Complainant Rajiv Vohra has filed the present complaint against the opposite parties U/S 35 of the Consumer Protection Act (for short, C.P.Act.) seeking necessary directions to the opposite parties to release Rs.2,16,239/- of the medical bills incurred on his treatment alongwith interest @ 18% from the date of treatment or filing of claim. Opposite parties be further directed to pay Rs.5,00,000/- as compensation for causing mental agony and harassment to a professional man by dilly-dallying the genuine claim alongwith Rs.1,00,000/- as litigation expenses, in the interest of justice.
2. The case of the complainant in brief is that he purchased a Pro Health Group Insurance Policy No.10200027797 for which Rs.10,178/- was being paid as premium to the opposite parties incessantly since the inception of the policy alongwith GST through his saving bank account maintained by opposite party no.2 which was auto debited in the account of opposite parties no.1 & 2 through Master Policy Holder i.e. opposite party no.2. He has next pleaded that the opposite parties also profess that the Manipal Cigna Pro Health Insurance is designed to provide health coverage for expenses arising out of hospitalization but in practical they hood wink the innocent customers after receiving the premium and cheat, swindle the customers as it has happened with him who is a senior lawyer. In the month of 1 July 2020, he all of a sudden felt pain in the heart and his rhythm slowed down due to which he had to undergo heart surgery of Pace maker to correct his rhythm at Abrol Hospital Gurdaspur. The opposite parties were immediately informed on telephone and also in black and white regarding the admission, treatment and the expenses incurred on the treatment which were sent through online on 7th July 2020 alongwith original medical bills of Rs.2,16,239/- to opposite parties which were received by them and they assured for speedy release of insured amount but the opposite parties kept on procrastinating the genuine claim and on 27.09.2020, they informed him that his claim has been repudiated without assigning any reason which developed the feeling of animosity against the opposite parties who have done unfair trade practice and cheated him without his fault. The repudiation of genuine claim on 27.09.2020 by the opposite parties is illegal, arbitrary, ultravirus, honest in the eyes of law be set aside by accepting the present complaint. Hence this complaint.
3. Notice of the complaint was issued to the opposite parties. Opposite parties no.1 &3 appeared through their counsel and filed their written reply by taking the preliminary objections that the present complaint is false, vexatious and has been filed with a malafide intention to harass the opposite parties no.1 & 3; the complaint is not maintainable against the opposite parties; the complainant has not come before the Hon'ble Commission with clean hands; the complainant is stopped by his own acts and conducts from filing the present complaint; the contract of insurance between the parties to the contract is governed by its terms and conditions; the complainant is not a consumer within the definition of Section 2 (d) of the Consumer Protection Act and the Hon'ble Commission has got no jurisdiction to try and entertain the present complaint. So the present complaint is liable to be dismissed for want of jurisdiction. On merits, it was submitted that the complainant by virtue of being the account holder at Bank of India (Master Policy holder) was eligible to be enrolled under the Pro Health Group Health Insurance Policy. Basis the information provided by the complainant in the proposal form certificate of Insurance (COI) was issued to the complainant bearing COI no.100200027797/01/00 by opposite parties no.1 & 3. In order to get the benefits under the policy the insured person has to disclose all the facts regarding his health to the insurer at the time of submitting the proposal form, truly without concealing of any facts. But in the present case the complainant concealed the fact that he was suffering from the diabetes and Hypertension and is under the treatment of the doctor. Had the complainant disclosed the same in the proposal form, company would not have issued coverage to the complainant under the group policy. By concealment of this material facts the complainant played the fraud with the opposite parties and on the basis of the declaration made by the complainant, the opposite parties no.1 & 3 issued the policy in question in good faith subject to policy terms and condition. Since the complainant had suppressed the material information intentionally and with malafide intent, the complainant is not entitled for any claim amount. It was denied that in the month of July 2020, the complainant all of a sudden felt pain in the heart and his rhythm slowed down due to which he had to undergo heart surgery of pace maker to correct his rhythm at Abrol Hospital Gurdaspur. The opposite parties no.1 & 3 has rightly denied the claim of the complainant as the present case is a clear cut case of concealment of material facts and misrepresentation. As per the investigation the complainant was suffering from Diabetes Mellitus and Hypertension since three years. The said fact was not disclosed by the complainant at the time of proposal. So the present case is a clear cut case of concealment of material facts and is also liable to be dismissed in the light of the violation of the policy terms and conditions. The claim of the complainant is repudiated by the opposite parties vide letter dated 27.09.2020. The claim was repudiated by the opposite parties as per the terms and conditions of the policy and due to the suppression of the material facts on the part of the complainant. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed.
4. Opposite party no.2 appeared and filed its written reply taking the preliminary objections that the complainant has filed a false and frivolous complaint against the opposite party no.2 as the opposite party no.2 has nothing to do with the present complaint neither the opposite party no.2 is concerned with the present complaint in any manner. Hence, the present complaint is liable to dismiss on this score alone; the complainant has no locus standi to file the present complaint against the opposite party no.2 and no cause of action arose to file the present complaint against the opposite party no.2. On merits, it was submitted that opposite party have neither received any money nor issued any policy to the complainant it is the subject matter, if any among the complainant and opposite party no.1 and 3 and would clear that opposite party doing of his own business of Banking under the name and style Bank of Maharashtra throughout world and opposite parties no.1 & 3 doing the business of insurance. Moreover opposite party is maintaining so many accounts of their customers and complainant fails to clear in which account number Rs.10,178/- got debited and credited. Opposite party did not issue any insurance policy to the complainant as alleged by the complainant. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed.
5. Alongwith the complaint complainant has tendered into evidence his own affidavit Ex.CW-1/A alongwith other documents Ex.C-1 to Ex.C-29.
6. Alongwith the written reply opposite party no.1 & 3 filed affidavit of Sh.Akhil Kulhari, Assistant Vice President (AVP) Legal Ex.OP-1 & 3/A alongwith other documents Ex.OP-1 & 3/1 to Ex.OP-1 & 3/5.
7. Rejoinder not filed on behalf of complainant.
8. Written arguments have been filed on behalf of complainant.
9. We have carefully gone through the pleadings of counsels for the parties; oral arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsels for the purposes of adjudication of the present complaint.
10. From the over all circumstances as enumerated in respective pleadings of the parties, it reveals that the complainant had purchased a Pro Health Group Insurance Policy No.102000277797 for Rs.10,178/-from opposite party No.1which is Ex.C2. Thereafter in the month of 1 July 2020,the complainant all of a sudden felt pain in the heart and his rhythm slowed down due to which he had to undergo heart surgery of Pace maker to correct his rhythm at Abrol Hospital Gurdaspur .Thereafter the complainant informed the opposite parties regarding the admission, treatment and the expenses incurred on the treatment. Thereafter on 7th July 2020 the complainant sent the original medical bills of Rs.2,16,239/-. to opposite parties which are Ex.C4 to Ex.C 27.But on 27.09.2020 the opposite parties repudiated the claim of the complainant on the ground of non disclosure of material facts which is Ex.OP-1/3/1.
11. The Ld. Counsel for complainant argued that opposite parties cannot repudiate the claim of the complainant on the ground of alleged terms and conditions, which were never supplied or explained to him at the time of inception of insurance Policy, moreover these were also not placed on file. He pointed out the 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 has been alleged by ld.counsel for complainant that generally its seen that insurance companies are only interested in a earning the premium and find ways and means to decline the claims. The opposite parties also profess that the Manipal Cigna Pro Health Insurance is designed to provide health coverage for expenses arising out of hospitalization but in practical they hood wink the innocent customers after receiving the premium as it has happened with the complainant in the present case. He placed reliance on citation titled as SBI General Insurance Company Limited Vs Balwinder singh Jolly and anothers 2016 (4)CLT 372 held as Under “ Preexisting diseases - age of insured when mediclaim insurance policy was issued was more then 45 years- Held- in that event as per Instructions issued by IRDA it was duty of the insurer to put insured to through medical examination – claim raised after issuance of insurance policy cannot be rejected on account of non disclosure of the fact of preexisting disease when policy was obtained.”
12. Opposite party in their written statement and written arguments mainly pressed upon the one point regarding non disclosure/concealment of the material facts regarding pre-existing disease of the complainant and claimed that the complainant was having this medical problem of diabetes and hypertension since three years but no such cogent evidence was placed on record by the opposite party.
13. In view of the above and relying upon the judgment of the case titled SBI General Insurance Co.Ltd Vs. Balwinder Singh as mentioned in the proceeding para, we are of the view that repudiation of the claim of the complainant is not justified. It is generally seen that insurance companies find ways and means just to reject the claims on various grounds.
14. From the above details of the case and latest development came up during the proceeding of the case, we observe that opposite parties No.2&3 cannot be considered liable for any claim in this case.
15. Therefore, as a sequel of the above discussion, this commission is of the considered opinion that the Opposite party no.1 has wrongly and illegally repudiated the claim of the complainant which amounts to deficiency in service on its part. Hence the present complaint is partly allowed and OP No.1 is directed to make the payment of insurance claim of Rs.2,16,239/- alongwith interest @ 6% per annum from the date of filing of the present complaint i.e. 12.10.2020 to the complainant within 45 days from the date of receipt of copy of this order, failing which opposite party no.1 shall pay the amount alongwith interest @ 9% P.A. till its realization. In addition to this the Opposite party no.1 is directed to pay Rs.5000/- on account of deficiency in service and litigation expenses to the complainant.
16. 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.
17. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record room.
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(Kiranjit Kaur Arora)
President
Announced: (B.S.Matharu)
April 06, 2023 Member
*MK*
