Dinesh Sharma, the complainant through the present complaint filed U/s 12 of the Consumer Protection Act, 1986 (hereinafter for short, ‘the Act’) has sought issuance of necessary directions to the titled opposite parties (for short, called ‘the OP’); to pay him the insurance amount along with the medical expenditure of Rs. 50,000/- besides a compensation of Rs.45,000/- for causing mental harassment and torture & another sum of Rs.3,000/- as cost of litigation; all with interest @ 12% PA and also to continue with the medical-policy in question.  

2.       The case of the complainant in brief is that he upon receipt of a telephonic offer for one Rs.14 Lac insurance Policy contacted the OP insurers sometime in October’ 2009 and on their advice subjected himself to medical-examination by Dr Ram Murti Heart & Sugar Specialist who detected him to be ‘diabetic’ and thus he was issued one other Policy (since continued through renewals etc) @ Rs.5,000/- half-yearly premiums, by getting his signatures on one Blank application-format. However, the complainant having met with an accident on 28.02.2014 remained hospitalized till 02.03.2014 and filed the related insurance claim for the incurred medical expenditure of Rs.50,000/- with the OP insurers who repudiated the same though illegally on the flimsy grounds of suppression of pre-existing ailments in the related proposal form. The complainant pleaded that all his aliments were very much in the OP’s notice since he had failed in the medical examination conducted by their Dr Ram Murti and only then he was issued the present Policy having refused the first Rs.14 Lac Policy on medical grounds only. Thus, the complainant having failed to move the OP insurers with his logic, preferred the present complaint with the desired relief, as prayed hereinabove.   

3.       Upon notice, the OP insurers’ appeared through their counsel and filed its written reply taking the preliminary objections of absence of cause of action, no proven deficiency in service on the OP’s part and the complainant himself being guilty of suppression of the material facts/pre-existing ailments in the proposal form, for wrongful gains. Further, it is clarified that the Policy in question was issued on the strength of the proposal form submitted by the complainant in which he had himself declared his ‘health status’ as affirmative by knowingly suppressing the fact of the pre-existing ailments and thus the related claim has been validly repudiated. On merits, the same objections and averments have been repeated while denying and rebutting all other allegations raised in the body of the complaint and lastly re-raising the issue of suppression of continuing ailments in the proposal form, the complaint being frivolous and filed without any cause of action has been prayed to be dismissed with costs in accordance with the provisions of the section 26 of the Act.    

4.       Both the parties produced their respective affidavits and documents in evidence to support their pleadings/allegations and objections/averments etc and their counsels also put forth their arguments to prove their respective claims. We have examined all the documents/evidence produced on record and have also duly considered and perused the heard arguments while adjudicating the present complaint. The OP insurers plea of ‘suppression of existing ailments’ by the complainant is straightaway rejected being inadvertently put forth as they very well had its knowledge, notice and availability of its cogent evidence on record by way of ‘medical-examination’ report of the complainant duly conducted at their instance by their own-designated Dr Ram Murti Heart & Sugar Specialist and on the basis of which the first Rs.14 Lac Policy was refused to the complainant. The complainant has produced the documents exhibited as: Ex.C1 being the affidavit of the complainant deposing the pleadings averred in the complaint and Ex.C2 to Ex.C22. In reciprocation, the OP insurers have produced its evidence exhibited as: Ex.OP1,2,3/1 being the affidavit of Gurjit Singh its authorized signatory; and others as: Ex.OP1,2,3/2 to Ex.OP1,2,3/5 and closed its evidence.

5.       We find that the complainant was first refused the Rs.14 Lac insurance Policy since he was detected ‘diabetic’ during the pre-insurance medical-examination conducted by (the OP’s designated) Dr Ram Murti Heart & Sugar specialist and then he was offered the present insurance Policy ‘Health Solution’ (on the strength of ‘self-declared health-status’ only) by the OP’s representative Manu Walia @ Rs.5,000/- premium per Half-Year and that continues for the next four years till the present claim. Obviously, in the seemingly ‘win-win’ situation the OP’s Manu Walia and the complainant both ignored and set-aside all virtues and ethics in their enthusiasm to cull an insurance policy and what they did was duly accepted by the authorities (that were) to issue the impugned Policy that resulted into the repudiated claim. Presently, the parties shall not be allowed to have the benefits of their own wrongs. Somehow, the complainant being a victim and an ignorant passive-offender deserves a somewhat lenient treatment. We understand that the insurance claims are paid out of the Public Money funds and need be dispensed with judicial precision but certainly not at the cost of judicious dispensation by way of arbitrary repudiations of otherwise valid and lawful claims and against the hopes, expectations and tears of the insured suffering from serious and/ or terminal ailments. With the advent of novel concept to consumer rights (under the larger umbrella of Civil Rights) as envisaged by the of-late UN Conventions on Human Rights, Corruption, Consumer Disputes etc (to which India has been a signatory, too) the Service Providers are bestowed upon with ample opportunities to serve the society and at the same time are beheld with certain social obligations, too. To sum it up, the Service Providers are desired to settle the insurance claims strictly as per the extant guidelines duly formulated by the IRDA, their governing body but in a consumer friendly way, also keeping in mind that all their claim-settling decisions are open to judicial review and any arbitrariness shall not pass the touchstone test of natural justice and equity besides that of the statute.      

6.       In the light of the all above, we ORDER the OP Insurers to settle and pay in full but only up to the eligible-amount (under the related insurance Policy) of the repudiated insurance claim for medical treatment at Arora Hospital, Gurdaspur (from 28.02.2014 to 02.03.2014) besides Rs.3,000/- as cost of litigation to the complainant within 30 days of the receipt of the copy of these orders otherwise the aggregate amount shall attract interest @ 9% PA from the date of filing of the complaint till actually paid. We are not inclined to award here any compensation since the complainant has already accepted the gracious-payment from the OP insurers who shall also be at liberty to exercise their discretion to renew or not the presently continuing insurance policy, if so.     

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

                                                                    (Naveen Puri)

                                                                               President

ANNOUNCED:                         (G.B.S.Bhullar)                    (Jagdeep Kaur)

January 13, 2015.                                Member.                                Member.

*MK*