Complainant Sumit Mahajan had filed the present complaint U/s 12 of the Consumer Protection Act against the opposite parties and praying that the directions may kindly be issued to opposite party to pay Rs.68050/- as claim along with interest @ 12 percent per annum from the date of accident of claim i.e. March 2019 till realization. Complainant had also claimed Rs.40,000/- as compensation for the sufferings and unnecessary harassment to him.

2.       The case of the complainant in brief is that he took a health insurance plan, i.e. Health Companion Variant II vide policy No.30645659201801 which issued by opposite party No.2 through its agent Tajinder Kaur who got the policy document dully filled and signed from the complainant at Gurdaspur and as such complainant is consumer within the meaning of section 12 of CPA. It was pleaded that on 03.02.2019 complainant met with an accident and undergone treatment at Abrol Medical Centre, Guddaspur from 03.02.2019 to 05.02.2019 with registration No.8870 with UHID- P- 14853 and diagnosed with comminuted fracture both bone forearm left and  underwent-CR & IF with JESS External Fixator and also spent Rs.68050/- on his treatment. It was further pleaded that opposite party was informed by the complainant about his accident and treatment also submitted the claim form with the opposite parties for reimbursement of expenses which were incurred upon the treatment to which he was legally entitled. It was also pleaded that the legal claim of the complainant was disallowed by the opposite parties vide their letter dated 09.04.2019 by giving vague and unsatisfactory reasons and this act of the opposite parties is illegal, arbitrary and uncalled for which amounts to breach of the terms and conditions of the said insurance policy. It was next pleaded that complainant suffered grave injury due to the said accident and also due to the non acceptance of his legal claim by the opposite parties, hence, this complaint.

3.       Upon notice opposite parties appeared through their counsel and filed its written reply by taking the preliminary objections that present complaint is false, frivolous and vexatious as the complainant has not disclosed any cause of action to proceed against the opposite parties and complaint is liable to be dismissed; that policy bearing No.30645659201700, Health Companion Plan was issued by the opposite parties in the name of complainant, his wife Rajani Mahajan, daughter Rishka Mahajan and son Aarul Mahajan on the information provided by the  complainant. It was stated that the treatment for which claim was raised due to an accident thorough investigation was conducted but complainant failed to submit his driving license and documents in respect of his treatment of hypertension and diabetes mellitus inspite of repeated requests of the company and its officials; that the claim under the said policy was repudiated by the opposite parties by its speaking order; that the present complaint is not maintainable, if policy is not suitable, the policy holder can review/cancel his policy by returning the policy and policy documents within 15 days (Free Look Period)  as per clause 4(1) and 6(2) of the IRDA Regulation, 2002 and in support of their version in para no.6 of the preliminary objections opposite parties have mentioned some case laws; that Forum/Commission has no jurisdiction to entertain the present complaint. It was stated that in para no.10 of the preliminary objections that if complainant submits his valid driving license and documents pertaining to his prior treatment of diabetes and hypertension, the company will re-evaluate his claim and take a decision. On merits, it was stated that the proposal form was duly signed by the complainant and an opportunity was given to him to re-examine the form and get the details rectified in case of any discrepancy but he did not approach to the opposite parties with any grievance regarding the policies terms and conditions. It was further stated that claim was raised by the complainant with the opposite parties for his treatment of injuries due to an accident at Abrol Medical Centre from 3rd Feb. 2019 to 5th Feb. 2019 and as per investigation of the company and hospital record it was found that complainant met with an accident but he did not produce his driving license due to which claim/treatment is not payable as per the terms and conditions. It was also stated that non submission of driving license raises doubts that the complainant does not possess the same and in that scenario the following terms of the policy are invoked:

          Permanent Exclusions: We will no be liable under any circumstances, for any claim in connection with or with regard to any of             the following permanent exclusions and any such other exclusions as may be specified in the schedule of Insurance Certificate.

          Unlawful Activity: Any condition as a result of insured person committing or attempting to commit a breach of law with criminal            intent.

It was next stated that the insurance company pays the claim amount from the common pool of the policyholders and payment of one wrongful claim adversely affects thousands of other rightful policyholders such as complainant failed to submit his valid driving license, it raises doubts that claim falls under unlawful activity and as such repudiation of claim by the opposite parties for non production of relevant documents vide their letter dated 29.10.2019 is legal and valid and present complaint is an abuse of process of law and is liable to be dismissed in accordance with section 26 of the CPA, 1986. In para-wise reply it is denied that any agent had sourced the policy and complainant himself opted for taking the policy in question. It was stated that complainant had failed to demonstrate any deficiency in service on the part of the opposite parties as the deficiency is defined under section 2(g) of the CPA. It was further stated that opposite parties have strictly acted as per the terms and conditions of the policy contract and Forum/Commission cannot pass any order in contravention of the same. Remaining contents are repeated by the opposite parties as mentioned above and some of the averments of the complaint are vehemently denied and prayed for dismissal of the complaint with exemplary cost.

4.       Counsel for the complaint to prove the case has filed self attested affidavit of complainant with copies of documents Annexure A-1 to Annexure A-33 alongwith some other documents.

5.       On the other hand counsel for the opposite parties has filed affidavit of Chandrika Bhattacharya Chief Manager Ex.OP-1,2/1/A with copies of documents Ex.OP-1,2/1 to Ex.OP-1,2/6.

6.       Rejoinder filed by the complainant.

7.       Written arguments filed by the complainant but not filed by the opposite parties.

8.       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.

9.       From the over all circumstances as enumerated in respective pleadings of the parties,  It reveals that the complainant took a health insurance plan, i.e. Health Companion Variant II vide policy No.30645659201801, issued by opposite party No.2 which is Ann.A-1. But on 03.02.2019 complainant met with an accident and undergone treatment at Abrol Medical Centre, Guddaspur from 03.02.2019 to 05.02.2019 with registration No.8870 with UHID- P- 14853 and spent Rs.68050/- on his treatment. Thereafter complainant informed the opposite party about his accident and treatment and also submitted the claim form for reimbursement of expenses .But the  claim of the complainant was repudiated by the opposite parties vide their letter dated 09.04.2019 which is Ann.A-24.

10.     Learned counsel for opposite party argued that the claim was raised by the complainant with the opposite parties for his treatment of injuries due to an accident at Abrol Medical Centre from 3rd Feb. 2019 to 5th Feb. 2019 and as per investigation of the company and hospital record it was found that complainant met with an accident but he did not produce his driving license due to which claim/treatment is not payable as per the terms and conditions further submitted that non submission of driving license raises doubts that the complainant does not possess the same. The insurance company pays the claim amount from the common pool of the policyholders and payment of one wrongful claim adversely affects thousands of other rightful policyholders such as complainant failed to submit his valid driving license, it raises doubts that claim falls under unlawful activity and as such repudiation of claim by the opposite parties for non production of relevant documents vide their letter dated 29.10.2019 and conditions of the policy. Thus, there is no deficiency in service on the part of the insurance company.

11.     The Ld. counsel for complainant argued that the Repudiation of the claim has been done on the ground that there was non-cooperation from the customer, hence claim reject as per the terms and conditions of the policy  .There is no evidence produced by the opposite party to establish this fact. Moreover, it is not clear on what basis the opposite party has concluded that claim falls under unlawful activity. The reason for repudiation of the claim is therefore, based not on evidence but on a surmise which cannot be a valid ground for repudiating the claim.  The Ld. counsel for complainant argued that opposite parties cannot repudiate the claim of the complainant on the ground of alleged terms and conditions. He placed reliance on citation 2001(1)CPR 93(SC) 242 titled as M/S Modern Insulators Ltd., Vs The Oriental Insurance Co. Ltd wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored. Furthermore, it generally seen that insurance companies are only interested in earning the premium and find ways and means to decline the claims.

12.    Therefore, as a sequel of the above discussion, facts and circumstances of the case, this commission is of the considered opinion that the Opposite parties have wrongly and illegally repudiated the claim of the complainant which amounts to deficiency in service on its part. Hence, the present complaint is hereby partly allowed and opposite parties are  directed to pay Rs.68050/- along with interest @ 6% P.A. from filling of the present complaint till its realization within 45 days from the date of receipt of copy of this order, failing which opposite parties shall pay the said amount along with interest @ 9% P.A. to the complainant , in addition to this opposite parties are directed to pay Rs.5000/- in lump sum as deficiency in services  and  litigation charges to the complainant.

13.      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.

14.      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.

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

                               (Kiranjit Kaur Arora)

                                                                         President   

Announced:                                          (B.S.Matharu)

April 19, 2023                                              Member

*YP*