Complainant Amit Kumar through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has prayed that the opposite parties be directed to make payment of Rs.1,95,000/- to him which he has spent on his treatment alongwith traveling expenses and counsel fee and also to pay compensation amounting to Rs.1,00,000/- due to harassment being suffered by him for physical harassment and mental agony alongwith litigation expenses, in the interest of justice.

2.      The case of the complainant in brief is that he had obtained a policy  No.52148188 having client ID No.90917408, MC, 1631349 showing his date of birth as 9^th April 1982 from the opposite parties which was commenced from 28 March 2015 for one year and paid a sum of Rs.3500/- approximately to the opposite parties. At the time of taking the said policy, he was having robust health and was not suffering from any disease. He was hale and hearty and was enjoying his life. Unfortunately, on 21.10.2015, he suffered a severe chest pain and he accordingly contacted a BAMS Doctor who have asked him that it might have been Heart ailment and accordingly he has been got admitted in Grecian Superspecialty Hospital, Sector 69, Mohali on the same day in the evening time, who have thoroughly got checked up him and has found that he has suffered a heart attack and admitted him in emergency and started giving treatment. Accordingly on the next day, they have done PTCA and have inserted 3 stents in the two arteries of his heart as both these arteries were completely closed due to blockage uptil 90 to 100% since he was found suffering from Triple Vessel Disease. He remained admitted in the hospital from 21.10.2015 to 24.10.2015. On the next day, there was Sunday and on next day i.e. Monday he has made number of telephonic calls on the helpline number of the opposite party company regarding lodging of his complaint but all the callers asked him to visit the nearest office i.e. the opposite party no.2. He visited the office of the opposite party no.2 on 26.10.2015 with the original bills alongwith hand written application for lodging his claim where an entry in the register was also made but the dealing hand was not aware with regard to the lodging of the complaint of the claim as he has asked that he is new comer and he not aware about the same. He had paid the amount in cash to the said Hospital. At the time of admission in the hospital, he was not in condition to carry his Mediclaim Card with him since he was suffering from acute chest pain but his wife who had made telephonic call on Toll Free number of the Insurance Company who allured them to pay the expenses in the Hospital and afterward lodge the insurance claim. He even also asked him that he will have to ask for complete bed rest for 15 days and he will go to Mohali after 15 days but he said that he will not be worried about it. On 7.11.2015 he has gone to Mohali for medical checkup and requested the hospital authorities to give his Hospital Summary and they gave him discharge and other record. On 8.11.2015 his wife admitted in hospital and gave birth to a male child in the 8^th month on 9.11.2015 and condition of male child was also serious and as such admitted in Kalsi Hospital, Gurdaspur from 9.11.2015 to 15.11.2015 whereas his wife remained admitted in City Hospital Gurdaspur from 8.11.2015 to 14.11.2015. He has again visited the office of the opposite party no.2 on 16.11.2015 for lodging his claim but at that point of time the officials of the  opposite party no.2 has refused to lodge his complaint on the pretext that he is not possessing the original bills. His original policy documents have also been lost and he has also moved hand written application for issuance of duplicate policy documents but so far no action has been taken in this regard by the opposite parties which have shown the negligence on the part of the opposite parties. He has made the payment of Rs.1,91,000/- in the Hospital during the period of his admission in the hospital and he has also purchased medicine amounting to Rs.813/- on 24.10.2015 and he further spent Rs.300/- on 7.11.2015 and purchased the medicine amounting to Rs.2402/- on same day from Jai Ambika Medicos, Mohali. He has spent more than Rs.2,00,000/- on his treatment including the traveling expenses. He has further pleaded that even he has also taken reimbursement claims forms from the opposite party no.2 and got it filled from the concerned doctor who have done his entire process and he has also submitted the said Reimbursement Claims Forms duly attested by the Hospital Authorities alongwith the entire Hospital summary and bills duly attested by the Hospital Authorities, but the opposite party no.2 has flatly refused to entertain the same and even did not give the address of the opposite party no.1 despite several requests being made by him.  A legal notice dated 20.11.2015 issued to the opposite parties calling upon them to settle his Medical claim but all in vain. The opposite parties have issued a vague letter to him dated 8.12.2015 in which they have denied his claim. The act of the opposite parties whereby they have repudiated his claim is wholly vague, illegal, null and void against the natural justice and is the act of fraud and cheating with the innocent consumers. Hence this complaint.

3.       Upon notice, the opposite parties appeared through their counsel and filed the written reply. Certain preliminary objections have been taken by the opposite parties. On merits, it was submitted that the complainant proposed for Reliance Care for advantage plan policy from the opposite party having sum assured of Rs.2,10,000/- for a period of 12 years. The annual premium payable under the policy was Rs.3535.76/-. The said policy was issued on 28.03.2015 and the same was duly received by the complainant. It was wrong that the policy was issued for one year. It was further submitted that as per the record of the opposite parties the complainant lodged the claim on 28.11.2015. After getting the claim documents the same was examined by TPA (Third Party Administrator) appointed by the company for assessing the claim and after examination the claim documents, submitted by the complainant, it was found that the complainant took the treatment of angioplasty and 3 stents were inserted in the arteries of the heart of complainant. The treatment taken by the complainant falls under the waiting period of 3 years as per the clause 5.5 of the policy. Therefore the claim was found not payable and the complainant was intimated vide letter dated 08.12.2015 that his claim is not payable. It was next submitted that the claim of the complainant was rightly repudiated vide letter dated 08.12.2015 as per terms and conditions of the policy. All other averments made in the complaint have been denied and lastly the complaint has been prayed to be dismissed with costs.        

4. Complainant tendered into evidence his own affidavit Ex.C1 alongwith other documents Ex.C2 to Ex.C24 and closed the evidence. 
5. Counsel for the opposite parties tendered into evidence affidavit of Gurdeep Singh Branch Manager Ex.OP-1 alongwith other document Ex.OP-2 and closed the evidence.

6.      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’ (Ex.C22) of 08.12.2015 of the insurance-claim (Ex.C15 part A & Ex.C16 part B) pertaining to the complainant’s hospitalization-expenses for Rs.1,94,282/- under clause 5.5 of the Health Policy # 52148188. The opposite party insurers (hereinafter for short ‘OP insurers’) have duly admitted the repudiation through their written statement and the accompanying affidavit (Ex.OP1) under the applicable clause 5.5 of Policy on the grounds that the ailment in question falls within the ‘three’ year waiting period whereas the hospitalization has been from 21.10.2015 to 24.10.2015 with the Policy’s inception-date as 28.03.2015.

7.       We find that the complainant has successfully proved the contents of his present complaint pertaining to purchase of the health policy, absence of any pre-existing ailment, non-intimation & non-receipt of the terms of the related Policy, his subsequent hospitalization, medical treatment expenses incurred and filing of the related claim with its repudiation etc vide evidentiary documents exhibited here as: Ex.C1 to Ex.C24. The OP insurers, in rebuttal, have filed Ex.OP1 affidavit and the related Policy Ex.OP2 that clearly contains its applicable clause 5.5 barring reimbursement of all such claim(s) on the grounds that the contacted ailment has a clear waiting period of ‘three’ years from the inception of the policy whereas the instant claim stood filed within ‘one’ year of the same.

8.       Further, we find that the OP insurers have not proved the very ‘delivery’ or even communication of the related Policy along with its applicable ‘terms’ etc to the insured complainant that has been vital under the circumstances. Even, its very dispatch (of the Policy etc) has not been attempted to be proved, either. And as such the OP insurers are presently barred from availing any benefit of the ‘undisclosed’ terms of the related contact of insurance and that in turn also proves adoption of ‘unfair trade practice’ to turn down an otherwise a routine claim. To remove all ambiguity, it may be clarified here that an ‘insurance claim’ and for that matter any ‘issue’ can be neither legally ‘favored’ nor legally ‘ousted’ on the basis of mere ‘presumption’ how strong it might appear to be. We further find that the present policy in question was purchased through the services of the OP insures’ agents and thus it had been their duty to clearly disclose and make the insured understand all the applicable ‘terms’ of the Policy but no such agent’s declaration/ deposition has been put forth during the present proceedings.  

9.       Lastly, the OP insurers must realize that their administrative decisions in settling insurance claims are open to judicial reviews and thus need be taken with due application of mind and not arbitrarily and these should also be speaking in nature duly explaining the reason and logic of the decision as to how the same has been reached. All the facts in issue need be appreciated while awarding sanctity to the current applicable law. The duty of settlement of insurance claims shall not be, in routine, delegated to the TPA (Third Party Insurers) who shall simply provide assistance on technical issues pertaining to the same. The insurance-contract has been between insured and the insurers and the TPA shall not repudiate the same.

10.     In the matter pertaining to the present complaint and in the light of the all above, we set aside the OP’s impugned repudiation being arbitrary (contra to laws of natural justice) and amounting to ‘deficiency in service’ etc. Thus, we ORDER the OP insurers to settle and pay the impugned ‘insurance claim’ pertaining to the Policy in question with full accrued benefits etc if any, along with Rs.5,000/- as compensation for the undue harassment inflicted besides Rs.3,000/- as cost of litigation; within 30 days of the receipt of the copy of these orders, otherwise the entire awarded amount shall attract interest @ 9 % PA form the date of the orders till actually paid.

11.     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 13, 2017                                              Member.

*MK*