Order by:

Sh.Amrinder Singh Sidhu, President

1.       The  complainant  has filed the instant complaint under section 12 of the Consumer Protection Act, 1986 (now section 35 of Consumer Protection Act, 2019) on the allegations that she purchased policy bearing No.P/211222/01/2019/00399 from the Opposite Parties-Insurance Company for a sum of Rs.5 lakhs against the paid up premium of Rs.24,142/- valid for the period w.e.f. 01.06.2018 to 31.05.2019. Further alleges that during the currency of the aforesaid policy period, the complainant remained admitted following hospitals.

Further alleges, that after discharge from the hospitals, the complainant submitted the claim with the Opposite Parties-Insurance Company for the reimbursement of her claim and also completed all the formalities, but the Opposite Parties-Insurance Company repudiated the claim of the complainant vide letter dated 08.02.2019  without explaining any reason. In view of this, there is deficiency in service on the part of the Opposite Parties-Insurance Company and they have illegally repudiated the genuine and legal claim of the complainant taking the false and frivolous ground and the Complainant is suffering in the hands of the Opposite Parties and hence, the Complainant also remained under mental tension and harassment. The complainant approached the Opposite Parties time and again for making the insurance claim, but  the Opposite Parties  flatly refused to reimburse the total claim of the complainant, as such, there is deficiency in service on the part of the Opposite Parties. Vide instant complaint, the complainant has sought the following reliefs.

a)       The Opposite Parties may be directed to reimburse the claim amounting to Rs.3,60,717/- alongwith interest  @ 12 % per annum from the date of payment till its actual realization.

b)      The amount of Rs.50,000/- be allowed to be paid by the opposite parties on account of compensation due to mental tension and harassment caused by the complainant.

c)       And any other relief to which this Hon’ble Consumer Commission, Moga may deem fit be granted in the interest of justice and equity.       

2.       Opposite Parties-Insurance Company  appeared through counsel and contested the complaint by filing  the written version taking preliminary objections therein inter alia that the complaint filed by the complainant is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead this District Consumer Commission. Further   the intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure  under the Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court. The complainant has not approached this District Consumer Commission with clean hands, rather she has wilfully concealed the material and patent facts from this District Consumer Commission which ipso-facto disentitles the complainant to seek any relief against the Opposite Parties. In fact, the complainant has availed Family  Health Optima Insurance Plan Policy bearing No.P/211222/01/2019/00399 from the Opposite Parties-Insurance Company for the period w.e.f01.06.2018 to 31.05.2019 and the terms and conditions of the policy were explained to the complainant and served to the complainant alongwith the policy schedule and the said insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. The claim is reported in the Ist yeara of the policy vide claim No.CLI/2019/211222/0503542. As per the Pre Authorisation request, the complainant was provisionally diagnosed with age (Acute gastroenteritis) and raised pre authorisation request for cashless treatment and the same  was denied stating that as per the records, patient is known case of Coronary Artery Disease in the year 2013 and it shows Esophageal Varices (Esophageal Varices are enlarged veins in the oesophagus and they are often due to obstructed blood flow  through the portal vein, which carries blood from the intestine, pancreas and spleen to the liver, which is prior to the policy inception and was not disclosed hence th4e claim was rejected.  On merits, Opposite Parties-Insurance Company took up the same and similar pleas as taken up by them in the preliminary objections. It is further submitted that the complainant has submitted the claim only for Rs.3,09,726/-.   Hence, Opposite Parties-Insurance Company has rightly repudiated the claim of the complainant after application of mind  vide repudiation letter dated 08.02.2019 on the  ground of non disclosure of material facts and disease at the time of policy inception and the complaint may be dismissed with costs.  

3.       In order to  prove  her  case, the complainant has tendered into  evidence her affidavit Ex.CW1/A alongwith copies of documents Ex.C1 to Ex.C7 and closed the evidence on behalf of the complainant.

4.       On the other hand,  to rebut the evidence of the complainant,  Opposite Party No.1 also tendered into evidence the affidavit of Sh.P.C.Tripathy, Zonal Manager Ex.Ops21 alongwith copies of documents Ex.Ops1 to Ex.Ops20 and closed the evidence.

5.       We have heard the ld.counsel for the parties, written submissions filed by the Opposite Parties-Insurance Company and  also  gone through the documents placed  on record.

6.       Ld.counsel for the Complainant has  mainly reiterated the facts as narrated in the complaint and contended that at the time of issuance of the said policy  to the complainant, no term and conditions were ever explained or supplied by Opposite Parties to the complainant. Further contended that the complainant purchased policy bearing No.P/211222/01/2019/00399 from the Opposite Parties-Insurance Company for a sum of Rs.5 lakhs against the paid up premium of Rs.24,142/- valid for the period w.e.f. 01.06.2018 to 31.05.2019. Further alleges that during the currency of the aforesaid policy period, the complainant remained admitted following hospitals.

Further contended that after discharge from the hospitals, the complainant submitted the claim with the Opposite Parties-Insurance Company for the reimbursement of her claim and also completed all the formalities, but the Opposite Parties-Insurance Company repudiated the claim of the complainant vide letter dated 08.02.2019  without explaining any reason. In view of this, there is deficiency in service on the part of the Opposite Parties-Insurance Company and they have illegally repudiated the genuine and legal claim of the complainant taking the false and frivolous ground and the Complainant is suffering in the hands of the Opposite Parties and hence, the Complainant also remained under mental tension and harassment. The complainant approached the Opposite Parties time and again for making the insurance claim, but  the Opposite Parties  flatly refused to reimburse the total claim of the complainant and hence the ground for the repudiation of the claim of the complainant is quite illegal and false one.

7.       On the other hand, ld.counsel for the Opposite Party has repelled the aforesaid contention of the ld.counsel for the complainant on the ground that the complaint filed by the complainant is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead this District Consumer Commission.  First of all,  the intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure  under the Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court and this Hon’ble District Consumer Commission has no jurisdiction to try and decide the present complaint. It is further contended that  the complainant has not approached this District Consumer Commission with clean hands, rather he has wilfully concealed the material and patent facts from this District Consumer Commission which ipso-facto disentitles the complainant to seek any relief against the Opposite Parties. Further contended that in fact, the complainant has availed Family  Health Optima Insurance Plan Policy bearing No.P/211222/01/2019/00399 from the Opposite Parties-Insurance Company for the period w.e.f01.06.2018 to 31.05.2019 and the terms and conditions of the policy were explained to the complainant and served to the complainant alongwith the policy schedule and the said insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. The claim is reported in the Ist year of the policy vide claim No.CLI/2019/211222/0503542. As per the Pre Authorisation request, the complainant was provisionally diagnosed with age (Acute gastroenteritis) and raised pre authorisation request for cashless treatment and the same  was denied stating that as per the records, patient is known case of Coronary Artery Disease in the year 2013 and it shows Esophageal Varices (Esophageal Varices are enlarged veins in the oesophagus and they are often due to obstructed blood flow  through the portal vein, which carries blood from the intestine, pancreas and spleen to the liver, which is prior to the policy inception and was not disclosed hence the claim was rejected.  On merits, Opposite Parties-Insurance Company took up the same and similar pleas as taken up by them in the preliminary objections. It is further submitted that the complainant has submitted the claim only for Rs.3,09,726/- and the Opposite Parties-Insurance Company has rightly repudiated the claim of the complainant after application of mind  vide repudiation letter dated 08.02.2019 on the  ground of non disclosure of material facts and disease at the time of policy inception and the complaint deserves dismissal.

8.       Perusal of the contention of the ld.counsel for the Opposite Parties-Insurance Company that the complainant has violated the terms and conditions of the policy in question and as per the terms and conditions of the policy, the complainant is not entitled to the claim as claimed.  But the Opposite Party could not produce  any evidence to prove that terms and conditions of the policy were ever supplied to  the complainant 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. Reliance in this connection can be had on Modern Insulators Ltd.Vs. Oriental Insurance Company Limited (2000) 2 SCC 734, wherein it is held that “In view of the above settled position of law, we are of the opinion that the view expressed by the National Commission is not correct. As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclosed to the appellant, the respondent can not claim the benefit of the said exclusion clause. Therefore, the finding of the National Commission is untenable in law.”  Our own Hon’ble State Commission, Punjab, Chandigarh in First Appeal No.871 of 2014 decided on 03.02.2017 in case titled as Veena Mahajan (Widow) and others Vs. Aegon Religare Life Insurance Company Limited in para No.5 has held that

“Counsel for the appellant argued that copy of insurance policy was not supplied to the appellant and hence, the exclusion clause in the contract of the insurance policy is not binding upon him. He further argued that no proof of sending of insurance policy was ever produced by the respondent despite specific contention raised by the complainant that the insurance policy was never received by him. He argued that though there is an averment of the OP that the policy in question was delivered through Blue Dart Courier to the complainant. In order to prove their contention, no affidavit of any employee of Blue Dart was produced who would have made a statement to have the effect that the policy was delivered to the complainant nor any acknowledgement slip for having received the article by the complainant through courier company was produced by the insurance company. He argued that since no policy document was received by the insured and argued that the terms and conditions as alleged to be part of the insurance policy were not binding upon the insured. He argued that policy was issued in the name of deceased Sh.Vijinder Pal Mahajan with his wife Mrs.Veena Mahajan as beneficiary and the same was never refused by the OP and the proper premium for insurance was paid by late complainant. He argued that as per the specific allegations made in the complaint in para No.4, no rebuttal to that contention was specifically there in their written reply in para No.2 and para No.4 in the reply filed by OP in the District Forum. He argued that Hon'ble National Consumer Disputes Redressal Commission, New Delhi in case of "Ashok Sharma Vs. National Insurance Co. Limited", in Revision Petition No. 2708 of 2013 held in para No.8 to the point of non-delivery of terms and conditions of the policy. He also cited Hon'ble Supreme Court's decision given in the matter of "United India Insurance Co. Limited Vs. M.K.J.Corporation" in Appeal (civil) 6075-6076 of 1995 (1996) 6 SCC 428 wherein the Apex court held that a fundamental principle of Insurance Law makes it that utmost good faith must be observed by the contracting parties. Good faith forbids either party from concealing what he privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary. Just as the insured has a duty to disclose, "similarly, it is the duty of the insurers and their agents to disclose all material facts within their knowledge, since obligation of good faith applies to them equally with the assured and further argued that since the terms and conditions were not supplied even on repeated requests the same cannot be relied upon by the opposite party in order to report to repudiate the genuine claim of the wife of the deceased policy holder.”

9.  Further, ld.counsel for the Opposite Parties-Insurance Company has contended that  the intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure  under the Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court and this  District Consumer Commission has no jurisdiction to try and decide the present complaint. So far as the objection that complicated question of the fact is involved as such the Insured be relegated to go before Civil Court, is concerned, The Consumer Protection Act, 1986 (as amended upto date) (hereinafter referred to as the Act) was enacted with object to provide for better protection of the interests of the consumers and for that purpose, to make provision for the establishment of consumer council and other authorities for settlement of consumer disputes and other matter connected therewith. Section 13 (4) confers same powers upon the authorities under the Act, which are vested in Civil Court under Code of Civil Procedure, 1908, while trying a suit in respect of (i) The summoning and enforcing the attendance of any defendant or witness and examining the witness on oath, (ii) the discovery and production of any document or other material object producible as evidence, (iii) the reception of evidence on affidavits, (iv) the requisitioning of the report of the concerned analysis or test the appropriate laboratory or from other relevant source, (v) issuing of any commission for the examination of any witness and (vi) any other matter which may be prescribed. The authorities are conferred jurisdiction to decide the issue of “unfair trade practice” which has been defined under Section 2 (r) of the Act, 1986. This definition is similar to the definition of “fraud” as given under Section 17 of Indian Contract Act, 1872. From these provisions it is clear that this Commission can hold a full trail as held by civil court or adopt summary procedure for decision of any complaint. Under the Act, although the jurisdiction of the authorities is limited to consumer complaint, but while deciding such complaint no limit has been fixed for adjudicating of the dispute. Three Judges Bench of Supreme Court in Dr. J.J. Merchant Vs. Shrinath Chaturvedi, (2002) 6 SCC 635, (paragraph-7) held that the object and purpose of the Act is to render simple, inexpensive and speedy remedy to the consumer with complaint against defective goods and deficient services and the benevolent piece of legislation, intended to protect a large body of consumer from exploitation. Consumer Forum is an alternate Forum, established under the Act, to discharge the function of Civil Court. Under the Act, the consumers are provided with an alternative efficacious and speedy remedy. As such the Consumer Forum is an alternative forum established under the Act to discharge the functions of Civil Court. Therefore, delay in disposal of the complaint would not be a ground for rejecting the complaint and directing the complainant to approach the Civil Court. The argument that the complicated question of fact cannot be decided by the Forum, has been specifically rejected (In paragraph-12). Similar view has been taken in Amar Jwala Paper Mills Vs. State Bank of India, (1998) 8 SCC 387, CCI Chambers Coop. Hsg. Society Ltd. Development Credit Bank Ltd. (2003) 7 SCC 233. Recently, Hon’ble National Commission, New Delhi in CC No. 101 of 2009 titled as mahalaxmi Dyes & Chemicals Ltd. Vs. New India Assurance Company Limited decided on 07.09.2021 also held so.  Hence, this District Consumer Commission is  not convinced with the aforesaid contention of the ld.counsel for the Opposite Parties.
10. We have heard the learned counsel for the parties at considerable length and have also examined the record of the case. The first contention is that the complainant has no locus standi to file the complaint, because  the complainant has availed Family  Health Optima Insurance Plan Policy bearing No.P/211222/01/2019/00399 from the Opposite Parties-Insurance Company for the period w.e.f01.06.2018 to 31.05.2019 and the terms and conditions of the policy were explained to the complainant and served to the complainant alongwith the policy schedule and the said insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. The claim is reported in the Ist year of the policy vide claim No.CLI/2019/211222/0503542. As per the Pre Authorisation request, the complainant was provisionally diagnosed with age (Acute gastroenteritis) and raised pre authorisation request for cashless treatment and the same  was denied stating that as per the records, patient is known case of Coronary Artery Disease in the year 2013 and it shows Esophageal Varices (Esophageal Varices are enlarged veins in the oesophagus and they are often due to obstructed blood flow  through the portal vein, which carries blood from the intestine, pancreas and spleen to the liver, which is prior to the policy inception and was not disclosed hence the claim was rejected. Since the policy holder had fraudulently suppressed her past medical history from the proposal form, hence the company was well within its rights to repudiate the death claim preferred by the complainant. The evidence on the record has been perused by this District Consumer Commission. Ex.C7 is the document issued to complainant on the side of Opposite Parties-Insurance Company regarding repudiation of claim.  Ex.C1 is the policy document which makes it clear that Opposite Parties issued the policy to complainant. It is, thus, plain from perusal of above referred documents and pleadings of the parties and submissions of counsel for the parties, that Opposite Parties-Insurance Company charged premium amount from the complainant and thereafter issued the policy accordingly. The Opposite Parties are now  estopped from denying the fact of availing the services of Opposite Parties-Insurance Company to complainant. This fact should have been taken care of by the Opposite Parties before receiving the premium and issuing the policy. Once the contract of insurance has been concluded between the parties, they are bound by the same. We find no force in this submission, as advanced before us by counsel for the Opposite Parties-Insurance Company. Once Opposite Parties-Insurance Company has received the premium from the complainant and issued the policy, then they cannot back out from the same on such type of pleas.
11. The next point for adjudication vehemently contended before us by Opposite Parties is that deceased life assured Ram Raj was suffering from pre-existing disease of kidney and she suppressed this material fact from Opposite Parties, when she took the insurance policy. On this point, evidence has to be referred to by us on the record. The onus to establish this fact is upon the Opposite Parties in this case.  We have perused the copies of  medical record placed by Opposite Party No.1 of the treating hospitals, but there is neither any affidavit nor  complete particulars of the investigator recorded in them. Even the original certificate has not been placed on the record. There is no affidavit of doctor of the treating hospital to establish this fact on the record regarding previous disease of insured. He is a private doctor and not posted in any recognized health institute or government hospital. We are unable to rely upon the above referred investigation report appended with the Photostat copy of  medical record of complainant. In the absence of any affidavit of investigator and the affidavit of treating doctor of the hospital, we do not place any reliance upon these documents, as pressed into service by the Opposite Parties in this case. Consequently, we are of this view that Opposite Parties have failed to discharge the onus solemnly laid upon it to prove this fact that complainant was suffering from above pre-existing disease before taking the policy and he deliberately and fraudulently concealed this material fact from Opposite Parties. We, thus, conclude that there is no substantive evidence on the record to prove this fact that complainant was suffering from any kidney disease before she took the insurance policy and she willfully suppressed this fact fraudulently from the Opposite Parties. Moreover, if the complainant was suffering from any diseases 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.”

12.     Furthermore,  as per the proposal form dated 01.06.2018, at the time of obtaining the policy, the complainant has duly mentioned her age as 58 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 her 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 Parties-Insurance Company 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 and once the policy was issued the insurer cannot take the plea of pre-existing disease of the insured.

13.     It also needs to be mentioned that Section 19 of the General Insurance Business (Nationalization) Act, 1972 states that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community. The denial of medical expenses reimbursement is utterly arbitrary on the ground that disease in question was pre-existing disease. It is mere an excuse to escape liability and is not bona fide intention of the insurance company. Fairness and non-arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State and public behavior. Any policy in the realm of insurance company should be informed, fair and non-arbitrary. When the insurance policy has exclusions/conditions to repudiate the claim or limit the liability, the same must be specifically brought to the notice of the insured and are required to be got signed to show that such exclusions and conditions have been brought to his/her notice.  Recently, our own Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in  First Appeal No. 50 of 2019 titled as Bajaj Alliance General Vs. Arjan Singh decided on 04.03.2021 also held so.

14.     The need for interpreting a contract always arises in two situations, (i) when a gap is needed to be filled in the contract and (ii) an ambiguity is needed to be resolved in the contract, then to find out correct intention of the contract, spirit behind it is required to be considered. Normally, the insurance policy is a contract of adhesion in which other party is left with hardly any bargaining power as compared to the insurer. Insurance contracts are standard form contracts and are drafted by the insurance company and as such, insurance company is at higher footing than the insured. The benefit of such clause, as exclusion clause, would go to the insured unless the same is explained in clear terms by the insurer. In such circumstances, the tribunal would be more oriented towards the interpretation which goes against the party who has inserted/drafted the disputed clause in the agreement/contract. The adjudicating authority is required to look into whether the intention of the party is to exclude or limit liability has been appropriately explained to the other party or not. This Commission while interpreting insurance agreement is to honour the intention of the parties, who have signed the agreement. Even if the agreement had general exclusion/condition for misrepresentation still fraudulent misrepresentation and non-disclosure may not be there. The innocent and negligent misrepresentations are to be ignored.  On the other hand, the rulings (i) Satwant Kaur Sandhu Vs. New India Assurance Company Limited, (ii) Murti Devi Vs. Birla Sun Life Insurance and (iii) Mamohan nanda Vs. United India Insurance Company Limited,   cited by the ld.counsel for the Opposite Parties  are not applicable and relevant  to the facts of the present case.  The insurance companies are in haste to charge the premium, but when the time to pay the insurance claim comes, they generally take up one excuse or the other to avoid their liability. The reliance of counsel for the appellant on law laid down in “Life Insurance Corporation of India Vs. Priya Sharma & others” 2012(4)CPJ-646, “Life Insurance Corporation of India & others Vs. Harbans Kaur” 2009(3)CPC-677, and “Life Insurance Corporation of India & another Vs. Ashok Manocha” 2011(3)CPC-285, would have been applicable, had this fact been established that life assured suffered from pre-existing ailment of kidney and he deliberately suppressed this fact fraudulently from the Opposite Parties, when he took the insurance policy. In view of our finding recorded above that Opposite Parties had failed to prove this fact that complainant was suffering from any pre-existing ailment of kidney and hence these authorities would not be attracted in this case. In this regard, on the same and similar facts and circumstances of the case, Hon’ble State Consumer Disputes Redressal Commission, in First Appeal No.62 of 2015  decided on 02.02.2017 in case India First Life Insurance Vs. Ms.Sudesh Rani also held so.   

15. 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 seams 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.

16.     In view of the above discussion, we hold that the Opposite Party-Insurance Company have  wrongly and illegally rejected the claim of the complainant.

17.     Now come to the quantum of compensation.  The complainant has placed on record the expenses borne by her in the treating hospitals Ex.C3 to Ex.C6 amounting to Rs.3,60,717/- and we hold that the complainant is entitled to the reimbursement of this amount.   

18.     In view of the aforesaid facts and circumstances of the case,  we allow the complaint of the Complainant and direct Opposite Parties-Insurance Company to reimburse the amount of Rs.3,60,717/- (Rupees three lakh sixty thousands seven hundred and seventeen only)  to the complainant  alongwith interest @ 8% per annum from the date of filing the complaint i.e. 23.09.2019 till its realization. Opposite Parties-Insurance Company  is also directed to pay compensation to the complainant for causing her mental tension and harassment to the tune of Rs.10,000/- (Ten thousands only) and Rs.5,000/- (Rupees five thousands only) as litigation expenses. The compliance of this order be made by Opposite Parties-Insurance Company within 45 days from the date of receipt of this order, failing which the complainant  shall be at liberty to get the order enforced through the indulgence of this District Commission. Copies of the order be furnished to the parties free of cost. File be consigned to record room after compliance.

19.     Reason for delay in deciding the complaint.

          This complaint could not be decided within the prescribed period because the State Government has not appointed any of the Whole Time Members in this Commission for about 3 years i.e. w.e.f. 15.09.2018 till 27.08.2021 as well as due to pandemic of COVID-19.

Announced in Open Commission.

Dated:28.03.2022.