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 complainant has 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 he purchased cashless health insurance policy from the Opposite Parties valid for the period 26.11.2014 to 25.11.2015 for a sum of Rs.3 lakhs and at that time, the Opposite Parties also carried out all the necessary medical tests and got signed proposal form from the complainant and issued policy bearing No.000000000 2319882. During the policy period, the complainant remained admitted in Dayanand Medical College & Hospital, Ludhiana for the period 26.02.2015 to 02.03.2015 and after discharge from the hospital, the complainant lodged the claim for the reimbursement of his medical expenses with the Opposite Parties and also completed all the formalities, but the Opposite Parties repudiated the claim of the complainant vide letter dated 03.07.2015 on the ground of non retrieval of documents within prescribed period as specified by insurance company. On rejection of the claim, the complainant filed consumer complaint bearing No. 469 of 2015 which was decided on 06.06.2016 with the directions that the complainant will submit the documents or the certified copies thereof available with him within 15 days from the date of receipt of copy of order and in case, some more documents are required by the Opposite Parties, they will issue notice in writing to the complainant within 15 days after receipt of documents as per the directions. After receipt of that requisition (if any) from Opposite Parties, the complainant will submit further required documents within 30 days and in case, those required documents not available with the complainant, then the complainant will submit his sworn affidavit qua non possession of those documents. After completion of these formalities, Opposite Parties will adjudicate the claim of the complainant within 60 days therefrom. In case, after such reconsideration, complainant found entitled to any amount, then disbursal of the same will be made by Opposite Parties within 30 days from the date of final order to be passed by Opposite Parties. In case, this compliance not made within 30 days period, then complainant will be entitled to interest on adjudged amount @ 8% per annum w.e.f. today till recovery. The complainant duly complied with the order while completing formalities in time, but the Opposite Parties failed to comply with the order within the time frame then execution application u/s 27 of the C.P.Act was filed and said execution application was disposed off by the District Consumer Commission on 23.08.2017 while penalizing Opposite Parties with Rs.2000/- for non compliance of the order within time period. But the Opposite Parties repudatied the claim of the complainant on the ground of concealment of the pre existing disease and hence, 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 make the payment of medical expenses amounting to Rs.1,20,000/- alongwith interest @ 18% per annum till its realization. and also to pay of Rs.25,000 on account of compensation due to mental tension and harassment caused by the complainant, besides Rs.15,000/- as costs of litigation.
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 not denied that the complainant purchased health insurance policy bearing No.000000000 2319882 from the Opposite Parties valid for the period 26.11.2014 to 25.11.2015 for a sum of Rs.3 lakhs and it is also not disputed that the complainant remained admitted in Dayanand Medical College & Hospital, Ludhiana for the period 26.02.2015 to 02.03.2015 and after discharge from the hospital, the complainant lodged the claim for the reimbursement of his medical expenses with the Opposite Parties and also completed all the formalities, but the Opposite Parties repudiated the claim of the complainant vide letter dated 03.07.2015 on the ground of non retrieval of documents within prescribed period as specified by insurance company. Not only this, on rejection of the claim, the complainant filed consumer complaint bearing No. 469 of 2015 which was decided on 06.06.2016 and in compliance of the said order of this District Consumer Commission, he Opposite Parties reconsidered the claim of the complainant and opined that the complainant is for diabetes mellitus type 2, hepatitis C with chronic liver disease and portal hypertension or which medical management was done. But all these diseases were not disclosed by the complainant at the time inception of the policy and hence, as per the policy terms and conditions, a expense related to diabetes and related complications are excluded for first year of cover from the date of commencement of policy and hence this claim for hospitalization falls beyond purview of policy coverage and hence not payable. On merits, the Opposite Parties took up the same and similar pleas as taken up by them in the preliminary objections. Hence, Opposite Parties have rightly repudiated the claim of the complainant after application of mind and the complaint may be dismissed with costs.
4. In order to prove his case, the complainant has tendered into evidence his affidavit Ex.C-A alongwith copies of documents Ex.C1 to Ex.C8 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 of Sh.Jitendra Dhabhai Ex.RA alongwith copies of documents Ex.R1 to Ex.R14 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. During the course of arguments, ld.counsel for the Complainant has mainly reiterated the facts as narrated in the complaint and contended that the written version filed on behalf of Opposite Parties-Insurance Company 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 no such terms and conditions were ever conveyed or supplied to the complainant at the time of insurance of the cows and the alleged terms and conditions are not applicable on the case of complainant. Further contended that the complainant purchased cashless health insurance policy from the Opposite Parties valid for the period 26.11.2014 to 25.11.2015 for a sum of Rs.3 lakhs and at that time, the Opposite Parties also carried out all the necessary medical tests and got signed proposal form from the complainant and issued policy bearing No.000000000 2319882. During the policy period, the complainant remained admitted in Dayanand Medical College & Hospital, Ludhiana for the period 26.02.2015 to 02.03.2015 and after discharge from the hospital, the complainant lodged the claim for the reimbursement of his medical expenses with the Opposite Parties and also completed all the formalities, but the Opposite Parties repudiated the claim of the complainant vide letter dated 03.07.2015 on the ground of non retrieval of documents within prescribed period as specified by insurance company. On rejection of the claim, the complainant filed consumer complaint bearing No. 469 of 2015 which was decided on 06.06.2016 with the directions that the complainant will submit the documents or the certified copies thereof available with him within 15 days from the date of receipt of copy of order and in case, some more documents are required by the Opposite Parties, they will issue notice in writing to the complainant within 15 days after receipt of documents as per the directions. After receipt of that requisition (if any) from Opposite Parties, the complainant will submit further required documents within 30 days and in case, those required documents not available with the complainant, then the complainant will submit his sworn affidavit qua non possession of those documents. After completion of these formalities, Opposite Parties will adjudicate the claim of the complainant within 60 days therefrom. In case, after such reconsideration, complainant found entitled to any amount, then disbursal of the same will be made by Opposite Parties within 30 days from the date of final order to be passed by Opposite Parties. In case, this compliance not made within 30 days period, then complainant will be entitled to interest on adjudged amount @ 8% per annum w.e.f. today till recovery. The complainant duly complied with the order while completing formalities in time, but the Opposite Parties failed to comply with the order within the time frame then execution application u/s 27 of the C.P.Act was filed and said execution application was disposed off by the District Consumer Commission on 23.08.2017 while penalizing Opposite Parties with Rs.2000/- for non compliance of the order within time period. But the Opposite Parties repudatied the claim of the complainant on the ground of concealment of the pre existing disease and hence, there is deficiency in service on the part of the Opposite Parties.
8. 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 it is not denied that the complainant purchased health insurance policy bearing No.000000000 2319882 from the Opposite Parties valid for the period 26.11.2014 to 25.11.2015 for a sum of Rs.3 lakhs and it is also not disputed that the complainant remained admitted in Dayanand Medical College & Hospital, Ludhiana for the period 26.02.2015 to 02.03.2015 and after discharge from the hospital, the complainant lodged the claim for the reimbursement of his medical expenses with the Opposite Parties and also completed all the formalities, but the Opposite Parties repudiated the claim of the complainant vide letter dated 03.07.2015 on the ground of non retrieval of documents within prescribed period as specified by insurance company. Not only this, on rejection of the claim, the complainant filed consumer complaint bearing No. 469 of 2015 which was decided on 06.06.2016 and in compliance of the said order of this District Consumer Commission, he Opposite Parties reconsidered the claim of the complainant and opined that the complainant is for diabetes mellitus type 2, hepatitis C with chronic liver disease and portal hypertension or which medical management was done. But all these diseases were not disclosed by the complainant at the time inception of the policy and hence, as per the policy terms and conditions, a expense related to diabetes and related complications are excluded for first year of cover from the date of commencement of policy and hence this claim for hospitalization falls beyond purview of policy coverage and hence not payable.
9. Perusal of the contention of the ld.counsel for the complainant shows that the written version filed on behalf of 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 case titled as Shubh Shanti Services Limited v. Manjula S.Agarwalla and others (2005) 5 SCC 30, decided on 11.05.2005 has and observed to the following effect:
“..............As already stated, it has not been averred in the plaint nor sought to be proved that any resolution had been passed by the Board of Directors of the plaintiff company authorising Shri A.K. Shukla to sign, verify and institute the suit. It has also not been averred that the memorandum/articles of the plaintiff company give ny right to Shri A.K. Shukla to sign, verify and institute a suit on behalf of the plaintiff company. It, therefore, follows that the plaint has been instituted by Shri A.K. Shukla only on the authority of Sh. Raj K.Shukla, CEO of the plaintiff company. Such an authority is not recognized under law and, therefore, I held that the plaint has not been instituted by an authorised person. Issue No.1 is accordingly, decided against the plaintiff and in favour of the defendants.”
Further, 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.”
Recently Hon’ble State Consumer Disputes Redressal Commission, Punjab at 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.
10. The main 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.”
- We have heard the learned counsel for the parties at considerable length and have also examined the record of the case. The main contention of the Opposite Party is that since the complainant has concealed the pre existing disease, so his claim has rightly been repudiated by the Opposite Parties as per the terms and conditions of the policy. On the other hand, ld.counsel for the complainant has repelled the aforesaid contention of the complainant on the ground that at the time of purchasing said policy, due medical examination of the complainant was conducted and after confirming that the insurer is not suffering from any disease, the Opposite Party issued the policy in question in favour of the complainants.
- On this point, evidence has to be referred to by us on the record with regard to pre existing disease upon complainant. The onus to establish this fact is upon the Opposite Parties in this case. We have perused the copies of documents of the hospital produced by the Opposite Party, but there is neither any affidavit nor complete particulars of the investigator recorded in them. Even the certificate has not been placed on the record. There is no affidavit of doctor of the treating hospital to establish this fact on the record regarding previous disease of insured. He is a private doctor and not posted in any recognized health institute or government hospital. We are unable to rely upon the above referred investigation report appended with the Photostat copy of medical record of complainant. In the absence of any affidavit of investigator and the affidavit of treating doctor of the hospital, we do not place any reliance upon these documents, as pressed into service by the Opposite Parties in this case. Consequently, we are of this view that Opposite Parties have failed to discharge the onus solemnly laid upon it to prove this fact that the complainant was suffering from above pre-existing disease before taking the policy and he deliberately and fraudulently concealed this material fact from Opposite Parties. We, thus, conclude that there is no substantive evidence on the record to prove this fact that the complainant was suffering from any disease before he took the insurance policy and he willfully suppressed this fact fraudulently from the Opposite Parties. Moreover, as contended by the complainant that before the issuance of the policy in question, the Opposite Party has also conducted the medical examination of the complainant and after finding everything Okay, the Opposite Party issued the aforesaid policy. Moreover, if the complainant was suffering from any diseases prior to issuance of the policy, in question, the same must not have escaped the notice of the empanelled doctors of the Insurance Company. However, no such investigation record has been produced by the opposite parties. In case Bajaj Allianz Life Insurance Co. Ltd. & Ors. Vs. Raj Kumar III (2014) CPJ 221 (NC), it was held by the Hon’ble National Commission that “usually, the authorized doctor of the Insurance Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. It was held that the Insurance Company wrongly repudiated the claim of the complainant.”
13. It also needs to be mentioned that Section 19 of the General Insurance Business (Nationalization) Act, 1972 states that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community. The denial of medical expenses reimbursement is utterly arbitrary on the ground that disease in question was pre-existing disease. It is mere an excuse to escape liability and is not bona fide intention of the insurance company. Fairness and non-arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State and public behavior. Any policy in the realm of insurance company should be informed, fair and non-arbitrary. When the insurance policy has exclusions/conditions to repudiate the claim or limit the liability, the same must be specifically brought to the notice of the insured and are required to be got signed to show that such exclusions and conditions have been brought to his/her notice. Recently, our own Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in First Appeal No. 50 of 2019 titled as Bajaj Alliance General Vs. Arjan Singh decided on 04.03.2021 also held so.
14. The need for interpreting a contract always arises in two situations, (i) when a gap is needed to be filled in the contract and (ii) an ambiguity is needed to be resolved in the contract, then to find out correct intention of the contract, spirit behind it is required to be considered. Normally, the insurance policy is a contract of adhesion in which other party is left with hardly any bargaining power as compared to the insurer. Insurance contracts are standard form contracts and are drafted by the insurance company and as such, insurance company is at higher footing than the insured. The benefit of such clause, as exclusion clause, would go to the insured unless the same is explained in clear terms by the insurer. In such circumstances, the tribunal would be more oriented towards the interpretation which goes against the party who has inserted/drafted the disputed clause in the agreement/contract. The adjudicating authority is required to look into whether the intention of the party is to exclude or limit liability has been appropriately explained to the other party or not. This Commission while interpreting insurance agreement is to honour the intention of the parties, who have signed the agreement. Even if the agreement had general exclusion/condition for misrepresentation still fraudulent misrepresentation and non-disclosure may not be there. The innocent and negligent misrepresentations are to be ignored. On the other hand, the rulings (i) Satwant Kaur Sandhu Vs. New India Assurance Company Limited, (ii) Murti Devi Vs. Birla Sun Life Insurance and (iii) Mamohan nanda Vs. United India Insurance Company Limited, cited by the ld.counsel for the Opposite Parties are not applicable and relevant to the facts of the present case. The insurance companies are in haste to charge the premium, but when the time to pay the insurance claim comes, they generally take up one excuse or the other to avoid their liability. The reliance of counsel for the appellant on law laid down in “Life Insurance Corporation of India Vs. Priya Sharma & others” 2012(4)CPJ-646, “Life Insurance Corporation of India & others Vs. Harbans Kaur” 2009(3)CPC-677, and “Life Insurance Corporation of India & another Vs. Ashok Manocha” 2011(3)CPC-285, would have been applicable, had this fact been established that life assured suffered from pre-existing ailment of and he deliberately suppressed this fact fraudulently from the Opposite Parties, when he took the insurance policy. In view of our finding recorded above that Opposite Parties had failed to prove this fact that complainant was suffering from any pre-existing ailment and hence these authorities would not be attracted in this case. In this regard, on the same and similar facts and circumstances of the case, Hon’ble State Consumer Disputes Redressal Commission, in First Appeal No.62 of 2015 decided on 02.02.2017 in case India First Life Insurance Vs. Ms.Sudesh Rani also held so. On the other hand, the rulings cited by the ld.counsel for the Opposite Parties are not applicable to the facts of the present case and we distinguish the same.
15. The ground on which the claim of the complainant has been repudiated that the complainant was suffering from diabetes prior to the issue of the insurance cover in dispute. But diabetes is not a material disease; therefore, non disclosure thereof is not 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 diabetes and 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.
16. The law on the question of applicability of exclusion clause, suppression of the relevant factually position regarding any pre-existing disease from which the insured was suffering and the treatment thereof, if any, received from any hospital etc., has been the subject matter of number of decisions by the Hon’ble National Commission as also by the Hon’ble Supreme Court of India. In nutshell, the settled position is that it is the duty of the insured to disclose the above mentioned information to the insurance company at the time of buying the insurance policy and, if the same was not disclosed by the insured, the insurance company was well within their rights to repudiate the claim. However, the insured was under no obligation whatsoever to foresee, assess and apprehend the probable and future complications, which might or could suddenly arise from the earlier disorder. In this regard, the Hon’ble Supreme Court in their latest judgment in case Civil Appeal No.8386 of 2015 titled as “Manmohan Nanda Vs. United India Assurance Co. Ltd. & Anr.” decided on 06.12.2021, has held the object of buying a Medi-claim Policy is to seek indemnification in respect of a sudden illness or sickness which is not expected or imminent and that may occur overseas, “If the insured suffers a sudden sickness or ailment, which is not expressly excluded under the Policy, a duty is cast upon the insurer to indemnify the appellant for the expenses incurred there under”. In this regard, recently Honble State Consumer Disputes Redressal Commission, Punjab at Chandigarh in First Appeal No.482 of 2019, decided on 10.01.2022 in case titled as Bajaj Allianz General India Insurance Company Versus Kewal Singh Kainth also held so.
17. 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.
18. In view of the above discussion, we hold that the Opposite Party-Insurance Company have wrongly and illegally rejected the claim of the complainant.
19. 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.
20. The complainant in his complaint has claimed the reimbursement of his medical bill upto the extent of Rs.1,20,000/- and this amount spent by the complainant on treatment has nowhere denied by the Opposite Party by filing any cogent and convincing evidence and hence, the claim of the complainants to that amount is genuine and we allow the claim of the complainant accordingly.
21. In view of the aforesaid facts and circumstances of the case, we allow the complaint of the Complainant and direct Opposite Party-Insurance Company to pay the amount of Rs.1,20,000/- (Rupees One lakh twenty thousands only) to the complainant alongwith interest @ 8% per annum from the date of filing the present complaint i.e. 18.09.2017 till its actual realization. Opposite Party–Insurance Company is also directed to pay compensation to the complainant for causing mental tension and harassment to the tune of Rs.5,000/- (five thousands only). The compliance of this order be made by Opposite Party-Insurance Company within 45 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.
Announced in Open Commission at Camp Court, Ludhiana.
Dated:29.04.2022.
