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 the complainant purchased an insurance policy bearing No.211222/01/2022/008121 for the period from 22.01.2022 to 21.01.2023 under Family Health Optima Insurance Plan from Opposite Parties. The said policy was port from SBI Insurance at the instance of Opposite Parties. The complainant operated from Sargun Hospital for the removal of uterus and ovaries and paid Rs.55,489/- for the treatment of the same. After discharge from the hospital, the complainant lodged the claim with Opposite Parties and submitted all the relevant documents with regard to the operation. However, the opposite parties repudiate the claim of the complainant on the ground that insured had not submitted the documents called for by them. But the complainant submitted the entire documents to the Opposite Parties as per their demand. Thereafter, the complainant approached the Opposite Parties and asked many times to refund the amount, but to no effect. 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.55,489/- with regard to the treatment taken by the complainant under the policy bearing no.P/211/222/01/2022/008121.

b)      To pay an amount of R.1,00,000/- as compensation on account of mental tension and harassment to the complainant.

c)       To pay an amount of Rs.50,000/- as litigation expenses.

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 husband of the complainant namely Sanjeev Kumar availed the Family Health Optima Insurance Plan Policy No.P/211222/01/2022/008121 for the period 22.01.2022 to 21.01.2023 and in this policy Sanjeev Kumar complainant their dependent child Jyotika were insured for an amount of Rs.3 lakh. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to complainant alongwith the policy schedule. It is clearly stated in the policy schedule that “The Insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form and No pre-existing disease was declared by the insured. Further alleged that policy in question has been ported from SBI GIC Limited Company to this Company. The claim in dispute is reported in the first year of the policy of this company and the claim was registered vide claim no.CIR/2023/211222/0495977. After submitted the claim form in the present case regarding the medical  reimbursement expenses towards the treatment of complainant taken by her at Sargun Hospital, Jalandhar from 12.07.2022 to 15.07.2022 diagnosis with Dub with Ascus H and lodge claim of Rs.45700/- only. On perusal of the submitted record medical team of the Opposite Parties demanded documents i.e. patient symptomatic since once year alongwith consultation taken, HPE Reports, Indoor case papers and OT Notes, but the said documents were not provided by complainant till today, so vide letter dated 25.08.2022 the claim was repudiated and duly informed to complainant. Further alleged that present complaint has been filed for claiming the amount of Rs.55,489/- as mentioned in the complaint, but as per the alleged claim form the amount was claimed only for Rs.45,700/- so, the complaint is liable to be dismissed on this ground alone being pre-mature and filed by violating the terms and conditions of the policy and even not disclose any pre existing disease at the time of taking policy in question.  The complainant has violated the terms and conditions of the policy. Hence, the Opposite Parties are not liable to pay any claim. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       Complainant also filed replication to the written reply of Opposite Parties, denying the objections raised by the Opposite Parties in their written reply.

4.       In order to prove her case, complainant tendered in evidence her affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C10.

5.       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.OPs/1 alongwith copies of documents Ex.OPs/2 to Ex.OPs/13.

6.       We have heard the counsel for the parties and also gone through the documents placed on record and also gone through the written arguments submitted on behalf of the Opposite Parties.  

7.       During the course of arguments, both the 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 reply  respectively. We have perused the rival contentions of the parties. The purchase of the policy by complainant, treatment taken by her during the policy period from Sargun Hospital, Jalandhar is not disputed. The main dispute arises between the parties, when the claim of the complainant was repudiated by the Opposite Parties, vide letter dated 25.08.2022 Ex.OPs/12 on the ground of non submission of required documents. But the repudiation of the claim of the complainant on the ground of non submission of documents does not appear to be genuine. It is unbelievable that without the documents of the complainant, how the Opposite Parties considered the claim of the complainant and made Bill Assessment Sheet attached with Ex.OPs/12 and how the Opposite Parties ascertained the said amount without going through the produced documents. Moreover, if the Opposite Parties ever raised the demand of requisite documents, what was the hitch for the insured/complainant not to supply the same and why a person will delay his/ her own claim by not submitting the requisite documents. In this way, Opposite Parties were not justified in repudiating the case of the complainant.

8.       As per the version of the Opposite Parties insurance policy of the complainant was ported from SBI General Insurance Company Ltd. to Star Health and Allied Insurance Co. Ltd. this company. If the complainant ported his insurance policy from the previous insurance company to the present insurance company of the Opposite Parties, then it is duty of the Opposite Parties to get the details with regard to the health of the complainant and treatment taken by her during the policy coverage from the previous insurance company. Further it is duty of the Opposite Parties to get medically examined the complainant at the time of issuing the policy. But at this stage the demand of the Opposite Parties with regarding to previous medical history of the insured is not genuine. Moreover, if the complainant was suffering from any disease 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.

9.       The other plea of the Opposite Parties is that complainant/insured has not submitted the required documents as demanded by them, that’s why claim of the complainant was rejected as per terms and conditions of the policy. But the Opposite Party 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? 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.

10.     Now come to the quantum of amount to be awarded to the complainant. Vide instant complaint, the complainant claimed the amount of Rs.55,489/- and to prove this amount, complainant has placed on record Ex.C5 and Ex.C8. Hence, we allow the same amount.

11.     From the above discussion, we partly allow the complaint of the complainant and direct the Opposite Parties to pay an amount of Rs.55,489/- (Rupees Fifty Five Thousand Four Hundred Eighty Nine only) to the complainant for the expenses incurred by her on her treatment. Opposite Parties are further directed to pay Rs.4,000/-(Rupees Four Thousand only) as compensation and Rs.3000/- (Rupees Three Thousand Only) as litigation costs to the complainant. The compliance of this order be made by the Opposite Party within 45 days from the date of receipt of copy of this order, failing which, the Opposite Parties 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