Mr.Anoop Sharma, Presiding Member

1.       Smt.Rupinder Kaur  has brought the instant complaint under section 11 & 12 of the Consumer Protection Act, 1986 on the allegations that  the complainant received a call from the agent of Opposite Parties with their consistence persuasion, the complainant had purchased family health insurance policy known as Health Companion Silver commencing by paying a premium of Rs.7446/- for a sum assured of Rs.3 lacs from Opposite Party No.1 through Opposite Party No.2 vide policy No. 30256949201401 valid for the period from 8.10.2014 to 7.10.2015 against the requisite premium covering the medical check up of all the family members of the complainant and as such the  complainant is a consumer of the Opposite Parties as defined under the Consumer Protection Act. It is pertinent to mention over here that prior to that, the complainant had been regularly purchasing/ obtaining the mediclaim policy from united India Insurance Company limited w.e.f 2008 till 2012 and thereafter on account of consistence persuasions of the agents of Opposite Parties, the complainant port the said mediclaim policy from ops for valuable premium as detailed above and at the time of obtaining the said mediclaim policy, the said agents of Opposite Parties have obtained the signatures of  both the complainant on various blank papers and forms etc. under the impression that all the documents are related to their insurance policy, but however, no explanation of any kind whatsoever was given to the complainant at that  time by the said agents of the Opposite Parties.  The complainant is holder of cashless medical hospitalization facilities under the scheme under the policy having card No. 1847037 issued by Opposite Party No.1 through Opposite Party No.2 to provide cashless hospitalization facilities to the holder of said card. During the validity period of said policy, the complainant was hospitalized in Mrs.Khushbir Kalra’s Memorial Hospital, Ajit Nagar, Amritsar and after conducting proper medical examination she was operated for DNS & turbinate hypertrophy. The complainant was not having any such past disease and the complainant was suddenly suffered from said disease and came to know about the same only 22.09.2015 and as such she was got treated and her surgery was got conducted and she remained hospitalized w.e.f. 29.9.2015 to 30.09.2015 as per the advise of concerned doctor. At the time of admission, the complainant presented the card issued by Opposite Parties, but Opposite Parties refused the complainant to provide cashless facilities and insisted her to deposit the cash amount with the concerned hospital. After that the complainant approached the Opposite Parties and the officials of the Opposite Parties assured that they would refund the amount spent by the complainant for the operation of complainant in Mrs.Khushbir Kalra’s Memorial Hospital alongwith all other expenses incurred on her medical treatment and medicines etc. Further time to time the father  of the complainant approached the Opposite Parties and made them aware that the complainant is entitled for the cashless hospitalization facilities of Rs.19,887/-, but the Opposite Parties refused to pay the genuine claim of the complainant, though the complainant spent the huge amount on the medical treatment and even deposited the original bills, cash memo and other documents with the Opposite Parties. The impugned claim was lodged for reimbursement of medical expenses with the Opposite Parties and all the requisite documents and original medical bills etc. were  supplied to the Opposite Parties, but the Opposite Parties have failed to process the claim of complainant within the stipulated period and rather on the contrary instead of  paying the genuine claim Opposite Parties repudiated the impugned claim of the complainant on 7.12.2015 on false and flimsy grounds.  Vide instant complaint, the complainant has sought the following reliefs.

a)       Opposite Parties may please be directed to pay a sum insured amount to the tune of Rs.19,887/- alongwith interest @ 18% per annum and compensation of Rs.40,000/-  and litigation expenses of Rs.11000/-. 

Hence, this complaint.

2.       Upon notice, opposite parties appeared and contested the complaint by filing  joint written statement taking preliminary objections therein inter alia that the complainant has shown complete disregard towards the sanctity and dignity of the judicial process and  has not only concealed the material facts from this Forum, but is also guilty of making misrepresentations and distorting facts to suit his own ends, thus the complainant is guilty of suppressio very and suggestio falsi and the complainant has no right whatsoever to maintain the present complaint before this Forum, and fraudulent claim and thus the claim is devoid of any merit; that the issue raised in the present matter necessarily requires that the Opposite Party in order to prove the case, would have to lead evidence and examine its witnesses and expert evidences; that the complainant did not disclose any medical history in the policy proposal form. Admittedly, the policy in question was issued by the Opposite Parties in favour of the complainant and her family members and it was again renewed  from 8.10.2015 to 7.10.2016. It is submitted that the complainant was hospitalised for treatment of DNS and Turbinate Hypertrophy on 29.9.2015 and was discharged on 30.9.2015. However, the Opposite Party was intimated on 20.10.2015 i.e. after a delay of around three weeks without assigning any reason whatsoever for the same. It is further submitted that an investigation was conducted by the person authorised by the Opposite Parties to ascertain the facts. During the course of the investigation it was revealed that the complainant was suffering  from chronic rhinitis & nasal obstruction due to DNS since 3-4 years i.e. since before policy inception. It is further submitted that the complainant had accepted the terms of the policy proposal form, which obligated him to make full and frank disclosure of all facts material to the assumption of risk in relation to him, that would influence the decision of the Opposite Party regarding issuance of the policy or its terms.  On merits, the Opposite Parties took the same and similar pleas as taken by them in the preliminary objections.   Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.

3.       In her bid  to prove the case, complainant tendered into evidence  affidavit Ex.CW1/A  in support of the allegations made in the complaint and also produced copies of documents Ex.C1  to Ex.C20  and closed his evidence.

4.       On the other hand, to rebut the evidence of the complainant, the Opposite Party tendered into evidence the affidavit of Sh.Sumeet Bajaj, Chief Manager Legal Ex.Op1,2/1  alongwith copies of documents Ex. Op1,2/2 to Ex.Op1,2/14 and closed the evidence on behalf of the Opposite Party.

5.       We have heard the ld.counsel for the parties and have carefully gone through the evidence on record.

6.       From the entire above discussion, we have come to the conclusion that  the complainant got family health insurance policy known as Health Companion Silver commencing by paying a premium of Rs.7446/- for a sum assured of Rs.3 lacs from Opposite Party No.1 through Opposite Party No.2 vide policy No. 30256949201401 valid for the period from 8.10.2014 to 7.10.2015 against the requisite premium covering the medical check up of all the family members of the complainant and as such the  complainant is a consumer of the Opposite Parties as defined under the Consumer Protection Act. It is pertinent to mention over here that prior to that, the complainant had been regularly purchasing/ obtaining the mediclaim policy from united India Insurance Company limited w.e.f 2008 till 2012 and thereafter on account of consistence persuasions of the agents of Opposite Parties, the complainant port the said mediclaim policy from ops for valuable premium as detailed above and at the time of obtaining the said mediclaim policy, the said agents of Opposite Parties have obtained the signatures of  both the complainant on various blank papers and forms etc. under the impression that all the documents are related to their insurance policy, but however, no explanation of any kind whatsoever was given to the complainant at that  time by the said agents of the Opposite Parties.  The complainant is holder of cashless medical hospitalization facilities under the scheme under the policy having card No. 1847037 issued by Opposite Party No.1 through Opposite Party No.2 to provide cashless hospitalization facilities to the holder of said card. During the validity period of said policy, the complainant was hospitalized in Mrs.Khushbir Kalra’s Memorial Hospital, Ajit Nagar, Amritsar and after conducting proper medical examination she was operated for DNS & turbinate hypertrophy. The complainant was not having any such past disease and the complainant was suddenly suffered from said disease and came to know about the same only 22.09.2015 and as such she was got treated and her surgery was got conducted and she remained hospitalized w.e.f. 29.9.2015 to 30.09.2015 as per the advise of concerned doctor. At the time of admission, the complainant presented the card issued by Opposite Parties, but Opposite Parties refused the complainant to provide cashless facilities and insisted her to deposit the cash amount with the concerned hospital. After that the complainant approached the Opposite Parties and the officials of the Opposite Parties assured that they would refund the amount spent by the complainant for the operation of complainant in Mrs.Khushbir Kalra’s Memorial Hospital alongwith all other expenses incurred on her medical treatment and medicines etc. Further time to time the father  of the complainant approached the Opposite Parties and made them aware that the complainant is entitled for the cashless hospitalization facilities of Rs.19,887/-, but the Opposite Parties refused to pay the genuine claim of the complainant.

7.       On the other hand, ld.counsel for Opposite Parties has repelled the aforesaid contention of the ld.counsel for the complainant on the ground that  the complainant is guilty of suppressio very and suggestio falsi and the complainant has no right whatsoever to maintain the present complaint before this Forum, and fraudulent claim and thus the claim is devoid of any merit; that the issue raised in the present matter necessarily requires that the Opposite Party in order to prove the case, would have to lead evidence and examine its witnesses and expert evidences; that the complainant did not disclose any medical history in the policy proposal form. Admittedly, the policy in question was issued by the Opposite Parties in favour of the complainant and her family members and it was again renewed  from 8.10.2015 to 7.10.2016. It is submitted that the complainant was hospitalised for treatment of DNS and Turbinate Hypertrophy on 29.9.2015 and was discharged on 30.9.2015. However, the Opposite Party was intimated on 20.10.2015 i.e. after a delay of around three weeks without assigning any reason whatsoever for the same. It is further submitted that an investigation was conducted by the person authorised by the Opposite Parties to ascertain the facts. During the course of the investigation it was revealed that the complainant was suffering  from chronic rhinitis & nasal obstruction due to DNS since 3-4 years i.e. since before policy inception and as such, the claim of the complainant was rightly repudiated after due application of mind.

8.       It is not disputed that  the complainant got family health insurance policy known as Health Companion Silver commencing by paying a premium of Rs.7446/- for a sum assured of Rs.3 lacs from Opposite Party No.1 through Opposite Party No.2 vide policy No. 30256949201401 valid for the period from 8.10.2014 to 7.10.2015 against the requisite premium, but the only ground for repudiation of the claim of the complainant is that  the complainant is guilty of suppressio very and suggestio falsi and the complainant has no right whatsoever to maintain the present complaint before this Forum, moreover, the  complainant did not disclose any medical history in the policy proposal form.  The complainant was hospitalised for treatment of DNS and Turbinate Hypertrophy on 29.9.2015 and was discharged on 30.9.2015. However, the Opposite Party was intimated on 20.10.2015 i.e. after a delay of around three weeks without assigning any reason whatsoever for the same. It is further submitted that an investigation was conducted by the person authorised by the Opposite Parties to ascertain the facts. During the course of the investigation it was revealed that the complainant was suffering  from chronic rhinitis & nasal obstruction due to DNS since 3-4 years i.e. since before policy inception. Though  Opposite Party has produced on record the discharge summary of life insured regarding his admission in the hospital Ex.OP1,2/7, but they   could examine any medical practitioner/ doctor who has treated the complainant for the said disease nor the Opposite Party has filed any affidavit of any doctor who has medically treated the insured for the disease prior to taking of the policy. It has been held by the Hon'ble National Commission in case New India Assurance Co.Ltd & Anr Vs. Murari Lal Bhusri 2011(III) CPJ 198 (NC) that where the Insurance company failed to produce any evidence to show that respondent was aware of any pre-existing disease at the time when insurance policy was taken, opposite party was not justified in repudiating the claim of the complainant on the ground of pre-existing disease. It has been held by the Hon'ble Supreme Court of India in case P.Vankat Naidu Vs. Life Insurance Corporation of India & Anr 2011(3) CPC 350 that where no cogent evidence was produced by the respondent to prove that insured/deceased had concealed any fact about his illness or hospitalization, it was held that no material fact was suppressed by the deceased in this respect. It has been held by the Hon'ble State Commission of Punjab in case  Life Insurance Corporation of India Vs. Miss Veenu Babbar and another 2000(1) CLT 619 that repudiation on the basis of history recorded in the hospital records is illegal and arbitrary and the same could not be treated as substantive material to base any decision. Same view has been taken by the Hon'ble National Commission in case Life Insurance Corporation of India & Ors. Vs. Kunari Devi IV(2008) CPJ 89 (NC) that where no document has been produced in support of allegation of suppression of disease at the time of taking policy or revival of policy, history recorded in hospital's bed ticket, not to be treated as evidence as doctor, recording history not examined, suppression of disease not proved, insurer was held liable under the policy. It has further been held by the Hon'ble National Commission in case Sahara India Life Insurance Co. Ltd. & Anr Vs. Hansaben Deeepak Kumar Pandya IV(2012) CPJ 13(NC) that where the opposite party insurance company has failed to produce on record any evidence to show that deceased insured ever consulted doctor for taking treatment of heart disease, the repudiation of the claim on the ground of suppression of material fact is totally illegal. It has been  held by Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in case titled as Ashwani Gupta & Ors. Vs. United India Insurance Company Limited 2009(1) CPC page 561 that where the claim of the complainant has been repudiated on the ground that the assured had pre-existing disease of diabetes mellitus which was not disclosed- apparently, burden to prove lies  upon the insurer- If assured was suffering from pre-existing disease why insurer  had not checked it at the time when proposal form was accepted by its  staff-Respondent has failed to fulfill this requirement before repudiating the claim and the appellant was held entitled  to claim alongwith interest.

9.       In view of the above discussion, we are of the opinion that the Opposite Parties have  wrongly repudiated the claim of the complainant. Consequently, we allow the complaint with costs and the Opposite Parties are directed to pay the claim amount of Rs.19,887/- to the complainant, within one month from the date of receipt of copy of this order failing which the complainant shall be entitled to interest @ 6% per annum on this amount from the date of filing of the complaint till the payment is made to the complainant. Opposite Parties are  also directed to pay to the complainant  Rs.5000/- on account of compensation for causing mental tension and harassment  besides Rs.2,000/- as costs of litigation. Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

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