Order dictated by:

Sh.Anoop Sharma, Presiding Member

1.  Munish Sharma complainant has brought the instant complaint under section 12 of the Consumer Protection Act, 1986  on the allegations that on the persuasions of opposite party No.4 Mr. Vishal Kalra, authorized agent of opposite party No.1 , the complainant became member of mediclaim Insurance policy ‘Family Health Optima Insurance Revised’ which covers family members Nitika Sharma (wife), Jagdish Sharma (dependent child) and submitted his proposal form  alongwith complete particulars and documents required by the opposite parties No.3 & 4 on 5.1.2016 by paying premium of Rs. 6389/- for the period from 5.1.2016 to 4.1.2017. Opposite parties No.3 & 4 assured the complainant that the policy will be issued shortly.  The Insurance policy No. P/211111/01/2016/004940 was issued to the complainant by opposite party No.3. Unfortunately wife of the complainant namely Nitika suffered acute stomach pain on 5.2.2016 and she was immediately admitted in Mahajan Hospital which is in the list of network hospitals of the opposite parties  and Appendix operation was done by the doctors of the said hospital and she was discharged from the hospital on 8.2.2016. After completing the entire formalities,  complainant submitted his claim form alongwith all original hospital bills, medicine bills, lab bills etc in the office of opposite party No.2 on 15.2.2016. After waiting for a month , complainant visited the office of opposite party at Amritsar and met opposite party No.3, who told that proposal forms of the complainant could not be updated his claim forms and  they updated medical claim in the month of April, 2016 which amounts to deficiency in service  . The complainant was given claim No. 0354465 and demanded some other documents for approval of the case by the opposite party through  e-mail, which was supplied by the complainant . The opposite party repudiated the claim vide letter dated 13.4.2016  on the ground that it was observed from the discharge card of the above hospital that the insured patient is admitted in the hospital on 5.2.2016 which is during the first 30 days from the date of commencement of the policy. On receipt of the letter of repudiation,  the complainant was surprised  that the opposite parties No.3 & 4 accepted the proposal form and cash of Rs. 6389/- from the complainant on 5.1.2016, but they kept the amount and premium amount with them and had not updated the same which result to delay in issue of policy but the risk period in the policy was given from 7.1.2016 to 6.1.2017. On receipt of the claim repudiation letter, the complainant sent detailed reply  and fully explained that he became member  on 5.1.2016 and premium was paid on 5.1.2016 but policy was wrongly issued for risk from 7.1.2016 which is not the fault of the complainant but it was due to deficiency in service on the part of their employees and agent in the local office, who had not updated the proposal of the complainant and kept cash premium in their pocket. But till date no reply was received by the complainant from the opposite parties . Vide instant complaint, complainant has sought for the following reliefs :-

1. Opposite parties be directed to sanction and pay the claim amount of Rs. 39,276/- alongwith interest @ 18% p.a.
2. Compensation of Rs. 20000/- alongwith adequate litigation expenses were also demanded.

Hence, this complaint.

2.       Upon notice, opposite parties appeared and filed written version in which it was submitted that the complainant obtained Insurance policy under Family Health Optima Insurance Plan for himself , his wife Nitika Sharma and dependent child Jagdish Sharma son bearing policy No. p/211111/01/2016/004940 valid for the period from 7.1.2016 to 6.1.2017. However, the claim was reported in 29^th day of the inception of the policy for claim amount of Rs. 35,155/- with the plea that the complainant’s wife Nitika Sharma admitted in Mahajan Hospital on 5.2.2016 for treatment of Acute Appendicitis  and submitted the claim  for reimbursement of the medical expenses for the treatment of Acute Appendicitis vide claim No. CL1/2016/211111/0354465 and on scrutiny of records of the claim, it was observed that as per discharge summary, the patient was admitted on 5.2.2016 and diagnosed for Acute Appendicitis and discharged on 8.2.2016. Thus the patient was admitted in the hospital for treatment within 29^th day of inception of the policy. It was stated that as per exclusion No.2 of the policy, the company is not liable to pay any claim pertaining to treatment of disease contracted during the first 30 days from the date of commencement of the policy, as such the claim of the complainant is not payable under section 64 of the Insurance Act and the claim has rightly been repudiated and intimation in this regard was given to the complainant vide letter dated 13.4.2016. While submitting that there is no deficiency of service on the part of the opposite parties and while denying and controverting other allegations, dismissal of complaint was made.

3.       In his bid to prove the case complainant tendered into evidence duly sworn affidavit of the complainant Ex.CW1/A, copy of proposal form Ex.C-1, copy of policy schedule Ex.C-2, copies of medical bills Ex.C-3, copy of claim approval Ex.C-4, copy of repudiation letter Ex.C-5, copy of e-mail Ex.C-6 and closed his evidence.

4.       To rebut the aforesaid evidence Sh.S.S.Salaria,Adv.counsel for the opposite parties tendered into evidence affidavit oif Sh.P.C.Tripathy, Zonal Manager Ex.OP1,2,3,4/1 alongwith documents Ex.OP1,2,3,4/2 to Ex.OP1,2,3,4/9 and closed the evidence on behalf of the opposite parties.

5.       We have heard the ld.counsel for the parties and have carefully gone through the record on the file.

6.       From the record i.e. pleadings of the parties and the evidence produced on record by both the parties, it is clear that   complainant obtained health Insurance policy for himself, his wife Nitika Sharma and son Jagdish Sharma vide policy No. P/211111/01/2016/004940 by submitting proposal form alongwith complete particulars and documents on 5.1.2016 and  paying premium of Rs. 6389/- . Wife of the complainant  suffered actue stomach pain on 5.2.2016 and she was got admitted in Mahajan Hospital where operation of Appendix was done by the doctors of the said hospital and she was discharged from the hospital on 8.2.2016.  Thereafter complainant after completing all the formalities submitted his claim form  alognwith all original hospital bills, medicine bills, lab bills etc to opposite party No.2 upto15.2.2016. However,  when after waiting for a month, the complainant visited the office of opposite party No.2, opposite party told that proposal form of the complainant could not be updated and they updated medical claim in the month of April 2016. It has been alleged by the complainant that the opposite party had repudiated the claim of the complainant vide letter dated 13.4.2016 on the ground that insured patient was admitted in the hospital on 5.2.2016 which is during the first 30 days from the date of commencement of the policy. However, the opposite party accepted the proposal form and cash of Rs. 6389/- from the complainant on 5.1.2016 but they  kept the amount and premium amount with them and had not updated the same  but the risk period in the policy was given from 7.1.2016 to 6.1.2017 and this act of the opposite party itself amounts to deficiency in service.

7.       Whereas the case of the opposite party is that the complainant obtained the Insurance policy under Family Health Optima Insurance Plan for himself, his wife Nitika Sharma  and dependent child namely Jagdish Sharma  bearing policy No. P/211111/01/2016/004940 valid from 7.1.2016 to 6.1.2017. However, the claim was reported in 29^th day of the inception of the policy for claim amount of Rs. 35,155/- for the treatment Acute Appendicitis  of complainant’s wife Nitika Sharma, who admitted in Mahajan Hospital on 5.2.2016 and discharged on 8.2.2016. It was submitted that as per exclusion No.2 of the policy the company is not liable to pay any claim  pertaining to treatment of disease contracted during the first 30 days from the date of commencement of the policy. As such the claim has rightly been repudiated by the opposite party.

8.       But, however, from the appreciation of the facts and circumstances of the case, it becomes evident that the complainant has obtained Family Health Optima Insurance Revised by submitting proposal form alongwith complete particulars and documents as required by the opposite parties No.3 & 4 on 5.1.2016 by paying premium of Rs. 6389/-in cash for the period of one year i.e. from 5.1.2016 to 4.1.2017. In this regard complainant submitted copy of proposal form Ex.C-1 from which it is proved that the complainant has deposited the premium  of Rs. 6389/- on 5.1.2016 and period of insurance has been written as 5.1.2016 to 4.1.2017. Copy of Proposal form accounts for Ex.C-1 on record.  It was the case of the complainant that during the subsistence of the policy period, wife of the complainant Nitika Sharma suffered from Acute stomach pain on 5.2.2016 and she was got admitted in Mahajan Hospital,  where Appendix operation was done by the doctors of the said hospital and she was discharged from the hospital on 8.2.2016. The complainant incurred Rs. 39,276/- on the treatment of his wife. Copies of medical bills are Ex.C-3 (consisting of 14 pages) on record. However, when the complainant lodged claim with the opposite parties after completing all the formalities as required by the opposite parties, the opposite parties repudiated the claim of the complainant  vide letter dated 13.4.2016 on the ground that the insured patient was admitted in the hospital on 5.2.2016 which is during the first 30 days from the date of commencement of policy. However, on receipt of repudiation letter, complainant was surprised that the opposite parties No.3 & 4 had accepted the proposal form  and cash of Rs. 6389/- on 5.1.2016 and issued proposal form , copy of which is ExC-1 on record . The complainant then approached the opposite parties , who told that they kept the amount and premium amount with them and had not updated the same which result in delay in issue of policy and the risk period was given from 7.1.2016 to 6.1.2017. In this regard complainant has placed on record copy of Insurance policy Ex.C-2 covering the risk period from 7.1.2016 to 6.1.2017. The act of the opposite parties in issuing the copy of policy  for the period from 7.1.2016 to 6.1.2017  despite filling of proposal form on 5.1.2016 and premium amount of Rs. 6389/- , amounts to deficiency in service. In this regard Ld.counsel for the complainant has placed reliance upon Oriental Insurance  Co.Ltd. Vs. Dharam Chand 2010(3) CPC 16 of the Hon’ble Supreme Court of India wherein it has been held that since the cheque for the premium amount was received by the company at 4.00 a.m. on May 7,1998, the insurance must be deemed to have commenced from that time and four hours later when the vehicle met with the accident, the owner must be deemed to have been covered by the Insurance policy.

9.       It is also seen that insurance companies show green pastures to the insured persons at the time of selling  the insurance policy 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 Dharmendra Goel 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.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.       

The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

10.     The above said authorities cover the case of the complainant from all its fours. So the complainant is entitled to reimbursement of the medical expenses incurred on the treatment of the wife of the complainant in Mahajan Hospital, which is network hospital of the opposite parties, to the tune of Rs. 39,276/-.

11.     In view of the above discussion, the complaint stands allowed accordingly. The opposite parties are directed to pay the claim amount of Rs. 39,276/- incurred on the treatment of insured patient Nitika Sharma. The complainant is also awarded compensation to the tune of Rs. 2000/- as well as litigation expenses to the tune of Rs. 1000/-. Opposite parties are directed to make the payment of the awarded amount within 30 days of the receipt of copy of the order ; failing which awarded amount shall carry interest @ 9% p.a. from the date of filing of the claim until full and final recovery. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Announced in Open Forum

Dated :4.5.2017