Order by:

Sh.Amrinder Singh Sidhu, President

1.       This Consumer Complaint has been received by transfer vide order dated 26.11.2021 of Hon’ble President, State Consumer Disputes Redressal Commission, Punjab at Chandigarh under section 48 of CPA Act, vide letter No.04/22/2021/4 C.P.A/38 dated 17.1.2022 from District Consumer Commission, Ludhiana to District Consumer Commission, Moga to decide the same in Camp Court at Ludhiana and said order was ordered to be affected from 14^th March, 2022.

2.       The  complainant  has filed the instant complaint under section 12 of the Consumer Protection Act, 1986 (now section 35 of Consumer Protection Act, 2019) on the allegations that on the assurance of the Opposite Parties, the complainant had purchased med claim policy bearing No. 30436599201500 on 19.05.2015 valid for the period 20.06.2015 to 19.0.2016 against the paid up premium of Rs.47,591/- for sum assured of Rs.19 lakhs which was subsequently renewed upto 19.06.2017. Further alleges that during the policy period,  due to chest problem, the complainant remained admitted in Dayanand Medical College & Hospital, Ludhiana  from 20.02.2016 to 03.03.2016 where he spent Rs.2,76,549/- on his treatment. After discharge, the complainant lodged the claim with the Opposite Parties for the reimbursement of his medical bills, but the Opposite Parties  has refused to make the payment of the bills on the false and frivolous grounds   and as such, there is deficiency in service on the part of the Opposite Parties. Vide instant complaint, the complainant has sought the following reliefs.

a)       The Opposite Parties may be directed to pay a sum of Rs.2,76,549/- being the hospitalization charges alongwith the damages  to the tune of Rs.2 lakhs on account of compensation due to mental tension and harassment caused by the complainant besides Rs.22,000/- as costs of litigation or any other relief to which this District Consumer Commission may deem fit be also granted.

3.       Opposite Parties  appeared through counsel and contested the complaint by filing  the written version taking preliminary objections therein inter alia that the complaint filed by the complainant is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead this District Consumer Commission.  It is admitted that the complainant purchased policy in question for himself, but the benefit under the policy are subject to certain conditions and exclusions which have been clearly specifically and categorically mentioned under the policy wording. It is further submitted that  the claim of the complainant was for treatment wherein the complainant was admitted under severe chest pain and  underwent Coronary artery bypass graft surgery (CABG).  It is submitted that for the complainant, there is a personable waiting period of 24 months as per his medical reports for Ischemic Heart Disease. The Coronary artery bypass grafting (CABG) is a type of surgery that improves blood flow to the heart. Surgeons use CABG to treat people  who have Ischemic Heart Disease. The personal waiting period is mentioned on the very face of the policy and the personal waiting period is as per clause 4.d. of Part II of the schedule and hence the said treatment is not covered for 24 months from the commencement of the policy and the same is covered from the commencement of the 3^rd policy year only as per the policy terms and conditions.   On merits, the Opposite Parties took up the same and similar pleas as taken up by them in the preliminary objections.   Hence, Opposite Party has rightly repudiated the claim of the complainant after application of mind and the complaint may be dismissed with costs.  

4.       In order to  prove  his  case, the complainant has tendered into  evidence his affidavit Ex.CA alongwith copies of documents Ex.C1, Ex.C2 and Mark A to Mark N and closed the evidence on behalf of the complainant.

5.       On the other hand,  to rebut the evidence of the complainant,  Opposite Parties also tendered into evidence the affidavit Ex.RA alongwith copies of documents  Ex.R1 to  Ex.R6 and  closed the evidence.

6.       We have heard the ld.counsel for the parties, perused the written submissions of the Opposite Parties and also  gone through the documents placed  on record.

7.       Ld.counsel for the Complainant has  mainly reiterated the facts as narrated in the complaint and contended that first of all, at the time of issuance of the said policy  to the complainant, no term and conditions were ever explained or supplied by Opposite Parties to the complainant. Further contended that on the allurement of the Opposite Parties, the complainant had purchased med claim policy bearing No. 30436599201500 on 19.05.2015 valid for the period 20.06.2015 to 19.0.2016 against the paid up premium of Rs.47,591/- for sum assured of Rs.19 lakhs which was subsequently renewed upto 19.06.2017. Further alleges that during the policy period,  due to chest problem, the complainant remained admitted in Dayanand Medical College & Hospital, Ludhiana  from 20.02.2016 to 03.03.2016 where he spent Rs.2,76,549/- on his treatment. After discharge, the complainant lodged the claim with the Opposite Parties for the reimbursement of his medical bills, but the Opposite Parties  has refused to make the payment of the bills on the false and frivolous ground. On the other hand, ld.counsel for the Opposite Parties has repelled the aforesaid contention for the ld.counsel for the complainanton the ground that  admittedly, the complainant purchased policy in question for himself, but the benefit under the policy are subject to certain conditions and exclusions which have been clearly specifically and categorically mentioned under the policy wording. It is further submitted that  the claim of the complainant was for treatment wherein the complainant was admitted under severe chest pain and  underwent Coronary artely bypass graft surgery (CABG).  It is submitted that for the complainant, there is a personable waiting period of 24 months as per his medical reports for Ischemic Heart Disease. The Coronary artery bypass grafting (CABG) is a type of surgery that improves blood flow to the heart. Surgeons use CABG to treat people  who have Ischemic Heart Disease. The personal waiting period is mentioned on the very face of the policy and the personal waiting period is as per clause 4.d. of Part II of the schedule and hence the said treatment is not covered for 24 months from the commencement of the policy and the same is covered from the commencement of the 3^rd policy year only as per the policy terms and conditions.

8.       The main contention of the ld.counsel for the Opposite Parties is that said treatment of the complainant is not covered for 24 months from the commencement of the policy and the same is covered from the commencement of the 3^rd policy year only as per the policy terms and conditions and hence,  the complainant is not entitled to the claim as claimed.  But the Opposite Party could not produce  any evidence to prove that terms and conditions of the policy were ever supplied to  the complainant insured, when and through which mode? It has been held by Hon’ble National Commission, New Delhi in case titled as The Oriental Insurance Company Limited Vs. Satpal Singh & Others 2014(2) CLT page 305 that the insured is not bound by the terms and conditions of the insurance policy unless it is proved that policy was supplied to the insured by the insurance company. Onus to prove that terms and conditions of the policy were supplied to the insured lies upon the insurance company. From the perusal of the entire evidence produced on record by the Opposite Party,  it is clear that Opposite Party  has failed to prove on record that they did supply the terms and conditions of the policy to  the complainant insured. As such, these terms and conditions, particularly the exclusion clause of the policy is not binding upon the insured. Reliance in this connection can be had on Modern Insulators Ltd.Vs. Oriental Insurance Company Limited (2000) 2 SCC 734, wherein it is held that “In view of the above settled position of law, we are of the opinion that the view expressed by the National Commission is not correct. As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclosed to the appellant, the respondent can not claim the benefit of the said exclusion clause. Therefore, the finding of the National Commission is untenable in law.”  Our own Hon’ble State Commission, Punjab, Chandigarh in First Appeal No.871 of 2014 decided on 03.02.2017 in case titled as Veena Mahajan (Widow) and others Vs. Aegon Religare Life Insurance Company Limited in para No.5 has held that

“Counsel for the appellant argued that copy of insurance policy was not supplied to the appellant and hence, the exclusion clause in the contract of the insurance policy is not binding upon him. He further argued that no proof of sending of insurance policy was ever produced by the respondent despite specific contention raised by the complainant that the insurance policy was never received by him. He argued that though there is an averment of the OP that the policy in question was delivered through Blue Dart Courier to the complainant. In order to prove their contention, no affidavit of any employee of Blue Dart was produced who would have made a statement to have the effect that the policy was delivered to the complainant nor any acknowledgement slip for having received the article by the complainant through courier company was produced by the insurance company. He argued that since no policy document was received by the insured and argued that the terms and conditions as alleged to be part of the insurance policy were not binding upon the insured. He argued that policy was issued in the name of deceased Sh.Vijinder Pal Mahajan with his wife Mrs.Veena Mahajan as beneficiary and the same was never refused by the OP and the proper premium for insurance was paid by late complainant. He argued that as per the specific allegations made in the complaint in para No.4, no rebuttal to that contention was specifically there in their written reply in para No.2 and para No.4 in the reply filed by OP in the District Forum. He argued that Hon'ble National Consumer Disputes Redressal Commission, New Delhi in case of "Ashok Sharma Vs. National Insurance Co. Limited", in Revision Petition No. 2708 of 2013 held in para No.8 to the point of non-delivery of terms and conditions of the policy. He also cited Hon'ble Supreme Court's decision given in the matter of "United India Insurance Co. Limited Vs. M.K.J.Corporation" in Appeal (civil) 6075-6076 of 1995 (1996) 6 SCC 428 wherein the Apex court held that a fundamental principle of Insurance Law makes it that utmost good faith must be observed by the contracting parties. Good faith forbids either party from concealing what he privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary. Just as the insured has a duty to disclose, "similarly, it is the duty of the insurers and their agents to disclose all material facts within their knowledge, since obligation of good faith applies to them equally with the assured and further argued that since the terms and conditions were not supplied even on repeated requests the same cannot be relied upon by the opposite party in order to report to repudiate the genuine claim of the wife of the deceased policy holder.”

9. We have heard the learned counsel for the parties at considerable length and have also examined the record of the case. The main contention of the Opposite Party is that  the claim of the complainant does not cover under the policy and is not payable. On the other hand, ld.counsel for the complainant has repelled the aforesaid contention of the complainant on the ground that at the time of purchasing said policy, the complainant  disclosed  the Opposite Party regarding everything and as such, the complainant has not concealed any fact from the Opposite Parties. Moreover, if the proposer of the policy was not covering said policy,  then why the Opposite Parties have issued the policy to the complainant.

10.     The law on the question of applicability of exclusion clause, suppression of the relevant factually position regarding any pre-existing disease from which the insured was suffering and the treatment thereof, if any, received from any hospital etc., has been the subject matter of number of decisions by the Hon’ble National Commission as also by the Hon’ble Supreme Court of India. In nutshell, the settled position is that it is the duty of the insured to disclose the above mentioned information to the insurance company at the time of buying the insurance policy and, if the same was not disclosed by the insured, the insurance company was well within their rights to repudiate the claim. However, the insured was under no obligation whatsoever to foresee, assess and apprehend the probable and future complications, which might or could suddenly arise from the earlier disorder. In this regard, the Hon’ble Supreme Court in their latest judgment in case Civil Appeal No.8386 of 2015 titled as “Manmohan Nanda Vs. United India Assurance Co. Ltd. & Anr.” decided on 06.12.2021, has held the object of buying a Medi-claim Policy is to seek indemnification in respect of a sudden illness or sickness which is not expected or imminent and that may occur overseas, “If the insured suffers a sudden sickness or ailment, which is not expressly excluded under the Policy, a duty is cast upon the insurer to indemnify the appellant for the expenses incurred there under”. In this regard, recently Honble State Consumer Disputes Redressal Commission, Punjab at Chandigarh in First Appeal No.482 of 2019, decided on 10.01.2022 in case titled as Bajaj Allianz General India Insurance Company Versus Kewal Singh Kainth also held so.

11.     In such a situation the repudiation made by Opposite Party-Insurance Company regarding genuine claim of the complainant have been made without application of mind. It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.  The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

12.     In view of the above discussion, we hold that the Opposite Party-Insurance Company have  wrongly and illegally rejected the claim of the complainant.

13.     The complainant in his complaint has claimed the reimbursement of medical expenses upto the extent of Rs.2,76,549/- and this amount spent by the complainant on  treatment has nowhere denied by the Opposite Party by filing any cogent and convincing evidence and hence, the claim of the complainants to that amount is genuine and we allow the claim of the complainant accordingly.  

14.     In view of the aforesaid facts and circumstances of the case,  we partly allow the complaint of the Complainant and direct Opposite Party-Insurance Company to pay the amount of Rs.2,76,549/- (Rupees two lakh seventy six thousands five hundred forty nine only) to the complainant alongwith interest @ 8% per annum from the date of filing the present complaint i.e. 24.10.2017 till its actual realization.    The compliance of this order be made by Opposite Party-Insurance Company within 60 days from the date of receipt of copy of this order, failing which the complainant  shall be at liberty to get the order enforced in accordance with law. Copies of the order be furnished to the parties free of cost by District Consumer Commission, Ludhiana and thereafter, the file be consigned to record room after compliance.

15.     Reason for delay in deciding the complaint.

This Consumer Complaint was originally filed at District Consumer Disputes Redressal Forum (Now Commission) at Ludhiana and it keep pending over there until Hon’ble State Consumer Disputes Redressal Commission, Punjab vide letter No.04/22/2021/4 C.P.A/38 dated 17.1.2022 has transferred the instant Consumer Complaint alongwith Other Complaints to District Consumer Commission, Moga with directions to work on this file onward from 14^th March, 2022 and accordingly District Consumer Commission, Moga has decided the present complaint at Camp Court, Ludhiana, as early as possible as it could decide the same.

Announced in Open Commission at Camp Court, Ludhiana.