ORDER                                       

Sh. K.S. Mohi, President

1.  The complainant has filed the present complaint on 28-06-2016 U/s 12 of the Consumer Protection Act, 1986 .  The facts as alleged in the complaint are that the complainant had taken a Happy Family Floater Cashless policy bearing no. 214300/48/2016/04913 valid from 19.12.2015 to 18.12.2016 from OP1 for himself and his family members.  It is alleged by the complainant that her wife namely Ms. Jaibunisha developed severe abdominal pain and remainED admitted at  Bhatia global Hospital & Endorsurgery Institute , Ambika Vihar , New Delhi from 27.02.2016 to 29.02.2016 for treatment of Vernal Hernia.   A total expense of Rs. 1,55,051/-  was incurred on her treatment     however OPs refused to provide cashless treatment without any sufficient cause vide letter dated 02.03.2016.   Aggrieved BY this , the   complainant approached this forum to direct  OPs to pay Rs. 1,55,051/-  ( cost of the treatment ) along with Rs. 18,000/- towards pre and post hospitalization charges  and Rs. 2,00,000/-  as compensation for mental agony and Rs. 15,000/- as litigation cost.
2. OPs filed reply taking preliminary objections inter-alia  that  there was violation of terms and conditions of the mediclaim policy on the part of the complainant and  vide letter dated 04-04-2016 and 12-04-2016  OPs demaned additional documents but the same had not been supplied by the complainant hence the claim of the complainant has been rightly closed vide letter dated 27.08.2016. OPs prayed for dismissal of the complaint.
3. Complainant  has filed his own affidavit affirming the facts alleged in the complaint. On the other hand, Sh.Jagdish Kumar, Senior Divisonal  Manager,  has filed affidavit in evidence on behalf of O.Ps. testifying all the facts as stated in the written statement. Complainant and OPs have also filed their respective written submissions.
4. We have carefully gone through the record of the case as well as written submissions filed by the parties and have also heard the submissions of Ld. Counsel  for the parties.
5. The main controversy in the present complaint revolves around the issue as to whether  the repudiation of claim of complainant was justified or not? Bare perusal of the contents of written statement filed by OPs would  show that claim of the complainant has been rejected on two counts (i)  Non-submission of medical papers (ii) violation of terms and conditions .  It is true that insurance company cannot proceed with the claim of the insured in the absence of relevant documents as to treatment/ illness.  However , in the present case Ex. PW1/A dated 12/03/2016 would demonstrate that all the medical papers demanded from the insured were very much delivered to OP vide diary no. 242171 against receipt of OP. Strangely enough, the OP once again demanded the same set of medical papers from complainant vide letter dated 4.05.2016 which already stood furnished to OPs vide letter dated 12.03.2016.  It is quite unknown as to why OPs did not proceed with assessment of claim of complainant after receipt of medical papers vide letter dated 12.03.2016.  So far as the violation of terms and conditions is concerned the written statement of OPs does not mention any specific term and condition which has been violated by the complainant nor did OPs filed terms and conditions on record. It is commonly seen that in such like cases the OPs would come up with false ground of  violation of terms and conditions to refute the  legitimate claim of insured particularly  when such terms and conditions were never supplied to the insured either at the time of inception of the insurance policy and anytime thereafter.  It is now well settled law that where the terms were never supplied to the insured at the time of inception of the policy the same cannot be pressed into service by the insurer to repudiate the claim.  In case titled I (2000) CPJ 1 (SC) M/s Modern Insulators Ltd. Vs  Oriental Insurance Co. Ltd., it was held that it is the fundamental principle of insurance law, that utmost good faith, must be observed by the contracting parties, and good faith forbids either party, from non-disclosure of the facts, which the parties knew.  The insured has a duty to disclose all the facts, and similarly it was the duty of the insurance company, and its agents, to disclose all the material facts, in their knowledge, as obligation of good faith applies to both equally. Since the terms and conditions of the insurance policy were not supplied to the complainant, it was neither aware of the exclusions, nor was bound by the same.
6. Keeping in view of the discussion stated above and the law point discussed above, we are of the considered view that repudiation by insurance company is totally unjustified and devoid of any merits and accordingly it clearly amounted to deficiency in service.  Accordingly we award a sum of Rs.1,55,051/- with interest @ 9% from the date of filing the present complaint i.e. 28.06.2016 till realization.  We also award a sum of Rs.10,000/- towards harassment, mental agony loss of time which will also include cost of litigation. It needs to be clarified that claim of the complainant for Rs. 18000/- being pre-hospitalization and follow up treatment stands  rejected as per term  of the policy which provides that the policy shall pay for hospitalization expenses for medical/ surgical treatment at any Nursing Home/ Hospital in India as an in-patient defined in the policy.  Ordered accordingly.
7. The OPs shall comply the order within 30 days from the date of receipt of this order failing which interest @ 9% shall be payable on the entire above mentioned amount from the date of this order till realization.

 Copy of this order be sent to the parties as per rules. File be consigned to record room.

                   Announced this ___________day of __________2017.