Complainant Deepak Aggarwal has filed the present complaint against the opposite parties U/S 12 of the Consumer Protection Act (for short, C.P. Act.) seeking necessary directions to the opposite parties to make his payment of claim i.e. Rs.1,44,081/-. Opposite parties be further directed to pay Rs.50,000/-  as damages/compensation for the unnecessary harassment, physical pain and mental agony suffered by him from the hands of the opposite party alongwith Rs.10,000/- as litigation expenses, in the interest of justice.

2.       The case of the complainant in brief is that he had taken health protection policy as Hospitalization Benefit policy vide policy No.401211/48/12/8500001075 from the period of 13.12.2010 to 12.12.2011, policy No.401211/48/12/8500000777  from the period of 13.12.2011 to 12.12.2012, and policy No.401211/48/12/850000514 from the period of 13.12.2012 to 12.12.2013, policy No.406002501410000123 which was expired on 12.12.2015 and thereafter policy no.406002/50/15/10000106 which expired on 12.12.2016 from the opposite party. He had paid the installments regularly without any fault to the Insurance Company for policy as Hospitalization Benefit policy.  He has further pleaded that in the month of Oct. 2016, unfortunately he was become ill and was indoor patient in the Patel Hospital. In that Hospital he was properly treated by the doctors and during his treatment, he had spent huge amount on his treatment. The copies of whole file of treatment i.e. bills and receipts etc was also submitted by him before Branch of opposite parties at the time of filing his claim. His claim number is NICCHI/27495 and policy No. 406002/50/15/10000106. Thereafter the opposite parties issued a letter dated 18.11.2016 by demanding the documents from him i.e. i) ECHO report with films. ii). Treatment records for Hospitalization due to sleep Apnea 2 year back. iii). When were you diagnosed to have HTN for the first time Record of treatment taken in the past for the same after its first detection may support this information. Previously too in the year 2015, he fell ill and submitted the entire documents mentioned above to the branch of opposite party but they did not issued his claim at that time. Thereafter he filed a complaint against the opposite parties before the Hon'ble Consumer Court Gurdaspur and in the Court opposite party issued the claim through a cheque. So the entire documents have already been in the custody of opposite party at Batala and opposite party no.3 (Park Medical). He had already sent the reply to the letter dated 18.11.2016 to the opposite parties. The letter dated 18.11.2016 is vague and baseless. Since then he several time visited to the office of the opposite party for his legal and genuine claim but all in vain. A legal notice regarding issuing the medical claim through his counsel vide postal receipt dated 21.8.2017 was served but even then the department did not take any action.  Hence this complaint.

3.        Notice of the complaint was issued to the opposite parties. Opposite parties no.1 to 3 appeared through their counsel and filed their joint written reply by taking the preliminary objections that complaint is not maintainable; the complaint is absolutely false, frivolous and no cause of action has ever arisen in favour of the complainant against the opposite party. On merits, it was submitted that the complainant Deepak Aggarwal got Hospitalization benefit policy no.406002/50/15/10000106 effective from 13.12.2015 to 12.12.2016 from opposite party no.1 Deepak Aggarwal was Hospitalized from 03.10.2016 to 05.10.2016 and claim was lodged by complainant before opposite party regarding expenses incurred on treatment of insured Deepak Aggarwal on  26.10.2016. The claim file was sent to PARK MEDICLAIM TPA PVT. LTD. THIRD PARTY ADMINISTRATOR- HEALTH SERVICES 702, VIKRANT TOWER, RAJENDRA PLACE NEW DELHI for investigation and admissibility of medical claim. That Dr.A.K.Batra MEDICAL DIRECTOR OF PARK MEDICLAIM TPA PVT. LTD. THIRD PARTY ADMINISTRATOR- HEALTH SERVICES 702, VIKRANT TOWER RAJENDRA PLACE NEW DELHI vide its letter dated 05.04.2017 declared that the claim of the complainant is not admissible as "In this case, the claimant had not submitted all the documents asked by us namely: i) ECHO report with films. ii) Treatment records of past 2-3 years are not available with us. Hence, you are requested to provide the treatment records or policy/claim details for the hospitalization done 2 years back for sleep Apnea. iii) When were you diagnosed to have HTN for the first time? It is pertinent to mention here that complainant Deepak Aggarwal failed to submit above mentioned documents to PARK MEDICLAIM TPA PVT. LTD. THIRD PARTY ADMINISTRATOR- HEALTH SERVICES 702, VIKRANT TOWER, RAJENDRA PLACE NEW DELHI despite of receiving reminder/letters dated 11.11.2016, 28.11.2016, 23.12.2016 and 06.01.2017 from abovesaid TPA.  That on 06.01.2017 PARK MEDICLAIM TPA PVT. LTD. THIRD PARTY ADMINISTRATOR- HEALTH SERVICES 702, VIKRANT TOWER, RAJENDRA PLACE NEW DELHI issued final reminder cum closure letter to complainant but he failed to submit requisite documents. Thereafter PARK MEDICLAIM TPA PVT. LTD. THIRD PARTY ADMINISTRATOR- HEALTH SERVICES 702, VIKRANT TOWER, RAJENDRA PLACE NEW DELHI issued a letter to opposite party no.1 intimating regarding closure of the file as "NO CLAIM'. That on 09.03.2017, Deepak Aggarwal wrote a letter to reopen his claim file. On his request the claim file was reopened but again the claim file of complainant was closed as NO CLAIM for non submission of documents and intimation regarding closure of file duly served upon complainant vide letter dated 05.04.2017 by PARK MEDICLAIM TPA PVT. LTD. THIRD PARTY ADMINISTRATOR- HEALTH SERVICES 702, VIKRANT TOWER, RAJENDRA PLACE NEW DELHI. Despite of repeated requests by TPA for submission of requisite documents the complainant was unable to submit the same. Hence, this claim is not admissible and claim file of complainant closed as NO CLAIM for non submission of documents. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed.

4.     Opposite party no.4 was ordered to be proceeded against exparte vide order 05.01.2018.

5.      Ld. counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW-1/A along with other documents Ex.C-1 to Ex.C-25 (Ex.C-23 to Ex.C-25 original receipts) and closed the evidence.

6.      Ld. counsel for the opposite parties no.1 to 3 tendered into evidence affidavit of Sh.Sunil Tuli, Divisional Manager, N.I.C. Ltd. Ex.OP-1 to 3/1 alongwith other documents Ex.OP-1 to 3/2 to Ex.OP-1 to3/11 and closed the evidence.

7.       Written arguments not filed by both the parties.

8.       Counsel for the complainant has argued that the complainant had purchased Health Protection Policy from the opposite parties No.1 to 3 i.e. Insurance Company w.e.f. 13.12.2010 which was renewed from time to time upto 12.12.2016. It is further argued that in the month October, 2016 during the continuation of renewed health policy of insurance complainant was hospitalized at Patel hospital and thereafter lodged claimed with the opposite parties alongwith entire record but opposite parties had not settled and paid the claim to the complainant. It is further argued that opposite parties later on vide letter dated 18.11.2016 demanded documents i.e. i) ECHO report with films. ii) Treatment records for Hospitalization due to sleep Apnea 2 year back. iii) When were you diagnosed to have HTN for the first time record of treatment taken in the past for the same after its first detection may support this information. It is further argued that whatever record was available with the complainant was submitted to the opposite parties. However, opposite parties closed the claim as "No Claim" which amounts to deficiency in service on the part of the opposite parties.

9.       On the other hand counsel for the opposite parties No.1 to 3 has argued that policy of insurance is admitted. Hospitalization of complainant from 03.10.2016 to 05.10.2016 is also admitted. However, opposite party No.4 had demanded documents from the complainant i.e. i) ECHO report with films. ii) Treatment records for Hospitalization due to sleep Apnea 2 year back. iii) When were you diagnosed to have HTN for the first time record of treatment taken in the past for the same after its first detection may support this information but inspite of receiving letters dated 11.11.2016, 28.11.2016, 23.12.2016 and 06.01.2017 complainant failed to submit the above referred documents. As such file was closed by the opposite parties. Thereafter, again on the request of the complainant, file was reopened and documents were demanded as referred above but complainant again failed to submit the documents as such vide letter dated 05.04.2017 claim was closed as "No Claim" and as such there is no deficiency in service on the part of the opposite parties and complaint is liable to be dismissed. 

10.     We have heard the Ld. counsels for the parties and gone through the record. It is admitted fact that complainant had purchased Health Protection Policy from the opposite parties No.1 to 3 w.e.f. 13.12.2010 which was renewed from time to time upto 12.12.2011. It is further admitted fact that complainant remained admitted in hospital from 03.10.2016 to 05.10.2016. It is further admitted fact that opposite parties demanded documents from the complainant i.e. i) ECHO report with films. ii) Treatment records for Hospitalization due to sleep Apnea 2 year back. iii) When were you diagnosed to have HTN for the first time record of treatment taken in the past for the same after its first detection may support this information. Thereafter on account of non supply of these documents the claim file was closed as "No Claim" vide letter Ex.OP-1 to 3/9.

11.     Perusal of letter  Ex.OP-1 to 3/9 shows that opposite parties have demanded ECHO films and treatment record for the past 2-3 years and thereafter demanded treatment records or policy/claim details for the hospitatlization done 2 years back for Sleep Apneoa and it is further mentioned that when you are diagnosed to have HTN for the first time ? Record of treatment taken in the past for the same after its first detection may support this information. Perusal of treatment record shows that the claim in respect of disease in respect of which complainant remained admitted in hospital from 03.10.2016 to 05.10.2016 i.e." chief complaints of dysponea since 1 year, snoring associated with frequent night awakening and excessive day time somnolence Lince 2 years. H/o hospitalization due to sleep apnea for 2 years meaning thereby that claim has not been settled by the opposite parties on the ground that complainant was suffering from hypertension and sleep apnea for the last 2 years and record in respect of above referred two ailments referred in discharge summary Ex.C16 is being demanded. However, opposite parties have not assigned any reason as to for what purpose the said record is required by the opposite parties for settlement of the present claim. Moreover, the disease for which complainant took treatment, which is subject matter of the present complaint has no concern with sleep apnea and hypertension and when there is no relation between the alleged previous disease and disease mentioned in the medical history of complainant, the opposite parties cannot refused to settle and pay the claim to the complainant.

12.     This Commission has placed reliance on judgment of Hon'ble Supreme Court of India 2023(2) Law Herald (SC) 1560 titled as Om Parkash Ahuja Vs. Reliance General Insurance Co. Ltd. Etc. wherein it was held by the Hon'ble Supreme Court of India as under:-

          Consumer Insurance Health Insurance Non-mentioning of disease from which the deceased suffered at the time of purchasing     the policy was not material, as the death was caused from a different   disease all together Both had no relation with each other    Insurance Company directed to pay.

As per this judgment it was held by the Hon'ble Supreme Court of India that non mentioning of disease from which wife of the applicant was suffering at the time purchasing policy is not material and the death was caused from different disease all together.

13.     Further, reliance is be placed on another judgment of Hon'ble Supreme Court of India reported in 2018(1) Law Herald (SC) 832 wherein it was held by Hon'ble Supreme Court of India as under:-

          Insurance Life Insurance Premium accepted without conducting of medical examination Amounts to waiving off condition    precedent in proposal form Insurer held liable to pay.

The other ground of the opposite parties regarding non settlement of the claim is previous history of hypertension but this Commission is of the view that hypertension is a common disease and it is not necessary that person suffering from hypertension would always suffer from some other disease and this Commission has placed reliance an order of Hon'ble Punjab State Consumer Dispute Redressal Commission, Chandigarh reported in 2017(3) CLT 140 wherein it was held as under:-

          Hypertension is a common disease and it can be controlled by medication.          

14.     We are of the view that the opposite parties cannot refuse to settle the claim of the complainant by demanding record of previous ailments with which there is no nexus of the present disease. Moreover, the opposite parties have renewed the policy of insurance from time to time receiving premium. As such having renewed the policy of insurance from time to time without having availed medical examination of the complainant prior to renewal of the policy amounts to waiver and as such opposite parties cannot refuse to settle the clam by referring to and repeatedly demanding the documents regarding previous ailment with which the present case has no concern. Perusal of file further shows that counsel for the complainant has also placed on record copy of order dated 20.03.2015 by way of which complaint filed by the complainant in respect of treatment taken by the complainant on 21.06.2013 was repudiated by the opposite parties and the opposite parties had paid the said claim after the directions from the Ld. Predecessor of this Commission which shows that opposite parties is in habit of repudiating the claim on false and flimsy grounds after receiving premium from the complainant which amounts to deficiency in service.

15.     We placed reliance upon judgment of Hon'ble Supreme Court of India reported in 2022 LiveLaw (SC) 506 wherein it was held by the Hon'ble Supreme Court of India as under:-

          Insurance Insurance companies refusing claim on flimsy grounds and or technical grounds While settling the claims, the insurance           company should not be too technical and ask for the documents, which the insured is not in a position to produce due to                             circumstances beyond his control. (Para 4.1).

16.     This Commission is of the view that it was obligatory on the part of the opposite parties before renewal of the policy of insurance must had insisted for medical examination of the complainant and since the opposite parties have failed to get the complainant medically examined before renewal, as such opposite parties have no right to take any such ground later on. Even, in the present case opposite parties have failed to place on record any evidence or affidavit of any doctor regarding previous ailment in respect of which documents are being demanded.

          We also placed reliance upon judgment of Hon'ble Punjab State Consumer Dispute Redressal Commission, Chandigarh reported in 2014(3) C.P.J. 13  2014(87) R.C.R.(Civil) 264 wherein it was held as under:-

          Insurance Company failed to produce any evidence to show that appellant was suffering from said disease at the time of taking policy No affidavit of any doctor or person who recorded history of patient.

17.     From the above discussion and evidence on record complainant has fully proved that during the continuation of policy of insurance complainant remained admitted in hospital and had submitted the necessary documents with the opposite parties and detail of treatment and expenditure which is duly mentioned in Ex.C15 for a sum of Rs.144081/- and the act of the opposite parties of having repeatedly demanding the same documents vide letters Ex.OP-1 to 3/3 to Ex.OP-1 to 3/7 amounts to deficiency in service particularly when the required documents have no connection with disease for which the complainant took treatment. As such complainant has fully proved deficiency on the part of the opposite parties for having failed to settle and pay the claim which was ultimately closed as "No Claim" vide Ex.OP-1 to 3/9 amounts to deficiency in service on the part of the opposite parties.

18.     Accordingly, we partly allowed the present complaint and opposite parties are directed to pay Rs.144081/- alongwith interest @ 9% P.A. from the date of filing of the complaint till realization. Opposite parties are further directed to pay Rs.10,000/- to the complainant for mental tension, inconvenience and cost of litigation. Entire exercise shall be completed within 30 days from the receipt of copy of this order.   

19.     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.

20.     Copy of the order be communicated to the parties free of charges. File be consigned.                                                                                                                                                               

            (Lalit Mohan Dogra)

                                                                                      President.

Announced:                                                   (B.S.Matharu)

Aug. 21, 2023                                                       Member.

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