Complainant Rakesh Kumar through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has sought issuance of necessary directions to the opposite parties to make him payment of claim amount on account of loss suffered by them. Opposite parties be further directed to pay Rs.79,359/- alongwith interest @ 18% per annum from the date of filing the claim till its realization and Rs.10,000/- for physical and mental harassment and deficiency in service. Opposite parties be next directed to pay Rs.10,000/- on account of litigation expenses, in the interest of justice.

2. The case of the complainants in brief is that he took Mediclaim policy vide No.233300/48/2016/5646 from M/s.Medi Assist India through Agent/Broker Oriental Bank of Commerce, valid from 4.2.2016 to 3.2.2017. On 20.2.2016 suddenly he was suffering from viral and admitted to Smt.Kaushalya Devi Hospital, Pathankot and was diagnosed having CAD with DM with Septicemia with spondylosis and after the treatment he was discharged on 26.2.2016. The claim was lodged with the Oriental Bank of Commerce and accordingly Chief Manager moved an application to Dy. General Manager, Oriental Bank of Commerce, Regional Office Amritsar on 12.3.2016 with the request to forward the claim to the concerned Medi Assist-TPA. However, the opposite party no.2 has repudiated his claim on the ground that it was a case of CAD with DM with Septicemia with spondylosis and Management was done. Policy inception date is 4.2.2016. Policy running in first year and present ailment is not payable in first two and three years. Hence, this claim is denied under Excl. 4.2. He has next pleaded that no policy alongwith terms and conditions has been sent to him and as such no such terms and conditions binding upon him. The premium has been deducted by the bank but no policy documents were sent to him by the Bank or by the M/s.Medi Assist India. When he got discharged from the Hospital he approached the bank and inquired regarding the policy and then bank provided the copy of policy and then the claim had been lodged by him. Due to illegal act and conduct of the opposite party, he has suffered great financial loss and also suffered mental harassment, it is a case of clear cut deficiency in service and unfair trade practice on the part of the opposite party who did not pay amount of claim to him on false and flimsy grounds and without any reason or rhyme. Hence this complaint.

3. Upon notice, the opposite party no.1 appeared and filed its written reply through its counsel taking the preliminary objections that the present complaint is not maintainable; the complainant has filed the present complaint by concealing true and material facts from this Ld.Forum and the complainant has purchased the policy on 4.2.2016 and he has suffered with CAD, (relating to Heart Problem) DM (relating to Diabetics problem) with Septicemia (infection in blood) with spondylosis (Problems in Joint) and allegedly hospitalized on 20.2.2016 and discharged on 26.2.2016, whereas fact remains that in the policy taken by the complainant, all the above mentioned ailments are covered in first two and three years from the date of purchase of policy under Excl.4.2 in which present ailments are not covered in first two and three years, which clearly shows that at the time of purchasing the policy, the complainant was already having the abovesaid ailments and he has taken the policy intentionally and malafidely only to get claim from the company, as such the complainant is not entitled for any claim and the complaint of the complainant is liable to be dismissed with costs. On merits, the same pleadings/objections have been repeated while denying and rebutting all other allegations as raised therein the complaint and lastly, the complaint being devoid of any merit has been prayed to be dismissed.

4. The opposite party no.2 appeared and filed its written reply through its counsel taking the preliminary objections that the present complaint is not maintainable. On merits, It was submitted that the Investigator of the opposite party could not investigate the matter properly as the hospital, wherein the complainant got admitted refused to provide in door case papers, hence, it is observed that the bills, receipts issued by the hospital are not in order and creates doubts about its correctness and validity. The treatment details chart was not disclosed regarding correct nature of illness suffered by the complainant and the complainant has concealed his pre-existing ailments. As per the statement given by the complainant, it is a known case of Diabetes and Hypertension for 20 years and Heart Disease and underwent for PTCA in 2009. It was further submitted that as soon as the claim of the complainant received by the insurance company, the same was referred to M/s.MEDI ASSIST INDIA PVT. LTD., for settling the claim as per the terms and conditions of the policy and as per the required record/documents. M/s.MEDI ASSIST INDIA PVT. LTD is the claim settling authority, who settles the claims under the terms and conditions of policy. On scrutinizing all the documents including medical treatment record M/s.MEDI ASSIST INDIA PVT. LTD observed that the case of the insured Rakesh Kumar is the case of CAD with DM with Septicemia with Cervical Spondylosis and treated accordingly. The policy of the insured is the first year policy, which does not cover the claim of the insured. Hence, the claim of the complainant is not covered under the terms and conditions of the policy and the company has rightly repudiated the claim of the complainant under the terms and conditions of policy. All other averments made in the complaint have been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

5. Notice issued to the opposite party no.3 had not been received back. Case called several times but none had come present on its behalf, therefore, it was proceeded against exparte vide order dated 21.11.2016.

6. Complainant tendered into evidence his own affidavit Ex.C1 alongwith other documents Ex.C2 to Ex.C8 and closed the evidence.

7. Sh.Sita Ram Attri, Sr.Manager of opposite party tendered into evidence his own affidavit Ex.OP-1, alongwith other document Ex.OP-2 and closed the evidence.

8. Ld. Counsel for the opposite party no.2 tendered into evidence affidavit of Sh.Karam Singh, Senior Divisional manager Ex.OP-2/1 alongwith copies of terms and conditions Ex.OP-2/2 and closed the evidence.

9. We have thoroughly examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective contestants. We find that the present dispute has arisen on account of the impugned ‘repudiation’ of the med-insurance/medical-treatment reimbursement-claim (Ex.C2 – Mark A & B) of the complainant-contacted ailments.

10. We find that the titled opposite party insurers (hereinafter for short ‘the OP insurers’) have duly admitted the repudiation through their written statement and accompanying affidavit (Ex.OP1/1) on the grounds as mentioned out in its paragraph ‘3’ being in violation/ contravention of the terms of the Policy as per its Exclusion Clause 4.2 (Ex.OP1/3) as per which a waiting period of ‘2’ years has been prescribed for the pre-existing ailments of HPN, CAD etc as were contacted by the instant complainant. Thus, we find that the impugned claim has been in contravention violation of the contracted terms of the Policy and as such the present complainant shall not be entitled to any statutory relief.

11. Lastly, we find that the complainant here has failed to prove his allegations as made out in the complaint and thus finding the same bereft of any actionable claim/statutory merit etc., we ORDER for its dismissal with however no orders as to its costs.

12. 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)

December 20, 2017 Member.

*MK*