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 has been purchasing the ‘Family Health Optima Insurance Plan’ Policy from the opposite party regularly from the last seven years continuously. Lastly the complainant renewed the policy for the period w.e.f. 20.08.2022 upto 19.08.2023 for a sum assured of Rs.20,00,000/-. During the policy period on 18.10.2022 complainant felt some uneasiness and became unconscious and due to emergency case, he was brought to the nearest hospital i.e. Harbans Nursing Home & Maternity Hospital, Dharamkot Road, Kot Ise khan District Moga, where he was completely diagnosed and found that he was suffering with pneumonia and remained admitted in the hospital till 26.10.2022. In this regard, the opposite party was duly informed  and Opposite Party was asked for  cashless treatment under the policy, but the officials of opposite party told that there may occur some delay in sending the case of the complainant for cashless treatment to the higher authority and the complainant has to pay the expenses from his own pocket and after discharge, the medical treatment claim amount will definitely be reimbursed under the policy. In these circumstances, the complainant paid the amount of expenses from his own pocket. For his treatment, the complainant paid an amount of Rs. 77, 686/- to Harbans Nursing Home & Maternity Hospital. After discharge from the hospital, the complainant lodged the claim for the reimbursement of the medical expenses with opposite party and also completed all the required formalities and submitted all the required documents with the opposite party, but the opposite party did not pay any heed to the request of the complainant. Initially, the opposite party lingered on the matter on one pretext or the other and at last vide repudiation letter dated 30.12.2022, the opposite party has repudiated the claim of the complainant on the false and frivolous ground that the insured patient admitted and treated in an excluded provider hospital and as per Exclusion clause no.11 of the policy, the expenses incurred towards treatment in any hospital or by any medical practitioner or any other provider specifically excluded by the insurer. But the repudiation of the claim by the Opposite Party is totally wrong and incorrect. Further alleged that at the time of issuing the policy in question, the opposite party never issued any terms and conditions of the policy documents. As such, the alleged terms and conditions, particularly the exclusion clause of the policy in question is not binding upon the insured. Further alleged that complainant was admitted in hospital in emergency conditions and it is quite natural at the time of emergency where there is threat to the life of patient, the patient or his attendants immediately will approach to the nearest hospital or doctors and will take treatment as per the advice of doctors to save the life of the patient and not supposed to find the empanelled hospital or go for the treatment as per alleged terms and conditions of insurance Company which can be fatal for patient. The complainant approached the opposite party time and again for the reimbursement of his genuine medical claim, but to no effect. As such, there is deficiency in service as well as unfair trade practice on the part of the Opposite Party. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite party may be directed to pay Rs.77,686/- alongwith future interest @ 12 % p.a. from the date of payment till its actual realization.

b)      To pay an amount of Rs.1,00,000/- as compensation on account of damages, mental tension and harassment.

c)       To pay an amount of Rs.21,000/- as cost of complaint.

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 party appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that present complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Parties as per terms and conditions and as per exclusion clause no.11, the Opposite Party is not liable to make payment under the policy in respect of expenses incurred for treatment at the hospital which is an Excluded Provider Hospital. Further averred that the insured was admitted in the hospital on dated 18.10.2022 and the alleged claim was intimated to the Opposite Party on 23.12.2022 which was after the two months from the date of admission in the hospital and the unreasonable and explained delay in lodging the claim amounts to violation of the terms and conditions of the insurance policy. As per the policy terms and conditions, the insured has to notify the Opposite Party within 24 hours of the hospitalization from the date of occurrence of the event so that the claim could have been verified on the actual circumstances. Further averred that the present complaint pertains to insurance claim under Family Health Optima Insurance Plan Policy a ported policy bearing no.P/21122/01/2023/005040 valid from 20.08.2022 to 19.08.2023 covering the complainant self and his spouse Supreet Kaur and dependent child Mehraj Singh for a sum of Rs.20,00,000/-. However the aforesaid insurance policy was issued to the insured by the answering Opposite Party subject to the terms and conditions of the insurance policy. The said terms and conditions were handed over and supplied to the insured at the time of the contract. Moreover the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same were served to the complainant along with policy schedule. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Therefore it is submitted that in case if any liability would arise against the answering Opposite Party, then it would be subject to the terms and conditions of the insurance policy. Further averred that the insured has been purchasing the insurance policy from the Opposite Party w.e.f. 17.08.2020 and the policy was ported from MBHI (17.08.2016 to 16.08.2021 onwards and the following policies were issued to the complainant:-

a.       P/21122/01/2021/002843 w.e.f 17.08.2020 to 16.08.2021

b.       P/21122/01/2022/004202 w.e.f 20.08.2021 to 19.08.2022

c.       P/21122/01/2021/005040 w.e.f 20.08.2022 to 19.08.2023

          Thus, it is crystal clear that the insured is not new to insurance contracts and he has the full knowledge about the insurance policies, he has been purchasing from time to time and moreover the insured has never demanded any clarification etc. from the Opposite Parties nor did he ever demand any second copy of the terms and conditions of the insurance policy. He never complained that the policy was issued without any terms and conditions and insured himself is a literate person and has signed the complaint in English language and from his habit of purchasing insurance policies, it is evident that the insured is fully aware person and now he cannot allege that Opposite Party has never supplied any terms and conditions of said policies. The complainant was given free look period after the issuance of the policy and the complainant has accepted the contract of insurance without any hazel and objection. These circumstances leads to a presumption that the complainant has received, read and understood the terms and conditions of the policy subsequently. Further averred that the insured submitted the claim documents for the reimbursement of the expenses towards the treatment of Pneumonia for hospitalization from 18.10.2022 to 26.10.2022 at Harbans Nursing Home. On  scrutiny of claim documents, the medical team of the answering Opposite Party observed that the patient was admitted and treated in an excluded provider hospital. Based on these findings, the claim was repudiated vide letter dated 30.12.2022 as according to the Exclusion clause no. 11 of the policy the claim for the medical expenses incurred in the said excluded hospital are not payable. Hence, the claim was finally rejected and it was conveyed to the insured. The claim was repudiated under the ambit of specific condition/exclusion no.11 as mentioned under the policy terms and conditions. Further averred that the instant complaint is neither maintainable in law nor on facts and the same is liable to be dismissed in limine. No deficient services have been rendered by the answering Opposite Party as alleged by the complainant. The claim in question was duly entertained, inquired into and after due application of mind the alleged claim has been repudiated on the basis of terms and conditions of the policy. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       In order to prove his case, complainant tendered in evidence his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C19.

4.       To rebut the evidence of the complainant, Opposite party tendered in evidence affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1/A alongwith copies of documents Ex.OP1/1 to Ex.OP1/12.  

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

6.       There is no dispute that complainant has purchased the health insurance policy bearing No. P/211222/01/2022/004202 for the period 20.08.2022 to 19.08.2023. During the policy period complainant suffered pneumonia and was got admitted in Harbans Nursing & Maternity Hospital, Kot Ise Khan, Tehsil Dharamkot, District Moga 18.10.022 and remained admitted till 26.10.2022 is also not disputed. The main dispute between the parties is that complainant got treatment from Excluded Provider Hospital that’s why the claim was repudiated and denied. It is not the case of the Opposite Party that the treating hospital from where the complainant treatment has charged more than the empanelled hospital. However, the rejection of claim on the ground that policy holder got the treatment from excluded provider hospital is totally arbitrary. Sometime it is not possible for the policy holder to approach the listed hospitals due to any reasons. On the point, we are well guided by judgement of  Hon’ble Supreme Court of India in case titled  Shiva Kant Jha Vs. Union of India in Civil Writ Petition No. 694 of 2015, decided on 13.04.201, in which it is held that:-

Can it be said that taking treatment in Specialty Hospital by itself would deprive a person to claim reimbursement solely on the ground that the said Hospital is not included in the Government Order. The right to medical claim cannot be denied merely because the name of the hospital is not included in the Government Order. The real test must be the factum of treatment. Before any medical claim is honoured, the authorities are bound to ensure as to whether the claimant had actually taken treatment and the factum of treatment is supported by records duly certified by Doctors/Hospitals concerned. 

In the facts of the present case, it cannot be denied that complainant was admitted in Harbans Nursing & Maternity Hospital, Kot Ise Khan, Tehsil Dharamkot, District Moga in emergency conditions due to pneumonia. Moreover, the law does not require that prior permission has to be taken in such situation where the survival of the person is the prime consideration. Once, it is established, the claim cannot be denied on technical grounds. Clearly, in the present case, by taking a very inhuman approach, the Opposite Parties have denied the grant of medical reimbursement to the Complainant and forcing him to approach this District Commission. 

7.       Moreover, the plea taken by the Opposite Party is that complainant was admitted and treated in an excluded provider hospital, so they rejected the claim of the complainant as per terms and conditions of the policy specifically exclusion no.11. But the Opposite Parties 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.”

8.       Now come to the quantum of amount to be awarded to the complainant. Vide instant complaint, the complainant claimed the amount of Rs.77,686/-. However, vide Bill Assessment Sheet Ex.OP1/12, the Opposite Parties assessed the final admissible amount to tune of Rs.77,056/-. Hence we allow the same.

9.       From the above discussion, we partly allow the complaint of the complainant and direct the Opposite Party to pay an amount of Rs.77,056/- (Rupees Seventy Seven Thousand Fifty Six only) to the complainant. Opposite Parties are also directed to pay compository costs of Rs.5,000/-(Rupees Five Thousand only) as compensation and litigation expenses to the complainants. The compliance of this order be made by the Opposite Parties within 45 days from the date of receipt of copy of this order, failing which, the Opposite Parties are further burdened with additional cost of Rs.10,000/-(Rupees Ten Thousand only) to be paid to the complainants for non compliance of the 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