Complainant Satnam Singh has filed the present complaint against the opposite party U/S 12 of the Consumer Protection Act (for short, C.P.Act.) seeking necessary directions to the opposite party to  make the payment of Rs.65,700/- to him. Opposite party be further directed to pay Rs.20,000/- as compensation for physical harassment and mental agony alongwith Rs.20,000/- as litigation expenses, in the interest of justice.

2.        The case of the complainant in brief is that he is son of the deceased Joginder Singh. Being L.R. of the deceased, he has legal right to file this complaint because he is beneficiary. His father namely Joginder Singh was medically insured with the opposite party and paid premium of the said Insurance policy scheme known as “Bhai Ghaniya Sehat Sewa Scheme” and the policy Card No.MD 15-BGSSS-00264130-S was issued to him. Under this policy, he was fully covered for medical facilities free of cost and under this policy, his dependents were also fully covered. It was also known as Cashless scheme. This cashless medical facility was also authorized only for few recognized Hospitals, in which Card holders could get free hospitality after showing his card which is given by the opposite party, then the opposite party is liable to pay all the expenditure born by him. He has further pleaded that his father Joginder Singh was got admitted in S.G.L.Charitable Hospital, Garha, Jalandhar on 18.3.2017 as this Hospital was fully authorized by the opposite party and Hospital admitted the same for treatment for his ailment after showing the Medicare card issued by the opposite party. On 18.3.2017, the Hospital authorities refused to give the benefit of the said policy by saying that “the Cashless Hospitalization was denied as insured person is not covered under the Policy on the date of Hospitalization.” Joginder Singh his father remained admitted there as his position was not allowing him to take at home then all the expenditure were paid by him to the tune of Rs.65,700/-. His father took his last breath on 24.3.2017 and hospital authorities have declared him dead. He has next pleaded that he connected the opposite party on Toll Free No.1800 2335758 regarding the bills of medical which were paid by him reimbursed to him but they refused to pay the same. Due to the illegal act and conduct of the opposite party, he has suffered great mental agony and has suffered mental as well as physical harassment from the hands of the opposite party. Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint. 

3.          Upon notice, opposite parties appeared through their counsel and filed their written reply by taking the preliminary objections that the complainant has no cause of action to file the present complaint; the complainant has no locus standi to file the present complaint; the complainant does not fall within the definition of Consumer as provided under the Consumer Protection Act.; the insurance is a contract between the two parties. Both the parties bind with the terms and conditions of the policy; there is no deficiency in services on the part of the opposite party. The present complaint is bad for non-joinder of necessary parties as the MD India (TPA) has not made party to the complaint; the claim has been denied by the MD India (TPA) with the reason that the insured person is not covered under the policy on the date of hospitalization and the complaint of the complainant is not within the limitations. On merits, it was submitted that the deceased was not covered under the policy. Actually, the claim has been denied by the MD India (TPA) with the reason that the insured person is not covered under the policy on the date of hospitalization. The deceased has concealed the material facts at the time of getting insurance/covered. As per eligibility for the scheme it has been duly provided that no person who is more than 75 years of the age  on the date of commencement of the policy plan period shall be eligible for under the scheme. In the present case the documents provided by the hospital regarding the patient age clearly mentioned the age of deceased as 82 years in the OPD slip and Lab investigation report. Further the voter card of the deceased is also very much clear in this regard. So, it become clear that the insurance policy was taken by beneficiary by hiding actual age at the time of enrolment just to take benefits from Insurance Company. So, there is no liability of the Insurance Company. It was further submitted that insurance is a contract based on utmost good faith. There is breach of utmost good faith on the part of insured who failed to give the correct particulars regarding his age. So, there is no liability of the insurance company. All other averments made in the complaint have been denied and lastly the complaint has been prayed to be dismissed.

4.      Counsel for the complainant has tendered into evidence affidavit of complainant Ex.C-1 alongwith other documents Ex.C-2 to Ex.C-35 and closed the evidence.  

5.       On the other hand, counsel for the opposite party has tendered into evidence affidavit of Sh.Suryadeep Singh  Thakur Authorized Signatory Ex.OP-1 alongwith other documents Ex.OP-2 to Ex.OP-8 and closed the evidence.

6.       On perusing the file minutely, it has come to our notice that complainant paid premium for getting medical insurance under “Bhai Kanhaiya Sehat Sewa Scheme” and a policy card No.MD15-BGSSS-00264130-S was issued to him by opposite party and the same is Ex.C-2. On this card the age of the complainant is written as 73 years. On the backside of this card the terms is provided and it is clearly written that “Beneficiaries above 60 years must also produce an age proof. (Same age proof as shown at the time of enrollment to his/her society secretary). This document clearly proves that opposite party must have issued this policy after checking the age proof and on this card the age of the complainant/Beneficiary is written as 73 (Ex.C-28, which is document of Bhai Ghanaiya Sehat Sewa Scheme, on this the maximum age limit is prescribed as 75 years meaning thereby that a person till he reaches the age of 75 years can take the benefit under this scheme. Moreover, Ex.C23 is a dispatch list by MD India Health Insurance TPA Pvt.Ltd., which is the TPA of the opposite party. On this dispatch list at serial No.6 the name of complainant Joginder Singh and insurance card No.MD 15-BGSSS-00264130-S is clearly written and this document is dated 02.02.2017. On comparing Ex.C2 and Ex.C23 it is clearly made out that the disputed policy was issued in the year 2017 and on it the age of the insured is written as 73 years which is covered under the maximum age limit prescribed for the insurance.

7.        Even otherwise also if we consider the plea of the opposite parties that claim is denied according to terms and conditions of the policy and those terms were duly informed to the complainant. Now the question arises before us is that whether opposite party has produced on the file any document to prove that those terms and conditions were duly sent to complainant and if so, by which mode? No document is produced to prove the mode of delivery of the policy terms and conditions, neither any postal receipt, nor any courier service slips etc. It means that the terms and conditions, of which the opposite party is stating, have not seen the light of the day.

8.         From above all discussion, this Forum finds force in the contentions of counsel for complainant and holds the opposite party liable for deficiency in service. In view of it the complaint of the complainant is partly accepted and the opposite parties are directed to refund the entire amount of hospital bills as is claimed by complainant which is Rs.65,700/- alongwith compensation of  Rs.20,000/- for mental agony and harassment and Rs.5000/- as litigation expenses. Entire compliance to be made within 30 days on receipt of the copy of this order, otherwise,  the opposite party will be liable to pay interest @ 9% on the entire abovesaid amount from the date of order till  its actual payment.  

 9.        Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room.                   

ANNOUNCED:                  (Shri Raj Singh)                   (Rajita Sareen) February 12, 2019.                   Member                         Presiding Member MK