavit of Ms.Shivani Garg  Ex.OP3/1, copy of statement of account Ex.OP3/2 and thereafter, the Opposite Parties closed their respective evidence. 

6.       We have heard the ld.counsel for the parties, perused the  written submissions filed by the complainant  and  also  gone through the documents placed  on record.

7.       During the course of arguments, ld.counsel for the Complainant as well as ld.counsel for Opposite Parties has mainly reiterated the facts as narrated in the complaint as well as in the written statement respectively. We have perused the rival contentions of the parties and also gone through the record on file.

8.       The main contention of the complainant is that at the time of proposal,  the life assured complainant was  assured by the Opposite Parties that all the diseases covers under this policy and on the allurement of the  Opposite Parties No.1 and 2 the complainant purchased the policy in question from Opposite Parties No.1 and 2 on the assurance that it will be helpful for him in his bad days, but the opposite parties intentionally and knowingly  repudiated the lawful and genuine claim of the complainant for the hospitalization of his medical treatment without application of mind.  It is further contended that at the time of policy, no such terms or conditions were ever conveyed or supplied to the complainant by Opposite Parties No.1 and 2 and in the absence of such terms and conditions, these can not be enforced at this stage.    On the other hand, ld.counsel for Opposite Parties No.1 and 2 has repelled the aforesaid contention of the complainant on the ground that the complainant has  raised the claim towards Critical illness Mycocardial Infarction (First Heart Attack of Specific Severity) under clause 2.2.6 (a) of the policy. After that, the answering Opposite Parties  asked for certain documents which were required to adjudicate the matter, however the complainant submitted all the documents on 11.02.2022. Thereafter, the answering Opposite Parties thoroughly studied the medical record  of the treating hospital and come to the conclusion that the definition of a First Heart Attack of Specific Severity was given by the IRDAI in the Guidelines of Standardization in Health Insurance, 2016, but  in the instant case out of the three  requirements, one has been met but since required documents have not been provided by the complainant, therefore, the said claim has been rightly denied by the Opposite Parties. As per the medical record, the LA was diagnosed with Coronary Artery Diseases which is the exclusion as per the policy terms and conditions, therefore, the answering Opposite Parties repudiated the claim of the complainant. 

9.       The first contention for the repudiation of the claim of the complainant by Opposite Parties No.1 and 2  is that  the complainant has violated the terms and conditions of the policy in question and as per the terms and conditions of the policy, the complainant is not entitled to the claim as claimed.  But the Opposite Party could not produce  any evidence to prove that terms and conditions of the policy were ever supplied to  the complainant insured, when and through which mode? It has been held by Hon’ble National Commission, New Delhi in case titled as The Oriental Insurance Company Limited Vs. Satpal Singh & Others 2014(2) CLT page 305 that the insured is not bound by the terms and conditions of the insurance policy unless it is proved that policy was supplied to the insured by the insurance company. Onus to prove that terms and conditions of the policy were supplied to the insured lies upon the insurance company. From the perusal of the entire evidence produced on record by the Opposite Party,  it is clear that Opposite Party  has failed to prove on record that they did supply the terms and conditions of the policy to  the complainant insured. As such, these terms and conditions, particularly the exclusion clause of the policy is not binding upon the insured. Reliance in this connection can be had on Modern Insulators Ltd.Vs. Oriental Insurance Company Limited (2000) 2 SCC 734, wherein it is held that “In view of the above settled position of law, we are of the opinion that the view expressed by the National Commission is not correct. As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclosed to the appellant, the respondent can not claim the benefit of the said exclusion clause. Therefore, the finding of the National Commission is untenable in law.”  Our own Hon’ble State Commission, Punjab, Chandigarh in First Appeal No.871 of 2014 decided on 03.02.2017 in case titled as Veena Mahajan (Widow) and others Vs. Aegon Religare Life Insurance Company Limited in para No.5 has held that

“Counsel for the appellant argued that copy of insurance policy was not supplied to the appellant and hence, the exclusion clause in the contract of the insurance policy is not binding upon him. He further argued that no proof of sending of insurance policy was ever produced by the respondent despite specific contention raised by the complainant that the insurance policy was never received by him. He argued that though there is an averment of the OP that the policy in question was delivered through Blue Dart Courier to the complainant. In order to prove their contention, no affidavit of any employee of Blue Dart was produced who would have made a statement to have the effect that the policy was delivered to the complainant nor any acknowledgement slip for having received the article by the complainant through courier company was produced by the insurance company. He argued that since no policy document was received by the insured and argued that the terms and conditions as alleged to be part of the insurance policy were not binding upon the insured. He argued that policy was issued in the name of deceased Sh.Vijinder Pal Mahajan with his wife Mrs.Veena Mahajan as beneficiary and the same was never refused by the OP and the proper premium for insurance was paid by late complainant. He argued that as per the specific allegations made in the complaint in para No.4, no rebuttal to that contention was specifically there in their written reply in para No.2 and para No.4 in the reply filed by OP in the District Forum. He argued that Hon'ble National Consumer Disputes Redressal Commission, New Delhi in case of "Ashok Sharma Vs. National Insurance Co. Limited", in Revision Petition No. 2708 of 2013 held in para No.8 to the point of non-delivery of terms and conditions of the policy. He also cited Hon'ble Supreme Court's decision given in the matter of "United India Insurance Co. Limited Vs. M.K.J.Corporation" in Appeal (civil) 6075-6076 of 1995 (1996) 6 SCC 428 wherein the Apex court held that a fundamental principle of Insurance Law makes it that utmost good faith must be observed by the contracting parties. Good faith forbids either party from concealing what he privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary. Just as the insured has a duty to disclose, "similarly, it is the duty of the insurers and their agents to disclose all material facts within their knowledge, since obligation of good faith applies to them equally with the assured and further argued that since the terms and conditions were not supplied even on repeated requests the same cannot be relied upon by the opposite party in order to report to repudiate the genuine claim of the wife of the deceased policy holder.”

10.     On merits, the next point for adjudication vehemently contended before us by Opposite Parties is that  complainant has  raised the claim towards Critical illness Mycocardial Infarction (First Heart Attack of Specific Severity) under clause 2.2.6 (a) of the policy, but after thoroughly studying the medical record  of the treating hospital, Opposite Parties No.1 and 2 come to the conclusion that the definition of a First Heart Attack of Specific Severity was given by the IRDAI in the Guidelines of Standardization in Health Insurance, 2016 and  therefore, the said claim has been rightly denied by the Opposite Parties. But we do not agree with the aforesaid contention of the ld.counsel for Opposite Parties No.1 and 2. The onus to establish this fact is upon Opposite Parties No.1 and 2 in this case.  We have perused the copies of  medical record placed by Opposite Parties of the treating hospital, but there is neither any affidavit nor  complete particulars of the investigator recorded in them. Even the original certificate has not been placed on the record. There is no affidavit of doctor of the treating hospital to establish this fact on the record regarding previous disease of insured. He is a private doctor and not posted in any recognized health institute or government hospital. We are unable to rely upon the above referred investigation report appended with the Photostat copy of  medical record of complainant. In the absence of any affidavit of investigator and the affidavit of treating doctor of the hospital, we do not place any reliance upon these documents, as pressed into service by the Opposite Parties in this case. Consequently, we are of this view that Opposite Parties have failed to discharge the onus solemnly laid upon it to prove this fact that life assured was suffering from above pre-existing disease before taking the policy and he deliberately and fraudulently concealed this material fact from Opposite Parties. We, thus, conclude that there is no substantive evidence on the record to prove this fact that life assured was suffering from any disease before he took the insurance policy and he willfully suppressed this fact fraudulently from the Opposite Parties. Moreover, if the life assured was suffering from any diseases prior to issuance of the policy, in question, the same must not have escaped the notice of the empanelled doctors of the Insurance Company. However, no such investigation record has been produced by the opposite parties. In case Bajaj Allianz Life Insurance Co. Ltd. & Ors. Vs. Raj Kumar III (2014) CPJ 221 (NC), it was held by the Hon’ble National Commission that “usually, the authorized doctor of the Insurance Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. It was held that the Insurance Company wrongly repudiated the claim of the complainant.” However, the Opposite Parties-Insurance Company has not placed on record any evidence that before issuing the policy they ever got medically examined the insured. So the abovesaid law squarely covers the case of the complainant that it was the duty of the insurer to get medically examined while issuing the policy and once the policy was issued the insurer cannot take the plea of pre-existing disease of the insured.

11.     It also needs to be mentioned that Section 19 of the General Insurance Business (Nationalization) Act, 1972 states that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community. The denial of medical expenses reimbursement is utterly arbitrary on the ground that disease in question was pre-existing disease. It is mere an excuse to escape liability and is not bona fide intention of the insurance company. Fairness and non-arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State and public behavior. Any policy in the realm of insurance company should be informed, fair and non-arbitrary. When the insurance policy has exclusions/conditions to repudiate the claim or limit the liability, the same must be specifically brought to the notice of the insured and are required to be got signed to show that such exclusions and conditions have been brought to his/her notice.  Recently, our own Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in  First Appeal No. 50 of 2019 titled as Bajaj Alliance General Vs. Arjan Singh decided on 04.03.2021 also held so.

12.     The need for interpreting a contract always arises in two situations, (i) when a gap is needed to be filled in the contract and (ii) an ambiguity is needed to be resolved in the contract, then to find out correct intention of the contract, spirit behind it is required to be considered. Normally, the insurance policy is a contract of adhesion in which other party is left with hardly any bargaining power as compared to the insurer. Insurance contracts are standard form contracts and are drafted by the insurance company and as such, insurance company is at higher footing than the insured. The benefit of such clause, as exclusion clause, would go to the insured unless the same is explained in clear terms by the insurer. In such circumstances, the tribunal would be more oriented towards the interpretation which goes against the party who has inserted/drafted the disputed clause in the agreement/contract. The adjudicating authority is required to look into whether the intention of the party is to exclude or limit liability has been appropriately explained to the other party or not. This Commission while interpreting insurance agreement is to honour the intention of the parties, who have signed the agreement. Even if the agreement had general exclusion/condition for misrepresentation still fraudulent misrepresentation and non-disclosure may not be there. The innocent and negligent misrepresentations are to be ignored.  On the other hand, the rulings (i) Satwant Kaur Sandhu Vs. New India Assurance Company Limited, (ii) Murti Devi Vs. Birla Sun Life Insurance and (iii) Mamohan nanda Vs. United India Insurance Company Limited,   cited by the ld.counsel for the Opposite Parties  are not applicable and relevant  to the facts of the present case.  The insurance companies are in haste to charge the premium, but when the time to pay the insurance claim comes, they generally take up one excuse or the other to avoid their liability. The reliance of counsel for the appellant on law laid down in “Life Insurance Corporation of India Vs. Priya Sharma & others” 2012(4)CPJ-646, “Life Insurance Corporation of India & others Vs. Harbans Kaur” 2009(3)CPC-677, and “Life Insurance Corporation of India & another Vs. Ashok Manocha” 2011(3)CPC-285, would have been applicable, had this fact been established that life assured suffered from pre-existing ailment of kidney and he deliberately suppressed this fact fraudulently from the Opposite Parties, when he took the insurance policy. In view of our finding recorded above that Opposite Parties had failed to prove this fact that complainant was suffering from any pre-existing ailment and hence these authorities would not be attracted in this case. In this regard, on the same and similar facts and circumstances of the case, Hon’ble State Consumer Disputes Redressal Commission, in First Appeal No.62 of 2015  decided on 02.02.2017 in case India First Life Insurance Vs. Ms.Sudesh Rani also held so.   

13.     In such a situation the repudiation made by Opposite Parties-Insurance Company regarding genuine claim of the complainant have been made without application of mind. It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.  The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

14.     In view of the above discussion, we hold that the Opposite Party-Insurance Company have  wrongly and illegally rejected the claim of the complainant.

15.     Now come to the quantum of compensation.  The contention of the complainant is that  since the policy purchased by him covers the claim maximum upto the extent of Rs.2 lakhs, so the complainant claims the amount of medical reimbursement upto the extent of Rs.2 lakhs against the medical paid up bills of Rs.3,05,193/-. Perusal of the record i.e. billing sheet shows that he has placed on record the payment receipt of Rs.3,05,193/-, the detail of which as under:-

On the other hand, Opposite Parties No.1 and 2-Insurance Company  have not denied these expenses incurred by the complainant on his treatment under the policy in question. But as discussed above, the policy in question covers the insurance claim upto the extent of Rs.2 lakhs, and hence, we hold that the complainant is entitled to the reimbursement of Rs.2 lakhs only under the policy in question.     

16.     In view of the aforesaid facts and circumstances of the case,  we partly allow the complaint of the Complainant and direct Opposite Parties No.1 and 2 -Insurance Company to pay Rs.2 lakhs (Rupees Two Lakhs  Only) to the complainant  alongwith interest @ 8% per annum from the date of filing the present complaint i.e. 30.03.2022 till its actual realization.   The compliance of this order be made by Opposite Parties No.1 and 2-Insurance Company within 60 days from the date of receipt of copy of this order, failing which the complainant shall be at liberty to get the order enforced through the indulgence of this District Consumer Commission.  Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced in Open Commission.