Complainant Vijay Puri had filed the present complaint U/s 35 of the Consumer Protection Act, (as amended upto date) against the opposite parties and praying that the directions may kindly be issued to opposite party to pay Rs.29,984/- with interest thereon at the rate 18% P.A. w.e.f. 09.11.2018. Opposite parties be further directed to pay Rs.50,000/- as compensation for harassment and mental agony caused to the complainant by the opposite party including Rs.22,000/- as litigation expenses, in the interest of justice.

2.       The case of the complainant in brief is that the complainant obtained a health care/health claim Policy No.4016/120339706/02/000 for the coverage period from 01.08.2018 to 31.07.2019 from the opposite party No.1 through the opposite party No.2 and due premium was paid by him as required by the opposite parties and as such he the consumer of the opposite party as per the definition of CPA (as amended upto date). It was pleaded that complainant was suffered from the disease Pro-state cancer and he remained under the treatment at day care centre of Patel Hospital Jalandhar w.e.f. 09.08.2018 to 09.11.2018 and spent Rs.29,984/- on his treatment at Day Care Centre Patel Hospital Jalandhar and after curing of treatment complainant informed the opposite party and requested to make the payment of Rs.29,984/- i.e. the amount of medical bills and also submitted the copies of the bills by completing all the formalities for the settlement of the claim of above said amount. It was further pleaded that the legal claim of the complainant was rejected by the opposite party vide their letter dated 19.04.2019 with the covering letter dated 27.05.2019 on the lame excuse and flimsy ground/remarks mentioned therein i.e. "As per documents submitted in support of the claim, insured was treated on OPD basis. As per policy OPD treatment is not covered, hence claim request is rejected" which was illegal, unlawful, in utter disregard and violation of principles of natural justice, equity and fairplay and against the provisions of CPA. It was also pleaded that rejection of legal claim of the complainant of Rs.29,984/- is not sustainable as complainant was not getting the medical treatment from Jalandhar as OPD patient as he was getting his treatment for his disease as a day care patient at Day Care Centre Patel Hospital Jalandhar and the claim forms and documents have been duly certified to that effect by the doctors of the hospital w.e.f. 09.08.2018 to 09.11.2018 and documents obtained by opposite party No.1 but they repudiated the legal claim of the complainant without considering the same. It was next pleaded that complainant was kept as Day Care Patient directly under the direct supervision of qualified Medical Officers due to precautionary measures so that his health could be regularly monitored by the doctors of the hospital and in case of any adverse health condition the medical staff may rush to the day care patient and to take care of him. It is very surprising that when the policy was introduced opposite party were in search of the customers and when the number of clientage including complainant attached with the opposite party they repudiated the legal claim of the complainant and it is a matter of record that the opposite parties have renewed the Health Insurance Policy of the complainant for the succeeding years after repudiation of his claim. Complainant is entitled to the compensation amount of   Rs.50,000/- for the harassment and mental agony caused to him by the opposite party. It is also stated by the complainant that inadvertently he filed complaint against policy No.4016/11155030012/000 which was not in existence and he withdrawn the same with permission to file fresh complaint on the cause of action of the present complaint, hence this complaint.

3.       Upon notice opposite parties appeared through their counsel and filed separate written replies. Written reply on behalf of opposite party No.1 filed by taking the preliminary objections that complainant has no cause of action and locus standi to file the present complaint; that there is no deficiency in service on the part of the insurance company; that the insurance is a contract between the two parties and the scope of the insurance cannot be increased or decreased and if this Ld. Commission comes to the conclusion that there is any liability of the insurance company then the same is only as per terms and conditions and coverage of the policy. On merits, it was stated that the documents submitted by the complainant clearly shows that he got treatment on OPD basis which was not covered under policy. It was further stated that the letter dated 19.04.2019 was legal and valid and the claim of the complainant was repudiated as the same was not covered under the policy and as per the documents submitted in support of the claim insured was treated on OPD basis and as per the preview of the policy OPD treatment is not covered under the policy and as such claim was rejected. It was also stated that complainant alleged in the complaint that he got treatment in Day Care Centre and wants to allege that he got day care treatment but as per the terms and conditions of the policy at point 12 Day Care Treatment and OPD both are different and the complainant intentionally referring these words. All other averments made in the complaint have been specifically denied and lastly prayed for dismissal of complaint.

4.       Written reply on behalf of opposite party No.2 also filed by taking the preliminary objections that complainant has no cause of action to file the present complaint; that complainant has no locus standi to file present complaint; that complainant has wrongly made ICICI Bank as party to the present complaint as the claim was repudiated by the ICICI Lombard General Insurance Company Limited and a letter dated 31.3.2021 given by the complainant and assured that he shall withdraw the complaint against the Bank but he did not withdraw the same. On merits, it was stated that the policy was issued by opposite party No.1 i.e. ICICI Lombard General Insurance Company and the payment if any is to be made by them as they repudiated the claim vide letter dated 19.04.2019 and complainant may put strict proof regarding the treatment. All other averments made in the complaint have been specifically denied and lastly prayed for dismissal of complaint.

5.       Counsel for the complaint to prove the case has filed affidavit of complainant Ex.CW-1/A with copies of documents Ex.C1 to Ex. C41.

6.       On the other hand counsel for the opposite party No.1 has filed affidavit of Nishant Gera authorized signatory Ex.OW-1/A with copies of document Ex.OP-1/1 to Ex.OP-1/3.

7.       On behalf of opposite party No.2 affidavit of Baljit Singh authorized signatory Ex.OP-2/1/A with copy of document Ex.OP-2/1 filed.

8.       Rejoinders filed by the complainant.

9.       Written arguments not filed by the parties.

10.     We have carefully examined all the documents/evidence produced on record for its contained statutory merit and have also judiciously considered and perused the arguments duly put forth by the learned counsels for the parties.

11.     From the over all circumstances as enumerated in respective pleadings of the parties, It reveals that the complainant had obtained a health care/health claim Policy No.4016/120339706/02/000 for the coverage period from 01.08.2018 to 31.07.2019 from the opposite party No.1 as Ex.C1. Thereafter the complainant was suffered from the disease Prostat cancer and he remained under the treatment at day care centre of Patel Hospital Jalandhar w.e.f. 09.08.2018 to 09.11.2018 and spent Rs.29,984/- on his treatment. Thereafter the complainant informed the opposite party and requested to make the payment of Rs.29,984/- i.e. the amount of medical bills and also submitted the copies of the bills for the settlement of the claim. But the opposite party no.1 vide letter dated 19.04.2019 repudiated the claim of the complainant on the ground that the claim was not covered under the policy as the insured/complainant  was treated on OPD basis and as per the preview of the policy, OPD treatment is not covered under the policy and as such claim was rejected as Ex.C2.

12.     It is admitted case of the opposite parties that intimation with regard to treatment was given by the complainant to the opposite party No.1. The stand of the Opposite party no.1 is that as per the preview of the policy, OPD treatment is not covered under the policy as such the claim was rightly rejected.

13.     The Ld. counsel for the complainant argued that Opposite party wrongly and illegally repudiated the claim of the complainant on the lame excuse and flimsy ground/remarks. Moreover policy terms and conditions were not supplied to the complainant; as such the terms and conditions are not binding upon the complainant.

14.     From the above details of the case and latest development came up during the proceeding of the case we see that the opposite party No.2 cannot be considered liable for any claim in this case.

15.     From the above said discussion, it is clear that there is no dispute as regards to the policy particulars, period of policy, sum insured. Due to the new technology, sometimes patients are treated in less time even or without hospitalization, if the patient is not admitted or is treated within a short time after admission due to new techniques, the insurance company cannot reject the claim on the ground that the patient was not admitted. It transpires that the genuine claim of the complainant has been repudiated by the opposite parties without any reasonable excuse. It is usual with the insurance companies to show green pastures to the consumers when they are to sell their policies. But however when it comes to the payment for claim, they invent all sort of excuses to deny the claim. Reliance on 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 claim. 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 111went 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".

16.     Therefore, as a sequel of the above discussion considering the facts and circumstances of the case and relying upon the above quoted judgments, this Commission is of considered opinion that the rejection of the medical claim of the complainant is not justified. Hence, the complaint in hand is hereby partly allowed and the claim rejection letter dated 19.04.2019 of opposite parties (Ex.C2) is set aside. Further, opposite party No.1 is directed to pay Rs.29,984/- along with interest @ 6% P.A. from filling of the present complaint i.e. 18.01.2021 till its realization within forty five days from the date of receipt of copy of this order, failing which opposite party shall pay the said amount along with interest @ 9% P.A. to the complainant , in addition to this opposite party No.1 is directed to pay Rs.5000/- in lump sum as deficiency in services and litigation charges to the complainant.        

17.      The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases.

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

                               (Kiranjit Kaur Arora)

                                                                         President   

Announced:                                          (B.S.Matharu)

March 16, 2023                                             Member

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