Charanjit Singh, President

1        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 11, 12 and 13 against the opposite party on the allegations that in the year 2017, the officials/ agents of the opposite parties have approached to son of the complainant namely Ajay Pal Singh and told about the insurance policies introduced by the opposite parties and further persuaded him to buy a health insurance policy for his parents. The son of the complainant got attracted/ impressed by the offers as dictated by the agent/officials of the opposite parties and got ready to purchase the health insurance policy for the company for his parents i.e. the complainant Tarsem Singh and Narinder Kaur wife of complainant vide proposal dated 15.10.2018. As such the opposite parties issued the floater health insurance policy No. 13177817 and the period of insurance was 16.10.2018 to 15.10.2019. The details of the insured persons is as follows (i) Tarsem Singh (ii) Narinder Kaur. The total amount of premium i.e. Rs. 29,743/- was paid at the time of purchasing of the policy. The basic floater sum insured is Rs. 5,00,000/- which can be used by any of the insured person in case of any health related problem.  In the month of March 2019, the complainant has suffered with drug induced thrombocytopenia at his residence, as such, he has taken treatment and got admitted in K.D. Hospital, Circular Road near Medical College, Amritsar and remained admitted in the hospital from 23.3.2019 up to 28.3.2019, where his treatment with regard to above said disease was undergone by the concerned doctors of the hospital and the complainant has incurred the total expenditure of Rs. 49,050/- on his treatment and the same were paid by the complainant to the lab,  medicos and hospital. The complainant has immediately given intimation with regard to the treatment and expenditure incurred by him to the opposite parties, as such the insurance company is under obligation to reimburse Rs. 49,050/- i.e. medical expenses to the complainant as per the policy. Thereafter, as per the directions of the concerned officials, the complainant has submitted all the relevant demanded documents to the opposite party. Further the complainant has also fulfilled all other documentary formalities as directed by the officials of the company. The officials of the opposite parties have assured the complainant that his claim will be settled very soon. After waiting for some time, the complainant has visited the office of the opposite party several times to know about the settlement of claim but of no avail. Later on, the son of the complainant has received a correspondence dated 4.6.2019 and the complainant got astonished to see that the opposite party has repudiated the claim by citing the observation which is reproduced here under:-

We have reviewed the claim filed by you pertaining to health insurance policy (13177817) and thereby inform you that the claim is not payable as per policy terms and conditions listed below.

1. All treatment record for ayurvedic and homeopathic treatment, 2. Medical condition for which insured taking ayurvedic treatment
2. Deficiency not relied.

with the above observations, the opposite parties have repudiated the claim of the complainant. The above said act on the part of the opposite party is an arbitrary, unbusinesslike act and gross deficiencies in service as the complainant has provided each and every document and information to the opposite party as demanding by its officials and have never withheld any document alongwith him. The alleged terms and conditions are neither part of the insurance policy nor have been dictated to the complainant or policy holder. It is a grave deficiency in services on the part of the insurance company to decline the claim on the basis of unattached, unexplained and inappropriate terms and conditions. The opposite parties have never demanded such kind of documents from the complainant related with the alleged Ayurvedic and Homeopathic treatment.  The company has taken irrelevant and baseless plea with regard to alleged Ayurvedic and Homeopathic treatment as the complainant has never taken the Ayurvedic and Homeopathic treatment as alleged by the opposite parties. As such, the opposite parties have repudiated the claim on the basis of said false submission in order to decline the genuine claim of the complainant. The complainant prayed that the opposite parties may be directed to reimburse the expenses of Rs.  49,050/- as inured by the complainant on the treatment of the insured   and also prayed Rs. 20,000/- as compensation and Rs. 10,000/- as litigation expenses and interest at the rate of 12% P.A. from the date of filing of the complaint.  Alongwith the complaint, the complainant has placed on record affidavit of complainant Ex. C-1, affidavit of Ajaypal Singh Ex. C-2, self attested copy of Policy certificate Ex. C-3, self attested copy of Premium acknowledgment Ex. C-4, self attested copy of correspondence Ex. C-5, Self attested copy of Policy Card Ex. C-6, Self attested copy of discharge card Ex. C-7, Self attested copy of bill of hospital Ex. C-8, Self attested copy of medicine bill Ex. C-9, Self attested copy of medicine bill Ex. C-10, Self attested copy of medicine bill Ex. C-11, Self attested copy of medicine bill Ex. C-12, Self attested copy of medicine bill Ex. C-13, Self attested copy of message Ex. C-14, Self attested copy of message Ex. C-15. Self attested copy of repudiation letter dated 4.6.2019 Ex. C-16, Self attested copy of Adhar Card Ex. C-17.

2        Notice of this complaint was sent to the opposite parties and opposite parties appeared through counsel and filed written version by interalia pleadings that the present complaint filed by the complainant is false and is devoid of any merits and same is liable to be dismissed. In this case, the complainant approached the opposite parties with the reimbursement claim with respect to his hospitalization from 23^rd March, 2019 till 28^th March 2019 at K.D. Hospital, Amritsar. The said claim form was received by the opposite parties on 24^th March 2019. After the receipt of the reimbursement request, the opposite parties sent a query letter dated 26.4.2019 and asked for the following documents:

          Treating Doctor’s certificate for etiology of present ailment

          Drug induced thrombocytopenia

But the complainant did not reply to the above mentioned query letter, thereafter, the opposite parties sent a reminder vide letter dated 6.5.2019 to the complainant. A reply was received from the complainant in which the complainant has provided treating doctor’s certificate in which it was mentioned that “Drug induced thrombocytopenia is due to patient taking ayurvedic and homeopathic treatment”. The said query reply was received by the opposite parties on 11.5.2019. Thereafter, relating to above reply from the complainant, another query was raised vide letter dated 12.5.2019 to the complainant and asked for the following documents .

Kindly provide all treatment record for ayurvedic and homeopathic treatment, also provide the name of Medical Condition for which insured taking Ayurvedic treatment    

And another query letter dated 14.5.2019 was sent to the complainant and asked for the following documents:-

1.      Investigation Report supporting Diagnosis

Provide investigation Report supporting alcoholic liver disease/ Ultrasound

2        Documents Required

          Kindly provide all treatment record for ayurvedic and homeopathic treatment, also provide the name of Medical condition for which Insured taking Ayurvedic treatment

As no reply was received from the complainant, therefore, a reminder letter dated 24^th May, 2019 was sent to the complainant but no reply was given by the complainant. On the perusal of documents received and information received during the investigation, the opposite parties asked the complainant to provide the documents as it is clearly mentioned in treating doctor’s certificate submitted by the complainant alongwith query reply that complainant is taking Ayurvedic and Homeopathic medicine from outside. However, the complainant failed to provide the reply to the above mentioned query. Therefore, the opposite parties rejected the claim of the complainant vide Claim Denial Letter dated 4.6.2019 with the following observations:-

1.All treatment record for Ayurvedic and Homeopathic treatment,  2.Medical condition for which insured taking Ayurvedic treatment

  Deficiency not Relied.

These facts have been concealed by the complainant, therefore, the present complaint is not maintainable and is liable to be dismissed on this short ground. As per clause 6- Claims procedure and Management which states as under:-

          Clause 4      Claims Procedure and Management

Clause 4.3 The Policyholder and Insured’s member duty at the time of claim

b        It is agreed and understood that as a condition precedent for a claim to be considered under this policy:

          vi)     We shall be provided with complete documentation and information which we have requested to establish our liability for the claim, its circumstances and its quantum.

But in the present case, the complainant neither submitted the documents nor given the reply, therefore, claim was rejected. In this case, the complainant had denied receiving the policy terms and conditions, but the terms and conditions of policy were duly supplied to the complainant. This fact is quite clear from the document Ex. C-5 which has been filed by the complainant himself, in which it has been specifically mentioned that the complete policy kit was supplied to the complainant including

1. Policy certificate,
2. Premium acknowledgement,  
3. Key Policy information,
4. Policy Terms and Conditions,
5. Claim Process

From this document it is quite clear that a false plea has been taken by the complainant with regard to non supply of terms and conditions. Moreover, the complainant never complained regarding non supplying of terms and conditions, now the complainant has denied regarding receiving the terms and conditions, just to take undue benefit. The complainant has concealed the true and material facts from this commission. The complainant is estopped by his own act and conduct from filing the present complaint. The complainant has filed the present complaint without any cause of action against the opposite parties. The complainant has no locus standi to file the present complaint. The opposite parties have denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite parties have placed on record affidavit of Tejinder Singh Manager Legal Ex. OP1,2/1, self attested copy of authority letter Ex. OP1,2/2, self attested copy of policy Ex. OP1,2/3, Self attested copy of terms and conditions Ex. OP1,2/4, self attested copy of query letter dated  26.4.2019 Ex. OP1,2/5, Self attested copy of query letter dated 12.5.2019 Ex. OP1,2/6, self attested copy of query letter dated 14.5.2019. Ex. OP1,2/7, Self attested copy of reminder letter dated 6.5.2019 Ex. OP1,2/8, Self Attested copy of Dr. Kuldeep Singh Arora dated 1.5.2019 Ex. OP1,2/9,self attested copy of reminder letter dated 24.5.2019 Ex. OP1,2/10, self attested copy of claim denial letter dated 4.6.2019 Ex. OP1,2/11, Self attested copy of claim form Ex. OP1,2/12, Self attested copy of discharge summary Ex. OP1,2/13, Self attested coy of Proposal form Ex. OP1,2/14.  

3        We have heard the Ld. counsel for parties and have also carefully gone through the documents on the file.

4        In the present case, insurance is not disputed. It is also not disputed that the complainant took the treatment from K.D. Hospital, Amritsar. It is also not disputed that the opposite parties received the claim form from the complainant. The opposite parties have denied the claim of the complainant vide repudiation letter Ex. C-16 which is reproduced as follows:-

“We have reviewed the claim filed by you pertaining to health insurance policy (13177817) and thereby inform you that the claim is not payable as per policy terms and conditions listed below.

1.All treatment record for ayurvedic and homeopathic treatment, 2. Medical condition for which insured taking ayurvedic treatment

- Deficiency not relied.

The opposite parties have denied the claim of the complainant on the ground that all the treatment record for ayurvedic and homeopathic treatment and Medical condition for which insured taking ayurvedic treatment has been produced on record. Further if at all the patient is taking some ayurvedic and homeopathic treatment the opposite parties have failed to show any clause of term and condition of the policy that a person cannot take the treatment under ayurvedic and homeopathic. Not even a single document on record has been placed on record which establishes that patient having drug induced thrombocytopenia due to ayurvedic and homeopathic treatment. Further the opposite parties have failed to prove on record and show any terms and condition of the policy according to which ayurvedic and homeopathic treatment is not covered under the policy. The opposite parties have placed on record certificate of one doctor Kuldeep Singh Arora M.B.B.S  K.D. Hospital, Amritsar who in his certificate mentioned that Tarsem Singh admitted in our hospital on 23.3.2019 with diagnosis of Drug induced thrombocytopenia. The etiology of drug induced thrombocytopenia is due to patient taking some ayurvedic and homeopathic medicine from outside. Patient did not give us any record of this treatment.  From the perusal of discharge summary of KD Hospital Ex. OP1,2/5 it was finally diagnosed that patient is suffering from drug induced thrombocytopenia but not even a single world uttered about drug induced thrombocytopenia due to patient taking ayurvedic and homeopathic treatment and subsequently Dr. Kuldeep Singh Arora of K.D. Hospital issuing a certificate Ex. OP1,2/9 that the thrombocytopenia is due to patient taking some ayurvedic and homeopathic medicine from outside. This commission is failed to understand that in discharge summary there is nothing about ayurvedic and homeopathic treatment how the doctor is issuing the said certificate and on what basis the doctor came to the conclusion that patient is under ayurvedic and homeopathic treatment. So this certificate cannot be relied upon. Moreover, the Doctor Kuldeep Singh Arora having a M.B.B.S. qualification and he is not specialized in any field.  Further the opposite parties have not placed on record affidavit of said doctor Kuldeep Singh Arora to prove on record that the alleged certificate Ex. OPs 1,2/9 has been issued by the said doctor. In this regard, a reference can be made to the judgment of the Hon'ble National Commission in Revision Petition No. 200 of 2007 "Mr. Satinder Singh versus National Insurance Co. Ltd." decided on 24.1.2011 wherein it has been observed that "recording of history of patient in the above stated manner does not become a substantiate piece of evidence and convincing evidence be brought on record that complainant was aware of preexisting disease." Further, it has been observed by the Hon'ble National Commission in the III 2014 CPJ 340 (NC) "New India Assurance Company Limited through its duly Constituted Attorney, Manager versus Rakesh Kumar" that people can live months/years without knowing the disease and it is diagnosed accidentally after routine checkup and on that ground repudiation is not justified. Further it has been observed by the Hon'ble National Commission in its judgment IV (2008) CPJ 89 (NC) "Life Insurance Corporation of India & Ors. Versus Kunari Devi" that history recorded in the hospital bed head ticket is not to be taken as evidence as Doctor recording history not examined and suppression of disease not proved. In the present case, except the medical record of the present ailment, Ops have not placed on the record any independent evidence that the insured had the knowledge or that he had been taking the treatment of the disease, in question, before purchasing this policy and in the absence of any specific evidence on the record how the disease, if any, to which the insured does not have the knowledge can be termed as pre-existing disease. Therefore, we are of the opinion that repudiation of the claim is not justified. It is usual with the insurance company to show all types of green pastures 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 DharmendraGoel 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.UshaYadav& 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.

Furthermore the correspondence made by the opposite parties Ex. OP1,2/6, 7,8,9 is not justified and served to the complainant because it does not show the mode by which the same was served upon the complainant.

5        In light of the above discussion, the complaint succeeds and the same is hereby allowed with costs in favour of the complainant and against the Opposite Parties. The opposite Parties are directed to make the payment of Rs. 49,050/- to the complainant. The complainant has been harassed by the opposite parties unnecessarily for a long time. The complainant is also entitled to Rs15,000/- as compensation on account of harassment and mental agony and Rs 7,500-/ as litigation expenses. Opposite Parties are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission and due to COVID-19. Copies of the order be furnished to the parties as per rules. File is ordered to be consigned to the record room. 

Announced in Open Commission.

11.01.2023