Punjab

Moga

CC/16/71

Meena Goyal - Complainant(s)

Versus

National Insurance Co. Ltd - Opp.Party(s)

Sh.Sunil Garg

19 Jul 2016

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MOGA.

 

                                                                                                                                                           CC No. 71 of 2016

                                                                                                                                                           Instituted on: 17.02.2016

                                                                                                                                                            Decided on: 19.07.2016

 

Meena Goyal widow of Arun Goyal son of Sat Narain Goyal, resident of House No. 1072/11, Railway Road, Moga.

                                                                          ……… Complainant

 

Versus

1.       National Insurance Company Limited, Regd. Office: 3 Middleton Street, Kolkata-700-071, Regional Office: S.C.O. 332-334, Sector 34-A, Chandigarh.

 

2.       The Park Mediclaim TPA Private Ltd., 702, Vikrant Tower Rajindera Palace, New Delhi.

 

3.       National Insurance Company Limited, Bansal Complex, Dholewal Chownk, G.T. Road, Ludhiana, Punjab.

 

4.       National Insurance Company Limited, through its Branch Manager, Moga.

 

                                                                           ……….. Opposite Parties

 

 

Complaint U/s 12/14  of the Consumer Protection Act, 1986.

 

 

Quorum:    Sh. Ajit Aggarwal,  President,

                   Smt. Vinod Bala, Member,

                   Smt. Bhupinder Kaur, Member.

 

Present:       Sh.Sunil Garg, Advocate Cl. for complainant. 

                   Sh. S.K. Jain, Advocate Cl. for opposite party nos. 1, 3 & 4.

                   Opposite party no.2 exparte.

 

 

ORDER :

(Per Ajit Aggarwal,  President)

 

1.                Complainant has filed the instant complaint under Section 12/14 of the Consumer Protection Act, 1986 ( hereinafter referred to as the "Act") against National Insurance Company Limited, Regd. Office: 3 Middleton Street, Kolkata, Regional Office: S.C.O. 332-334, Sector 34-A, Chandigarh and others (hereinafter referred to as the opposite parties) for directing them to pay the reimbursement of claim of Rs. 2,39,075/- alongwith interest @ 12% p.a. vide mediclaim insurance policy no. 401600/48/13/8500000121 towards hospitalization. Further opposite parties may be directed to pay Rs. 2,00,000/- as compensation for deficient services, mental tension, harassment alongwith costs of this complaint to the complainant or any other relief which this Forum may deem fit and proper be also granted.

2.                Briefly stated the facts of the case are that the husband of the complainant namely Sh. Arun Goyal has purchased a mediclaim policy for hospitalization and Domiciliary hospitalization vide its policy no. 401600/48/13/8500000121 for the period from 17.06.2013 to 16.06.2014 issued on 17.06.2013 from the opposite party company. After surrendering the previous policy bearing no. 401600/48/12/8500000105/2012 the policy on the name of the complainant as well as her husband was continuous from the period more than last 6 years. The husband of the complainant had purchased the Mediclaim policy no.401600/48/13/85/121 of National Insurance Company Ltd. and all the premiums upto date had been duly paid by the husband of the complainant to the insurance company. At the time of purchasing the policy as per norms and rules of the company and as per the agreement of company a complete medical examination of the husband of the complainant was got conducted by the approved medical Practitioner and the report of the same was duly sent to the company.  The company always issued the policy after medical examination of the policy holder and it will be continuous one i.e. year to year. Suddenly on 11.03.2014, the husband of the complainant fallen ill and some medicine has got reacted to the husband of the complainant and the complainant rushed to the DMC Hospital, Ludhiana, where husband of the complainant was got admitted and was discharged on 14.03.2014 and husband of the complainant was got conducted various examinations and tests. At the time of discharge from DMC, Hospital, the husband of the complainant was not completely well. As such, the husband of the complainant was got admitted in Fortis Escort Hospital on 01.05.2014, where he was got examined by the doctors of the Fortis Hospital, but the health of the complainant was not stable and unfortunately the husband of the complainant was died on 07.05.2014. Thereafter on 15.06.2014, the complainant lodged the mediclaim pertaining to her husband with the opposite party company alongwith the benefit policy claim form for Rs.2,39,075/- only. All the original documents including bills, receipts, discharge card summary, diagnostic reports, death certificate alongwith cancelled cheque were also submitted with the opposite parties as per their requirement. Further alleged that all the documents whatever demanded by the company were also submitted again and again and various times and the complainant requested the opposite party company to pay the insurance claim. The opposite party company on 13.03.2015 had taken an authorization from the complainant to check the record of all the hospitals, from where the husband of the complainant had taken the treatment by the TPA and accordingly the records of both the hospitals was duly got checked by the authorized persons of company. Thereafter company had written a letter dated 30.10.2014 vide which, the company had demanded the record of 1991 for the treatment taken by the husband of the complainant in past, despite getting the copy of the order passed in complaint no. 254 of 2010 titled as Arun Goyal Vs M/s New York Life Insurance Co. Ltd. decided on 28.03.2011 at the time of issuing the policy. The mark of the scar is already on the body of the complainant which had already been shown to the doctor of the company at the time of taking the insurance policy by the husband of the complainant. Further alleged that opposite party no.1 had engaged the opposite party no.2 for the purpose of ignoring the claim on false and flimsy grounds. The opposite party no.2 through various letters demanded the documents again and again, which was duly submitted by the complainant again and again. But despite that the opposite party company repudiated the genuine claim of the complainant. The complainant was astonished and surprised that despite submitting all necessary documents whatsoever of any kind demanded by the company, the company rejected the claim of the complainant on the basis that history was not disclosed at the time of getting the policy. The opposite parties asked many a times to admit the rightful claim of the complainant. But all in vain. Due to abovesaid act of the opposite parties, the complainant has suffered great mental tension and harassment. Hence this complaint.

3.                Upon notice, opposite parties appeared through his counsel and filed written reply taking certain preliminary objections inter alia that the present complaint is not maintainable in the eyes of law in view of the fact that the complainant has not submitted complete claim papers, as demanded vide letter dated 21.08.2014, 11.09.2014 and 30.10.2014 and final reminder-cum-closure letter dated 10.11.2014 issued by M/s Park Mediclaim TPA Pvt. Ltd; that the present complaint is not within time; that if any ailment or decease was diagnosed/or received medical advice or received treatment within 48 month prior to the first policy issued by the insurer. In that case, insurer is not entitled to any amount of the said treatment.

          On merits, it is admitted correct to the extent that the policy was purchased from the opposite party company. Further submitted that at the time of purchase of the policy, the complainant or her husband hds not disclosed the previous ailment/disease to the opposite party. Though, it is duty of the purchaser/insurer to disclose all these things without concealing any facts which were only well within his knowledge. But detail has not been given by the purchaser/insurer of his previous ailment/disease and this fact came to the knowledge of opposite party at the time of processing of claim. It is wrong to say that the husband of the complainant had suddenly fallen ill on 11.03.2014 and due to some reaction from medicine and was admitted to DMC Hospital, Ludhiana. As per the discharge summary of the patient, the hospital advised "Need for Coronary Angiography and Mitral Valve Replacement. But the patient and complainant were not willing for the procedure and requested for discharge and after the lapse of two months, patient was admitted in Fortis Escort Hospital on 01.05.2014. As per the death summary of the husband of the complainant, at the time of admission in Fortis Escort Hospital, the patient was suffering from k/c/o RHD, Severe MS and CAD (TVD) with chief complaint of Chest pain and Sweating and he was diagnosed as TVD with acute anterior was STEMI. His echo shows CAD, RDH, RWMA present (Akinetic apex anterior septum anterior wall and all apical segments) LVEF 20-25%, Normal RV Function, Severe MS, max gradient 14mmHg, means gradient 7mmHg. Mild TR, PASP 65mmHg. After above investigation, treatment was given, however he died in hospital on 07.05.2014 as per death summary of the Fortis Escort Hospital. So, the patient is having a known case of Rhematic Heart Disease since long with Mitral Valve Repair with Seizure Disorder for 2 years. Further the complainant submitted the claim with the company vide claim dated 15.06.2014 received on 17.06.2014 having intimation no.NKCHI/19.05.2015 and the claim was sent to Park Mediclaim TPA Pvt. Ltd. for process and verification of claim. Various letters dated 21.08.2014, 11.09.2014, 30.10.2014 and final reminder/closure letter dated 10.11.2014 were issued by Park Mediclaim TPA Pvt. Ltd. demanding the requisite information from the complainant. In the said letter following information has been sought:

a)       The patient was a known case of Rhematic Heart Disease since 1991 with Mitral Value Repair in the year 1991 with Seizure Disorder for 2 years and demanded all record regarding the same.

b)      The patient was advised Coronary Angiography on follow up advice at Dayanand Medical College and Hospital on 14.03.2014. Further patient was diagnosed to have Triple Vessel Disease on 02.05.2014. However, report of Angiography was not submitted from which confirm the diagnose TVD.

c)       The death certificate is not the substitute of Death Summary.

d)      All the policy copies prior to 17.06.2010.

                   The complainant had not submitted the relevant record from which it can be established that whether disease referred above is prior to the policy or lateron, nor disease been disclosed by the complainant or her husband at the time of purchase of policy. As per the report, the deceased was a known case of RHD with MVR in the years 1991 with Seizure Disorder for 2 years. Further the deceased was advised Coronary Angiography on the follow up advice at DMC Hospital on 14.03.2014. Further the patient was diagnosed to have Triple Valve Disease on 02.05.2014. But the report of Angiography was not submitted, then sought the Coronary Angiography from which confirms the diagnosed of TVD. But the same was not submitted. So ultimately Park Mediclaim TPA Pvt. Ltd. Recommended by their letter dated 22.01.2015 received on 30.01.2015 as 'No Claim' and file was closed and the same was duly intimated to the complainant. As the complainant has failed to disclose all the relevant and material facts relating to the illness and disease suffered by Sh. Arun Goyal in the past alongwith Angiography report. Although, he had to make full disclosure of such illness and disease at the time of purchase of policy. Complainant's husband was suffering from RHD with MVR in the year 1991 with Seizure Disorder for 2 years. Regarding which operation was done. But this fact was not disclosed and concealed with a malafide intention to extract the money from the opposite party. The policy premium prior to 2010 is required as it falls under the exclusive clause 4.1 i.e. Pre existing disease as well as guidelines issued by IDRD on standardization in health insurance as detailed mentioned in the preliminary objection as per terms and conditions of the policy point no. 16. The claim has not been repudiated rather the file has been closed as "No Claim" due the reason mentioned above and there is no deficiency in service on the part of the opposite party. The existence of the above disease was well within the knowledge of Sh.Arun Goyal as well as also in the knowledge of the complainant. The hospital from which deceased had been admitted for treatment clearly mentioned the past history. The complainant had suppressed and concealed the material facts at the time of purchase of the policy from the opposite parties. So, the complainant was not entitled to any reimbursement as per the terms and conditions of the policy being the same was pre-existing disease and has not been fully and truly disclosed at the time of purchase of policy. Further all other allegations made in the complaint have been denied and a prayer for dismissal of the complaint has been made.

4.                Upon notice, despite due service, none has appeared on behalf of opposite party no. 2. As such, opposite party no. 2 was proceeded against ex-parte.

5.                 In order to prove the case, complainant Meena Goyal tendered in evidence her duly sworn affidavit Ex. C-1 and copies of documents Ex. C-2 to Ex. C-12 and closed the evidence. 

6.                In rebuttal, the opposite party nos. 1, 3 & 4 tendered in evidence duly sworn affidavit of Sh. Kamaljit Singh, Divisional Manager, National Insurance Company Ex. OP-1,3,4/1 and copies of documents Ex. OP-1,3,4/2 to Ex. OP-1,3,4/16 and closed the evidence.

7.                We have heard the learned counsel for the parties and have very carefully gone through record placed on file.

8.                Learned counsel for complainant argued that Arun Goyal husband of the complainant had purchased a mediclaim policy for hospitalization and Domiciliary hospitalization from the OPs for the period 17.6.2013 to 16.06.2014 covering himself and complainant. This policy was continuous from the last about 6 years and the premium sum was paid by them to the company from time to time. Prior to issuing the policy, the OPs get the complete medical examination of the husband of the complainant from their approved Medical Practitioner and report of the same was duly sent to company by the medical practitioner alongwith E.C.G, x-rays, blood test reports and after satisfying from the medical examination, the company issued mediclaim policy to the complainant and her husband. Suddenly, on 11.03.2014, the husband of the complainant fallen ill and was admitted in DMC & Hospital, Ludhiana and discharged on 14.03.2014. In the hospital, the husband of the complainant gone through various examinations and tests, but after discharge from DMC & Hospital, the husband of the complainant was not completely well and again on 01.05.2014, he was got admitted in Fortis Escort Hospital, where he was got examined by the doctors of the said hospital. The husband of the complainant remained admit there, but his health was not stable and ultimately he died on 07.05.2014. The complainant spent a huge amount for the medical treatment of her husband. However, complainant lodged the insurance claim to the tune of Rs. 2,39,075/- only with the OPs alongwith claim form and she also supplied all the required document including bills, receipts, discharge summary, diagnostic reports, death certificate etc. to the opposite party company, as demanded by them. The complainant further submitted all other documents from time to time as demanded by OPs from her for the processing of her claim. She also gave authorization to the TPA of OPs to check the entire record of hospital on her behalf to process her claim. But the OPs did not settle the claim of the complainant and lingered on the matter on one pretext or the other only to harass the complainant and to avoid payment of the claim and they started demanding medical record of the husband of the complainant for the treatment taken by him in the year 1991. The medical insurance policy of the husband of the complainant was continuous from the last 8 years, but the OPs never demanded any prior medical record from them. So, at this stage, they cannot demand medical record of husband of the complainant pertaining to the year 1991. The OPs tried to decline the insurance claim of the complainant on false and flimsy ground only to harass and humiliate her. They repudiated the claim of the complainant wrongly and illegally. The complainant supplied all the required documents for processing of her claim and now OPs are making unnecessary and false issue of alignment of husband of the complainant in the year 1991. The complainant is entitled to get the claim regarding the medical expenses borne by her for the treatment of her husband. The acts of OPs for not paying the insurance claim of the complainant amounts to deficiency in service and mal trade practice on their part. The complainant has made a prayer that OPs may be directed to pay claim alongwith interest, compensation and litigation expenses.

9.                To controvert the arguments of the complainant, learned counsel for the OPs argued that the present complaint is not maintainable as the complainant has not submitted complete claim papers as demanded by OPs vide their various letters. The complainant had not supplied the required information, so her claim was closed as 'no claim'. They admitted that husband of the complainant was insured under the medicalim policy issued by the OPs. He further argued that at the time of purchase of the policy the complainant and her husband had not disclosed about the previous disease to the OPs. It was the duty of the complainant and her husband to disclose all things without concealing any fact, which was in their knowledge, but they did not give any information regarding the previous disease. It is wrong that at the time of purchase of insurance policy, the complete medical examination of the husband of the complainant was got conducted by the OPs, through their approved medical practitioner. No medical examination report was submitted with the OPs at the time of issuing the policy. The complainant and her husband concealed their previous disease. It is wrong that on 11.03.3014, the husband of the complainant suddenly fallen ill and was admitted in DMC Hospital, Ludhiana. As per discharge summary of the patient, the hospital has advised "Need for Coronary Angiography and Mitral Valve Replacement. But the patient and complainant were not willing for the procedure and requested for the discharge and after the lapse of two months, patient was again admitted in Fortis Escort Hospital on 01.05.2014. As per the death summary of the husband of the complainant, at the time of admission in Fortis Escort Hospital, the patient was suffering from k/c/o RHD, Severe MS and CAD (TVD) with chief complaint of Chest pain and Sweating and he was diagnosed as TVD with acute anterior was STEMI. His echo shows CAD, RDH, RWMA present (Akinetic apex anterior septum anterior wall and all apical segments) LVEF 20-25%, Normal RV Function, Severe MS, max gradient 14mmHg, means gradient 7mmHg. Mild TR, PASP 65mmHg. After above investigation, treatment was given, however he died in hospital on 07.05.2014 as per death summary of the Fortis Escort Hospital. So, the patient is having a known case of Rhematic Heart Disease since long with Mitral Valve Repair with Seizure Disorder for 2 years. It is correct that the complainant submitted the claim with opposite parties on 15.06.2014 and the insurance company duly sent the claim to Park Mediclaim TPA Pvt. Ltd. for process and verification. The TPA issued various letters to complainant demanding the required information from the complainant regarding previous medical record of husband of the complainant for his Rhematic heart disease suffered by him since 1991 with seizure disorder for 2 years. But the complainant has not submitted the relevant record from which whether disease referred above is prior to the policy or lateron, nor disease has been disclosed by the complainant or her husband at the time of purchase of policy. As per report deceased was a known case of RHD with MVR in the years 1991 with seizure Disorder for 2 years. Further he was advised Coronary Angiography on the follow up advice at DMC Hospital on 14.03.2014. The report of Angiography was not submitted, so ultimately TPA recommended by their letter dated 22.01.2015 received on 30.01.2015 as No Claim and file was closed and the same was duly intimated to the complainant, copy of the letter dated 22.01.2015 is Ex. OP-1,3, 4/8, copy of the letter sent by the TPA regarding no claim is Ex. OP-1,3, 4/7. The complainant has failed to disclose all the relevant and material facts relating to the illness and disease suffered by Arun Goyal in the past alongwith Angiography report. The husband of the complainant was suffering from RHD with MVR in the year 1991 with Seizure Disorder for 2 years. Regarding which operation was done. But this fact was not disclosed and concealed with a malafide intention to extract money from the opposite parties. The complainant and her husband purchased the policy from the opposite parties at first time in the year 2010 valid from 17.06.2010 to 16.06.2011, copy of the same is Ex. OP1,3,4/9 and policy was continuous  till 17.06.2013 to 17.06.2014, copies of the policies are Ex.OP1,3,4/9 to Ex. OP1,3,4/12. As per terms and conditions of the policy and guidelines issued by IRDA on standardization in health insurance case of the complainant falls under the exclusion clause 4.1 i.e. regarding pre-existing disease. As per this clause "All pre-existing diseases when the cover incepts for the first time until 48 months of continuous coverage has elapsed. Any complication arising from pre-existing ailment/disease/injuries will be considered as a part of the pre-existing health condition or disease and not covered under the policy upto the expiry of 48 months of continuous policy, copy of the terms and conditions of the policy and copy of the guidelines of IRDA are Ex. OP1,3,4/2 and Ex. OP1,3,4/3 respectively. The complainant and her husband purchased the insurance policy from opposite parties on first time on 17.06.2010 and vide her claim the complainant claimed expenses for the treatment taken by her husband from 11.03.2014 to 07.05.2014 i.e. till his death. As per conditions of the policy, on that time period of 48 months of continuous policy had not been elapsed, so the complainant is not entitled for any claim as per the terms and conditions of the policy. Moreover, at the time of purchase of policy, the fact of prior disease was well within the knowledge of complainant and her husband and they have to disclose this fact to the opposite parties. But they suppressed and concealed this fact from opposite parties, so they are not entitled for any claim as per terms and conditions of the policy. It is wrong that complainant spent an amount of Rs.2,39,075/- for the treatment of her husband. She had not submitted all documents alongwith her claim for the processing of same. She had not supplied the required documents demanded by them. So, finally as per the terms and conditions her claim file of the complainant was closed as "no claim" due to non-supply of required documents and information as demanded by opposite parties. The reason for closing the file as 'no claim' in fully detailed was conveyed to the complainant by the opposite parties. It is wrong that the opposite parties illegally repudiated the claim of the complainant. They repudiated the same as per terms and conditions of the policy. There is no deficiency in service and mal trade practice on the part of the opposite parties. The complainant has filed the present complaint only to harass the opposite parties and to extract money from them and the present complaint may be dismissed with costs.

10.              We have heard the arguments of both the parties and also gone through the pleadings and evidence led by both the parties. The case of the complainant is that her husband purchased a mediclaim insurance policy from the opposite parties. Suddenly, husband of the complainant was fallen ill on 11.03.2014 and admitted in DMC Hospital, Ludhiana and was discharged on 14.03.2014. Again he was admitted in Fortis Escort Hospital on 01.05.2014 and ultimately died on 07.05.2014 in the hospital. She lodged the claim for the reimbursement of the expenses borne by her on the medical treatment of her husband with opposite parties, but they rejected his claim illegally.

11.              In reply opposite parties admitted that the complainant and her husband purchased the mediclaim insurance policy from them. They further admitted that the complainant lodged the claim for the reimbursement of medical expenses borne by her on the treatment of her husband. But they argued that the husband of the complainant was suffering from Rhematic heart disease since 1991 and got operated for the same disease in the year 1991, but at the time of purchase of policy, they did not disclose this fact to opposite parties and suppressed and concealed prior disease from the opposite parties, which is violation of terms and conditions of the policy. They further argued that they demand the information regarding the previous ailment of husband of the complainant vide various letters, but the complainant did not provide required record and detail to the opposite parties for settlement of her claim. Moreover, as per terms and conditions of the policy and guidelines of IRDA the prior disease or ailment is to be covered under the policy only after 48 months of continuous insurance policy from its inception and in the present case the complainant and her husband purchased the insurance policy from opposite parties on 17.06.2010 and he died on 07.05.2014 i.e. prior to expiry of 48 months so as per terms and conditions of the exclusion clause, the complainant is not entitled for the reimbursement of medical claim of her husband for the disease for which he was suffering since 1991 prior to the inception of the policy, so they rightly closed her claim as no claim.

12.              On it learned counsel for complainant argued that the husband of the complainant was not suffering from any prior disease and they have not concealed any fact from opposite parties. Moreover, if it is admitted that husband of the complainant was suffering from heart disease, prior to inception of the insurance policy and as per terms and condition of the policy he was not entitled for the claim for pre-existing disease for 48 months from the inceptions of the policy, as per terms and conditions of the policy. In that case also the complainant is entitled for the medical claim of her husband. The husband of the complainant was insured for his mediclaim much prior then 48 months. He purchased the policy from the opposite parties first time in the year 2010 and prior to that he was insured with Max New York Life Insurance Company since 2008. He argued that during the currency the insurance policy of Max New York Company he was hospitalized on 17.01.2010 to 27.01.2010 for the treatment of Acute Coronay Syndrome with one O-wave infection and lodged his claim with said insurance company, who declined his claim on the same ground, for which the present claim is declined by the opposite parties i.e. non disclosure of past history of heart disease in the year 1991. Then the husband of the complainant filed the complaint again that insurance company before this Forum, which was allowed by this Forum in favour of husband of the complainant and against Max New York Life Insurance Company vide its order dated 28.03.2011 passed in complaint no. 254 of 2010 titled as Arun Goyal Vs Max New York Life Insurance Company Ltd declining the pleas of insurance company and they were directed to pay the insurance claim to husband of the complainant, copy of that order is Ex. C-12 and that policy was valid for 10 years. It was purchased on 21.03.2008 as there was dispute arose between the complainant and Max New York Life Insurance Company, then after during the currency of that policy the complainant and her husband purchased the policy of opposite party company. As such, there is a continuation in insurance policy purchased by the complainant and her husband since 2008 i.e. much more from 48 months. He argued that the date of inception is not date of inception of current policy rather it should be taken as first date of coverage under mediclaim by any Indian Insurance Company. He put reliance on the citation- 2016(2) CLT 326 titled as Ashish Sharma (Dr.) Vs United India Insurance Co. Ltd. & another, whereas our Hon'ble National Consumer Disputes Redressal Commission, New Delhi held that Insurance Claim (Mediclaim Policy). Death of Insured- Claim repudiated on the ground that patient is known as a case of HTN since 10 years and COPD since 15 years and the date of inception to medi-claim policy is 06.04.2005 so the ailment comes as pre-existing and as per terms and conditions of the policy, pre-existing ailments are not covered. Plea of complainant that insured cannot be treated having pre-existing disease at the time of start of the last policy as he has been taking the policies continuously right from the year 1990. Held. The date of inception is not date of inception of the current policy, rather it should be taken as first date of coverage under mediclaim by any Indian Insurance Company. Clearly, the inception date is 21.2.1990 when the first insurance was taken from insurance company and since then the mediclaim coverage was taken continuously every year till the death of the insured. Disease cannot be termed as pre-existing. So, the opposite parties cannot decline the claim of the complainant on the basis of exclusion clause. He submitted that insurance companies are only interested in earning the premiums and find ways and means to decline the genuine claims. At this reliance has been put on the citation - 2008 (3) RCR (Civil) Page 111 titled as New India Assurance Company Limited Vs Smt. Usha Yadav & others, whereby, our Hon'ble Punjab & Haryana High Court held that It seems 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 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. He argued that opposite parties wrongly and illegally repudiated the claim of the complainant and she is entitled to get the insurance claim alongwith compensation and litigation costs.

13.              From the above discussion, we are of the considered opinion that the insurance policy of the complainant and her husband is continuous from the year 2008 i.e. more than 48 months from the date of treatment as per the exclusion clause the opposite parties cannot denied the genuine claim of the complainant. We are fully convinced with the arguments and case laws produced by learned counsel for the complainant. We are of the considered opinion that the acts of the opposite parties vide which they closed the claim of the complainant as "No Claim" amounts to deficiency in service and mal trade practice on their part. Hence the complainant is entitled to get reimbursement of medical expenses for the treatment of her husband. However, the complainant filed the present complaint and lodged the claim with opposite parties for a sum of Rs. 2,39,075/-. But from the perusal of insurance policy Ex.C-10 it reveals that vide this policy the sum assured is Rs. 1 lac and in any case the complainant cannot claim mediclaim more than the sum assured so, in these circumstances, the present complaint is partly allowed to the extent of only sum assured of Rs 1 lac. As such, opposite parties are directed to pay Rs. 1,00,000/- (one lac only) as mediclaim amount for the treatment of deceased husband of the complainant alongwith interest @ 9% p.a. from 22.01.2015, when opposite parties closed the claim of the complainant as "no claim" till final realization. Opposite parties are also directed to pay Rs. 10,000/- (Ten thousand only) as compensation for mental agony and harassment faced by complainant and Rs.3000/- (Three thousand only) as litigation expenses to the complainant. Opposite parties are directed to comply with the order within one month from the date of receipt of the copy of the order failing which complainant shall be entitled to initiate proceedings under Section 25 and 27 of Consumer Protection Act. Copy of the order be supplied to parties free of cost. File be consigned to the record room. 

Announced in Open Forum

Dated : 19.07.2016

 

                         (Bupinder Kaur)         (Vinod Bala)                   (Ajit Aggarwal)

                              Member                     Member                           President