Order by:
Sh.Amrinder Singh Sidhu, President
The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that the complainant took a Health Insurance Policy no. P/211222/01/2020/0005817 through agent of the respondent namely Sh.Charanjit Singh. The complainant took the above said policy in the year of 2018-19. Complainant vide invoice dated 28.03.2020 paid Rs.24142/- against receipt issued by the Opposite Party. The policy was commenced from 31.03.2020 to 30.03.2021. The complainant had to undergo his surgery of knee replacement in August 2020. The said surgery of knee replacement of the complainant was performed at Babe Ke Cancer Care Multi Specialty Hospital village Daudhar, Distt. Moga (Punjab). Complainant remained admitted in the above said Hospital for his knee replacement surgery from 07.08.2020 to 10.08.2020. Complete record regarding admission, operation and follow up treatment of the complainant was provided to the branch office of Opposite Party and the said required record/documents were deposited by daughter of complainant namely Manpreet Kaur. Even the complainant authorized Opposite Party to seek any information/record from above said Babe Ke Cancer Care Multi Specialty Hospital at village Daudhar. Further alleges that in the end of June 2020 or in the beginning of July 2020, complainant contacted Fortis Hospital Chandigarh Road, Ludhiana regarding his knee replacement surgery, but amount of surgery and follow up treatment cited by said Fortis Hospital Ludhiana was more. In this regard respondent insurance company wrote letter dated 02.07.2020 to the complainant vide which respondent stated "that complainant may not get approval for cashless treatment" and in the said letter Opposite Party wrote to the complainant that he may submit documents seeking reimbursement of the expenses incurred by him concerning the treatment of knee replacement surgery. The complainant is a poor man and he was not in a sound financial position to part with said amount cited by Fortis Hospital Ludhiana for his knee replacement surgery. Accordingly complainant had to choose a Hospital which may perform his knee replacement surgery in a lesser amount. Therefore knee replacement surgery of the complainant was got performed at Babe Ke Cancer Care Multi Specialty Hospital Daudhar (Moga) through Dr. Parveen Gupta. The complainant remained admitted in the said hospital from 07.08.2020 to 10.08.2020 and the said hospital charged Rs.2,00,326/- for the said surgery. Claim form regarding reimbursement of expenses of the above said surgery was submitted to the Opposite Party. Amount of Rs.200326/- is the detail of bills of said Babe Ke Hospital and Rs.26890/- is the amount of medicines etc. taken by the complainant after his knee replacement surgery and Rs. 800/- is the cost of Health Check Up. Further alleges that there is no doubt that knee replacement surgery of the complainant was got performed by him as mentioned above, but the respondent health insurance company has repudiated the said claim of the complainant vide letter dated 03.01.2021. Letter dated 03.01.2021 and the grounds on the basis of which claim of the complainant has been repudiated/denied are illegal, null and void and hold no legal validity. In fact in order to escape its liability respondents have wrongly denied the claim of the complainant merely on technicalities. The act and conduct and concocted excuses made in its letter dated 03.01.2021 has disheartened the complainant. In view of the above said facts and circumstances the Opposite Party is guilty of adopting unfair trade practices and is also guilty of deficiency in services. Hence this complaint. Vide instant complaint complainant has sought the following relief.
a) Opposite Party may be directed to make the payment of Rs.2,28,000/- incurred by the complainant for his knee replacement surgery.
b) To pay Rs.1,00,000/- as compensation and damages alongwith interest @ 1% per month.
c) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite Party appeared through counsel and contested the complaint by filing written reply and taking preliminary objections therein inter alia that the complaint being pre-mature is not maintainable. The complaint being false, self contradictory, frivolous, vague and vexatious is liable to be dismissed with compensatory costs. The complainant has not come with clean hands. He has not disclosed the entire true facts. The complainant has also suppressed the material facts from this Hon'ble Forum as well as from the answering opposite party. No deficient services have been rendered to the complainant as alleged in the complaint. The claim of the complainant has been duly entertained and was being investigated. The complainant is estopped to file the present complaint by his own act and conduct. The complainant himself has not been cooperating with the answering opposite party, as the complainant did not furnish the required information, record and documents etc. with the answering opposite party for the successful processing of the claim in question, inspite of repeated requests made by opposite and resultantly, the alleged claim file has been closed and the claim was rejected and repudiated, in the absence of required documents as above said, as per terms and conditions of the insurance policy, which were explained to the complainant at the time of proposing policy and the same were served to the complainant along with policy schedule. And it has been clearly mentioned in the policy schedule that "The Insurance under the policy is subject to Conditions, Clauses, Warranties, Exclusions, etc.". Moreover, it is submitted that the Insurance policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the said policy. The complainant has accepted the policy agreeing and fully aware of such terms and conditions and had executed the proposal form. On merits, it is submitted that as a matter of fact, the insured has preferred claims in the 3rd year of the insurance policy. The earlier claim for the cashless treatment was denied and closed vide letter dated 02.07.2020 as on scrutiny of cashless documents, it was noted that the exact duration of the claim could not be ascertained. Hence, the Cashless treatment was denied calling the insured for reimbursement of medical expenses. Subsequently, the insured had submitted claim documents for reimbursement of medical expenses of Rs.2,15,216/- towards the treatment of Osteoarthritis Bilateral Knee for a hospitalization period of 07.08.2020 to 10.08.2020 at Babe Ke Multi-speciality Hospital. On scrutiny of documents, it has been observed that certain record was not submitted by the insured and thus it was demanded vide letter dated 08.10.2020 from insured by the opposite party. The following documents were required:-
i) Letter from treating doctor stating that exact duration of OA knee and when was hepatitis B first diagnosed.
ii) As per submitted prescription papers in Fortis states pain increased since last 6 months; Kindly submit previous consultation papers done for OA knee.
ii) Complete set of Indoor case papers with Dr notes, OT notes and anesthesia notes.
iii) Submit X-Ray knee since onset of symptoms along with post operative X Ray.
iv) Submit medical records of previous hospitalization if any.
The above said information was to be submitted by the complainant within 15 days from the receipt of above said letter. But inspite of receiving the letter, the complainant had failed to furnish the required important details and documents for processing the alleged claim. The answering Insurance Company as a good service provider had sent two reminders dated 23.10.2020 and 07.11.2020 to the complainant for advising him to send the above said documents but to no avail. Then vide letter dated 22.11.2020, the claim of the complainant was rejected (not being repudiated) for want of required documents presuming that the insured was not interested in the claim. In reply, the insured has only submitted the indoor case papers and Treating doctor Certificate and has not furnished the below mentioned documents:-
i) As per submitted prescription papers in Fortis states pain increased since last 6 months; Kindly submit previous consultation papers done for OA knee.
ii) Submit X-Ray knee since onset of symptoms along with post operative XRay.
iii) Submit medical records of previous hospitalization if any.
The required documents are not provided despite queried. In the absence of above documents/details, the claim was repudiated vide letter dated 03.01.2021 clearly informing the insured that he had not furnished the required documents and details. In the absence of the same the Insurance company was not able to process the claim and hence it was repudiated as per Condition no 5(2) of the Insurance policy. Thus from the above said circumstances, it is crystal clear that the complainant himself has been careless and not interested in the processing and settlement of the alleged claim and did not furnish the details etc to the company. The answering Insurance company is not at any default for the repudiation of the claim and no deficient services have been rendered as alleged by the complainant. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint is made.
3. Complainant has filed replication to the written reply of Opposite Party, vide which, it is submitted that the opposite party is in knowledge about the knee surgery of the claimant and all the relevant and required documents were submitted to them but now in order to wriggle out its liability, opposite party is leveling false allegations. Terms and conditions of the insurance policy and Law & Equity in no way require the repudiation of the claim in dispute on the ground on which it has been repudiated. Further submitted that opposite party is giving himself technical objections which cannot be considered to do justice between the parties to the claim petition. Further submitted that however correct that opposite party assured the complainant for reimbursement of medical expenses after his knee operation. Medical record was submitted to the opposite party and all the record of Babe Ke Multispecialty Hospital Daudhar was also submitted to the opposite party. Alleged scrutiny of the claim of the claimant is illegal and is a concoction. Relevant record which was available with the complainant was submitted to the opposite party. Record in possession of the opposite party provided by the claimant makes it fully clear that complainant has undergone his knee surgery and he has paid the amount in question to the hospital for performance of his knee surgery. Documents required by the opposite party were duly provided to them. Some X-rays and OPD slips were misplaced by the claimant and it was informed to the opposite party by the complainant to this effect. But the X-ray and documents as mentioned in para no. 4 of the written reply cannot be a valid reason for repudiation of the claim of the claimant. Rather technical objections have been made ground to repudiate the claim of the claimant whereas it is well within the knowledge of the opposite party that such objections are of no importance. There is no doubt about the fact that complainant has undergone his knee replacement surgery at Babe Ke Multispecialty Hospital Daudhar. Alleged reminders allegedly dated 23.10.2020 and 07.11.2020 are nothing else but is an illegal shield to justify repudiation of the claim in dispute. Letter dated 22.11.2020 vide which claim in dispute was rejected, is illegal and is without any legal basis. Remaining objections raised by the Opposite Party in the written reply are denied.
4. In order to prove his case, the complainant has tendered in evidence affidavit of complainant Ex.C1 along with copies of documents Ex.C2 to Ex.C12.
5. To rebut the evidence of complainant, ld. counsel for the opposite party has tendered in evidence affidavit of Sh.P.C.Tripathy, Zonal Manager Ex.OP1 along with copies of documents Ex.OP2 to Ex.OP14.
6. During the course of arguments both the parties ld. counsel for the complainant as well as ld. counsel for the opposite party have mainly reiterated the same facts as narrated in the complaint as well as written reply respectively. Ld. counsel for the complainant has contended that complainant took a Health Insurance Policy no. P/211222/01/2020/0005817 and complainant paid the premium of Rs.24142/-. The policy was commenced from 31.03.2020 to 30.03.2021. The complainant had to undergo his surgery of knee replacement in August 2020. The said surgery of knee replacement of the complainant was performed at Babe Ke Cancer Care Multi Specialty Hospital village Daudhar, Distt. Moga (Punjab). Complainant remained admitted in the above said Hospital for his knee replacement surgery from 07.08.2020 to 10.08.2020 and the said hospital charged Rs.2,00,326/- for the said surgery, despite the aforesaid amount complainant also spent an Rs 26890/- for medicines and Rs. 800/- is the cost of Health Check Up. Complete record regarding admission, operation and follow up treatment of the complainant was provided to the branch office of Opposite Party. Even the complainant authorized Opposite Party to seek any information/record from above said Babe Ke Cancer Care Multi Specialty Hospital at village Daudhar. But the Opposite Party has repudiated the claim of the complainant vide letter dated 03.01.2021. Ld. counsel for the opposite party has repelled the contentions of ld. counsel for the complainant on the ground that the insured had submitted claim documents for reimbursement of medical expenses of Rs.2,15,216/- towards the treatment of Osteoarthritis Bilateral Knee for a hospitalization period of 07.08.2020 to 10.08.2020 at Babe Ke Multi-speciality Hospital. On scrutiny of documents, it has been observed that certain record was not submitted by the insured and thus it was demanded vide letter dated 08.10.2020 from insured by the opposite party. The following documents were required:-
i) Letter from treating doctor stating that exact duration of OA knee and when was hepatitis B first diagnosed.
ii) As per submitted prescription papers in Fortis states pain increased since last 6 months; Kindly submit previous consultation papers done for OA knee.
ii) Complete set of Indoor case papers with Dr notes, OT notes and anesthesia notes.
iii) Submit X-Ray knee since onset of symptoms along with post operative X Ray.
iv) Submit medical records of previous hospitalization if any.
The above said information was to be submitted by the complainant within 15 days from the receipt of above said letter. But inspite of receiving the letter, the complainant had failed to furnish the required important details and documents for processing the alleged claim. The answering Insurance Company as a good service provider had sent two reminders dated 23.10.2020 and 07.11.2020 to the complainant for advising him to send the above said documents but to no avail. Then vide letter dated 22.11.2020, the claim of the complainant was rejected (not being repudiated) for want of required documents presuming that the insured was not interested in the claim. In reply, the insured has only submitted the indoor case papers and treating doctor Certificate and has not furnished the below mentioned documents:-
i) As per submitted prescription papers in Fortis states pain increased since last 6 months; kindly submit previous consultation papers done for OA knee.
ii) Submit X-Ray knee since onset of symptoms along with post operative XRay.
iii) Submit medical records of previous hospitalization if any.
The required documents are not provided despite queried. In the absence of above documents/details, the claim was repudiated vide letter dated 03.01.2021.
7. We have perused the rival contentions of ld. counsel for the both the parties and have also gone through the record. The plea of ld. counsel for the Opposite Party is that as the complainant has not submitted the required documents demanded by them previous consultation papers done for OA knee, knee X-Ray since onset of symptoms along with post operative X-Ray, medical records of previous hospitalization if any. On this, ld. counsel for the complainant contended that all the record of Babe Ke Multispeciality Hospital Daudhar was also submitted to the Opposite Party. Relevant record which was available with the complainant was submitted to the Opposite Party. However some X-rays and OPD slips were misplaced by the complainant. The perusal of the record shows that the complainant has placed on record document Ex.C4, vide which, the complainant authorized the Opposite Party/Insurance Company to seek any medical information/records from Babe-Ke Cancer Care Multi Speciality Hospital, Daudhar in connection with the above ailment and the treatment given. So, if the Insurance company has any query they can get it from the treating hospital and treating doctor. Moreover, complainant also placed on record certificate issued by Dr.Parveen Gupta, in which, he certify that “Patient Jagroop Singh admitted on 07.08.2020 for B/L OA Knee four which B/L TKR was done on 07.08.2020. All investigations were done on 02.08.2020 during investigation patient was found hepatitis-B positive. OA Knee from last Seven months.” From the above it is clear that complainant suffered OA Knee from last seven months. The treating doctor of the complainant already submitted that complainant was suffered OA knee from the last seven months. The demands of aforesaid documents demanded by the Opposite Parties are merely a ground to repudiate the claim of the complainant. It is not very uncommon that the insurance companies would issue repeated advertisement in the newspaper and through electronic media, highlighting many financial and other benefits, inviting general public to go for insurance policies. However, whenever any claim, including most genuine claim is put by the insured for disbursement of the due amount most of the insurance companies would start finding fault with the insured on one pretext or the other, raising even the technical and totally unwarranted objections. That is how, this kind of approach adopted by the insurance companies, gives rise to wholly unwarranted and avoidable litigation.
8. Furthermore, as per the document produced by the Opposite Parties themselves, at the time of obtaining the policy, the complainant was having the age of 56 years (meaning thereby which is more than 45 years, so it was the bounden duty of the Opposite Parties-Insurance Company to get the complainant medically examined before issuing the policy in his name who was above 45 years of age. In support of his contention Ld.counsel for the complainant placed reliance upon I.R.D.A.I Rules and Instructions with regard to thorough medical examination if the insured is more than 45 years which is reproduced as under:-
“As per instructions issued by the Insurance Regulatory and Development Authority of India (IRDAI), it was bounded duty of the insurer to put insured to thorough medical examination in case Mediclaim insured was more than 45 years and if insurance company failed to do so then insurance company has no right to decline the insurance claim on account of non disclosure of the facts of pre existing disease when the policy was taken. The above observations is supported by law cited in SBI General Insurance Company Limited Vs. Balwinder Singh Jolly” 2016(4) CLT 372 of the Hon’ble State Commission, Chandigarh.”
However, the opposite party has not placed on record any evidence that before issuing the policy they ever got medically examined the insured. So the abovesaid law squarely covers the case of the complainant that it was the duty of the insurer to get medically examined while issuing the policy.
9. In such a situation the repudiation made by Opposite Parties-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 seems 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.
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. In view of the aforesaid facts and circumstances of the complaint, we partly allow the complaint of the complainant and direct the Opposite Party-Insurance Company to pay an amount of Rs.2,28,000/- (Rupees Two Lac Twenty Eight Thousands only) to the complainant alongwith interest @ 8% per annum from the date of filing the present complaint i.e. 26.03.2021 till its actual realization. The compliance of this order be made by the Opposite Parties 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 through the indulgence of this District Consumer Commission. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Commission.
