Present:

For the  Complainant:                       Sh.Amandeep Passi, Advocate.

For Opposite Parties :                       Sh.Jasvinder Singh, Advocate.                  

Quorum:

Sh.Amrinder Singh Sidhu, President.

Sh.Mohinder Singh Brar, Member.

Smt.Aparana Kundi, Member.

Order by:

Sh.Amrinder Singh Sidhu, President

1.       The  complainant  has filed the instant complaint under section 12 of  the Consumer Protection Act, 1986 (as amended upto date) on the allegations that the complainant had purchased a policy from the Opposite Parties  under the name of Happy Family Floater Policy Plan valid for the period w.e.f. 24.06.2017 to 23.06.2018 and issued GST Invoice No.16518912000163  against the paid up premium of Rs.15,917/-. The complainant alleges that on 29.12.2017 he  suffered from paralyze attack and got admitted in Dayanand Medical College and Hospital (DMC) Ludhiana from 29.12.2017 to 03.01.2018 where the treating hospital charged Rs.36,155/- from the complainant on account of medical treatment. Thereafter, the complainant filed the claim for the reimbursement of his medical bills with the Opposite Parties  and also submitted the requisite papers and completed all the formalities, but the Opposite Parties  refused to admit the rightful claim of the complainant and repudiated the claim of the complainant on account of concealment of the pre existing disease, but the  ground for the repudiation of the claim of the complainant is quite illegal and false one.   As such, there is deficiency in service on the part of the Opposite Parties. Vide instant complaint, the complainant has sought the following reliefs.

a)       To reimburse the amount of Rs.36,155/- regarding the medical claim alongwith interest @ 18 % per annum till its realization.

b)      An amount of Rs.50,000/- as compensation for mental tension, harassment and agony suffered by the Complainant.

c)       An amount of Rs.25,000/- as litigation expenses.

2.       Opposite Parties-Insurance Company  appeared through counsel and contested the complaint by filing  the written version taking preliminary objections therein inter alia that the  complaint is not maintainable; that there is no deficiency in service on the part of the Opposite Parties  and the claim of the complainant is barred by limitation and by the terms and conditions of the insurance policy. Moreover, the  intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure  under the Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court. Actual facts are that the complainant has not approached this District Consumer Commission with clean hands, rather he has wilfully concealed the material and patent facts from this District Consumer Commission while filing the present complaint which ipso-facto disentitles the complainant to seek any relief against the Opposite Parties. The complainant has concealed the material fact regarding pre existing disease.  As per the discharge summary of Dayanand Medical College and Hospital (DMC) Ludhiana, the reasons of admission are:-

“51 years male was known case of hypertension since 5 years (on irregular treatment). Presented with complaint of right side weakness alongwith numbness, sudden in onset, involving both upper and lower limb. History of slurring of  speech with facial deviation towards left side. There is history of irrelevant talks present which improved. No history of diplopia, urinary bowel incontinence.  Hence the claim of the complainant is not admissible under exclusion clause 4.1 of the insurance policy terms and conditions. As per exclusion clause 4.1 of the General Exclusion of the Happy Family Floater Policy, all the pre existing disease (whether treated/ untreated, /untreated, declared or not declared in the proposal form) which are excluded upto 48 months of the policy being in force. Pre existing diseases shall be covered only after the policy has been continuously in force for 48 months. Mr.Prem Kumar was hospitalised at Dayanand Medical College and Hospital (DMC) Ludhiana from 29.12.2017 to 03.01.2018 with diagnosis hypertension, Acute CVA-ischemic, right Hemiparesis, Left PCA Territory Infract and was managed conservatively. Further, information  available from the discharge summary that the patient is a known case of hypertension since 5 years and he is covered under Happy Family Floater Policy since 24.06.2014 only.  As such, the claim of the complainant has been rightly found to be not admissible as per letter dated 15.03.2018 sent by the Mediclaim Insurance TPA Private Limited (IRDA approved third party administrator. On merits, the Opposite Parties  took up the same and similar pleas as taken up by them in the preliminary objections.  As such, in terms of the said proviso of the insurance policy, the insurance company has repudiated the claim of Complainant  in a proper manner.

3.       In order to  prove  his  case, the complainant has placed on record  his affidavit Ex.C1 alongwith copies of documents  i.e. copy of Aadhaar Card Ex.C2,  copy of policies Ex.C3 to Ex.C6,  copies of bills etc.Ex.C7 and Ex.C8 and closed the evidence the evidence.

4.       On the other hand,  to rebut the evidence of the complainant,  Opposite Parties also placed on record affidavit of Sh.Sukhwinder Singh Ex.OPs-1 alongwith copies of documents Ex.OPs2 to Ecx.Ops-58 and closed evidence.

5.       We have heard the ld.counsel for the parties and also  gone through the documents placed  on record.

6.       Ld.counsel for the Complainant has  mainly reiterated the facts as narrated in the complaint and contended that first of all, the written version  filed on behalf of the Opposite Party has not been filed by an authorized person. Therefore, the written version so filed is not maintainable. Opposite Party is limited Company and written version has been filed on the basis of special power of attorney given  to ld.counsel for the Opposite Party. Further contended that at the time of  issuance of the said policy  to the complainant, no term and conditions were ever explained or supplied by Opposite Parties to the complainant. It was  further contended that the complainant had purchased a policy from the Opposite Parties  under the name of Happy Family Floater Policy Plan valid for the period w.e.f. 24.06.2017 to 23.06.2018 and issued GST Invoice No.16518912000163  against the paid up premium of Rs.15,917/-. Further contended that on 29.12.2017  the complainant  suffered from paralyze attack and got admitted in Dayanand Medical College and Hospital (DMC) Ludhiana from 29.12.2017 to 03.01.2018 where the treating hospital charged Rs.36,155/- from the complainant on account of medical treatment. Thereafter, the complainant filed the claim for the reimbursement of his medical bills with the Opposite Parties  and also submitted the requisite papers and completed all the formalities, but the Opposite Parties  refused to admit the rightful claim of the complainant and repudiated the claim of the complainant on account of concealment of the pre existing disease, but the  ground for the repudiation of the claim of the complainant is quite illegal and false one and as such, there is deficiency in service on the part of the Opposite Parties.

7.       On the other hand, ld.counsel for the Opposite Parties has repelled the aforesaid contention of the ld.counsel for the complainant on the ground that first of all,  the intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure  under the Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court and this  District Consumer Commission has no jurisdiction to try and decide the present complaint. It is further contended that admittedly the complainant has concealed the material fact regarding pre  existing disease.  As per the discharge summary of Dayanand Medical College and Hospital (DMC) Ludhiana, the reasons of admission are:- “51 years male was known case of hypertension since 5 years (on irregular treatment). Presented with complaint of right side weakness alongwith numbness, sudden in onset, involving both upper and lower limb. History of slurring of speech with facial deviation towards left side. There is history of irrelevant talks present which improved. No history of diplopia, urinary bowel incontinence.  Hence the claim of the complainant is not admissible under exclusion clause 4.1 of the insurance policy terms and conditions. As per exclusion clause 4.1 of the General Exclusion of the Happy Family Floater Policy, all the pre existing disease (whether treated/ untreated, /untreated, declared or not declared in the proposal form) which are excluded upto 48 months of the policy being in force. Pre existing diseases shall be covered only after the policy has been continuously in force for 48 months. Mr.Prem Kumar was hospitalised at Dayanand Medical College and Hospital (DMC) Ludhiana from 29.12.2017 to 03.01.2018 with diagnosis hypertension, Acute CVA-ischemic, right Hemiparesis, Left PCA Territory Infract and was managed conservatively. Further, information  available from the discharge summary that the patient is a known case of hypertension since 5 years and he is covered under Happy Family Floater Policy since 24.06.2014 only.  As such, the claim of the complainant has been rightly found to be not admissible as per letter dated 15.03.2018 sent by the Mediclaim Insurance TPA Private Limited (IRDA approved third party administrator.

8.       Perusal of the contention of the ld.counsel for the complainant   shows  that  the written version  filed on behalf of the Opposite Party  has not been filed by an authorized person. Therefore, the written version so filed is not maintainable. The Opposite Party  is limited Company and written version has been filed on the basis of special power of attorney given  to ld.counsel for the Opposite Party. In this regard,  Hon’ble Supreme Court of India in a judgment (2011)II Supreme Court Cases 524 titled as “State Bank of Travancore Vs. Kingston Computers India Pvt. Ltd.” and in para no.11 of the judgment,  has held that

“the plaint was not instituted by an authorized person. On the plea that one authority letter dated 02.01.2003 was issued by Sh. R.K.Shukla in favour of Sh. A.K.Shukla. Further plaint failed to place on record its memorandum/articles to show that Sh. R.k.Shukla has been vested with the powers or had been given a general power of attorney on behalf of the Company to sign, verify and institute the suit on behalf of the Company.”

Similar proposition came before the Hon’ble Delhi High Court in “Nibro Ltd. Vs. National Insurance Co. Ltd.”, 2 (2005) 5SCC 30 that the

“bear authority is not recognized under law and ultimately, it was held that the plaint was not instituted by an authorized person. Here also appellant has not placed on record any resolution passed by any Board of Director in favour of Mr. Soonwon Kwon and that he was further authorised to delegate his power in favour of any other person. Further there is no memorandum/articles of the Company to show that Mr. Soonwon Kwon is one of the Director of the Company. In the absence of that evidence on record we cannot say that the special power of attorney given by Director Soonwon Kwon is a competent power of attorney issued in favour of Sh. Bhupinder Singh. In the absence of any resolution of the Company or any memorandum/articles of the Company to show that Sh. Soonwon Kwon is Director and that he was further authorised to issue power of attorney in favour of Sh. Bhupinder Singh.”

Recently our own Hon’ble State Commission, Punjab Chandigarh in FAO No.1235 of 2015 decided on 25.01.2017 in case titled as L.G.Electronics India Private Limited Vs. Sita Ram Chaudhary also held that the plaint instituted by  an unauthorized person has no legal effect.

9.       For the sake of arguments, for the time being, if the written reply filed by Opposite Party is presumed to be correct, the next  plea  raised by Opposite Party  is that the complainant has violated the terms and conditions of the policy in question and as per the terms and conditions of the policy, the complainant is not entitled to the claim as claimed.  But the Opposite Party could not produce  any evidence to prove that terms and conditions of the policy were ever supplied to  the complainant insured, when and through which mode? It has been held by Hon’ble National Commission, New Delhi in case titled as The Oriental Insurance Company Limited Vs. Satpal Singh & Others 2014(2) CLT page 305 that the insured is not bound by the terms and conditions of the insurance policy unless it is proved that policy was supplied to the insured by the insurance company. Onus to prove that terms and conditions of the policy were supplied to the insured lies upon the insurance company. From the perusal of the entire evidence produced on record by the Opposite Party,  it is clear that Opposite Party  has failed to prove on record that they did supply the terms and conditions of the policy to  the complainant insured. As such, these terms and conditions, particularly the exclusion clause of the policy is not binding upon the insured. Reliance in this connection can be had on Modern Insulators Ltd.Vs. Oriental Insurance Company Limited (2000) 2 SCC 734, wherein it is held that “In view of the above settled position of law, we are of the opinion that the view expressed by the National Commission is not correct. As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclosed to the appellant, the respondent can not claim the benefit of the said exclusion clause. Therefore, the finding of the National Commission is untenable in law.”  Our own Hon’ble State Commission, Punjab, Chandigarh in First Appeal No.871 of 2014 decided on 03.02.2017 in case titled as Veena Mahajan (Widow) and others Vs. Aegon Religare Life Insurance Company Limited in para No.5 has held that

“Counsel for the appellant argued that copy of insurance policy was not supplied to the appellant and hence, the exclusion clause in the contract of the insurance policy is not binding upon him. He further argued that no proof of sending of insurance policy was ever produced by the respondent despite specific contention raised by the complainant that the insurance policy was never received by him. He argued that though there is an averment of the OP that the policy in question was delivered through Blue Dart Courier to the complainant. In order to prove their contention, no affidavit of any employee of Blue Dart was produced who would have made a statement to have the effect that the policy was delivered to the complainant nor any acknowledgement slip for having received the article by the complainant through courier company was produced by the insurance company. He argued that since no policy document was received by the insured and argued that the terms and conditions as alleged to be part of the insurance policy were not binding upon the insured. He argued that policy was issued in the name of deceased Sh.Vijinder Pal Mahajan with his wife Mrs.Veena Mahajan as beneficiary and the same was never refused by the OP and the proper premium for insurance was paid by late complainant. He argued that as per the specific allegations made in the complaint in para No.4, no rebuttal to that contention was specifically there in their written reply in para No.2 and para No.4 in the reply filed by OP in the District Forum. He argued that Hon'ble National Consumer Disputes Redressal Commission, New Delhi in case of "Ashok Sharma Vs. National Insurance Co. Limited", in Revision Petition No. 2708 of 2013 held in para No.8 to the point of non-delivery of terms and conditions of the policy. He also cited Hon'ble Supreme Court's decision given in the matter of "United India Insurance Co. Limited Vs. M.K.J.Corporation" in Appeal (civil) 6075-6076 of 1995 (1996) 6 SCC 428 wherein the Apex court held that a fundamental principle of Insurance Law makes it that utmost good faith must be observed by the contracting parties. Good faith forbids either party from concealing what he privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary. Just as the insured has a duty to disclose, "similarly, it is the duty of the insurers and their agents to disclose all material facts within their knowledge, since obligation of good faith applies to them equally with the assured and further argued that since the terms and conditions were not supplied even on repeated requests the same cannot be relied upon by the opposite party in order to report to repudiate the genuine claim of the wife of the deceased policy holder.”

10.     Ld.counsel for the Opposite Parties further contended the intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure  under the Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court and this  District Consumer Commission has no jurisdiction to try and decide the present complaint. So far as the objection that complicated question of the fact is involved as such the Insured be relegated to go before Civil Court, is concerned, The Consumer Protection Act, 1986 (as amended upto date) (hereinafter referred to as the Act) was enacted with object to provide for better protection of the interests of the consumers and for that purpose, to make provision for the establishment of consumer council and other authorities for settlement of consumer disputes and other matter connected therewith. Section 13 (4) confers same powers upon the authorities under the Act, which are vested in Civil Court under Code of Civil Procedure, 1908, while trying a suit in respect of (i) The summoning and enforcing the attendance of any defendant or witness and examining the witness on oath, (ii) the discovery and production of any document or other material object producible as evidence, (iii) the reception of evidence on affidavits, (iv) the requisitioning of the report of the concerned analysis or test the appropriate laboratory or from other relevant source, (v) issuing of any commission for the examination of any witness and (vi) any other matter which may be prescribed. The authorities are conferred jurisdiction to decide the issue of “unfair trade practice” which has been defined under Section 2 (r) of the Act. This definition is similar to the definition of “fraud” as given under Section 17 of Indian Contract Act, 1872. From these provisions it is clear that this Commission can hold a full trail as held by civil court or adopt summary procedure for decision of any complaint. Under the Act, although the jurisdiction of the authorities is limited to consumer complaint, but while deciding such complaint no limit has been fixed for adjudicating of the dispute. Three Judges Bench of Supreme Court in Dr. J.J. Merchant Vs. Shrinath Chaturvedi, (2002) 6 SCC 635, (paragraph-7) held that the object and purpose of the Act is to render simple, inexpensive and speedy remedy to the consumer with complaint against defective goods and deficient services and the benevolent piece of legislation, intended to protect a large body of consumer from exploitation. Consumer Forum is an alternate Forum, established under the Act, to discharge the function of Civil Court. Under the Act, the consumers are provided with an alternative efficacious and speedy remedy. As such the Consumer Forum is an alternative forum established under the Act to discharge the functions of Civil Court. Therefore, delay in disposal of the complaint would not be a ground for rejecting the complaint and directing the complainant to approach the Civil Court. The argument that the complicated question of fact cannot be decided by the Forum, has been specifically rejected (In paragraph-12). Similar view has been taken in Amar Jwala Paper Mills Vs. State Bank of India, (1998) 8 SCC 387, CCI Chambers Coop. Hsg. Society Ltd. Development Credit Bank Ltd. (2003) 7 SCC 233. Recently, Hon’ble National Commission, New Delhi in CC No. 101 of 2009 titled as mahalaxmi Dyes & Chemicals Ltd. Vs. New India Assurance Company Limited decided on 07.09.2021 also held so.  Hence, this District Consumer Commission is  not convinced with the aforesaid contention of the ld.counsel for the Opposite Parties.

11.     The further contention of the ld.counsel for the Opposite Party is that  the complainant was known case of hypertension since 5 years (on irregular treatment). Presented with complaint of right side weakness alongwith numbness, sudden in onset, involving both upper and lower limb. History of slurring of  speech with facial deviation towards left side. There is history of irrelevant talks present which improved. No history of diplopia, urinary bowel incontinence.  Hence the claim of the complainant is not admissible under exclusion clause 4.1 of the insurance policy terms and conditions. As per exclusion clause 4.1 of the General Exclusion of the Happy Family Floater Policy, all the pre existing disease (whether treated/ untreated, /untreated, declared or not declared in the proposal form) which are excluded upto 48 months of the policy being in force. Pre existing diseases shall be covered only after the policy has been continuously in force for 48 months. On the other hand, the complainant has placed on record, the copies of policies for the continuous period of last 4 years, i.e. for the period from 24.06.2014 to 23.06.2015 (Ex.C4), from 24.06.2015 to 23.06.2016 (Ex.C5), from 24.06.2016 to 23.06.2017 (Ex.C6) and from 24.06.2017 to 23.06.2018, (Ex.C3), and this factum regarding the continuation of the polices purchased by the complainant has nowhere been denied by the Opposite Parties. The main reason for the repudiation of the claim of the complainant by the Opposite Parties  is that the case of the complainant falls within 48 months, hence it can not be considered, but   this plea of the Opposite Parties is totally false and unfair and proves the high handedness of the Opposite Parties  by rejecting the genuine claim of the complainant  in contravention with the aforesaid four years  continuous policies as mentioned above and hence, we do agree with the aforesaid contention of the ld.counsel for the complainant in this regard. 

12.     Moreover, it is the duty of the Opposite Party before issuing such medical policy to  any proposer to get medically examined the proposer from their own doctors  and the same is usually done so and  it also needs to be mentioned that when the policy is issued to the insured, prior investigations regarding health of the insured are duly done by the Insurance Company. If the complainant was suffering from any diseases prior to issuance of the policy, in question, the same must not have escaped the notice of the empanelled doctors of the Insurance Company. However, no such investigation record has been produced by the opposite parties. In case Bajaj Allianz Life Insurance Co. Ltd. & Ors. Vs. Raj Kumar III (2014) CPJ 221 (NC), it was held by the Hon’ble National Commission that usually, the authorized doctor of the Insurance Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. It was held that the Insurance Company wrongly repudiated the claim of the complainant.

13.     Furthermore, Hon’ble National Commission in Satish Chander Madan Vs. Bajaj Allianz General Insurance Co. Ltd. I (2016) CPJ 613 (NC) held that hypertension and diabetes  is common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension/ diabetes would always suffer with such paralysis attack disease.

14.     It also needs to be mentioned that Section 19 of the General Insurance Business (Nationalization) Act, 1972 states that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community. The denial of medical expenses reimbursement is utterly arbitrary on the ground that disease in question was pre-existing disease. It is mere an excuse to escape liability and is not bona fide intention of the insurance company. Fairness and non-arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State and public behavior. Any policy in the realm of insurance company should be informed, fair and non-arbitrary. When the insurance policy has exclusions/conditions to repudiate the claim or limit the liability, the same must be specifically brought to the notice of the insured and are required to be got signed to show that such exclusions and conditions have been brought to his/her notice.  Recently, our own Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in  First Appeal No. 50 of 2019 titled as Bajaj Alliance General Vs. Arjan Singh decided on 04.03.2021 also held so.

15.     The need for interpreting a contract always arises in two situations, (i) when a gap is needed to be filled in the contract and (ii) an ambiguity is needed to be resolved in the contract, then to find out correct intention of the contract, spirit behind it is required to be considered. Normally, the insurance policy is a contract of adhesion in which other party is left with hardly any bargaining power as compared to the insurer. Insurance contracts are standard form contracts and are drafted by the insurance company and as such, insurance company is at higher footing than the insured. The benefit of such clause, as exclusion clause, would go to the insured unless the same is explained in clear terms by the insurer. In such circumstances, the tribunal would be more oriented towards the interpretation which goes against the party who has inserted/drafted the disputed clause in the agreement/contract. The adjudicating authority is required to look into whether the intention of the party is to exclude or limit liability has been appropriately explained to the other party or not. This Commission while interpreting insurance agreement is to honour the intention of the parties, who have signed the agreement. Even if the agreement had general exclusion/condition for misrepresentation still fraudulent misrepresentation and non-disclosure may not be there. The innocent and negligent misrepresentations are to be ignored.  On the other hand, the rulings (i) Satwant Kaur Sandhu Vs. New India Assurance Company Limited, (ii) Murti Devi Vs. Birla Sun Life Insurance and (iii) Mamohan nanda Vs. United India Insurance Company Limited,   cited by the ld.counsel for the Opposite Parties  are not applicable and relevant  to the facts of the present case. 

16.     It has been held by the Hon'ble National Commission in case New India Assurance Co.Ltd & Anr Vs. Murari Lal Bhusri 2011(III) CPJ 198 (NC) that where the Insurance company failed to produce any evidence to show that respondent was aware of any pre-existing disease at the time when insurance policy was taken, opposite party was not justified in repudiating the claim of the complainant on the ground of pre-existing disease. It has been held by the Hon'ble Supreme Court of India in case P.Vankat Naidu Vs. Life Insurance Corporation of India & Anr 2011(3) CPC 350 that where no cogent evidence was produced by the respondent to prove that insured/deceased had concealed any fact about his illness or hospitalization, it was held that no material fact was suppressed by the deceased in this respect. It has been held by the Hon'ble State Commission of Punjab in case  Life Insurance Corporation of India Vs. Miss Veenu Babbar and another 2000(1) CLT 619 that repudiation on the basis of history recorded in the hospital records is illegal and arbitrary and the same could not be treated as substantive material to base any decision. Same view has been taken by the Hon'ble National Commission in case Life Insurance Corporation of India & Ors. Vs. Kunari Devi IV(2008) CPJ 89 (NC) that where no document has been produced in support of allegation of suppression of disease at the time of taking policy or revival of policy, history recorded in hospital's bed ticket, not to be treated as evidence as doctor, recording history not examined, suppression of disease not proved, insurer was held liable under the policy. It has further been held by the Hon'ble National Commission in case Sahara India Life Insurance Co. Ltd. & Anr Vs. Hansaben Deeepak Kumar Pandya IV(2012) CPJ 13(NC) that where the opposite party insurance company has failed to produce on record any evidence to show that deceased insured ever consulted doctor for taking treatment of heart disease, the repudiation of the claim on the ground of suppression of material fact is totally illegal. It has been  held by Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in case titled as Ashwani Gupta & Ors. Vs. United India Insurance Company Limited 2009(1) CPC page 561 that where the claim of the complainant has been repudiated on the ground that the assured had pre-existing disease which was not disclosed- apparently, burden to prove lies  upon the insurer- If assured was suffering from pre-existing disease why insurer  had not checked it at the time when proposal form was accepted by its  staff-Respondent has failed to fulfill this requirement before repudiating the claim and the appellant was held entitled  to claim alongwith interest”.

17.     In such a situation the repudiation made by the Opposite Parties regarding genuine claim of the complainant appears to have been made without application of mind. It is usual with the insurance company to show all types of green pesters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seams 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 of 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. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

18.     In view of the above discussion, we are of the opinion that the Opposite Parties-Insurance Company have  wrongly and illegally repudiated the claim of the complainant. Consequently, we allow the complaint and  the Opposite Parties-Insurance Company is directed to reimburse the medical bill of the Complainant amounting to Rs.36,155/- (Rupees thirty six thousands one hundred and fifty five only) alongwith interest @ 8% per annum from the date of filing the present complaint i.e. 27.09.2018 till its actual realization.  Opposite Parties-Insurance Company is also directed to pay the lump sum compensation to the complainant to the tune of Rs.10,000/- (ten thousands only) on account of harassment, mental tension  and litigation expenses. The compliance of this order be made by  the Opposite Parties-Insurance Company within 45 days from the date of receipt of this order, failing which the complainant  shall be at liberty to get the order enforced through the indulgence of this District Commission. Copies of the order be furnished to the parties free of cost. File be consigned to record room after compliance.

19.     Reason for delay in deciding the complaint.

This complaint could not be decided within the prescribed period because the government has not appointed any of the Whole Time Members in this Commission for about 3 years i.e. w.e.f. 15.09.2018 till 27.08.2021 as well as due to pandemic of COVID-19.

Announced in Open Commission.

Dated: 02.11.2021.