Haryana

Karnal

CC/284/2020

Kapil Arora - Complainant(s)

Versus

Star Health & Allied Insurance Company Limited - Opp.Party(s)

Tapan Verma

23 Jul 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No.284 of 2020

                                                        Date of instt.07.08.2020

                                                        Date of Decision:23.07.2024

 

Kapil Arora son of Shri Sham Sunder, resident of house no.16/6, Ram Nagar, near Sanatan Dharam Mandir, Kanral. Aadhar no.5519 9497 0814.

                                                 …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance Co. Ltd., # SCF-137, 2^nd floor , near ICICI Bank, Sector-13, Urban Estate, Karnal-132001, through its Branch Manager.

                                               

2. Star Health and Allied Insurance Co. Ltd.,# no.15, Shri Balaji Complex, 1^st floor, Whits Lane, Roy Apettach Chennai-600014 through its M.D./CEO/Authorized Signatory.

 

3. The Grievance Redressal Officer, Corporate Grievance Department, Star Health and Allied Insurance C. Ltd. no.1, New Tank Street, Valluvar Kottam High Road, Chennai-600034.

 

4. Virk Hospital Pvt. Ltd.# 363-364, Randhir Lane, near Dayal Singh College Karnal through its Managing Director.

 

5. The Oriental Insurance Co. Ltd. Divisional Office at Mahila Ashram Complex, behind Bus Stand, Karnal, through its Divisional Manager (Insurer of Virk Hospital, Karnal).

 

…..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member

      Ms. Sarvjeet Kaur…..Member

 

Argued by:  Shri Sukhbir Beniwal, counsel for the complainant.

                    Shri Mohit Goyal, counsel for the OPs no.1 to 3.

                    Shri Baljeet Chawla, counsel for the OP no.4.

                    Shri Naveen Khetarpal, counsel for the OP no.5.

 

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant continuously purchasing Health Insurance Policies in the name and style of “Family Health Optima Insurance Plan’ from the OPs no.1 and 2. The details of which are as under:-

Policy number	Period of  Policy
P/700002/01/2016/029577	15.10.2015 to 14.10.2016
P/700002/01/2017/042824	15.10.2016 to 14.10.2017
P/700002/01/2018/050750	15.10.2017 to 14.10.2018
P/700002/01/2019/025507	15.10.2018 to 14.10.2019
P/700002/01/2020/032535	15.10.2019 to 14.10.2019

 

The complainant himself, his wife Pooja and his son Kanishk Arora are duly covered in the aforesaid policies. In the year 2014, wife of complainant had got swelling in her feet and thereafter the complainant has got medical check-up of his wife from Dr. Udham Singh, who got Renal Pathology Examination (Biopsy to Kidney) form Dr. Lal Pathlabs, Patiala, Punjab. In the aforesaid report some leakage of protein was found in her urine and the concerned doctor advised six month treatment to the wife of the complainant and had ensure that after such treatment, the wife of the complainant will be fine. Afer such medical checkup the complainant has got treatment of his wife from Dr. Udham Singh, c/o Colombia Asia Hospital Patiala, Punjab and after getting aforesaid treatment of six months, the wife of complainant had improved her good health and become fit and fine. While purchasing the aforesaid health insurance policy, the complainant had duly informed about the aforesaid problem of wife i.e. protein leakage in urine and complainant had also informed about ongoing treatment of his wife to the representative of OPs. The representative of OPs even after checking and inspecting all the medical record of the wife of complainant, at his own had declared fit case for the grant of aforesaid health insurance policy in favour of the complainant. Then complainant purchased the aforesaid Family Health Optima Insurance Plan from the OPs. However, in the aforesaid policies, the company of OPs has duly mentioned pre-existing disease as Urine Infection. In the month of April 2018, the wife of complainant suffered some physical problem and then complainant had brought her P.G.I.M.E.R Chandigarh for her treatment, where it has been transpired that now the wife of the complainant is suffering from Chronic Kidney Disease and she should require diagnosis of CKD (Dialysis). After coming to know these facts, complainant had started getting treatment of his wife from the P.G.I.M.E.R. Chandigarh as well as from the hospital of OP no.4. As per the terms of policies, complainant was not eligible for getting claim qua treatment of his wife Smt. Pooja Arora till October 2019, so the complainant has not claimed for medical reimbursement or any other claim, while getting treatment of his wife from PGIMER Chandigarh as well as from the hospital of OP no.4 whereas the treatment of the wife of the complainant is continuously going on. After attaining the eligibility for filing claim, the complainant had lodged claim before the company of the OPs no.1 and 2. The detail of the submitted claim are as under:-

Date of admission	Claim Intimation Number	Amount Claimed
16.10.2019	CLI/2020/161130/0549925	Rs.7,750/-
29.10.2019	CLI/2020/161130/0590657	Rs.40,002/-
09.11.2019	CLI/2020/161130/0628773	Rs.7,636/-
03.12.2019	CLI/2020/161130/0706908	Rs.1,30,235/-
	Total	Rs.1,85,623/-

 

2.             It is further alleged that after attaining eligibility for getting claim, the aforesaid four claims have been repudiated by the OPs no.1 and 2 with the observation that “the insured patient is known case of chronic kidney disease for the past 4½ years, which confirms that insured patient is suffering from chronic kidney disease prior to date of commencement of first year policy. OPs repudiated the claim of complainant by alleging that as per condition no.12, the policy is liable to be cancelled and necessary action will be taken by the corporate office of the OPs no.1 and 2. Aforesaid observation i.e. the injured patient is known case of chronic kidney disease for the past 4½ years, has been considered by the OPs no.1 and 2 on the basis of alleged certificate issued by the OP no.4, vide which the OP no.4 has wrongly mentioned that the patient is K/C/O CKD for the last 4 years and on dialysis (Hemodialysis) for last one year. After receiving the aforesaid letters, complainant contacted the OP no.4 and asked about the reason for giving said certificate to the OPs no.1 and 2, then OP no.4 admitted its gild and had issued another certificate in favour of the complainant vide which has been mentioned that “the patient Pooja 30 years/F who was admitted in this hospital on 19.07.2018, vide IPD no.1824/18 (UHD no.19396/18) with diagnosis of CKD, Anaemia, Uremia and CHF. During admission, some attendant has provided the history of disease for last four years while patient visited this hospital, on 19.07.2018 only and we are not having any such record of CKD history. Thereafter, the OPs no.1 and 2 has sent an email as well as a letter dated 27.12.2019 to the complainant, vide which it has been informed by the OPs no.1 and 2 to the complainant that the name of the wife of complainant i.e. patient Pooja has been removed from the policy. The said act and conduct of the OPs no.1 and 2 is an illegal and unlawful and against the principles of natural justice. Whereas the patient/wife of complainant is eligible to be treated as insurer in the aforesaid policy till its validity. It is further pleaded that complainant approached the OP no.3, who is Grievance Redressal Officer of OPs no.1 and 2 and requested to disburse the claim amount of aforementioned four claims in favour of the complainant and further declare the complainant eligible for lodging further claims in the company of OPs no.1 and 2 till the validity of the policy but OP no.3 has also repudiated the claim of the complainant. The claim of the complainant has been repudiated by the OPs no.1 and 2 on the basis of certificate issued by OP no.4 without any record. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

3.             On notice, OPs no.1 to 3 appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action and concealment of true and material facts. On merits, it is pleaded that OPs issued Family Health Optima Insurance Plan, vide policy no.P/700002/01/2016/029577 for the period of 15.10.2015 to 14.10.2016. It was further renewed vide policy no. P/700002/01/2017/042824 for the period of 15.10.2016 to 14.10.2017. It was further renewed vide policy no.P/700002/01/2018/50750 for the period from 15.10.2017 to 14.10.2018. It was further renewed vide policy no.P/700002/01/2019/025507 for the period from 15.10.2018 to 14.10.2019. It was further renewed vide policy no.P/161130/01/2020/032535 for the period from 15.10.2019 to 14.10.2020 covering risk of Kapil Arora (self), Pooja Arora (spouse) (PED Urnine Infection) and Kanishak Arora (Dependent child), the basic floater sum assured was Rs.5,00,000/-. The terms and conditions were explained to the complainant at the time of proposing policy and same was served to the complainant alongwith the policy schedule. It is further pleaded that claims were reported on the abovesaid policy were registered. The detail of all the claims is as under:-

1. Claim no.CLI/2020/161130/0549925

That insured patient Mrs. Pooja Arora aged 32 years female was admitted on 16.10.2019 at Virk Hospital, Karnal. As per medical record, the insured patient was admitted in day care for (CKD) dialysis. As per claim form the insured patient claimed Rs.7750/- during imbursement of medical expenses. The patient submitted claim documents for reimbursement of medical expenses and the same was repudiated and communicated to the insured vide letter dated 26.11.2019.

2. Claim no.CLI/2020/161130/0590657

That insured patient Mrs. Pooja Arora aged 32 years female was admitted on 20.10.2019 at Virk Hospital, Karnal and discharged on 01.11.2019 as per discharge summary, the insured patient was diagnosed with CKD on HD with Hyperkalemia. As per claim form the insured patient claimed Rs.40,002/- during reimbursement of medial expenses. The patient submitted claim documents for reimbursement of medical expenses and the same was repudiated and communicated vide letter dated 23.11.2019 and 25.01.2020 respectively.

3. Claim no.CLI/2020/161130/0628773

That insured patient Mrs. Pooja Arora Aged 32 years female was admitted on 09.11.2019 at Virk Hospital, Karnal, the insured patient was diagnosed with CKD Dialysis. As per claim form the insured patient claimed Rs.7636/- during reimbursement of medical expenses. The patient submitted claim documents for reimbursement of medical expenses and the same was repudiated and communicated, vide letter dated 12.12.2019.

4. Claim no.CLI/2020/161130/0706908

That insured patient Mrs. Pooja Arora aged 32 years female was admitted on 03.12.2019 at Virk Hospital, Karnal and discharge on 12.12.2019 as per discharge summary, the insured patient was diagnosed with Hypertension/CKD with Hyperkalemia. As per claim form the insured patient claimed Rs.1,30,235/- during reimbursement of medical expenses. The patient submitted claim documents for reimbursement of medical expenses and the same was repudiated and communicated, vide letter dated 25.01.2020.

On scrutiny of the claim documents of the four claims, it has been observed by the OPs that,

As per the Indoor case papers dated 03.12.2019, the insured is a known case of CKD on dialysis.

As per the treating doctor certificate submitted by the insured, that the insured is a known case CKD for the last foru years and on dialysis (Hemodialysis) for the last one year.

As per indoor case record, history sheet dated 19.10.2019 from the treating hospital, the insured patient was a known case for the past 4-5 years. However, the insured submitted another treating doctor certificate dated 25.12.2019, stating that some attendant has provided the history of disease for last four years while patient visited this hospital on 19.07.2018 only.

4.                 It is further pleaded that the treating hospital insured has not provided any first consultation slip or investigation report to prove this contention. From the above findings, it is confined that insured patient was known case of chronic kidney disease prior to the date of commencement of 1^st year policy and same was not disclosed in the proposal at the time of taking the insurance policy which amount to non-disclosure of material facts. The present admission and treatment of the insured patient is non-disclosed of CKD. Information sought in the proposal which the proposal should provide in the respective column for each of the person proposed to be covered under the column health history for a query do you have any health problem? The insured disclosed only Urine Infection for Pooja Arora and under the query whether any of the insured Member covered in the policy has suffered/advised treatment for any of the following disease:

a. Cancer                              -       No

b. Chronic Kidney Disease      -       No

c   Brain Stroke/CVA               -       No

d. Parksinsons Disease           -       No

e  Alzehimer’s disease            -       No

f.  Renal Complications           -       No

g. Heart Diseases                   -       No.

 

The insured replied in negative, which is clearly a non-disclosure of material facts making the contract of insurance. Thus, claim was rightly repudiated by the OPs and communicated to the insured.  There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

5.             OP no.4 filed its separate written version raising preliminary objections with regard to maintainability. On merits, it is pleaded that the present complaint is related to the treatment obtained by the wife of the complainant from various hospitals and the same does not relate to OP. The complaint relates to the OPs no.1 and 2. It is further pleaded that on the basis of information provided by some attendant, it was mentioned in the record that patient was having the history of said disease from the last 4 years. No such record was produced by the patient at the time of admission nor such record was perused, therefore, the OP cannot vouch safe whether the patient had the history of CKD from the last four years or not. The fact regarding mentioning of history of patient from the last four years was brought to the notice of the hospital by the complainant and the hospital immediately issued a letter in this regard to the complainant clarifying regarding the mentioning of history of patient. There is no relation with the answering OP regarding the repudiation of the claim of the complainant. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint qua OP no.4.

6.             OP no.5 filed its written version raising preliminary objections with regard to maintainability and concealment of true and material facts. On merits, it is pleaded that no intimation was given regarding the alleged claim to the OP either by complainant or by the OP no.4. It is further pleaded that it is not the case of medical negligence on the part of treating hospital which has been insured with OP and as such no claim is maintainable against the OP. As the matter of fact the case is with regard to deficiency in service on the part of the OPs no.1 and 2 for repudiating the claim of the complainant. In the absence of pleading against the OP, the alleged complaint is liable to be dismissed against the answering OP. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint qua OP no.5.

7.             Parties then led their respective evidence.

8.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copies of insurance policies from the year 2015 to 2021 Ex.C1 to Ex.C5, copy of Renal Pathology report Ex.C6, copy of PGI Report Ex.C7, copy of repudiation letters dated 26.11.2019, 23.11.2019, 12.12.2019, 25.01.2020 Ex.C8, copy of certificate of doctor dated 15.11.2019 Ex.C9, copy of clarification letter of doctor dated 25.12.2019 Ex.C10, copy of endorsement schedule dated 16.10.2019 regarding deletion of name of Pooja Arora from the insurance policy Ex.C11, copy of email dated 15.07.2020 of Grievance Redressal Officer, Corporate Grievance Department, Star Health and Allied Insurance Company Ex.C12, copy of latest policy dated 15.10.2022 to 14.10.2023 wherein Chronic Kidney disease permanently excluded Ex.C13, copy of letter addition of name of Pooja Arora after soft deletion Ex.C14, copy of conversion between complainant and employee of policy bazaar Ex.C15, Pen Drive Ex.C16, copy of certificate under section 65B of the Evidence Act Ex.C17 and closed the evidence  on 03.01.2023 by suffering separate statement.

9.             On the other hand, learned counsel for the OPs no.1 to 3 has tendered into evidence affidavit of Sumit Kumar Sharma Senior Manager Ex.OPW1/A, copy of proposal form Ex.OP1, copy of terms and conditions of the insurance policy Ex.OP2, copy of endorsement schedule Ex.OP3, copy of terms and conditions of the insurance policy Ex.OP4, copy of claim form Ex.OP5, copy of certificate of doctor dated 15.11.2019 Ex.OP6, copy of bills Ex.OP7, copy of repudiation letter dated 26.11.2019 Ex.OP8, copy of bill assessment sheet Ex.OP9, copy of claim form Ex.OP10, copy of consultation slips Ex.OP11 and Ex.OP12, copy of letter dated 12.12.2019 Ex.OP13, copy of bill assessment sheet Ex.OP14, copy of claim form Ex.OP15, copy of discharge summary Ex.OP16, copy of final bill Ex.OP17, copy of letter dated 25.01.2020 Ex.OP18, copy of claim form Ex.OP19, copy of discharge summary Ex.OP20, copy of history sheet Ex.OP21, copy of final bill Ex.OP22, copy of claim letter dated 23.11.2019 Ex.OP23, copy of letter dated 25.01.2020 Ex.OP24, copy of order dated 10.09.2020 passed by Insurance Ombudsman Ex.OP25, copy of Renal Pathology Report Ex.OP26, copy of complaint to Insurance Ombudsman Ex.OP27, copy  of mail conversion Ex.P28, copies of bills assessment sheets Ex.29 and Ex.30 and closed the evidence on 14.12.2023 by suffering separate statement.

10.           Learned counsel for the OP no.4 has tendered into evidence affidavit of Dr. Neterpal Rawal Ex.OP4/A, copy of admission file and history sheet Ex.OP4/1, copy of certificate issued by Virk Hospital Ex.OP4/2, copy of discharge summary Ex.OP4/3, copy of insurance policy of Dr. Neterpal Ex.OP4/4, copy of insurance policy of Virk Hospital Ex.OP4/5 and closed the evidence on 14.12.2023 by suffering separate statement.

11.           Learned counsel for the OP no.5 has tendered into evidence affidavit of Dr. Neterpal Rawal Ex.RW1/A, copy of insurance policy alongwith terms and conditions Ex.R1 and Ex.R2 and closed the evidence on 27.07.2023 by suffering separate statement.

12.           We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

13.           Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant  purchased a Health Insurance Policy from the OPs no.1 And 2 for insuring a sum of Rs.5,00,000/-. Complainant continuously renewed the said insurance policy from the OP from the year 2015 without any break. At the time of inception of the insurance policy, complainant disclosed the problem of his wife i.e. protein leakage in urine and also disclosed the outgoing treatment of his wife and after knowing the said fact, OPs issued the insurance policy and has also mentioned in the policy pre-existing disease as Urine Infection. The wife of complainant has taken the treatment from the various hospitals and complainant has spent an amount of Rs.1,85,623/- on the treatment of his wife. Complainant submitted the claim with the OPs no.1 and 2 but same was repudiated on the false and frivolous ground and lastly prayed for allowing the complaint. Learned counsel for the complainant relied upon the case law titled as United India Insurance Company Ltd. Vs. Reetu Goyal, in appeal no.466 of 2018, date of decision 18.01.2023 and Apollo Munich Health Insurance Co. Vs. Mr. Girish Kapoor in First Appeal no.197 of 2018, date of decision 09.03.2023 of our own Hon’ble State Commission.

14.           Per contra, learned counsel for the OPs no.1 to 3, while reiterating the contents of written version, has vehemently argued that complainant has availed the Family Health Optima Insurance Plan covering-self,  his spouse Pooja Arora and his dependent children, for the sum insured Rs.5,00,000/-. The wife of complainant had taken treatment from Virk Hospital, Karnal and thereafter taken the treatment from PGI Chandigarh. The complainant submitted the claims for reimbursement of the medical expenses towards the treatment of his wife and on scrutiny of claim documents, it is observed that insured patient was known case of chronic kidney disease prior to the date of commencement of 1^st year policy and same was not disclosed at the time of purchasing the insurance policy, which amounts to non-disclosure of material facts. Thus, the claim of complainant was rightly rejected and lastly prayed for dismissal of the complaint.

15.           Learned counsel for the OP no.4, while reiterating the contents of written version, has vehemently argued that there is no role of OP no.4 regarding the repudiation of the claim of the complainant and lastly prayed for dismissal of the complaint qua OP no.4.

16.           Learned counsel for the OP no.5, while reiterating the contents of written version, has vehemently argued that it is not the case of medical negligence on the part of treating hospital which has been insured with OP and as such no claim is maintainable against the OP and lastly prayed for dismissal of the complaint qua OP no.5.

 17.          We have duly considered the rival contentions of the parties.

18.           Admittedly, in the year 2015, complainant purchased a health insurance policy from OPs no.1 and 2. It is also admitted that complainant get renewed the said policy without any break. It is also admitted that the wife of complainant is also covered in the said policy. It is also admitted that during the subsistence of the insurance policy the wife of complainant has taken the treatment from Virk Hospital, Karnal and PGI, Chandigarh and spent an amount of Rs.1,85,623/-.

19.           The insured submitted four claims with the OPs for reimbursement of Rs.1,85,623/- The said claims have been repudiated by the OPs no.1 and 2, vide repudiation letter Ex.C8/Ex.OP8 dated 26.11.2019, Ex.OP23 dated 23.11.2019, Ex.OP13 dated 12.12.2019 and Ex.OP24 dated 25.01.2019 on the grounds, which are reproduced as under:-

“we have processed the claim records relating to the above insured patient seeking reimbursement of hospitalization expenses for dialysis for chronic kidney disease (CKD).

It is observed from the indoor case records of above hospital submitted vide our claim no.0590657, the insured patient is known case of chronic kidney disease for the past 4½ years, which confirms that insured patient is suffering from chronic kidney disease prior to date of commencement of first year policy. The present admission and treatment of the insured patient is for non-disclosed kidney disease.

At the time of inception of policy which is from 15.10.2015 to 14.10.2016, you have not disclosed the above mentioned medical history/health details of the insured-person in the proposal form which amounts to mis-representation/non-disclosure of material facts.

As per condition no.6 of the policy issued to you, if there is any misrepresentation/non-disclosure of material facts whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim.

We, therefore, unable to settle your claim under the above policy and hereby repudiated the claim.”

20.           The claims of the complainant have been repudiated by the OPs on the aforesaid ground. The complainant alleged that at the time of purchasing the policy, complainant has disclosed that his wife is having urine problem and said fact has also been mentioned in the insurance policies Ex.C1 to Ex.C4 for the period from 15.10.2015 to 14.10.2020. The onus to prove his version was relied upon the complainant. To prove his version, complainant has relied upon the insurance policy Ex.C1 dated 15.10.2019 to 14.10.2020, Ex.C2 dated 15.10.2018 to 14.10.2019, Ex.C3 dated 15.10.2015 to 14.10.2016 and Ex.C4, 15.10.2016 to 14.10.2017. On perusal of said policies, it reveals that Pooja Arora insured was suffering from Urine Infection and at the time of purchasing the policy she has disclosed about said problem. This fact has not been denied by the OPs. The case of the OPs based upon the certificate Ex.OP6 dated 15.11.2019 issued by Doctor Neterpal Rawal wherein the said doctor has mentioned that patient is K/C/O CKD for last four year and on dialysis (Hemodialysis) for last one year. Furthermore, for the purpose of clarification of the said certificate, the concerned doctor again clarified and issued a fresh certificate Ex.C10 dated 25.12.2019, which is reproduced as under:-

TO WHOM IT MAY CONCERN

It is certified that patient Pooja 30 years/F who was admitted in this hospital on 19.07.2018, vide IPD no.1824/18 (UHID 19396/18) with the diagnosis of CKD, Anaemia, Uremia and CHF. During admission, some attendant has provided the history of disease for last four yars while patient visited this hospital on 19.07.2018 only and we are not having any such record of CKD history.

       

21.           From perusal of the said documents, it is crystal clear that the wife of complainant was not suffering from CKD at the time of purchasing the first policy. Furthermore, if for the sake of gravity, it is presumed that the insured was suffering from CKD at the time of purchasing the insurance policy, in that case also the claim of the complainant cannot be repudiated on the said ground, because  at the time of purchasing the policy, insured disclosed her urine infection problem, same is mentioned in all the policies. The urine infection problem is direct nexus with the kidney disease. Furthermore, OPs have also renewed the insurance policy effected from 15.10.2022 to 14.10.2023 Ex.C13, wherein Chronic Kidney disease has been permanently excluded. Thus, complainant has not concealed the fact regarding the health of insured Pooja Arora at the time of purchasing the policy.

22.           Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

23.           Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OPs no.1 and 2, while repudiating the claim of the complainant amounts to deficiency in services, which is otherwise proved genuine one.

24.           The complainant has claimed Rs.1,85,623/-and the said amount neither denied nor rebutted by the OPs no.1 and 2. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

25.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs no.1 and 2 to pay Rs.1,85,623/- to the complainant alongwith interest @ 9% per annum from the date of filing the complaint till its realization. We further direct the OPs no.1 and 2 to pay Rs.25,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses. The complaint qua OPs no.3 to 5 stands dismissed. This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:23.07.2024                                                                    

                                                                President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

 

(Vineet Kaushik)                (Sarvjeet Kaur)    

                     Member                           Member