Order by:
Sh.Amrinder Singh Sidhu, President
1. This Consumer Complaint has been received by transfer vide order dated 26.11.2021 of Hon’ble President, State Consumer Disputes Redressal Commission, Punjab at Chandigarh under section 48 of CPA Act, vide letter No.04/22/2021/4 C.P.A/38 dated 17.1.2022 from District Consumer Commission, Ludhiana to District Consumer Commission, Moga to decide the same in Camp Court at Ludhiana and said order was ordered to be affected from 14th March, 2022.
2. The complainants have filed the instant complaint under section 12 of the Consumer Protection Act, 1986 (now section 35 of Consumer Protection Act, 2019) on the allegations that Amar Singh (since deceased) had purchased policy from the Opposite Parties bearing No.103559913 under the plan known as ‘Care’ valid for the period 12.08.2015 to 11.08.2016 by paying the premium of Rs.9042/-. In this policy, Amar Singh and his wife Smt.Gurpreet Kaur both were covered for a sum assured of Rs.5 lakhs. Further alleges that during the policy period, Smt.Gurpreet Kaur suffered some problems and was admitted in Ivy Hospital, Khanna on 06.04.2016, where she was discharged on the same day. Again on 27.06.2016 said Gurpreet Kaur again felt uneasiness with breathing and she was brought to DMC Heart Institute, Ludhiana, and again on 01.07.2016 Gurpreet Kaur insured was admitted in Fortis Hospital Ludhiana where she remained for the period of one week and in the said hospital, the policy holder spent a sum of Rs.7,08,892/- which was paid by the policy holder from their own pocket. Thereafter, policy holder lodged a claim for the reimbursement of his claim, and completed all the formalities, but the Opposite Parties are not interested to finalize the claim of the complainant due to the reasons best known to them and 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 sum assured of Rs.5 lakhs as per the policy alongwith compensation of Rs.2 lakhs due to mental tension and harassment caused by the complainant and also to pay any other relief to which this District Consumer Commission may deem fit.
3. Opposite Parties appeared through counsel and contested the complaint by filing the written version taking preliminary objections therein inter alia that the complaint filed by the complainant is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead this District Consumer Commission. It is submitted that on receipt of the cashless facility request, the Opposite Parties sent query letters dated 1.07.2016, 2.7.2016, 6.7.2016, 22.07.2016, 29.08.2016, 22.11.2016, 15.12.2016, 2.2.2017 requesting the complainant to provide the requisite documents, but on raising complete documents, the complainant submitted the part documents despite sending numerous of letters to the complainant and not submitted the complete papers to the Opposite Parties and due to non receipt of the requisite documents, the Opposite Parties closed the claim of the complainant. On merits, the Opposite Parties took up almost same and similar pleas as taken up by them in the preliminary objections and the complaint may be dismissed with costs.
4. In order to prove their case, the complainants tendered into evidence his affidavit Ex.C-A alongwith copies of documents Ex.C1 to Ex.C49 and closed the evidence on behalf of the complainant.
5. On the other hand, to rebut the evidence of the complainant, Opposite Parties also tendered into evidence the affidavit Ex.RA alongwith copies of documents Ex.R1 to Ex.R9 and closed the evidence.
6. We have heard the ld.counsel for the parties, written submissions of the Parties and also gone through the documents placed on record.
7. Ld.counsel for the Complainant as well as Opposite Parties have mainly reiterated the facts as narrated in the complaint as well as in the written statement. We have perused the rival contentions of the parties. It is not the denial of the case that Amar Singh (since deceased) had purchased policy from the Opposite Parties bearing No.103559913 under the plan known as ‘Care’ valid for the period 12.08.2015 to 11.08.2016 by paying the premium of Rs.9042/-. In this policy, Amar Singh and his wife Smt.Gurpreet Kaur both were covered for a sum assured of Rs.5 lakhs. It is also not denied by the Opposite Parties that Gurpreet Kaur insured remained admitted in different hospitals and after discharge, the original complainant Amar Singh (since deceased) has lodged the claim for the reimbursement of the claim under the policy upto the extent of Rs.5 lakhs, but on the other hand, the contention of the Opposite Parties is that for want of submission of complete documents on the part of the complainants, the claim of the complainant could not be finalized and rather it was closed for want of submission of required documents. Perusal of the record i.e. Ex.C16, complete bill of the hospitalization shows that final bill of the treatment has been duly submitted with the Opposite Parties. Apart from it, the report of ECO test recommended by Dr.Vishav Mohan was also submitted to the Opposite Party, copy of which is placed on record as Ex.C38. Since, no treatment was taken in DMC Hospital, Ludhiana, as such, there is no question arise of any record of treatment of DMC Hospital. Further as admitted, Gurpreet kaur insured remained admitted in Ivy Hospital and all the relevant record of IVY hospital is also submitted, the copy of which is placed on record as Ex.C4 to Ex.C14 and Ex.C39. Perusal of the record shows that while purchasing the policy Ex.C2, Gurpreet Kaur present complainant also disclosed about her pre-existing diseases on the policy certificate Ex.R1. These documents are placed on record from last about 4 years. Moreover, these documents were also submitted to the Opposite Parties during the course of evidence produced by the complainant in their evidence about 4 years back. But we fail to understand, why the Opposite Parties are slept over by keeping the matter pending for no reasons and rather closed the claim case of the complainants. Perusal of the record further shows that original complainant Amar Singh has also died on 18.11.2017 during the pendancy of the present complaint by waiting his reimbursement of amount which he spent on the treatment of his wife Smt.Gurpreet Kaur.
8. In such a situation the repudiation made by Opposite Party-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.
9. In view of the above discussion, we hold that the Opposite Party-Insurance Company have wrongly and illegally rejected the claim of the complainant.
10. To support their contention, the Opposite Party has cited the rulings, but these rulings are not applicable to the facts of the present case and are not supportive to the instant case.
11. In view of the aforesaid facts and circumstances of the case, we partly allow the complaint of the Complainant and direct Opposite Parties-Insurance Company to pay the insured amount of Rs.5 lakh (Rupees five lakh only) to the complainants alongwith interest @ 8% per annum from the date of filing the present complaint i.e. 16.10.2017 till its actual realization. The compliance of this order be made by Opposite Parties-Insurance Company within 60 days from the date of receipt of copy of this order, failing which the complainant shall be at liberty to get the order enforced in accordance with law. Copies of the order be furnished to the parties free of cost by District Consumer Commission, Ludhiana and thereafter, the file be consigned to record room after compliance.
12. Reason for delay in deciding the complaint.
This Consumer Complaint was originally filed at District Consumer Disputes Redressal Forum (Now Commission) at Ludhiana and it keep pending over there until Hon’ble State Consumer Disputes Redressal Commission, Punjab vide letter No.04/22/2021/4 C.P.A/38 dated 17.1.2022 has transferred the instant Consumer Complaint alongwith Other Complaints to District Consumer Commission, Moga with directions to work on this file onward from 14th March, 2022 and accordingly District Consumer Commission, Moga has decided the present complaint at Camp Court, Ludhiana, as early as possible as it could decide the same
Announced in Open Commission at Camp Court, Ludhiana.
Dated: 27.06.2022.
