Order by:

Sh.Amrinder Singh Sidhu, President

1.       The complainants have filed the instant complaint u/s 35 of the Consumer Protection Act, 2019 on the allegations that complainants have purchased the Family Health Optima Insurance-2017-MED-PRD-051 from the Opposite Parties. Previously complainants were holder of Health Insurance Policy issued by the HDFC Ergo and thereafter Opposite parties and their agent explaining the reputation of their company and got succeed to get migrate complainants in their company and at the time of migration opposite parties assured that all the previous benefits will be available to the complainants and each and every ailment is covered under the policy and by this way complainants and his other family members are fully secured under the said policy for all the ailments. Complainants are regular policy holder of above said product of opposite party and opposite parties have issued the renewal Policy No. P/211222/01/2020/000803 and period of Insurance was 30.06.2019 to 29.06.2020 and thereafter the said policy is renewed further in continuous manner vide policy no.211222/01/2021/001527 and period of Insurance was 30.06.2020 to 29.06.2021. During the enforcement of above said policy, unfortunately complainant Satnam Singh Bhardwaj suffered from stomach pain and he was got admitted in Deepak Hospital, Ludhiana on 06.10.2020. Complainants presented the above said policy and cards with claims form to the requisite counter for claim on the basis of above said policy and so immediately intimated the admission of complainant Satnam Singh Bhardwaj in the hospital and filed the requisite forms as per the requirement of policy for treatment. So the cashless facility could be availed. Complainant Satnam Singh Bhardwaj remained in the hospital upto 12.10.2020. Despite complainants timely performed all the formalities relating to the claim, the opposite parties have not honored/paid the medical bills and other bills covered under the said policy of complainant and eventually in order to avoid their liability opposite parties arbitrary, illegally rejected the claim of complainants. The whole medical expenses suffered by the complainants from their own pocket, which caused great hardship for the complainant in the hard period of pandemic. Despite the submission of claim form and relevant documents the opposite parties failed to process and settle the claim of complainants. The opposite parties were asked to admit the rightful claim of the complainants. but they never bothered to the request of the complainants. Hence this complaint. Vide this complaint complainant has sought the following relief:-

a)       Opposite parties may be directed to pay Rs.65,000/- on account of medical expenses to the complainant.

b)      To pay an amount of Rs.50,000/- as compensation on account of mental tension and harassment and other expenses.

2.       Opposite Parties appeared through counsel and filed written reply taking preliminary objection therein inter alia that the present complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Parties on the ground of treatment of expenses due to consumption of alcohol is not payable. It is established from the medical/treatment records as filed by the insured and as received from the treating hospital that the insured was a k/c/o Chronic Liver Disease and is a known Alcoholic. Alcohol consumption is one of the main cause for the liver disease and hence the claim of the complainant was repudiated as per the terms and conditions of the policy. Further alleges that the present application pertains to insurance claim under Family Health Optimal Insurance Plan bearing No. P/211222/01/2021/001527 valid from 30.06.2020 to 29.06.2021 covering the complainants self with disclosed PED of diseases related to female genital system and their complications directly or indirectly related to the surgeries or procedure performed previously-Hysterctomy and their daughter for a sum of Rs 3,00,000/-. However, it is submitted that the aforesaid insurance policy was issued to the insured by the answering Opposite Parties 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 Parties, then it would be subject to the terms and conditions of the insurance policy. The answering Opposite Parties craves for the leave of this Commission to put the true and correct facts, as they stand, before this Commission and the same are set forth in the following paras:-

a)       That the insured requested for a cashless authorization for the treatment from Deepak Hospital, Ludhiana. On scrutiny of the cashless claim documents as provided by the insured, initially, amount of Rs.10,000/- was approved but on receipt of additional documents from the hospital, it was observed from the treating doctor letter dated 12.10.2020, that the insured patient has been admitted for treatment of CLD and the patient is a known alcoholic. Thus expenses for this treatment are not admissible in accordance with the exclusion clause no 4.8 of the policy. Thus the previous approval for the amount of Rs.10,000/- was withdrawn being not payable vide letter dated 12.10.2020. Subsequently the insured submitted the claim documents for the reimbursement of medical expenses towards the treatment of CLD, PHT, TCP and ASCITES. On scrutiny of claim documents the medical team of the answering company observed from the indoor case records of the treating hospital that the insured patient is an alcoholic and the treatment of the insured patient is for the disease due to use of alcohol and the insured has not disclosed the fact regarding his being alcoholic in the proposal form thus, the claim was found not payable. As per Exclusion clause code Excl. 12 of the policy, the company is not liable to make any payment in respect of expenses for treatment for alcoholism, drug or substance abuse or any addictive condition and consequences thereof and the claim was rejected and conveyed to insured vide letter dated 17.01.2021.

b)      As such, in terms of the said provision of the insurance policy, the insurance company have repudiated the claim of applicant in a proper manner, after due application of mind.

          Further Opposite Parties put reliance on judgements of Hon’ble Supreme Court of India in case United India Insurance Co. Ltd. Vs Harchand Rai Chandan Lal, judgement of Hon’ble State Consumer Disputes Redressal Commission, Chhattisgarh in case Star Health Allied Insurance Co. Ltd. Vs.  Sanjay Goyal, judgement of Hon’ble National Consumer Disputes Redressal Commission in case LIC  Vs Kuldeep Singh. Further alleges that in order to prove its case, the Opposite Parties will have to lead evidence and examine its witnesses and expert evidences and the Hon'ble Supreme Court of India has stated that the Civil Court is the appropriate forum to decide cases which are complicated in nature and in which oral and documentary evidences are required to be led. The Hon'ble Supreme Court has specifically stated that the proceedings before the Commission are essentially summary in nature and adjudication of issues which involve disputed factual questions should not be adjudicated. Therefore, in the fact and circumstances of the present case, Civil Court is the appropriate forum to decide and adjudicate the present case, as this Commission cannot receive evidence in detail in its summary jurisdiction under the Act. The Complainant has got no cause of action and locus-standi to file the present complaint. The instant complaint is false, malicious, incorrect and with malafide intent and is nothing but an abuse of the process of law and is an attempt to waste the precious time of this  Court, as the same has been filed by the complainant just to avail undue advantage. That the instant complaint is neither maintainable in law nor on facts and the same is liable to be dismissed in limine. This Commission has got no jurisdiction to try and decide the present complaint. No deficient services have been rendered by the answering opposite parties as alleged by the complainant. The claim in question was duly entertain, inquired into and after due application of mind the alleged claim has been repudiated on the basis of terms and conditions of insurance policy. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint is made.

3.       In order to prove his case, complainants tendered in evidence their affidavits Ex.CW1/A and Ex.CW1/B alongwith copies of documents Ex.C1 to Ex.C23.

4.       To rebut the evidence of complainant, Opposite Parties tendered in evidence affidavit of Sh.Sumit Kumar Sharma, Senior Manager Ex.OP1 to 3/A, affidavit of Sh.A.K.Sharma, Investigator Ex.OP1 to 3/B alongwith copies of documents Ex.OP1 to 3/1 to Ex.OP1 to 3/18.

5.       During the course of arguments, Ld. counsel for both the parties have mainly reiterated the same facts as narrated in the complaint as well as written reply. Ld. counsel for the complainants contended that complainants were insured with the opposite parties, vide policy no.211222/01/2021/001527 for the period 30.06.2020 to 29.06.2021. During the enforcement of above said policy, unfortunately the complainant no.2 suffered from stomach pain and he was got admitted in Deepak Hospital, Ludhiana on 06.10.2020 and discharged on 12.10.2020. However, claim of the complainant was rejected by opposite parties. Ld. counsel for the opposite parties repelled the aforesaid contentions of ld. counsel for the complainant on the ground that complainants were insured under Family Health Optimal Insurance Plan bearing No. P/211222/01/2021/001527 valid from 30.06.2020 to 29.06.2021. Further contended that the insured requested for a cashless authorization for the treatment from Deepak Hospital, Ludhiana. On scrutiny of the cashless claim documents as provided by the insured, initially, amount of Rs.10,000/- was approved but on receipt of additional documents from the hospital, it was observed from the treating doctor letter dated 12.10.2020, that the insured patient has been admitted for treatment of CLD and the patient is a known alcoholic. Thus expenses for this treatment are not admissible in accordance with the exclusion clause no 4.8 of the policy. Thus the previous approval for the amount of Rs.10,000/- was withdrawn being not payable vide letter dated 12.10.2020. Subsequently the insured submitted the claim documents for the reimbursement of medical expenses towards the treatment of CLD, PHT, TCP and ASCITES. On scrutiny of claim documents the medical team of the answering company observed from the indoor case records of the treating hospital that the insured patient is an alcoholic and the treatment of the insured patient is for the disease due to use of alcohol and the insured has not disclosed the fact regarding his being alcoholic in the proposal form thus, the claim was found not payable. As per Exclusion clause code Excl. 12 of the policy, the company is not liable to make any payment in respect of expenses for treatment for alcoholism, drug or substance abuse or any addictive condition and consequences thereof and the claim was rejected and conveyed to insured vide letter dated 17.01.2021.

6.       The case of the complainant is that due to stomach pain he was admitted in the hospital for treatment on 06.10.2020 thereafter, he was discharged on 12.10.2020 and it was a case of CLD with PHTN with Ascites with TCP as diagnosed by the doctors of Deepak Hospital, whereas the stand taken by the opposite party, the said ailment was caused due to use of alcohol. The plea of the Opposite Parties is that on scrutiny of claim documents by the insured, the medical team of the Opposite Parties observed from the records of the treating hospital that insured patient is an alcoholic and the treatment of the insured is for the disease due to use of alcohol, copy of Field Visit Report is Ex.OP1 to 3/8. So, the claim of the complainant was rejected as per exclusion clause of the policy. The claim of the complainant was rightly rejected and it is not permissible as per terms and conditions of the insurance policy. But in the medical record of Deepak Hospital even in the discharge summary, it is nowhere mentioned that the complainant suffered CLD with PHTN with Ascites with TCP due to alcohol intake. Thus, the opposite parties failed to prove the fact of repudiation of claim of the complainant by any cogent and convincing evidence on record that the ailment suffered by the complainant is the result of alcohol intake. Simply by relying upon the alleged medical history, the claim has been rejected is amounts to deficiency in service on the part of the Opposite Parties, however there is no such medical evidence is available on record.

7.       The other plea raised by Opposite Parties is that the claim of the complainant was rejected as per the terms and conditions of the policy.  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.”

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

9.       In view of the aforesaid facts and circumstances of the case,  we partly allow the complaint of the Complainants and direct Opposite Parties-Insurance Company to pay Rs.65000/- (Rupees Sixty Five Thousand only) incurred by complainant no.2 on his treatment alongwith interest @ 8% per annum from the date of filing the present complaint i.e. 26.11.2021 till its actual realization.   The compliance of this order be made by the Opposite Parties within 60 days from the date of receipt of copy of this order, failing which the complainant shall be at liberty to get the order enforced through the indulgence of this District Consumer Commission.  Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced in Open Commission.