BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No. 627 of 2017
Date of Institution:8.9.2017
Date of Decision:28.3.2018
Shri Deepak Malhotra Aged 39 years son of Shri Ram Lal Malhotra, resident of House No. F-9/11, Batala Road, Vijay Nagar, 54-A, Malhotra Niwas, Gali No.2/3, Near Manjot Gas Agency, Batala Road, Vijay Nagar, Amritsar
Complainant
Versus
Star Health and Allied Insurance Company Limited through its Branch Manager Branch office at SCO 26, First Floor, Ranjit Avenue, District Shopping Complex, Amritsar
Opposite Party
Complaint under section 11 & 12 of the Consumer Protection Act, 1986
Present : For the complainant : Sh.Vikram Puri,Advocate
For the opposite party : Sh. S.S.Salaria,Advocate
Coram:
Mr.Anoop Sharma, Presiding Member
Ms. Rachna Arora, Member
Order dictated by:
Sh.Anoop Sharma, Presiding Member
1. Sh. Deepak Malhotra, complainant has brought the instant complaint under section 11 & 12 of the Consumer Protection Act, 1986 on the allegations that the complainant obtained Health Insurance policy bearing No. P/211111/01/2017/004328 by paying premium of Rs. 11,800/- for sum assured Rs. 5 lacs covering the risk for himself, his wife and two children from the opposite party under Family Health Optima Insurance Plan covering the risk period from 10.10.2016 to 9.10.2017. Therefore, the complainant having hired the services of the opposite party for a valid consideration and becomes the consumer under the
Consumer Protection Act and is competent to invoke the jurisdiction of this Forum. During the validity period of the policy i.e. in the first week of March, 2017 the complainant suffered from some health problem i.e. fever . On 6.3.2017 the complainant contacted Dr. Jagdish Goswami, who examined the complainant and recommended certain tests and ultrasound. It was detected to be a case of CKD (Chronic Kidney disease) stage v. Lateron complainant went to Mokha Hospital & Kidney Care Centre, Amritsar where he was admitted on 9.3.2017 and discharged on 10.3.2017. During his admission in the said hospital, complainant incurred an expenditure of Rs. 14000/- on his treatment and tests conducted in that hospital. It is pertinent to mention over here that the complainant was never having such problem i.e. CKD Stage v prior to taking of the Health Insurance Policy from the opposite party and it was for the first time in the first week of March, 2017 when the complainant had fever and contacted Dr. Jagdish Goswami and on the basis of certain tests and ultrasound, the complainant come to know that he was suffering from the said disease i.e. CKD stage v. When the condition of the complainant did not improve, the complainant went to Kidney Hosptial and Lifeline Medical Institution , Jalandhar , where he was admitted on 12.5.2017 and discharged on 16.5.2017 and during his admission he incurred an expenditure of Rs. 39,000/- on the medical tests and ultrasound as well as stay in the said hospital. On the basis of the said reports, doctor of Kidney Hosptial and Lifeline Medical Institution , Jalandhar recommended the complainant for kidney transplantation . It is further submitted that prior to that the complainant used to visit Mokha Hospital, Amritsar for the purpose of Dialysis from 26.3.2017 to 2.6.2017 and spent approximately Rs. 41,200/-.
2. Subsequently on 5.6.2017 complainant was admitted to Kidney Hosptial and Lifeline Medical Institution , Jalandhar where operation of the complainant was got conducted on 12.6.2017 and the complainant was discharged from the said hospital on 22.6.2017,. During this period i.e. from 5.6.2017 to 22.6.2017 the complainant spent a sum of Rs. 5,33,000/- for the said kidney transplant operation . It is pertinent to mention over here that since the complainant was admitted to Kidney Hosptial and Lifeline Medical Institution , Jalandhar on 5.6.2017 and the complainant submitted his claim with regard to the amounts spent by him during the period from 9.3.2017 to 10.3.2017 as well as from 12.5.2017 to 16.5.2017. However, the complainant was shocked when the opposite party issued letters dated 7.6.2017 vide which the claim of the complainant was repudiated on the ground that insured patient had stage (v) CKD which confirm chronic, longstanding kidney disease and the patient had kidney disease prior to inception of mediclaim Insu.policy. Further as per the claim verification report, the patient had consulted with Dr. Goswami and Dr. Soni for hypertension and fever for 6 months prior to March 2017 and the present admission and treatment of the insured patient is for the non disclosed disease. Lateron the opposite party had issued an undated letter whereby the opposite party cancelled the coverage for the complainant under the abovesaid policy w.e.f. 3.8.2017. The action of the opposite party is wrong, illegal, null and void and against the principle of natural justice as the complainant was never having such chronic kidney disease prior to taking of the said mediclaim policy. After his operation from Kidney Hosptial and Lifeline Medical Institution , Jalandhar and after his discharge from the said hospital, the complainant submitted his claim for the amount spent on kidney transplant operation i.e. a sum of Rs. 5,33,000/-, but the opposite party has flatly refused to receive the claim of the complainant on the ground that the policy in question covering the risk of the complainant has already been cancelled by them on the ground of non disclosure of the disease . The complainant requested the opposite party to disburse the sum insured to the complainant but the opposite party has flatly refused to listen to the genuine request of the complainant. Vide instant complaint, complainant has sought for the following reliefs:-
- Opposite party be directed to settle the genuine claim of the complainant and to disburse the sum insured of Rs. 5,00,000/- alongwith interest from the date of making payment of the complainant till actual realization ;
- Compensation to the tune of Rs. 30000/- alongwith adequate litigation expenses to the tune of Rs. 5000/- may also be awarded to the complainant.
Hence, this complaint.
3. Upon notice, opposite party appeared and filed written version taking certain preliminary objections therein inter-alia that the present complaint is not legally maintainable ; that the complainant has not come to the Forum with clean hands and suppressed the true and material facts from this Forum, as such , he is not entitled to any relief as claimed for ; that the complainant obtained the policy of Family Health Optima Insurance Policy from the opposite party covering Mr. Deepak Malhotra, self, Mrs. Aarti , spouse and Muskan and Samily dependent children for the sum assured Rs. 5 lacs vide policy No. P/211111/01/2017/004328 valid for the period from 10.10.2016 to midnight of 9.10.2017. It was further stated that during the current period of policy, the complainant has reported two claims during 5th month of the policy and claimed amount of Rs. 7500/- and Rs. 38,447/- vide claim No. 127369 and claim No. 56380 respectively. As per claim No.127369 the insured was admitted to Mokha Hospital and Kidney Care Centre, Amritsar on 9.3.2017 for the treatment of CKD and as per claim No. 56380 the insured was admitted in Kidney Hospital and Lifeline Medical on 12.5.2017 for the treatment of CKD and submitted pre authorization request for cashless treatment and the same was denied stating that since the previous claim for CKD is pending , the present claim cannot be processed. Subsequently, the insured has submitted claim records for reimbursement of medical expenses for the above referred two claims. On scrutiny of the claim records, it was observed that “As per discharge summary, the insured was admitted on 12.5.2017 and discharged on 16.5.2017 and diagnosed as HTNWTH CKD-v and As per the claim verification report, the patient has consulted Dr. Goswami and Dr. Soni for hypertension and fever 5 months prior to March, 2017. From the above findings , it was observed that the policy was only five months old and as per discharge summary, the insured has CKD stage v. Within the short span of five months, the insured cannot develop CKD. Thus the insured has long standing kidney disease which is prior to policy commencement. At the time of inception of the policy i.e. from 10.10.2016 to 9.10.2017 the insured has not disclosed the above mentioned medical history/health details of the insured person in the proposal form which amounts to disclosure of medical facts. As per condition No. 8 of the policy , “if there is any misrepresentation/non disclosure of material facts whether by insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim”. Hence, the claim was repudiated and the same was duly communicated to the complainant vide letter dated 7.6.2017. Thereafter the complainant submitted a representative dated Nil alongwith a medical certificate dated 13.7.2017 from Dr. Shekhar Soni, in response to the letter dated 7.6.2017 and the same was reviewed and replied vide letter dated 9.8.2017 stating that the discharge summary of the abovesaid hospital that the insured patient has stage v chronic kidney disease which confirms chronic longstanding kidney disease and the patient has kidney disease prior to inception of the medical insurance policy. Further as per claim verification report, the patient has consulted Dr. Goswami and Dr. Soni for hypertension and fever six months prior to March, 2017.It was submitted that chronic kidney disease does not reach the end stage until 5 to 10 years after it is diagnosed ESRD is the fifth stage of the progression of chronic kidney disease which is measured by the Glomerular Filtration Rate. As per discharge summary, the insured has CKD since 64 months and on MHD since 3 months is not acceptable because as of reasons stated above . As such the repudiation of claim is genuine and valid and claim is not at all payable. On merits, the Opposite Parties took up the same and similar pleas as taken up by them in the preliminary objections. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.
4. In his bid to prove the case Sh.Vikram Puri,Adv.counsel for the complainant tendered into evidence duly sworn affidavit of the complainant Ex.C-1 alongwith documents Ex.C-2 to Ex.C-17 and closed the evidence on behalf of the complainant.
5. To rebut the aforesaid evidence Sh.S.S.Salaria,Adv.counsel for the opposite party tendered into evidence affidavit of Sh.N.Gopalan, Chief Manager Ex. OP1 alongwith documents Ex.OP2 to Ex.OP23 and closed the evidence on behalf of the opposite party.
6. We have heard the ld.counsel for the parties and have carefully gone through the record on the file.
7. The complainant have submitted his affidavit Ex.C1 in which he has reiterated the facts as detailed in the complaint and contended that the complainant obtained Health Insurance policy under Family Health Optima Insurance Plan bearing No. P/211111/01/2017/004328 for sum assured Rs. 5 lacs covering the risk for himself, his wife and two children from the opposite party for the period from 10.10.2016 to 9.10.2017. It was the case of the complainant that during the subsistence of the policy period i.e. in the first week of March, 2017 the complainant suffered from some health problem i.e. fever . On 6.3.2017 the complainant contacted Dr. Jagdish Goswami, who examined the complainant and recommended certain tests and ultrasound. It was detected to be a case of CKD (Chronic Kidney disease) stage v. Lateron complainant went to Mokha Hospital & Kidney Care Centre, Amritsar, where he was admitted on 9.3.2017 and discharged on 10.3.2017. During his admission in the said hospital, complainant incurred an expenditure of Rs. 14000/- on his treatment and tests conducted in that hospital. It is pertinent to mention over here that the complainant was never having such problem i.e. CKD Stage v prior to taking of the Health Insurance Policy from the opposite party and it was for the first time in the first week of March, 2017 when the complainant had fever and contacted Dr. Jagdish Goswami and on the basis of certain tests and ultrasound, the complainant come to know that he was suffering from the said disease i.e. CKD stage v. When the condition of the complainant did not improve, the complainant went to Kidney Hosptial and Lifeline Medical Institution , Jalandhar , where he was admitted on 12.5.2017 and discharged on 16.5.2017 and during his admission he incurred an expenditure of Rs. 39,000/- on the medical tests and ultrasound as well as stay in the said hospital. On the basis of the said reports, doctor of Kidney Hosptial and Lifeline Medical Institution , Jalandhar recommended the complainant for kidney transplantation . It is further submitted that prior to that the complainant used to visit Mokha Hospital, Amritsar for the purpose of Dialysis from 26.3.2017 to 2.6.2017 and spent approximately Rs. 41,200/-. Subsequently on 5.6.2017 complainant was admitted to Kidney Hosptial and Lifeline Medical Institution , Jalandhar where operation of the complainant was got conducted on 12.6.2017 and the complainant was discharged from the said hospital on 22.6.2017,. During this period i.e. from 5.6.2017 to 22.6.2017 the complainant spent a sum of Rs. 5,33,000/- for the said kidney transplant operation . It is pertinent to mention over here that since the complainant was admitted to Kidney Hospital and Lifeline Medical Institution , Jalandhar on 5.6.2017 and the complainant submitted his claim with regard to the amounts spent by him during the period from 9.3.2017 to 10.3.2017 as well as from 12.5.2017 to 16.5.2017. However, the complainant was shocked when the opposite party issued letters dated 7.6.2017 vide which the claim of the complainant was repudiated on the ground that insured patient had stage (v) CKD which confirm chronic, longstanding kidney disease and the patient had kidney disease prior to inception of mediclaim Insu. policy. Further as per the claim verification report, the patient had consulted with Dr. Goswami and Dr. Soni for hypertension and fever for 6 months prior to March 2017 and the present admission and treatment of the insured patient is for the non disclosed disease. Lateron the opposite party had issued an undated letter whereby the opposite party cancelled the coverage for the complainant under the abovesaid policy w.e.f. 3.8.2017. The action of the opposite party is wrong, illegal, null and void and against the principle of natural justice as the complainant was never having such chronic kidney disease prior to taking of the said mediclaim policy. After his operation from Kidney Hosptial and Lifeline Medical Institution , Jalandhar and after his discharge from the said hospital, the complainant submitted his claim for the amount spent on kidney transplant operation i.e. a sum of Rs. 5,33,000/-, but the opposite party has flatly refused to receive the claim of the complainant on the ground that the policy in question covering the risk of the complainant has already been cancelled by them on the ground of non disclosure of the disease . The act of the opposite party firstly repudiating the genuine claim and second cancelling the policy amounts to deficiency in service, unfair trade practice .
8. On the other hand the opposite party has repelled the aforesaid contentions of the ld.counsel for the complainant on the ground that the complainant obtained the policy of Family Health Optima Insurance Policy from the opposite party covering Mr. Deepak Malhotra, self, Mrs. Aarti , spouse and Muskan and Samily dependent children for the sum assured Rs. 5 lacs vide policy No. P/211111/01/2017/004328 valid for the period from 10.10.2016 to midnight of 9.10.2017. It was further submitted that during the current period of policy, the complainant has reported two claims during 5th month of the policy and claimed amount of Rs. 7500/- and Rs. 38,447/- vide claim No. 127369 and claim No. 56380 respectively. As per claim No.127369 the insured was admitted to Mokha Hospital and Kidney Care Centre, Amritsar on 9.3.2017 for the treatment of CKD and as per claim No. 56380 the insured was admitted in Kidney Hospital and Lifeline Medical on 12.5.2017 for the treatment of CKD and submitted pre authorization request for cashless treatment and the same was denied stating that since the previous claim for CKD is pending , the present claim cannot be processed. Subsequently, the insured has submitted claim records for reimbursement of medical expenses for the above referred two claims. On scrutiny of the claim records, it was observed that “As per discharge summary, the insured was admitted on 12.5.2017 and discharged on 16.5.2017 and diagnosed as HTNWTH CKD-v and As per the claim verification report, the patient has consulted Dr. Goswami and Dr. Soni for hypertension and fever 5 months prior to March, 2017. From the above findings , it was observed that the policy was only five months old and as per discharge summary, the insured has CKD stage (v). Within the short span of five months, the insured cannot develop CKD. Thus the insured has long standing kidney disease which is prior to policy commencement. At the time of inception of the policy i.e. from 10.10.2016 to 9.10.2017 the insured has not disclosed the above mentioned medical history/health details of the insured person in the proposal form which amounts to disclosure of medical facts. As per condition No. 8 of the policy , “if there is any misrepresentation/non disclosure of material facts whether by insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim”. Hence, the claim was repudiated and the same was duly communicated to the complainant vide letter dated 7.6.2017. Thereafter the complainant submitted a representative dated Nil alongwith a medical certificate dated 13.7.2017 from Dr. Shekhar Soni, in response to the letter dated 7.6.2017 and the same was reviewed and replied vide letter dated 9.8.2017 stating that the discharge summary of the abovesaid hospital that the insured patient has stage v chronic kidney disease which confirms chronic longstanding kidney disease and the patient has kidney disease prior to inception of the medical insurance policy. Further as per claim verification report, the patient has consulted Dr. Goswami and Dr. Soni for hypertension and fever six months prior to March, 2017.It was submitted that chronic kidney disease does not reach the end stage until 5 to 10 years after it is diagnosed ESRD is the fifth stage of the progression of chronic kidney disease which is measured by the Glomerular Filtration Rate. As per discharge summary, the insured has CKD since 64 months and on MHD since 3 months is not acceptable because of reasons stated above . As such the repudiation of claim is genuine and valid and claim is not at all payable.
9. From the aforesaid discussion, it stands proved on record that the complainant got Family Health Optima Insurance Plan for himself, his spouse and two children from Opposite Party covering the risk period 10.10.2016 to 9.10.2017 for the sum assured Rs. 5 lacs, copy of Insurance policy is Ex.C-3 on record. The complainant fell ill and contacted Dr. Jagdish Goswami, who further examined and recommended some tests and on the basis of tests reports, it was detected that the complainant was suffering from CKD (Chronic kidney Disease) Stage V. Thereafter the complainant approached Mokha Hospital and was to be hospitalized firstly from 9.3.2017 till 10.3.2017, where the complainant incurred an expenditure of Rs. 14000/- on his treatment and secondly at Kidney Hospital & Lifeline Medical Institution, Jalandhar for the period from 12.5.2017 to 16.5.2017 and the treatment cost of the said hospital came to Rs.39000/- . Thereafter the complainant used to visit Mokha Hospital for the purpose of dialysis from 26.3.2017 to 2.6.2017 and incurred approximately Rs. 41,200/- on his treatment of dialysis. However, on 5.6.2017 complainant was admitted to Kidney Hospital and Lifeline Medical Institutions, Jalandhar where his operation of kidney transplantation was got conducted and the complainant incurred an expenses of Rs.5,33,000/- on his kidney transplantation at Kidney Hospital and Lifeline Medical Institutions, Jalandhar . However, when the claim for his abovesaid hospitalization and medical treatment at Mokha Hospital for the period from 9.3.2017 as well as at Kidney Hospital and Lifeline Medical Institutions, Jalandhar for the period from 12.5.2017 to 16.5.2017 was lodged, the same was repudiated by the Opposite Party on the ground that the insured patient had stage (v) CKD which confirms chronic longstanding kidney disease and the patient had kidney disease prior to inception of mediclaim policy. However, when the complainant lodged his claim regarding admission in Kidney Hospital and Lifeline Medical Institutions, Jalandhar for kidney transplantation where the complainant incurred an expenditure of Rs. 5,33,000/- the same was flatly refused on the ground that the policy in question covering the risk of the complainant has already been cancelled by them on the ground of non disclosure of the disease at the time of obtaining the policy. It was further contended that on thorough scrutiny of all the submitted claim documents and also from expert opinion it is observed that the present ailment is a long standing pathology, which will take 5 to 10 years to progress to the present stage, hence the present ailment is considered as pre existing disease, which is not covered under the scope of the policy. The only case of the opposite party is that as the complainant has concealed his pre-existing disease i.e. chronic kidney disease from which, he was suffering since long as this type of disease does not reach the end stage until 5 to 10 years after it is diagnosed ESRD is the fifth stage of the progession of chronic kidney disease and the insured has CKD since 64 months and on MHD since 3 months i.e. before taking the policy. But, however, perusal of discharge summary for the period from 5.6.2017 to 22.6.2017 produced by the complainant Ex.C-12 dated shows the past history CKD since 4 months. On MHD since 3 months. H/o HTN since 4 months which fully proves that as the complainant has obtained the policy for the period from 10.10.2016 to 9.10.2017 and the complainant fell sick in the month of March 2017 i.e. approximately after six months of the taking of the policy and the discharge summary of Kidney Hospital and Lifeline Medical institution, Jalandhar is for the period from 5.6.2017 to 22.6.2017 i.e. after nine months of the taking of the policy vide which in the column past history the doctor has fully described that CKD since 4 months on MHD since 3 months. H/o HTN since 4 months i.e. the complainant suffered from these disease after taking of the aforesaid policy. Moreover, the opposite party has not produced on record any previous medical record of the complainant that he ever took or underwent medical treatment of the aforesaid disease prior to the taking of the policy nor the opposite party has filed affidavit of any doctor/medical expert to prove that the patient was being treated by him for the aforesaid diseases prior to the taking of the policy. It has been held by the Hon'ble Punjab State Consumer Disputes Redressal Commission in case National Insurance Company Limited and Another Vs. Balwinder Singh 2012(1) CLT 34 that as regards pre-existing disease i.e. suppression of material fact, the appellants have not produced any evidence to prove that before the purchase of the policy, the insured/respondent had taken any treatment from any doctor or any hospital and the insured/respondent had the knowledge that he was suffering from the heart disease and concealed this fact from the appellants at the time of issuance of the mediclaim policy. In the absence of any reasonable evidence the insurance company was not correct in repudiating the claim under the policy. Same view has been taken by the Hon'ble National Commission in case Tarlok Chand Khanna Vs. United India Insurance Co.Ltd. 1(2012) CPJ 84 (NC). More so the plea of the opposite party that the complainant consulted Dr. Goswami and Dr. Soni for hypertension and fever , as such the complainant has not disclosed the said disease while obtaining the aforesaid policy. . But hypertension and diabetes is not a material disease, therefore, non disclosure thereof is not a concealment. We draw support from Life Insurance Corporation of India Vs. Sushma Sharma from II (2008) CPJ 213 wherein Hon'ble State Commission has held as under:-
“So far as hypertension is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.
We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease.
10. Moreover there was no bar on the Opposite Party to get the thorough medical check up at the time of issuance of the policy. The Opposite Party was within their right to cancel the policy if it doubted or found any information supplied by the life assured being false or wrong, but this has not been done by the Opposite Party. The investigation has been got done at the time when the claim was lodged by the complainant. It was for the Opposite Party to ensure about the health of the insured before issuance of the policy of such amount. Many times a person may not know himself/ herself if he/ he is suffering from any particular disease. Moreover, prior to issuance of the policy, it was required to check up life assured thoroughly. It was the bounden duty of the Opposite Party to make thorough investigation at the initial stage. It appears that the Opposite Party has different yard stick at the time of accepting the policy for procuring the business and different face at the time of discharge of its lawful liability. The act of the Opposite Party firstly by repudiating the claim lodged by the complainant and secondly by cancelling the mediclaim policy of the complainant is illegal and void and against the principles of natural justice. This is a common practice of the Insurance Companies to repudiate the claim on flimsy grounds without any justification. In this regard, we are supported with the rulings: Life Insurance Corporation of India Vs. Ambika Prasad Pandey, AIR 1999 MP 13 and Life Insurance Corporation of India Vs. Narmada Agarwalla, AIR 1993 Ori 103. 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., 2008(3) CPJ 377 (SC) is fully attracted. 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.”
11. On this point, 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.
12. Regarding the quantum of compensation, the complainant has initially lodged claim to the tune of Rs. 7500/- vide claim No. 127369 and secondly claimed Rs. 38,447/- vide claim No. 56380 which were wrongly repudiated by the opposite party and the last claim lodged by the opposite party to the tune of Rs 5,33,000/- for the kidney transplantation which the opposite party has also refused on frivolous ground that the policy has already been cancelled w.e.f 3.8.2017. The act of repudiating the genuine claim of the complainant and thereby cancelling the policy on the frivolous grounds is an act of deficiency in service for which the opposite party is liable to make good the loss of the complainant .But as the complainant has placed on record copies of bills Ex.C-13 and Ex.C-14 amounting to Rs. 5,28,000/-.But, however, as the sum insured of the policy in dispute is Rs. 5 lacs, as such the complainant cannot be granted more than the sum insured, as such the complainant is entitled to the sum assured Rs. 5 lacs.
13. In view of the above discussion, we allow the present complaint with costs and direct the opposite party to reinstate the policy in question and also to pay the amount of Rs. 5,00,000/- to the complainant within a period of one month from the date of receipt of copy of orders; failing which complainant shall be entitled to interest at the rate of 9% per annum from the date of filing of the present complaint till payment is made to the complainant. Opposite party is also directed to pay litigation expenses of Rs.5000/- to the complainant. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Forum
Dated: 28.3.2018 (Rachna Arora) (Anoop Sharma) Member Presiding Member
