1. Brief Facts : Complainant is a 55 years old grocery merchant. On 11.12.2020 he had purchased one Family Health Optima Insurance Plan from the OP bearing policy no. P/211232/01/2021/000224. The said policy was valid for one year from 11.12.2020 to 10.12.2021. Copy of the policy is Ex. C-1. 

On 14.12.2020, around 7.30 pm, the complainant was going towards his home on a motorcycle after closing his grocery shop and suddenly a bright light of the headlights of a vehicle coming from the front hit in his eyes, due to which he lost his balance from the said motorcycle and fell on the ground and got his wrist bones fractured. Copy of the DDR is Ex. C-2. Firstly, on the same evening, he was admitted into Pankaj Nursing Home, Mansa but on 15.12.2020 on the prescription of said nursing home he was taken to Fortis Hospital, Mohali where he remained under treatment upto 17.12.2020 and incurred an amount of Rs. 1,52,423/- on his treatment. During the said treatment, complainant demanded cashless treatment facility from the OP but the OP denied it vide letter dated 16.12.2020 (Ex. C-8) and the complainant bore all the expenses on his treatment out of his own pocket. Complainant has submitted that including the post treatment expenses on medicine, he has so far incurred an amount of Rs. 1,64,417/-. After that, the complainant applied for reimbursement of these expenses and submitted the claim form (Ex. OP-8) alongwith the required documents but the OP vide letter dated 08.03.2021 (Ex.C-17) repudiated the said claim and aggrieved with that the complainant has preferred the present complaint praying that OP be directed to pay the claim amount of Rs. 1,64,417/- alongwith interest @18% p.a. and Rs. 50,000/- as compensation and Rs. 30,000/- as Litigation expenses.

2. In reply, interalia to various other objections, the OP mainly has alleged that as per the company's medical team opinion, the insured patient had the above injury prior to the inception of the policy, hence the claim was not payable as per the Exclusion Clause-01 of the policy. Claim Repudiation Letter is Ex. OP-12.

3. Complainant has tendered into evidence his Self-Declaration and documents Ex.C-1 to C-19 and closed the evidence. OP tendered into evidence the Self-Declaration of Mr. Sumit Kumar Sharma, Senior Manager and some documents Ex. OP-1/1 to Ex. OP-1/14 and closed the evidence. Written Arguments submitted by the parties are also on the record.

4. We have heard the learned counsels of the parties and gone through the oral & documentary evidence placed on record, with their kind assistance.

5. OP has said that the company's medical team had opined that the complainant had the above said injury prior to the inception of the policy, hence the claim was not payable. First of all, it is pertinent to mention here that the OP has not produced on record the opinion report of that alleged Medical Team. It is not known who were the members of this team, what they referred to and how they formed their opinion. Prima facie it appears that OP does not have any opinion from any medical team and this is merely his stunt to dismiss a claim.

Ex. C-5 is the Discharge Summary of the Fortis Hospital, Mohali. Here, under the heading of Past History/Comorbidities, it is clearly mentioned Nothing Significant.

Ex. OP-5 is the Field Visit Report prepared by an empanelled doctor of the OP. He also under paragraph no. 9 of this report has answered the question of any previous history of similar complaints with a 'No'. 

So, when neither the treating hospital's discharge summary nor the OP's own Field Visit Officer's report is suggesting that the said fracture injury was pre existing then the grounds on which the OP is labeling the said fracture injury as a pre-existing injury are beyond understanding.

Apparently, there is no evidence on record to support the allegation of the OP that the complainant had this fracture injury prior to the inception of the said policy.

One should not oppose a true claim simply because one wants to oppose it. So, when a claim is found genuine on merits then disallowing it on artificial grounds is not in consonance with the spirit of consumer protection act. Therefore, the repudiation of the claim by the OP was not justifiable and OP is guilty of deficiency in service. 

6. Resultantly, in view of the above, the present complaint is partly allowed and OP is directed to pay to the complainant Rs. 1,64,417/- alongwith interest at the rate 6% per annum from the date of injury i.e. 14.12.2020 till the date of actual payment. Further, the OP is directed to deposit Rs. 10,000/- as cost in the Consumer Legal Aid Fund of this Commission for this forced litigation.

7. Applications pending, if any, stand disposed of in terms of the aforesaid judgement. 

8. The complaint could not be decided within the statutory limits, due to Covid restrictions, unavailability of quorum and pendency of other cases.

9. Copy of the order be sent to the parties concerned free of cost and file be consigned to the record room.