Order by:

Smt.Aparana Kundi, Member

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that complainants have been obtaining the Family Health Optima Insurance Plan from the Opposite Parties from the last two year continuously. Firstly the policy was purchased for the period 19.08.2020 to 18.08.2021. Thereafter the said policy was renewed vide policy no.P/211222/01/2022/004029 valid for the period 19.08.2021 to 18.08.2022 for Basic Floater Sum Insured of Rs.5 lakhs, besides Rs.1,25,000/- as bonus with recharge benefit of Rs.1,50,000/- extra and the policy was a cashless policy. During the policy period, complainant no.2 felt uneasiness due to chest pain and she got admitted in Dayanand Medical College & Hospital, Unit-Hero DMC Heart Institute, Ludhiana where she was diagnosed Type-2 Diabetes Mellitus, Hypertension, CAD-Acute Coronary Syndrome (Trop-T+VE) Mild LV Dysfunction and Cholelithiasis, where Coronary Angiography-Double Vessel Disease with PTCA with Stenting to Lad was done. Complainant no.2 remained in Dayanand Medical College and Hospital w.e.f 26.06.2022 to 03.07.2022. In this regard, Opposite Parties duly informed. Complainant no.1 asked the officials of the Opposite Parties for cashless treatment under the policy, but the officials of the Opposite Parties told that for want of some formalities, there may occur some delay in sending the case of the complainants for cashless treatment to their higher authority and the complainant may get the treatment from their own pocket and after discharge, the medical treatment claim amount will be reimbursed. So, in these circumstances, the complainants have to pay the hospitalization charges from their own pockets. The complainants spent Rs.1,81,422 on the treatment. After discharge from the hospital, the complainants lodged the claim with Opposite Parties alongwith all the relevant documents, however the Opposite Parties repudiated the claim of the complainant vide letter dated 12.09.2022 on false and frivolous ground that the insured has not submitted the treatment record relating to carcinoma cervix which amount to non submission of required documents. The act of the Opposite Parties is illegal, unwarranted and uncalled for. Hence this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to pay the amount of Rs.1,82,117.42/- to the complainant as per final bill alongwith future interest @ 12 % p.a. from the date of payment till its actual realization.

b)      To pay an amount of R.2,00,000/- as compensation on account of damages for physical as well as mental pain and agony suffered by the complainant.

c)       To pay an amount of Rs.50,000/- as cost of the complaint.

d)      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 Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present complaint is filed without any cause of the action. The present complaint pertains to insurance claim under Family Health Insurance Policy No. optima bearing P/211222/01/2022/004029 valid from 19.08.2021 to 18.08.2022 covering both the Complainants for a sum of Rs.5,00,000/-. However the aforesaid insurance policy was issued to the insured by the answering Opposite parties subject to the terms and conditions of the insurance policy. The said terms and conditions were handed over and supplied to the insured at the time of the contract. Moreover the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same were served to the complainant along with policy schedule. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Therefore it is submitted that in case if any liability would arise against the answering Opposite parties, then it would be subject to the terms and conditions of the insurance policy. Further alleged that the insured requested for a cashless authorization for the treatment ACS Unstable Angina on dated 26.06.2022 and she got admitted in Dayanand Medical College and Hospital, Ludhiana. On scrutiny of the cashless claim documents as provided by the insured, it was found and observed by the answering insurance company that the insurance company was not able to ascertain the duration of the disease based on the documents/details received by it. It requires further evaluation and thus the Opposite parties Insurance company requested the insured to submit certain documents and information for the processing of the claim further. Hence cashless claim was rejected vide letter dated 29.06.2022. Subsequently, insured has submitted documents in reimbursement, on scrutiny of documents, it is observed from internal verification that the patient has been treated for Carcinoma Cervix in Garg Hospital on dated 11.09.2020 and thus the related discharge summary, Pre and Post hospitalization treatment details with all investigation reports done during those period USG/CT/PT scan with post operative Histopathology reports and complete indoor case papers were requested to be submitted but the insured has not submitted the said record papers which amounts to non submission of required documents. In the absence of above documents/details, the company is not able to further process the claim. As per Condition No.2 of the above policy, the insured person has to submit all the required documents and details called for by the insurer. Hence, the claim was repudiated vide letter dated 12.09.2022. The instant complaint is neither maintainable in law nor on facts. No deficient services has been rendered by answering Opposite Parties. The complaint being pre-mature and false is not maintainable. The complainant has not come with clean hands. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       In order to prove his case, complainants tendered in evidence affidavit of complainant no.1, Ex.C1 alongwith copies of documents, Ex.C2 to Ex.C29.

4.       To rebut the evidence of the complainant, Opposite Parties tendered in evidence affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1, 2/A alongwith copies of documents Ex.OP1, 2/1 to Ex.OP1, 2/15.

5.       We have heard the counsel for the parties and also gone through the documents placed on record.

6.       Purchasing of mediclaim policy by the complainants for the period 19.08.2021 to 18.08.2022 is not disputed. During the policy period complainant no.2 suffered some problem and admitted in Dayanand Medical College and Hospital (Unit-Hero DMC Heart Institute) is also not disputed. The main dispute arises between the parties, when the claim lodged by complainants for the expense incurred on the treatment of complainant no.2 was repudiated by the Opposite Parties, vide letter dated 12.09.2022 on the ground that “the insured has not submitted the treatment records relating to carcinoma cervix which amounts to non submission of required documents.” But the repudiation made by the Opposite Parties on the aforesaid ground does not appear to be genuine. Because at the time of selling the policy and taking the premium they did not investigate the medical records of the patient but when claim is to be given to the policy holder then they started collecting the past medical records of the insured.

7.       Perusal of the record shows that firstly the policy was purchased by the complainants for the period from 19.08.2020 to 18.08.2021and at that time while purchasing the policy it was the duty of the insurance company to get them medically checked. If they got them medical checked at that time, then definitely the disease she was suffering from was diagnosed by the empanelled doctors of the Insurance Company. In the next year, complainant again renewed the policy from 19.08.2021 to 18.08.2022 and the Insurance Company again renewed it without verifying any fact regarding the previous ailment. But now when complainant no.2 got admitted in Dayanand Medical College and Hospital, Ludhiana w.e.f. 26.06.2022 to 03.07.2022 for the treatment of Coronary Angiography-Double Vessel Disease with PTCA with Stenting to Lad in the second year of policy and lodged the claim with Opposite Parties, they are demanding the treatment record relating to treatment taken by complainant no.1 for Carcinoma Cervix in Garg Hospital on 11.09.2020, for which neither she has lodged the claim nor taken the treatment of the same in the present policy period.

8.       Moreover, the plea taken by the Opposite Parties is that as the complainants did not submit the treatment record relating to carcinoma cervix, so as per terms and conditions of the policy claim of the complainants was repudiated. But the Opposite parties could not produce any evidence to prove that whether terms and conditions of the policy were ever supplied to the complainant i.e. insured, when and through which mode? No document placed on record which shows that policy has been given to the complainant. 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 parties, it is clear that Opposite parties have 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.

9.       Furthermore, as per the policy document Ex.C18, the life assured has duly mentioned his age as 11.09.1966 (meaning thereby which is more than 45 years), so it was the bounden duty of the Opposite Parties-Insurance Company to get the life assured medically examined before issuing the policy in his name who was above the 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.”

10.     Now come to the quantum of amount to be awarded to the complainant. Vide instant complaint, the complainant claimed the amount of Rs.1,82,117/-, but the Final Bill placed on record Ex.C5 shows that during the hospitalization complainants spent Rs.1,81,422/- on the treatment of complainant no.2. Hence, we allow the same.

11.     From the above discussion, we partly allow the complaint of the complainant and direct the Opposite Parties to pay an amount of Rs.1,81,117/- (Rupees One Lakh Eighty One Thousand One Hundred Seventeen only) to the complainants for the expenses incurred by them on the treatment. Opposite Parties are further directed to pay compository costs of Rs.12,000/-(Rupees Twelve Thousand only) as compensation and litigation expenses to the complainants. The compliance of this order be made by the Opposite Parties within 45 days from the date of receipt of copy of this order, failing which, they are burdened with additional amount of Rs.5000/-(Rupees Five Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced on Open Commission