The present complaint filed U/s 12 of the Consumer Protection Act' 1986 (for short, 'the Act') by the complainant Dharminder Singh prays for the necessary directions to the opposite party to pay the claim of Rs.32,000/- and Rs.82,000/- and repudiation letter dated 30.01.2018 may be declared as illegal, null and void. The letter dated 3.3.2018 vide which his name was deleted from the policy coverage may also be declared as illegal, null and void. Opposite party be further directed to pay compensation amounting to Rs.40,000/- for harassment and deficiency in service alongwith Rs.10,000/- as litigation expenses, in the interest of justice.

2.          The case of the complainant in brief is that he got the policy having no.P/211212/012017/000956 for a period from 29.12.2016 to 28.12.2017 after paying the premium for himself and for his family members after paying the premium and as such he is consumer of the opposite party. Previously, he had taken the health policy from New India Assurance Co. in the year 2007 upto year 2016. During the subsistence of the policy with the New India Assurance the officials of the opposite party approached him and convinced him to port their health policy from New India Assurance Co. to Star Health and Allied Insurance Co. Ltd. At that time they also assured that this policy will give more benefits. On their assurance he got ported his health policy from New India Assurance Co. to Star Health and Allied Insurance Policy. During the subsistence of the said policy he fell ill and got a treatment from Fortis Hospital, Mohali and spent Rs.32,000/- on his treatment and Engiography was conducted. The pre authorization is denied by the opposite party and amount of Rs.32,000/- has been paid by him to the hospital authority from his own pocket. Secondly, he again remained admitted in Fortis Escort Hospital, Amritsar from 21, Aug, 2017 to 26, Aug, 2017 and the Engiography was conducted. At that time also pre authorization denied by the opposite party and the amount of Rs.82,000/- spent by him from his own pocket. His claim has been repudiated vide letter dated 30.1.2018 by the opposite party illegally and without any reasonable cause. He has further pleaded that the policy was again renewed by the opposite party from 29.12.2017 to 28.12.2018 after receiving the premium. To his utter surprise the opposite party sent one letter dated 3.3.2018 and illegally deleted his name from policy coverage. With the said letter the opposite party also sent cheque of Rs.5912/- dated 3.3.2018 and the said cheque has not been encashed by him. In the said letter, the opposite party deleted his name on the ground of the non disclosure of material fact. Actually, there is no concealment on his part and he was not suffering from any previously disease at the time of getting the policy. The letter dated 3.3.2018 is illegal, null and void. Thus, there is deficiency in service on the part of the opposite party. Hence this complaint.

3.       Upon notice, the opposite party filed their written reply through their counsel taking the preliminary objections that the complaint is false, malicious, incorrect and malafide and is nothing but an abuse of the process of the law; the complaint is neither maintainable in law nor on facts and the same is liable to be dismissed in limine; the complainant has not approached this Hon'ble Forum with clean hands; the present complaint is liable to be dismissed on the ground that the insurance being a contract of 'uberrimae fidae' (utmost good faith), the policy holder is duty bound to reveal all the relevant material facts to the insurer in order to avail the Insurance Policy. Thus, the concealment of the material facts by the complainant's about his previous medical illness gives the valid ground for rejection of the complaint; there is no deficiency in service on the part of the insurance company. The matter of fact is that the insured availed Family Health Optima Insurance Plan vide policy no.P/211212/01/2017/000956 for a period from 29.12.2016 to 28.12.2017 covering Dharminder Singh, Jaswinder Kaur, Mankaran Singh, Tejvir Singh for a sum insured of Rs.10,00,000/-. The insured was admitted at Fortis Hospital, Mohali on 16.8.2017 for the treatment of acute de-compensated heart failure/CAG/D.M. Type-2, HTN/OBNESITY and submitted pre-authorization request for cashless treatment and the same was denied vide letter dated 17.8.2017 stating that as per documents submitted ethiology and duration of complaints cannot be ascertained as no past treatment papers provided. The insured was admitted at Fortis Hospital again on 21.8.2017 for the treatment of CAD for which the cashless has been denied as from the documents submitted, the patient is a k/c/o dilated cardiompathy and CRF. Hence the claim is beyond the scope of the policy to be proceeded. Afterwards the insured has submitted claim towards the reimbursement of medical expenses. On merits, it was submitted that the policy has been issued but the complainant concealed the material facts at the time of getting policy and not disclosed the relevant facts regarding his health condition, due to which the name of the complainant has been deleted from the policy.  Actually, the complainant got the policy from opposite party by his own free wish and will. The complainant concealed the material facts at the time of getting policy and as such there is concealment on his part. It was wrong and incorrect that any amount of Rs.32,000/- has been spent on treatment and further the amount of Rs.82,.000/- spent by the complainant from his own pocket. There is no liability of the insurance company and the claim has rightly been repudiated vide letter dated 3.01.2018 on the ground that patient is a known case of diabetes, hypertension and dilated cardio myopathy for the last 10/12 years.  It was next submitted that the letter dated 30.01.2018 is legal and valid and the claim has rightly been repudiated. The letter dated 3.3.2018 is legal and valid and the name of the complainant has been deleted due to non-disclosure of material fact regarding his health at the time of getting the policy. There is material concealment on his part. Even the premium amount has been returned through cheque. All other averments made in the complaint have been vehemently denied and prayed for dismissal of the complaint. 

4.   Counsel for the complainant tendered into evidence affidavit of complainant Ex.C1, alongwith other documents Ex.C2 to Ex.C23 and closed the evidence. 

5.         Ld counsel for the opposite party has made a separate statement that as per new procedure they have filed affidavit and documents alongwith written reply and the same may be read as their evidence and they did not want to produce any new documents and closed the evidence of the opposite party.

6.     We have thoroughly examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective contestants. We find that the present dispute has arisen at the impugned ‘repudiation’ dated 30.01.2018 (Ex.C6) by the opposite party insurers of the insurance hospitalization-claim pertaining to the complainant’s Health Med-claim Policy for the assured amount   per the applicable policy on the grounds of pre-existing ailment(s) and non-disclosure of Obesity, HTN, CAD etc thus the related medical treatment expenses are not payable/reimbursable vide the Policy’s Exclusion Clauses.

7.         We find that the titled opposite party insurers (hereinafter for short ‘the OP insurers’) have duly admitted the repudiation through their written statement and accompanying affidavit on the grounds as mentioned out in the written reply/statement being in violation/contravention of the terms of the related Policy. Further, the Fortis Hospital’s requisition for cashless treatment was also arbitrarily declined by the OP insurers without assigning any acceptable logic. Further, the OP insurers are desired to settle the claim per the overall evidence available on cogent grounds and not on hearsay conjectures and presumptions etc. The record case-history with the hospital is nothing more than a ‘recital’ as narrated by the accompanying attendant and must be held in the light of some independent and cogent ‘proofs’ to impart it the legal authenticity and acceptability to settlement of the mediclaim. We find that the instant impugned repudiation has not been in resonance with the contracted terms of the Policy and the present complainant shall be entitled to statutory relief. Lastly, we set aside the impugned repudiation.  

8.        Finally, we partly allow the present complaint and thus ORDER the OP insurers to pay the impugned ‘insurance claim’ in full pertaining to the related Health Policy in question with full accrued benefits etc if any, along with Rs.10,000/- as compensation for the undue harassment inflicted besides Rs.5,000/- as cost of litigation; within 30 days of the receipt of the copy of these orders, otherwise the entire awarded amount shall attract interest @ 9 % PA form the date of the orders till actually paid.

9.         Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.

(Naveen Puri)                                                                                         President

ANNOUNCED:                                                 (Jagdeep Kaur)                 

August 06, 2018.                                       Member                                     

*MK*