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 had purchased a Family Health Optima Insurance Plan, from the Opposite Party No.2 having coverage of Rs.5,00,000/- on 06.03.2020. The complainant was suffering from pyrexia in the month of May-2021. The complainant remained admit at Sidhu Hospital Ferozepur Road, Moga for seven days. The complainant spent approximately Rs. 80,000/-. Thereafter the complainant submitted his claim before the officials of Opposite Parties alongwith medical bills etc. The claim of complainant was rejected by the opposite party with remarks that the "Insured patient could have been managed as an outpatient and hospitalization of the insured patient is not warranted, whereas the claim of the complainant is genuine one. The officials of opposite parties intentionally and knowingly refused the claim of the complainant. The complainant visited in the office of Opposite Party No.2 many a times, but the officials of Opposite Party postponed the matter on one pretext or the other. A legal notice was served by the complainant to the Opposite Party No.2 through his counsel. The complainant also visited the office of Opposite Party No.2 and requested them to admit the claim of the complainant but the officials of Opposite Parties refused to admit the claim of the complainant. Hence this complaint. Vide instant complaint, the complainant has sought the  following reliefs:-

a)       Opposite Parties may be directed to pay a sum of Rs.80,000/- with regard to the policy no.P/211222/012020/0051.

b)      To pay an amount of R.50,000/- as compensation for causing mental tension, harassment and agony to the complainant.

c)       To pay an amount of Rs.11,000/- as costs of 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  the written version taking preliminary objections therein inter alia 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 Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court. The complainant has concealed material facts and documents from this Commission as well as from the opposite parties, therefore, the complainant is not entitled to any relief. The complainant has not disclosed material facts. The husband of complainant namely Mr.Dinesh Kumar availed the Family Health Optima Insurance Plan Policy No.P/211222/01 /2017/000111 for the period 06/03/2017 to 05/03/2018 and subsequently renewed the policy in policy No. P/211222/01/2021/008411 for 06/03/2021 to 05/03/2022. The said Dinesh Kumar, complainant and their dependent child Harshit Gupta was insured for an amount of Rs.5 Lac. The terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. 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. The claim in dispute is reported in the 5^th year of the policy and the claim was registered vide claim no.CIR/2022/211222/2611035. Three claims of the complainant have already been paid. On the basis of submitted record, medical team of Opposite Parties is of the opine that "the insured patient could have been managed as an outpatient and hospitalization of the insured patient is not warranted". So, vide letter Dt.03.07.2021, the claim was repudiated and same was duly informed to the complainant. Moreover, the present complaint has been filed for claiming the amount of Rs.80,000/- as mentioned in the complaint regarding the treatment taken from Sidhu Hospital, Moga but as per the alleged claim form, the amount was only Rs.60,007/- and the medical records were prepared by the complainant from the concerned doctor only to take the claim which is otherwise not required regarding the treatment taken by the complainant from the said hospital as the disease mentioned in the complaint was 'Pyrexia' of unknown origin which is only a simple fever and it does not require any admission in the hospital and even every time the fever of complainant was normal and duly shown in the medical record as submitted by the complainant alongwith her claim form and moreover, as per the medical record the B.P and other tests were also normal which is clear from the medical record submitted by the complainant along-with the claim form, so the complaint is liable to be dismissed on this ground alone. Opposite Parties also relied upon the pronouncement of the Hon'ble Supreme Court in Satwant Kaur & Others V/s New India Assurance Co. Ltd (2009) 8 SCC 316. Further alleged that the complainant is not the consumer of the opposite parties. The complainant has no locus standi or cause of action to file the present complaint against the opposite parties. The complaint is not maintainable in the present form and is liable to be dismissed. 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 filed replication to the written reply of the Opposite Parties, in which, all the objections raised by the Opposite Parties are denied.

4.       In order to prove her case, the complainant tendered in evidence her affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C45.

5.       To rebut the evidence of complainant, Opposite Parties tendered in evidence copies of documents Ex.OPs/1 to Ex.OPs/14 and affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ex.OPs/15.

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

7.       All the facts as told by the complainant were admitted by the Opposite Parties except the admission of the patient/complainant. The plea of the Opposite Parties is that insured patient could have been managed as an outpatient and hospitalization of the insured patient is not warranted and on this ground claim of the complainant was repudiated. We do not agree with the aforesaid contention of ld. counsel for the Opposite Parties, as doctor is the expert of his field and he can decide whether the admission of the patient is required or not. Moreover, the Opposite Parties has not placed on record the affidavit of any other doctor to prove this fact that hospitalization of the complainant was not warranted.  As per the record placed on file we are of the opinion that here in this complaint when the complainant was not feeling well she got herself checked from the doctor and thereafter she was at the decision of the doctor, who is expert in his field will decide whether the complainant needs admission in hospital or not, as he knows what the problem is and in that problem what precautionary treatment he would given to his patients. Moreover, the insurance company has not placed on record any evidence or the report from any other doctor, which states that the patient can be treated in OPD only and need not any admission.

8.       In such a situation the repudiation made by the Opposite Party-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 greener pastures 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 seems 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.

9.       The complainant has claimed the amount of Rs.80,000/- for her treatment, but she placed on record copies of the bills from Ex.C12 to Ex.C24, totaling Rs.57,642/-. However, vide Ex.OP/14 opposite parties estimated the Final Admissible Amount to be paid to the complainant Rs.54,364/-, which was bifurcated by the Opposite Parties as under:-

Hence we allow the same.

10.     In view of the above discussion, we partly allow the complaint of the complaint and direct the Opposite Parties to pay a sum of Rs.54,364/- (Rupees Fifty Four Thousand Three Hundred Sixty Four only) to complainant alongwith interest @ 8% p.a. from the date of filing of the complaint i.e. 04.05.2022 till its actual realization. Opposite Parties are further directed to pay compository amount of Rs.10,000/- (Rupees Ten Thousand only) towards compensation and litigation costs to the complainant. The compliance of this order be made by the Opposite Party within 30 days from the date of receipt of copy of this 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