Order by:

Sh.Amrinder Singh Sidhu, President

1.       The  complainant  has filed the instant complaint under section 35 of Consumer Protection Act, 2019 on the allegations that the complainant  has been purchasing the Group Insurance Medical Policy from the last more than 3 years continuously without any break from the Opposite Parties against the premium fully paid up, in which the complainant alongwith his spouse (wife) namely Smt.Kavita Jindal and two children namely Lipi (daughter) and Piyush Jindal (son) were fully insured  for Rs.5 lakhs each. The detail of last three policies is given below:-

The aforesaid detail of the policies shows that the complainant has been purchasing the aforesaid policy from the last more than 3 years i.e. from the year 2017, till date continuously against payment of  requisite premiums and hence, the complainant is consumer of the Opposite Parties as required under the Consumer Protection Act, 2019.  This policy was cashless policy and in case of any medical treatment, the Complainant and his family members were fully insured for cashless payment. Further alleges that at the first time of purchasing the policy in question, the Complainant and his family members were fully medically got checked up by the  Opposite Parties from their own doctors with their own expenses and after full satisfaction, the Opposite Parties issued the policy cover note i.e. Mediclaim Policy and thereafter without any break, the Complainant has been purchasing the policy in question continuously by making the hefty amount of premium  since 2017 till date, which is obvious for the complainant to claim for sum assured in case of reimbursement of medical expenses incurred by the complainant as and when required.  The case of the complainant is that  during the policy period i.e. 28.02.2019 to 27.02.2020  the Complainant felt uneasiness and he immediately brought to Amrit Hospital, Moga where he remained admitted for the period 15.02.2020 to 16.02.2020 and said hospital charged Rs.11,500/-, but the Complainant not recovered from said hospital and he was brought and  remained admitted in Dayanand Medical College & Hospital, Ludhiana for the period w.e.f. 17.02.2020 to 21.02.2020, where the said treating hospital charged Rs.1,34,475/- from the Complainant. In this way, the Complainant paid total amount of Rs.1,45,975/- in both the hospitals besides other general expenses amounting more than Rs.50,000/- and in this regard, the Opposite Parties were immediately informed. Further alleges that the aforementioned policy was Cashless Policy, so at the time of discharge of insured, the Complainant requested the Opposite Parties to make the payment of the medical bill of the treating hospital, but the officials of the Opposite Parties told the Complainant that after submitting the claim, the medical bill could be reimbursed and hence, the Complainant was compelled to make the aforesaid medical bills to the treating hospitals. After discharge from the hospitals, the Complainant lodged the claim for the reimbursement of the medical bill with the Opposite Parties, but initially, the Opposite Parties lingered on the matter on one pretext or the other and at last vide repudiation letter dated 26.10.2020, the Opposite Parties have repudiated the rightful and lawful claim of the complainant on the false and frivolous ground of Pre-existing condition/ disease of hypertension, DM, CAD, on the opinion of TA M/s.Raksha TPA Private Limited, whereas   hypertension and diabetes is not a material disease, therefore, non disclosure thereof is not a concealment. Since the complainant has been regularly obtaining the health insurance cover w.e.f. 2017 till date, which is obvious for the complainant to claim for sum assured in case of reimbursement of medical expenses incurred by the complainant. There is no dispute inter se parties regarding the expenses incurred by the complainant on the treatment.  Further alleges that at the time of issuing the policy in question as mentioned above, alongwith this cover note, the Opposite Parties never issued any terms and conditions of the policy documents. As such, the alleged  terms and conditions, particularly the exclusion clause of the policy in question is not binding upon the insured. It is further respectfully submitted that admittedly, the complainant has been regularly obtaining the health insurance cover w.e.f. 2017 till date, which is obvious for the complainant to claim for sum assured in case of reimbursement of medical expenses incurred by him and there is no dispute inter se parties regarding the expenses incurred by the complainant on the treatment for which the complainant has also produced on record. In view of this, there is deficiency in service on the part of the Opposite Parties and they have illegally repudiated the genuine and legal claim of the complainant taking the false and frivolous ground on the report of Raksha TPA. But TPA is legally not competent to decide the claim of the complainant as there is no contract of the complainant with said TPA. Further alleges that  TPA who is yes-man of the Opposite Parties  has no legal right to decide the fate of the claim of the complainant.  That regarding the aforesaid medical reimbursement of his genuine claim regarding his treatment,  the claim was submitted by the Complainant with the Opposite Parties immediately after the discharge from the hospital, but the Opposite Parties has delayed the claim of the Complainant intentionally and knowingly without any reasonable cause and now at last after lapse of about  8 months, the Opposite Parties have repudiated the claim of the Complainant vide letter dated 26.10.2020  and the Complainant is suffering in the hands of the Opposite Parties and hence, the Complainant also remained under mental tension and harassment. The complainant approached the Opposite Parties time and again for the reimbursement of his  genuine remaining medical claim, but  the Opposite Parties  flatly refused to reimburse the total claim of the complainant, 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)       The Opposite Parties may be directed to reimburse the remaining medical claim of the complainant amounting to Rs. 1,45, 975/- as per final bill alongwith future interest  @ 12 % per annum from the date of payment to the respective hospitals till its actual realization.

b)       The amount of Rs.5,00,000/- be allowed to be paid by the opposite parties on account of compensation due to mental tension and harassment caused by the complainant.

c)       The cost of complaint amounting to Rs.50,000/- may please be allowed.

d)       And any other relief to which this Hon’ble Consumer Commission, Moga may deem fit be granted in the interest of justice and equity.       

2.       Opposite Parties appeared through counsel and contested the complaint by filing  the written version taking preliminary objections therein inter alia that 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. 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 which ipso-facto disentitles the complainant to seek any relief against the Opposite Parties. That the claim of the complainant is non payable under clause 4.1 of the insurance policy. In fact, two claims were lodged by the complainant during the validity of the policy and the claims were repudiated vide separate letters dated 11.02.2021 on the advise of   Raksha TPA Private Limited  on the ground that  claim is not admissible under exclusion clause 4.1 of the PNB-Oriental Mediclaim Insurance Policy with the observation that claim for hypertension, DM, CAD. As patient is suffering from DM for last 4 years and hypertension for last 10 years but claims falls in 3^rd year of policy. Pre existing disease covered only in 4^th year of policy hence claim for pre-existing disease is not covered under policy terms and conditions hence claim is recommended for repudiation as per clause 4.1. “Exclusion Clause 4.1 All Pre-existing diseases (whether treated/ untreated, declared or not declared in the proposal form), are excluded upto 36 months of the policy being in force and shall be covered only after the policy has been continuously in force for 36 months. For the purpose of applying this condition, the date of inception of the first PNB-Oriental Royal Mediclaim shall be considered, provided the renewals have been continuous and  without any break in the policy period. This exclusion shall also apply to any complication (s) arising from pre-existing diseases. Such complications will be considered as part of the pre-existing health condition or diseases.  Therefore, the claim was repudiated by the Opposite Party vide letters dated 13.05.2020 and 08.06.2020 respectively under Exclusion Clause 4.1 of the PNB-Oriental Mediclaim Insurance Policy. On merits, the Opposite Parties took up the same and similar pleas as taken up by them in the preliminary objections.   Hence, the Opposite Parties has rightly repudiated the claim of the complainant after application of mind and the complaint may be dismissed with costs.    

3.       In order to  prove  his  case, the complainant has placed on record  his affidavit Ex.C1 alongwith copies of documents  Ex.C2 to Ex.C37 and  closed the evidence on behalf of the complainant.

4.       On the other hand,  to rebut the evidence of the complainant,  Opposite Parties also tendered into evidence the affidavit of Sh.Sukhwinder Singh, Sr.Divisional manager Ex.Ops1 alongwith copies of documents Ex.Ops2 to Ex.Ops26 and closed the 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 the case of the complainant that the complainant  has been purchasing the Group Insurance Medical Policy from the last more than 3 years continuously without any break from the Opposite Parties against the premium fully paid up, in which the complainant alongwith his spouse (wife) namely Smt.Kavita Jindal and two children namely Lipi (daughter) and Piyush Jindal (son) were fully insured  for Rs.5 lakhs each. The detail of last three policies is given below:-

The aforesaid detail of the policies shows that the complainant has been purchasing the aforesaid policy from the last more than 3 years i.e. from the year 2017, till date continuously against payment of  requisite premiums and hence, the complainant is consumer of the Opposite Parties as required under the Consumer Protection Act, 2019.  This policy was cashless policy and in case of any medical treatment, the Complainant and his family members were fully insured for cashless payment. Further alleges that at the first time of purchasing the policy in question, the Complainant and his family members were fully medically got checked up by the  Opposite Parties from their own doctors with their own expenses and after full satisfaction, the Opposite Parties issued the policy cover note i.e. Mediclaim Policy and thereafter without any break, the Complainant has been purchasing the policy in question continuously by making the hefty amount of premium  since 2017 till date, which is obvious for the complainant to claim for sum assured in case of reimbursement of medical expenses incurred by the complainant as and when required.  The case of the complainant is that  during the policy period i.e. 28.02.2019 to 27.02.2020  the Complainant felt uneasiness and he immediately brought to Amrit Hospital, Moga where he remained admitted for the period 15.02.2020 to 16.02.2020 and said hospital charged Rs.11,500/-, but the Complainant not recovered from said hospital and he was brought and  remained admitted in Dayanand Medical College & Hospital, Ludhiana for the period w.e.f. 17.02.2020 to 21.02.2020, where the said treating hospital charged Rs.1,34,475/- from the Complainant. In this way, the Complainant paid total amount of Rs.1,45,975/- in both the hospitals besides other general expenses amounting more than Rs.50,000/- and in this regard, the Opposite Parties were immediately informed. Further contended that the aforementioned policy was Cashless Policy, so at the time of discharge of insured, the Complainant requested the Opposite Parties to make the payment of the medical bill of the treating hospital, but the officials of the Opposite Parties told the Complainant that after submitting the claim, the medical bill could be reimbursed and hence, the Complainant was compelled to make the aforesaid medical bills to the treating hospitals. After discharge from the hospitals, the Complainant lodged the claim for the reimbursement of the medical bill with the Opposite Parties, but initially, the Opposite Parties lingered on the matter on one pretext or the other and at last vide repudiation letter dated 26.10.2020, the Opposite Parties have repudiated the rightful and lawful claim of the complainant on the false and frivolous ground of Pre-existing condition/ disease of hypertension, DM, CAD, on the opinion of TPA M/s.Raksha TPA Private Limited, whereas   hypertension and diabetes is not a material disease, therefore, non disclosure thereof is not a concealment. Since the complainant has been regularly obtaining the health insurance cover w.e.f. 2017 till date, which is obvious for the complainant to claim for sum assured in case of reimbursement of medical expenses incurred by the complainant. There is no dispute inter se parties regarding the expenses incurred by the complainant on the treatment.  Further contended that at the time of issuing the policy in question as mentioned above, alongwith this cover note, the Opposite Parties never issued any terms and conditions of the policy documents. As such, the alleged  terms and conditions, particularly the exclusion clause of the policy in question is not binding upon the insured. It is further respectfully submitted that admittedly, the complainant has been regularly obtaining the health insurance cover w.e.f. 2017 till date, which is obvious for the complainant to claim for sum assured in case of reimbursement of medical expenses incurred by him and there is no dispute inter se parties regarding the expenses incurred by the complainant on the treatment for which the complainant has also produced on record. In view of this, there is deficiency in service on the part of the Opposite Parties and they have illegally repudiated the genuine and legal claim of the complainant taking the false and frivolous ground on the report of Raksha TPA. But TPA is legally not competent to decide the claim of the complainant as there is no contract of the complainant with said TPA. It is settled law that TPA who is yes-man of the Opposite Parties  has no legal right to decide the fate of the claim of the complainant.  That regarding the aforesaid medical reimbursement of his genuine claim regarding his treatment,  the claim was submitted by the Complainant with the Opposite Parties immediately after the discharge from the hospital, but the Opposite Parties has delayed the claim of the Complainant intentionally and knowingly without any reasonable cause and now at last after lapse of about  8 months, the Opposite Parties have repudiated the claim of the Complainant vide letter dated 26.10.2020  and the Complainant is suffering in the hands of the Opposite Parties and hence, the Complainant also remained under mental tension and harassment. The complainant approached the Opposite Parties time and again for the redressal of his grievances, but the    Opposite Parties  did not pay any heed to the request of the complainant and hence the ground for the repudiation of the claim of the complainant is quite illegal and false one.

7.       On the other hand, ld.counsel for the Opposite Party 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 Hon’ble District Consumer Commission has no jurisdiction to try and decide the present complaint. It is further contended 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 which ipso-facto disentitles the complainant to seek any relief against the Opposite Parties. Further contended that the claim of the complainant is non payable under clause 4.1 of the insurance policy. In fact, two claims were lodged by the complainant during the validity of the policy and the claims were repudiated vide separate letters dated 11.02.2021 on the advise of   Raksha TPA Private Limited  on the ground that  claim is not admissible under exclusion clause 4.1 of the PNB-Oriental Mediclaim Insurance Policy with the observation that claim for hypertension, DM, CAD. As patient is suffering from DM for last 4 years and hypertension for last 10 years but claims falls in 3^rd year of policy. Pre existing disease covered only in 4^th year of policy hence claim for pre-existing disease is not covered under policy terms and conditions hence claim is recommended for repudiation as per clause 4.1. “Exclusion Clause 4.1 All Pre-existing diseases (whether treated/ untreated, declared or not declared in the proposal form), are excluded upto 36 months of the policy being in force and shall be covered only after the policy has been continuously in force for 36 months. For the purpose of applying this condition, the date of inception of the first PNB-Oriental Royal Mediclaim shall be considered, provided the renewals have been continuous and  without any break in the policy period. This exclusion shall also apply to any complication (s) arising from pre-existing diseases. Such complications will be considered as part of the pre-existing health condition or diseases.  Therefore, the claim was repudiated by the Opposite Party vide letters dated 13.05.2020 and 08.06.2020 respectively under Exclusion Clause 4.1 of the PNB-Oriental Mediclaim Insurance Policy and the Opposite Parties has rightly repudiated the claim of the complainant after application of mind.

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.     It is not denial of the case that during the policy period i.e. 28.02.2019 to 27.02.2020  the Complainant felt uneasiness and he immediately brought to Amrit Hospital, Moga where he remained admitted for the period 15.02.2020 to 16.02.2020 and said hospital charged Rs.11,500/-, but the Complainant not recovered from said hospital and he was brought and  remained admitted in Dayanand Medical College & Hospital, Ludhiana for the period w.e.f. 17.02.2020 to 21.02.2020, where the said treating hospital charged Rs.1,34,475/- from the Complainant and the complainant paid total amount of Rs.1,45,975/- in both the hospitals besides other general expenses. It is not  disputed that that after discharge, the complainant lodged claim with the Opposite Parties for the  reimbursement  of his claim.   On the other hand, ld.counsel for the Opposite Parties  has specifically mentioned that  the claim of the complainant is has duly been scrutinised and found non payable under clause 4.1 of the PNB-Oriental Mediclaim Insurance Policy with the observation that claim for hypertension, DM, CAD. As patient is suffering from DM for last 4 years and hypertension for last 10 years but claims falls in 3^rd year of policy. Pre existing disease covered only in 4^th year of policy hence claim for pre-existing disease is not covered under policy terms and conditions hence claim is recommended for repudiation as per clause 4.1. Hence, the main ground on which the claim of the complainant has been repudiated has been that the complainant was suffering from hypertension and diabetes  prior to the issue of the insurance cover in dispute. But  hypertension and diabetes is not a material disease, therefore, non disclosure thereof is not a concealment. We draw support from Life Insurance Corporation of India Vs. Sushma Sharma from II (2008) CPJ 213 wherein Hon'ble State Commission has held as under:-

“So far as hypertension is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.

 We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease.

11.     Further the repudiation of the claim of the Complainant was made specifically on the report of Raksha Health Insurance TPA Pvt.Limited Ex.OP4 to OP8 and OP18  with which the Complainant has no concern at all. But recently, our own Hon’ble State Commission, Punjab, Chandigarh in First Appeal No.1105 of 2014 decided on 25-04-2017 in case titled as Sukhdev Singh Nagpal Vs. New Karian Pehalwal Cooperative Agriculture service Society & Others has held that TPAs have no authority to reject the claim- such power lies, exclusively with the Insurance Companies (Para No.25 to 27). The TPA can only process the claim and forward the same to the Insurance Company and the competent authority of the Insurance Company is to decide about the same. The claim of the complainant was illegally and arbitrarily rejected by the TPA, against the instructions of the IRDA. In view of this, the repudiation merely on the basis of report of the TPA is not legal.  

12.     In such a situation the repudiation made by the Opposite Parties-Insurance Company regarding genuine claim of the complainant have been made without application of mind. It is usual with the insurance company to show all types of green pasters 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.

13.     In view of the above discussion, we hold that the Opposite Party-Insurance Company have  wrongly and illegally rejected the claim of the complainant.

14.     Now come to the quantum of compensation. As per the claim of the complainant, he  spent the amount of Rs.1,45,975/- on his medical treatment in the hospital and in this regard placed on record the deposit receipts Ex.OP13, Ex.OP14, Ex.OP15, Ex.OP16, Ex.OP23 and Ex.OP25 establish that the complainant paid Rs.1,45,975/- to the treating hospitals and hence we allow the complaint upto that extent.

15.     In view of the aforesaid facts and circumstances of the case,  we allow the complaint of the Complainant and direct Opposite Parties to reimburse the medical bills of the complainant upto the extent of Rs.1,45,975/- (Rupees one lakh forty five thousands nine hundred seventy five only)  alongwith interest @ 8% per annum from the date of filing the complaint i.e. 11.02.2021 till its realization. Opposite Parties–Insurance Company is also directed to pay compensation to the complainant for causing him mental tension and harassment to the tune of Rs.5,000/- (five thousands only) and Rs.5,000/- (Rupees five thousands only) as litigation expenses. The compliance of this order be made by Opposite Parties 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.

Announced in Open Commission.

Dated: 08.03.2022.