Order by:
Sh.Amrinder Singh Sidhu, President
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that on the allurement of the agent of the Opposite Parties, the complainant purchased a health insurance policy bearing No.LTPRCC070052242 which includes basic cover of 15 critical illnesses as well as enhanced cover of 30 critical illness valid for the period w.e.f. 29.06.2018 to 28.06.2019 for a sum of Rs.40 lakhs carrying premium of Rs.16,472.80 paisa. Further alleges that unfortunately, on the night of 19.01.2019 the complainant felt uneasiness, sweating, chest pain and he immediately taken to the Bhiwani Hospital where the necessary medical tests/ diagnosis were conducted upon the complainant and the patient was found to be suffering from CAD with AWMI (heart disease) where the patient remained admitted till 23.01.2019. After discharge, the complainant lodged for the insurance claim with the Opposite Parties and also completed all the relevant formalities, but the Opposite Parties repudiated the genuine claim of the complainant on the false and frivolous grounds vide repudiation letter dated 26.09.2019. Hence, it is clear cut deficiency in service and unfair trade practice on the part of the Opposite Parties. Vide instant complaint, the complainant has sought the following reliefs.
- The Opposite Party may be directed to pay the sum assured of Rs.40 lakhs alongwith interest @ 18% per annum and the Opposite Parties may also be directed to pay Rs.1 lakh as compensation for causing mental tension and harassment and Rs.50,000/- as costs of litigation or any other relief to which this District Consumer Commission deem fit may please be granted to the Complainant, in the interest of justice and equity.
Hence, the Complainant has filed the present complaint for the redressal of his grievances.
2. Opposite Parties appeared through their counsel and contested the complaint by filing the written version taking preliminary objections therein inter alia that the present complaint is not maintainable and is liable to be dismissed. Further alleges that the intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure under the Consumer Protection Act and the appropriate remedy if any lies only in the Civil Court. The complainant on 26.06.2018 had submitted a proposal form bearing NO.LTPRCC070052242 for purchasing ‘CignaTTK Lifestyle Protection-Critical Care’ Plan. Under Section 5 (Medical and Lifestyle Information) of the proposal form, the complainant was required to answer various questions pertaining to his medical and lifestyle information. The complainant in response to the said questions had answered in negative, implying that he was not suffering from any medical illness. Further the complainant alleges that he was admitted at the hospital with h/o chest pain, however, the hospital records contrary to it does not mention any such fact. Secondly as per one of the Daily Progress Chart from the hospital, it appears that the complainant was requested to undergo various medical examinations-CBC, Lipid Profile, ECG, CPKMG which was refused by the complainant’s attendant and only ECG could be performed. Upon medical examination of the ECG report, it was found that the findings mentioned in the Admission Record of complainant of Coronary Artery Disease (CAD), with Anterior Wall Myocardial Infection (AMWI) does not correlate with the ECG report. Moreover, the complainant alleges that he was discharged next day from the hospital for further treatment at another hospital, however, he has failed to submit any discharge summary from the hospital for further management. Further alleges that from the perusal of the medical documents of Deepanjali Multi Speciality Hospital, Bhiwani, he was advised to undergo Coronary Artery Angiography(CAG), however, the complainant and the attendant refused to undergo the same. The coronary angiogram is a procedure that uses x-ray imaging to see a patient’s heart’s blood vessels. The test is generally done to see if there is a restriction in blood flow going to the heart. A coronary angiogram, which can help diagnose heart conditions, is the most common type of cardiac catheterization procedure. The complainant’s resistance not to undergo the said test at the time of his admission in itself reveals that the complainant had a malafide intention to grab the claim amount. Had the complainant undergone for CAG, it would have revealed correct picture of the alleged heart ailment. It is further submitted that as the dispute involves the determination of the issue of fraud, the same requires examination and cross examination of the witnesses including the hospital authorities, neighbours of the complainant etc. and forensic/ expert examination of the disputed documents and therefore, the present complaint is not maintainable. On merits, the Opposite Parties took up the same and similar pleas as taken up by the Opposite Parties in the preliminary objections and as such present complaint is liable to be dismissed.
3. In order to prove his case, the complainant has tendered into evidence his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C5 and closed the evidence on behalf of the complainant.
4. On the other hand, Opposite Parties also tendered into evidence the affidavit of Sh.Akhil Kulhari, Deputy Vice President Ex.Ops/1 alongwith copies of documents Ex.Ops/2 to Ex.Ops/8 and affidavit of Sh.Rajeev Ghanta Ex.Ops/9 and closed the evidence on behalf of the Opposite Parties.
5. We have heard the complainant as well as ld.counsel for the Opposite Parties and also gone through the documents placed on record.
6. During the course of arguments, the complainant as well as ld.counsel for Opposite Parties have mainly reiterated the facts as narrated in the complaint as well as written reply respectively. We have perused the rival contentions of the parties and also gone through the record on file. The main contention of the complainant is that he purchased a health insurance policy bearing No.LTPRCC070052242 which includes basic cover of 15 critical illnesses as well as enhanced cover of 30 critical illness valid for the period w.e.f. 29.06.2018 to 28.06.2019 for a sum of Rs.40 lakhs carrying premium of Rs.16,472.80 paisa. Further alleges that unfortunately, on the night of 19.01.2019 the complainant felt uneasiness, sweating, chest pain and he immediately taken to the Bhiwani Hospital where the necessary medical tests/ diagnosis were conducted upon the complainant and the patient was found to be suffering from CAD with AWMI (heart disease) where the patient remained admitted till 23.01.2019. After discharge, the complainant lodged for the insurance claim with the Opposite Parties and also completed all the relevant formalities, but the Opposite Parties repudiated the genuine claim of the complainant on the false and frivolous grounds vide repudiation letter dated 26.09.2019. On the other hand, ld.counsel for the Opposite Parties has repelled the aforesaid contention of the complainant on the ground admittedly, the complainant on 26.06.2018 had submitted a proposal form bearing NO.LTPRCC070052242 for purchasing ‘CignaTTK Lifestyle Protection-Critical Care’ Plan. Under Section 5 (Medical and Lifestyle Information) of the proposal form, the complainant was required to answer various questions pertaining to his medical and lifestyle information and in response to the said questions, the complainant had answered in negative, implying that he was not suffering from any medical illness. Further the complainant alleges that he was admitted at the hospital with h/o chest pain, however, the hospital records contrary to it does not mention any such fact. Secondly as per one of the Daily Progress Chart from the hospital, it appears that the complainant was requested to undergo various medical examinations-CBC, Lipid Profile, ECG, CPKMG which was refused by the complainant’s attendant and only ECG could be performed. Upon medical examination of the ECG report, it was found that the findings mentioned in the Admission Record of complainant of Coronary Artery Disease (CAD), with Anterior Wall Myocardial Infection (AMWI) does not correlate with the ECG report. Moreover, the complainant alleges that he was discharged next day from the hospital for further treatment at another hospital, however, he has failed to submit any discharge summary from the hospital for further management. Further alleges that from the perusal of the medical documents of Deepanjali Multi Speciality Hospital, Bhiwani, he was advised to undergo Coronary Artery Angiography(CAG), however, the complainant and the attendant refused to undergo the same. The coronary angiogram is a procedure that uses x-ray imaging to see a patient’s heart’s blood vessels. The test is generally done to see if there is a restriction in blood flow going to the heart. A coronary angiogram, which can help diagnose heart conditions, is the most common type of cardiac catheterization procedure. The complainant’s resistance not to undergo the said test at the time of his admission in itself reveals that the complainant had a malafide intention to grab the claim amount. Had the complainant undergone for CAG, it would have revealed correct picture of the alleged heart ailment. It is further submitted that as the dispute involves the determination of the issue of fraud, the same requires examination and cross examination of the witnesses including the hospital authorities, neighbours of the complainant etc. and forensic/ expert examination of the disputed documents and therefore, the present complaint is not maintainable.
7. In view the aforesaid facts and circumstances and matter regarding fraud allegedly committed by the complainant regarding suppression of facts in regard to his alleged treatment and moreover, the complainant has failed to prove his case by filing any cogent and convincing evidence on the record, we are of the view that intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure under the Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court. Not only this, the nature of the dispute, in the present complaint, is squarely covered by the law laid down by their lordships of the Hon'ble Supreme Court in various judgements. Further in case Oriental Insurance Company Ltd. Vs. Munimahesh Patel 2006(IV) CPJ page 1, wherein the Hon'ble Supreme Court has held that :-
“Proceedings before the commission are essentially summary in nature and adjudication of issues which involve disputed factual questions should not be adjudicated. It is to be noted that commission accepted that insured was not a teacher. Complainant raised dispute about genuineness of the documents (i.e. proposal forms) produced by the appellant.”
Their lordships have further held that :-
“The nature of the proceedings before the commission as noted above, are essentially in summary nature. The factual position was required to be established by documents. Commission was required to examine whether in view of the disputed facts it would exercise the jurisdiction. The State Commission was right in its view that the complex factual position requires that the matter should be examined by an appropriate court of Law and not by the Commission.”
A similar view has been taken by the Hon'ble National Consumer Disputes Redressal Commission in 1(2004) CPJ page 101 wherein it has been held by the Hon'ble National Commission in a revision petition titled as R.D. Papers Ltd. Vs. New India Assurance Co. Ltd. & Ors. in para No.7 of the judgement which reads as under:-
“After going through the complaint and the written version, it appears to us that the complaint raises complicated questions of facts which cannot be decided by us in our summary jurisdiction.”
8. Keeping in view the aforesaid facts and circumstances of the case, the instant complaint is not maintainable in this District Consumer Commission for its proper adjudication and the same stands dismissed. However, the complainant can get redressal of her grievance from the Civil Court/ or any other competent authority, in accordance with law, for which the time spent before this District Commission shall stand excluded under Section 14 of the Limitation Act in the light of the judgment of the Hon'ble Supreme Court in case titled 'Lakshmi Engineering Works vs PSG Industrial Institute reported in 1995(3) SCC 583'. However, keeping in view the peculiar circumstances of the case, the parties are left to bear their own costs. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to record room.
Announced in Open Commission.
