Punjab

Tarn Taran

CC/61/2022

Manjinder Singh - Complainant(s)

Versus

Star Health and Allied - Opp.Party(s)

M.P.Arora

23 Oct 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION,ROOM NO. 208
DISTRICT ADMINISTRATIVE COMPLEX TARN TARAN
 
Complaint Case No. CC/61/2022
( Date of Filing : 04 Jul 2022 )
 
1. Manjinder Singh
Manjinder Singh s/o Narinder Singh, R/o Gali Gurmej Singh Tehsildar Wali, Jandiala Road, Tarn Taran, Tehsil and District Tarn Taran
...........Complainant(s)
Versus
1. Star Health and Allied
Star Health and Allied Insurance Company Branch Office Tarn Taran at Sarhali Road, Opposite Co-operative Bank, Near Muthoot Finance, Tarn Taran through its Branch Manager
2. Star Health and Allied
Star Health and Allied Insurance Company Limited Regd. Corporate Office : 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034 through its Authorized Officer/Head
............Opp.Party(s)
 
BEFORE: 
  Sh.Charanjit Singh PRESIDENT
  Mrs.Nidhi Verma MEMBER
 
PRESENT:
For the complainant Sh. M.P. Arora Advocate
......for the Complainant
 
For the O.Ps. Sh. R.P. Singh Advocate
......for the Opp. Party
Dated : 23 Oct 2024
Final Order / Judgement

ORDERS:

Charanjit Singh, President

1        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 34, 35, 36 and 38 of the Consumer Protection Act (herein after called   as 'the Act') against the opposite parties by alleging that the opposite parties i.e. Star Health and Allied insurance Company Ltd, "hereinafter called the Company" through its agents has approached the complainant and told about the insurance policies introduced by the opposite health parties. The complainant got attracted by the offers as dictated by the agents/officials of the company and got ready to purchase the Family Health Optima Insurance Plan vide proposal dated 21.8.2019 and the period of insurance is 21.8.2019 to 20.8.2020 and the policy commenced on date 21.8.2019. The detail of the insured persons is as following (1) Manjinder Singh (Self) (ii) Gurpreet Kaur (Spouse) (iii) Manikdeep Singh Maini (dependent child) (iv) Kirat Maini (dependent child). The basis floater sum insured is Rs. 5,00,000/- (Rs. Five Lakhs only), which can be used by any of the insured person. The insured complainant i.e. Manjinder Singh has suffered with Triple Vessel Disease as such she remained admitted in the hospital namely Amandeep Medicity Hospital, Mall Road, Amritsar from 16.12.2019 upto 20.12.2019, where his treatment with regard to above said disease was undergone by the concerned doctors of the Hospital and the complainant has incurred the total expenditure of Rs.2,81,000/- on his treatment in the hospital and the same were paid by the complainant to the hospital. The intimation with regard to the treatment & expenditure incurred was given by the complainant to the Insurance Company as the insurance company is under obligation to reimburse Rs.2,81,000/- complainant as per the policy. Afterwards, as per the directions of the concerned officials, the complainant has provided all the relevant demanded documents to the insurance company. Further the complainant has also fulfilled all others documentary formalities as directed by the officials of the company. The officials of the company have assured the complainant that his claim will be settled very soon. After waiting for some time, the complainant has visited the office of insurance company for several times to know about the settlement of claim and further has contacted concerned officials for many times but no positive response has been given by the concerned officials and further the company has done nothing favorable in this respect in order to settle the claim of the complainant. Later on, the complainant has come to know that the company has repudiated the claim of the complainant on 7.7.2020 (wrongly written as 7.7.2022), which was intimated to him after several months and he astonished to see that the company has repudiated the claim by citing the observation, which is reproduced here under "Based on findings our medical team is of the opinion that insured patient has longstanding cardiac disease i.e. heart disease prior to date of commencement of first year policy. We are, therefore unable to consider your representation favorably."  The complainant has several times asked the officials of the company that on the basis of which document or findings, the company has repudiated his claim but no satisfactory answer has ever been given to the complainant. The complainant has prayed that the opposite parties may be directed to reimburse the expenses of Rs. 2,81,000/- as incurred by the complainant on the treatment of the insured. The opposite parties may also be directed to compensate the complainant for mental and physical harassment to the complainants suffered due to unfair trade practice and deficiencies in services to the tune of Rs. 20,000/-. The opposite parties may also be directed to pay amount of Rs. 10,000/- to the complainants by way of costs of litigation and counsel fee and pendentelite interest @ 12% P.A. from the date of filing of the complaint. Alongwith the complaint, the complainant has placed on record affidavit of complainant Ex. C-1, self attested copy of policy schedule HDFC Ex. C-2, Self attested copy of identity cards Ex. C-3, Self attested copy of Advance premium receipt Ex. C-4, Self attested copy of medical record Ex. C-5, Self attested copy of Discharge Summary Ex. C-6, Self attested copy of Cash detail Bill Ex. C-7, Self attested copy of Rejection details Ex. C-8, Self attested copy of Adhar Card Ex. C-9.

2        Notice of this complaint was sent to the opposite parties and the opposite parties appeared through counsel and filed written version by interalia pleadings that the complainant has moved the present complaint with malafide intention and ulterior motives to grab illegal amount from the opposite parties, hence the complaint is not maintainable in the eyes of law and same deserves to be dismissed. The opposite parties had rendered all possible services to the complainant and there was/ is no deficiency in services on the part of insurance company as such the complaint deserves to be dismissed. The complainant has not approached this commission with clean hands and the complaint contains misleading statements, averments and suppression of material facts, hence, the case deserves to be dismissed in limini.  The insured availed Family Health Optima Insurance Plan vide policy No. P/211226/01/2020/000786 for the period from 21.8.2019 to 20.8.2020 covering Mr. Manjinder Singh self Mrs. Gurpreet Kaur-spouse and two dependent children Mr. Manikdeep Singh Maini and Ms. Kirat Maini for the sum insured of Rs. 5,00,000/-. 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 alongwith the Policy Schedule. Moreover, it is clearly stated in the Policy Schedule “The Insurance Under this Policy is subject to conditions, clauses, warranties, exclusions etc. attached” The policy is contractual in nature and the claims arising therein are subject to the terms and condition forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions executed the proposal form. The opposite parties had rendered all possible services to the complainant. The complainant has never raised any issue with regard to non-receipt of terms and conditions of Insurance Policy.  The complainant has never raised any issued with regard to non-receipt of terms and conditions of Insurance Policy. Further being a prudent man, the insured would have read the schedule as he had chosen to be insured and had paid for the same. The covering letter sent to the insured does have reference to the terms and conditions, further, the schedule also reads, the insurance under the policy is subject to conditions, clauses, warranties, exclusions etc. attached. Nothing had stopped the insured from approaching the insurer to obtain the policy terms and conditions. The insured was in possession of the policy since 21.8.2019 but the complainant has never raised any objection that he had not received the terms and conditions of the Insurance Policy. This contention is devoid of merits.  In this case insured patient Mr. Manjinder Singh was admitted at Amandeep Medicity for the treatment of CAD, LVEF 42% & triple vessel disease and raised pre authorization request for cashless treatment. On scrutiny of the medical documents, it was observed by the opposite parties that during cashless process they were not able to ascertain duration of above illness as the claim require further evaluation thus cashless was denied and intimation to this affect was given to the complainant vide letter dated 18.12.2019. The opposite parties directed the insured to come for reimbursement alongwith medical record and bill.  Thereafter, the complainant submitted medical documents for reimbursement of the claim. On scrutiny of the medical documents, the opposite parties observed that the CAG report dated 16.12.2019 confirms chronic longstanding heart disease and also the cardiac enzymes were negative. It is evident from the above findings that the above medical condition cannot occur within a short span of time i.e. 4 months. Hence insured patient had longstanding cardiac disease i.e. heart disease prior to date of commencement of first year policy. The above admission and treatment of the insured patient is for the pre-existing heart (coronary artery) disease. During inception of the policy which was from 21.8.2019, insured failed to disclose the above health complication. Therefore, the claim was rejected and intimation in this regard was given to the complainant vide letters dated 23.1.2020 and 7.7.2020. As per the contract of insurance, the medical history/ health details of the person(s) proposed for insurance are to be disclosed in the proposal form at the time of inception of the policy. Since, the insured had not disclosed the above mentioned pre-existing disease in the proposal form at the time of inception of the policy, it is now incorporated in the policy as pre-existing disease/ condition by passing endorsement dated 18.1.2020. As per waiting period 3(iii) of the above policy issued the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease / condition until 48 months of continuous coverage has elapsed, since inception of the policy i.e. from 21.8.02019. as per the contract of insurance, it is the duty of the proposer to disclose all the material facts to the insurer so that the insurer evaluates the material facts and decide whether to accept the proposal or not, as the insurance contract is based on utmost good faith. In case of health insurance contracts, disclosure of health details are the material facts. Insured has to disclose all his past medical history in the proposal, which is material fact for issuing policy to the insured because of non disclosure, our company was deprived an opportunity to evaluate the risk and reject the proposal 2. Information was sought from the insurer on PED if any, in column 4, for a specific query the insured answered in the negative. The exact information on quarries and reply given by the insured is reproduced below:-

Has the person proposed for insured even suffered or suffering from any of the following:-

          (C)     Heart disease. If yes since when “No”

          The insured answering “No’ for the above specific questions relating to medical history in the proposal amounts to non-disclosure  of material fact making the contract of insurance voidable. The complainant is estopped by his own act and conduct from filing the present complaint, as the complaint has been filed without any cause of action. The complainant has got no locus standi to file the present complaint. The complaint has been filed without any cause of action against the opposite parties. The opposite parties have denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite parties have placed on record affidavit of Sumit Kumar Sharma Ex. OP1,2/1, Self attested copy of authority letter Ex. OP1,2/2, self attested copy of proposal form Ex. OP1,2/3, Self attested copy of policy Ex. OP1,2/4, Self attested copy of terms and conditions Ex. OP1,2/5, Self attested copy of pre authorization request form Ex. OP1,2/6, Self attested copy of cashless denial letter dated 18.12.2019 Ex. OP1,2/7, self attested copy of claim form Ex. OP1,2/8, Self attested copy of discharge summary Ex. OP1,2/9, Self attested copy of C.A.G report dated 16.12.2019 Ex. OP1,2/10, Self attested copy of final Bill Ex. OP1,2/11, Self attested copy of claim reputation letters dated 23.1.2020 and 7.7.2020 Ex. OP1,2/12, Self attested copy of endorsement schedule dated 18.1.2020 Ex. OP1,2/13.

3        We have heard the Ld. counsel for the complainant and opposite parties and have carefully gone through the record.

4        Ld. Counsel for the complainant contended that the complainant got attracted by the offers as dictated by the agents/officials of the company and got ready to purchase the Family Health Optima Insurance Plan vide proposal dated 21.8.2019 and the period of insurance is 21.8.2019 to 20.8.2020 and the policy commenced on date 21.8.2019. The detail of the insured persons is as following (1)Manjinder Singh (Self) (ii) Gurpreet Kaur (Spouse) (iii) Manikdeep Singh Maini (dependent child) (iv) Kirat Maini (dependent child). The basis floater sum insured is Rs. 5,00,000/- (Rs. Five Lakhs only), which can be used by any of the insured person. The insured complainant i.e. Manjinder Singh has suffered with Triple Vessel Disease as such she remained admitted in the hospital namely Amandeep Medicity Hospital, Mall Road, Amritsar from 16.12.2019 upto 20.12.2019, where his treatment with regard to above said disease was undergone by the concerned doctors of the Hospital and the complainant has incurred the total expenditure of Rs.2,81,000/- on his treatment in the hospital and the same were paid by the complainant to the hospital. He further contended that the intimation with regard to the treatment & expenditure incurred was given by the complainant to the Insurance Company as the insurance company is under obligation to reimburse Rs.2,81,000/- complainant as per the policy. Afterwards, as per the directions of the concerned officials, the complainant has provided all the relevant demanded documents to the insurance company. The complainant has come to know that the company has repudiated the claim of the complainant on 7.7.2020, which was intimated to him after several months and he astonished to see that the company has repudiated the claim by citing the observation, which is reproduced here under "Based on findings our medical team is of the opinion that insured patient has longstanding cardiac disease i.e. heart disease prior to date of commencement of first year policy. We are, therefore unable to consider your representation favorably." and prayed that the present complaint may be allowed.

5        Ld. Counsel for the opposite parties contended that the insured availed Family Health Optima Insurance Plan vide policy No. P/211226/01/2020/000786 for the period from 21.8.2019 to 20.8.2020 covering Mr. Manjinder Singh self Mrs. Gurpreet Kaur-spouse and two dependent children Mr. Manikdeep Singh Maini and Ms. Kirat Maini for the sum insured of Rs. 5,00,000/-. 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 alongwith the Policy Schedule. Moreover, it is clearly stated in the Policy Schedule “The Insurance Under this Policy is subject to conditions, clauses, warranties, exclusions etc. attached” The policy is contractual in nature and the claims arising therein are subject to the terms and condition forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions executed the proposal form. The opposite parties had rendered all possible services to the complainant. The complainant has never raised any issue with regard to non-receipt of terms and conditions of Insurance Policy.  The complainant has never raised any issued with regard to non-receipt of terms and conditions of Insurance Policy. Further being a prudent man, the insured would have read the schedule as he had chosen to be insured and had paid for the same. The covering letter sent to the insured does have reference to the terms and conditions, further, the schedule also reads, the insurance under the policy is subject to conditions, clauses, warranties, exclusions etc. He further contended that nothing had stopped the insured from approaching the insurer to obtain the policy terms and conditions. The insured was in possession of the policy since 21.8.2019 but the complainant has never raised any objection that he had not received the terms and conditions of the Insurance Policy. In this case insured patient Mr. Manjinder Singh was admitted at Amandeep Medicity for the treatment of CAD, LVEF 42% & triple vessel disease and raised pre authorization request for cashless treatment. On scrutiny of the medical documents, it was observed by the opposite parties that during cashless process they were not able to ascertain duration of above illness as the claim require further evaluation thus cashless was denied and intimation to this affect was given to the complainant vide letter dated 18.12.2019. The opposite parties directed the insured to come for reimbursement alongwith medical record and bill. The complainant submitted medical documents for reimbursement of the claim. On scrutiny of the medical documents, the opposite parties observed that the CAG report dated 16.12.2019 confirms chronic longstanding heart disease and also the cardiac enzymes were negative. It is evident from the above findings that the above medical condition cannot occur within a short span of time i.e. 4 months. Insured patient had longstanding cardiac disease i.e. heart disease prior to date of commencement of first year policy. The above admission and treatment of the insured patient is for the pre-existing heart (coronary artery) disease. During inception of the policy which was from 21.8.2019, insured failed to disclose the above health complication. Therefore, the claim was rejected and intimation in this regard was given to the complainant vide letters dated 23.1.2020 and 7.7.2020. As per the contract of insurance, the medical history/ health details of the person(s) proposed for insurance are to be disclosed in the proposal form at the time of inception of the policy. Since, the insured had not disclosed the above mentioned pre-existing disease in the proposal form at the time of inception of the policy, it is now incorporated in the policy as pre-existing disease/ condition by passing endorsement dated 18.1.2020. As per waiting period 3(iii) of the above policy issued the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease / condition until 48 months of continuous coverage has elapsed, since inception of the policy i.e. from 21.8.02019. He further contended that as per the contract of insurance, it is the duty of the proposer to disclose all the material facts to the insurer so that the insurer evaluates the material facts and decide whether to accept the proposal or not, as the insurance contract is based on utmost good faith. In case of health insurance contracts, disclosure of health details are the material facts. Insured has to disclose all his past medical history in the proposal, which is material fact for issuing policy to the insured because of non disclosure, our company was deprived an opportunity to evaluate the risk and reject the proposal 2. Information was sought from the insurer on PED if any, in column 4, for a specific query the insured answered in the negative. The exact information on quarries and reply given by the insured is reproduced below:-

Has the person proposed for insured even suffered or suffering from any of the following:-

          (C)     Heart disease. If yes since when “No”

          The insured answering “No’ for the above specific questions relating to medical history in the proposal amounts to non-disclosure  of material fact making the contract of insurance voidable. The complainant is estopped by his own act and conduct from filing the present complaint, as the complaint has been filed without any cause of action. The complainant has got no locus standi to file the present complaint. The complaint has been filed without any cause of action against the opposite parties and prayed for dismissal of the same.

6        We have carefully gone through the rival contentions of the parties.

7        In the present case insurance is not disputed and insurance is effective from 21.8.2019 to 20.8.2020. It is also not disputed that the complainant has taken treatment from Amandeep Medicity Hospital, Mall Road, Amritsar and remained admitted in the said hospital from 16.12.2019 to 20.12.2019 i.e. during the policy period. The case of the complainant is that he lodged his claim of Rs. 2,81,000/- with the opposite parties but the opposite parties have not given his genuine claim. On the other hands the opposite parties have repudiated the claim of the complainant vide repudiation letter dated 23.1.20220 and repudiation letter dated 7.7.2020 Ex. OP1,2/,12 which are reproduced as follows:-

          Operative para of Letter dated 23.1.2022 is as:-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of coronary artery disease-triple vessel disease with angina.

It is observed that the findings of CAG report dated 16.12.2019 confirms chronic, longstanding heart disease and also, the cardiac enzymes are negative. Based on these findings, our medical team is of the opinion that the insured patient has heart disease existing prior to inception of the first medical insurance policy. Hence, heart disease is pre existing disease. The present admission and treatment of insured patient is for the pre existing heart (coronary artery) disease.

As per waiting period .3(iii) of the above policy issued to you, the Company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease/ condition, until 48 months of continuous coverage has elapsed, since inception of the policy i.e. from 21.8.2019.

We are therefore, unable to settle your claim under the above policy and where hereby repudiate your claim. It is brought to your attention that as per the contract of insurance, the medical history/ health details of the person (s) proposed for insurance are to be disclosed, in the proposal form at the time of inception of the policy. Since you have not disclosed then above pre existing disease in the proposal form at the time of inception of the policy, it is now incorporated in your policy as pre existing disease / condition by passing endorsement.

The above decisions are taken as per the terms and conditions of the policy and based on the claim details/ documents submitted

                   Operative Para of letter dated 7.7.2020 is as:-

We acknowledge receipt of copy of investigation reports in response to our letter dated 23.1.2020 seeking reconsideration of your claim

Our medical team has perused your medical records referred above and has noted the contents. The team which re-examined the claim records has observed that the stress ECHO dated 01.06.2019-TMT equivocal. The cardiac enzymes are negative and CAG report dated 16.12.2019 shows chronic long standing multiple vessel disease with significant stenosis. Our medical team is of the opinion that these findings cannot occur within 4 months. Based on these findings our medical team is of the opinion that insured patient has longstanding cardiac i.e. heart disease prior to date of commencement of first year policy.

We are therefore unable to consider your representation favourably

The opposite parties have merely rejected the claim on the ground that the complainant was having pre-existing disease at the time of taking the policy in question and he has not disclosed the same at that time. But we are not agreed with the contention of the opposite parties because the opposite parties have not placed on record any document regarding the pre-existing disease of the complainant.  The opposite parties have also not placed on record any investigation report as well as medical record of any hospital from which the complainant has taken treatment and there is no medical certificate of any expert which suggests that the complainant is suffering from alleged disease as alleged in repudiation letter dated 7.7.2020. The opposite parties have repudiated the claim of the complainant only on oral version which is not proved as per requirement of law.

8        We have also gone through some judicial pronouncements relevant to the present case. In case M/s ICICI Prudential Life Insurance company Ltd. Vs Veena Sharma & Others 2014(4) CLT 507(NC), the Hon’ble National Commission held that it was for the insurance company to prove that complainant was suffering from pre-existing disease and has knowingly failed to disclose the same. The Hon’ble National Commission has also relied upon a case decided by the Hon’ble Supreme Court titled Balwinder Kaur Vs Life Insurance Corporation of India, Civil Appeal No. 7969 of 2010 decided on 13.9.2010, wherein it was held that the onus to prove that deceased had obtained policy by suppressing the material facts relating to his illness, was on the corporation at the time of taking policy and he deliberately suppressed the facts.

9        In case National Insurance Company Limited and Another Vs Balwinder Singh 2012(1) CLT 34, the Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh held that the appellants have not produced any evidence to prove that before the purchase of 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. This pronouncement was based upon the decision of the Hon’ble Apex Court in case titled LIC Vs GM Channabasamna, 1991(1) SCC 357  and of the Hon’ble National Commission in case titled LIC Vs Joginder Kaur and others, 2005(2) CLT 229

10      In case Kotak Mohindra Old Mutual Life Insurance Ltd. Vs Chander Isarsingh Dhansinghani & anr 2013(3) CLT 186, the Hon’ble State Commission Ahemdabad held that Doctor certificate without any affidavit of the doctor in support cannot be basis for repudiation of claim. It was held that the onus was upon the appellant to prove that the insured suppressed material facts. In this pronouncement citations Smt. Sunita Agarwal Vs LIC of India, III (2005) CPJ 446 = 2005 CTJ 874 relying on Supreme Court Judgment in case of Mithoolal Nayak, AIR 1962 SC 814, the Hon’ble MP State Commission were discussed.

11      In case Tarlok Chand Khanna Vs United India Insurance Co. Ltd. 2012(2) CLT 617(NC) wherein the Hon’ble National Commission held that onus to prove was on the respondent/ insurance company regarding pre-existing disease. In that case insurance company repudiated the claim on the ground that replacement of knees cannot occur within days or months and infact takes years for the keens to degenerate to a condition where total replacement is medically advised. In this case, Tarlok Chand Khanna obtained a mediclaim insurance policy from the respondent/ Insurance company valid from 1.1.2002 to 31.12.2002 for a sum of Rs. 1,50,000/- for himself and his wife Smt. Kurana Khanna. Smt. Karuna Khanna developed pain in her knees and on 15.9.2002 she underwent surgery for knees replacement of her both knees at a total cost of Rs. 1,78,945/-. She died due to sudden Cardiac arrest in the hospital on 29.9.2002. The complaint to claim the expenses was dismissed by the District Forum on the ground that there is no affidavit of any doctor of Nayyar Hospital nor there is any death certificate issued by Cardiologist showing cause of death of the wife of the complainant as cardiac arrest on 29.9.2002. The Hon’ble State Commission also dismissed the appeal. Sh. Updip Singh, ld. counsel for revisionist contended before the Hon’ble National Commission that the onus to prove that she had a pre-existing disease was on the respondent who failed to file any expert medical or credible evidence in support of its case. The counsel for petitioner relied upon a case titled National Insurance Co. Ltd. Vs Raj Narain, 1(2008)CPJ 501(NC), wherein Hon’ble National Commission had observed as follows:-

“Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the Insurance Company relies on their Clause 4.1 of the policy in a mala fide manner to repudiate all the claims. No claim is payable under the mediclaim policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him which he is genuinely unaware of them. Hindsight everyone relies much later that he should have known from some symptom. If this is so every person should do medical studies and further not take any insurance policy.” In view of the above facts, the Fora below erred in saying that claim was rightly repudiated.  

          In a nutshell it was held that onus was on the insurance company to prove that insured was suffering from pre-existing disease at the time of purchase of policy.

12      In case United India Insurance Company Vs Safiya 2013(3) CLT 195, identical view was taken by Hon’ble Kerala State consumer Disputes Redressal Commission, Thruvananthapuram

13      Furthermore, It is usual with the insurance company to show all types of green 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 DharmendraGoel 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.UshaYadav& 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.

14      In light of the above discussion, the complaint succeeds and the same is hereby allowed with costs in favour of the complainant. The opposite Parties are directed to make the payment of Rs. 2,81,000/- to the complainant. The complainant has been harassed by the opposite parties unnecessarily for a long time. The complainant is also entitled to Rs. 20,000/- as compensation on account of harassment and mental agony and Rs 10,000/- as litigation expenses. Opposite Parties are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation.  Copy of order be supplied to the parties free of costs as per rules. File be consigned to record room.

Announced in Open Commission

23.10.2024

 
 
[ Sh.Charanjit Singh]
PRESIDENT
 
 
[ Mrs.Nidhi Verma]
MEMBER
 

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