Complainants Prem Lata and Ashok Kumar through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has prayed that the opposite party be directed to pay the medical bills etc. amounting to Rs.60,000/- and also to pay Rs.1,00,000/- as compensation due to the mental harassment alongwith Rs.10,000/- as litigation expenses, in the interest of justice.

2.       The case of the complainant in brief is that they had taken the mediclaim insurance policy from the opposite parties on 27.09.2015 vide insurance cover note No.401410864522 which is valid from 27.09.2015 to 26.09.2016 and even prior to this period also they are continuously taking the mediclaim insurance policy from the opposite parties. The said policy was taken by Ashok Kumar for himself as well as for his wife. They paid the premium and the opposite parties accepted the premium and the officials of opposite party no.1 induced them to take the cashless insurance from them as they have tie up with the hospitals and the officer of the opposite party no.1 also ensured them that they will not face any difficulty with respect to any claim and they fulfilled all the formalities and again paid premium of Rs.19,961/- for the period from 27.09.2015 to 26.09.2016. They have further pleaded that unfortunately complainant no.1 Prem Lata was hospitalized for the period from 23.10.2015 to 27.10.2015 with the diagnosis Dengue Fever. Firstly she was admitted in the Mahajan Hospital Batala and thereafter she was referred to Amritsar and was got admitted in Madaan Hospital Amritsar. She requested the hospital for cashless treatment but the hospital requested them to pay cash and then they talked telephonically to the office  of opposite party no.1 and they assured them  they will make the payment and at this stage complainant is to pay the cash for clearing the bills and on that assurance they made the payment of all the bills and after discharge from the hospital she has submitted all the documents for reimbursement alongwith all the hospitalization bills which were available with her and hospital discharge card but the opposite parties did not pay any amount.  They visited so many times to the office of the opposite party but they did not pay any heed and unnecessarily harassed them and subsequently illegally on 26.05.2016 a letter was received that the file of the claimant stand closed illegally and malafidely. They had spent Rs.60,000/- on the hospitalization and treatment, medicines and medical test etc. However at present the bills around Rs.45,000/- are available with them. Hence this complaint.   

3.       Upon notice, the opposite party appeared through their counsel and filed the written reply by taking the preliminary objections that complaint is not maintainable and is liable to be dismissed, the complaint is absolutely false and no cause of action has ever arisen in favour of the complainant against the opposite party. On merits, it was submitted that complainant no.1 got National Mediclaim policy bearing no.401211/48/15/8500000315 effective from 27.09.2015 to 26.09.2016 from the opposite party. Smt.Prem Lata wife of Ashok Kumar Verma was hospitalized from 23.10.2015 to 27.10.2015 and claim was lodged by complainant before opposite party regarding expenses on treatment of insured Prem Lata. The claim file was sent to PARK MEDICLAIM TPA PVT.LTD THRD PRTY ADMINISTRATOR- HEALTH SERVICES 702, VIKRANT TOWER, RAJENDRA PLACE NEW DELHI for investigation and admissibility of claim. That Dr.A.K.Batra MEDICAL DIRECTOR OF PARK MEDICLAIM TPA PVT.LTD. THIRD PARTY RAJENDRA PLACE NEW DELHI vide its letter dated 06.05.2016 declared that the claim of the complainant is not admissible as :Mrs. Prem Lata was hospitalized from 23.10.2015 with diagnosis Dengue Fever with Diabetes Mellitus with Hypertension with Hypothyroidism with Anaemia with Leucopenia. She was manged conservatively. In this case, the claimant had submitted all the documents for reimbursement on 30.11.2015. It may further be noted that no intimation of hospitalization was received by us the reasons for non compliance of the condition was received from the insured and was forwarded to the Insurance Company for condoning the delay. However, no response was received from Insurance Company despite reminders. Hence it has been presumed that the competent authority is not willing to condone the delay. Hence, this claim is not admissible vide conditions 5.5.1 and 5.5.4 of the policy”. Thereafter the opposite party vide its letter dated 26.05.2016 closed the claim file of the complainant reason violation of policy conditions not covered in the policy duly conveyed to the complainant. So the opposite party is not liable to pay the claim to the complainant as per the terms and conditions of policy vide EXCLUSION CLAUSE 5.5.1 and 5.5.4 of the policy. Thus, there is no deficiency in service on the part of the opposite party.

4.      Counsel for the complainant tendered into evidence affidavit of complainant Ex.CW1/A alongwith other documents Ex.C1 to Ex.C14 and closed the evidence. 

5.      Sh.Parveen Chadha Branch Manager of the opposite party tendered into evidence his own affidavit Ex.OP-1, alongwith other documents Ex.OP-2 and Ex.OP7 and closed the evidence.

6.      We analytically observe with the judicial precision and find that the OP insurers have arbitrarily repudiated (vide Ex.OP2/ Ex.OP3/ Ex.OP4/Ex.OP6) the complainant’s insurance claim for Rs.42,194/- so as to score out her medical hospitalization Bills amounting to Rs.60,000/- (approximately) on account of the ‘presumed’ non-admissibility vide conditions 5.5.1 and 5.5.4 of the related possibility. The OP (opposite party) Insurers have clearly quoted/ stated and disposed vide the written statement and the accompanying affidavit Ex.OP1, as also affirmed in the exhibit Ex.OP2 by the TPA (Third Party Administrators) as: “In this case, the claimant had submitted all the documents for reimbursement on 30.11.2015. It may further be noted that no intimation of hospitalization was received by us, the reasons for non-compliance of the condition was received from the insured and was forwarded to the Insurance Company for condoning the delay. However, no response was received from Insurance Company despite reminders. Hence, it has been presumed that the competent authority is not willing to condone the delay. Hence the claim is not admissible vide conditions 5.5.1 and 5.5.4 of the policy.”

7.       Thus, we find that the impugned claim was rejected merely on account of the reported non-receipt of the OP insurers’ decision on ‘delay-condonation’ by the TPA and subsequent presumption that the same stood rejected at the OP’s end. It surely indicates of the presence of hue of arbitrariness & illegality in the impugned repudiation of the instant claim. We, further find that OP produced ‘prospectus’ Ex.OP7 does not contain the conditions 5.5.1 & 5.5.4 on the strength of which the impugned claim stood repudiated. However, the learned counsel for the OP insurers has produced another (un-exhibited) booklet by the OP insurers, titled ‘National Mediclaim Policy’ that prescribes the ‘time-limit’ for claim intimation, in case of emergency-hospitalization as: 72 hours and 15 days for submission of documents per reimbursement post-hospitalization. However, the OP insurers have failed to prove their allegations of violation of the prescribed conditions by not producing the complainant’s request for condonation of delay and also its subsequent disposal at their own end. Since, the opposite party insurers here have failed to prove their allegations to justify the impugned repudiation through some cogent evidence necessary to be produced during the present proceedings and as such this amount to ‘bald’ statements, only.

8.       We find that the valid purchase & validity of the related policy have been duly admitted along with the factum of hospitalization and medical treatment expenses by the OP insurers. The complainant has duly proved her case through presentation of her evidentiary documents exhibited here as Ex. C1 to Ex.C14. The OP insurers have based their above repudiation decision solely on presumptions and hearsay evidences and the same are not admissible in judicial adjudicatory. Further, there has been no documentary evidence available and/or produced on the records of the present proceedings proving the OP insurers allegations leading to the impugned repudiation.

9.       In the light of the all above, we are of the considered opinion that the OP insurers have indeed bruised the consumer rights of the present complainant by employing ‘unfair trade practice’ amounting to ‘deficiency in service’ (on their part) and that lines them up for an adverse statutory award under the applicable statute commonly known as the Consumer Protection Act’ 1986.

10.     We, therefore,  partly allow the present complaint and thus ORDER the OP insurers to settle the impugned ‘insurance claim’ for the full claim amount of Rs.42,194/- as per the governing ‘terms’ of the applicable Health Insurance Policy (to its full benefits) strictly in accordance with the IRDA guidelines on ‘settlement of claims’ favoring the complainant besides to pay her Rs.10,000/- as cost and compensation within 30 days of receipt of the copy of the present orders otherwise the aggregate award amount shall attract interest @ 9% PA from the date of the orders till actual payment.

11.     Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.

                      (Naveen Puri)

                                                                                      President   

Announced:                                                             (Jagdeep Kaur)

September,15 2017                                                          Member

*MK*