Order by:

Smt.Priti Malhotra, President

1.           The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that the complainant had purchased the Health Insurance Policy bearing no.0237868334/076487 from Opposite Party for the period from 16.02.2021 to 15.02.2022 and the same was renewed on 16.02.2022 to 15.02.2023. Unfortunately, the complainant suffered from Urinary Bladder Growth with H/O Turbt and remained admitted in RG Stone and Super Specialty Hospital, Ludhiana from 10.07.2021 to 12.07.2021. The complainant spent more than Rs.80,000/- on his treatment and thereafter complainant submitted entire medical bills and other relevant record as per the requirement of the Opposite Party, but the complainant was very astonished to see that on 24.05.2022, the Opposite Party rejected the claim of the complainant. Further alleged that at the time of purchasing the policy, the employee of the Opposite Party told to the complainant that every disease is covered under the policy, but not handed over any policy to the complainant at the time of selling the policy. The complainant also issued legal notice to Opposite Party, but to no effect. Hence this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to pay an amount of Rs.80,000/- with regard to policy no.0237868334/076487.

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

c)       To pay an amount of Rs.11000/- as costs of litigation expenses.

d)      And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite Party appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination under Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court; The complainant has concealed the material facts and documents from this Commission as well as the Opposite Party, therefore the complainant is not entitled to any relief; The complainant has concealed the fact that on scrutiny of claim documents it was found that the claim in question was for management of medical and surgical treatment of illness which falls in specific two years of waiting period as per the policy and the policy start date is 16.02.2021, hence no claim is payable, hence the claim was repudiated vide letter dated 24.05.2022; The complainant is not the consumer of the answering Opposite Party, hence deserves to be dismissed; The complainant has no locus standi or cause of action to file the present complaint against Opposite Party; On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       Complainant also filed replication to the written reply of Opposite Parties, denying the objections raised by the Opposite Party in their written reply.

4.       In order to prove his case, complainant tendered in evidence his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C16.

5.       To rebut the evidence of the complainant, Opposite Parties tendered in evidence copies of documents Ex.OPs/1 to Ex.OPs/10 and affidavit of Sh.Amit Chawla, AVP, Tata AIG General Insurance Company Ltd. Ex.OPs/11.

6.       We have heard the counsel for the complainant and gone through the written arguments submitted by ld. counsel for the Opposite Party and also gone through the documents placed on record.

7.       It is not disputed between the parties that the complainant purchased Heath Insurance policy bearing policy no. bearing no.0237868334/076487 from Opposite Party for the period from 16.02.2021 to 15.02.2022 and the same was renewed for the period 16.02.2022 to 15.02.2023 and during the coverage period, the complainant suffered Urinary Bladder Growth with H/O Turbt and taken treatment from RG Stone and Super Specialty Hospital, Ludhiana and in support of his assertion, he placed on record discharge summary issued by the hospital concerned Ex.C10. The dispute between the parties pertains to the rejection of the claim lodged by the complainant for the reimbursement of the expenses incurred by him for the treatment in question. The record reveals that reimbursement claim of the complainant under policy had been rejected vide letter dated 24.05.2022 Ex.OP/1 stating therein that “On Scrutiny of claim documents, it is observed that submitted claim is for management of the medical and surgical treatment of illness which falls in two years of waiting period. Hence we regret to inform that claim is repudiated as per Section 3 (1) (ii)”.

The thorough perusal of the record reveals that the stand taken by the Opposite Party in their defence is not supported by any evidence on record. There is no record on file with regard to the relevant section 3(1) (ii) so relied upon by them for the rejection of the claim of the complainant and no terms and conditions of the policy have been placed on record by the Opposite Party revealing the referred clause for rejection of the claim of the complainant. In the absence of any cogent evidence, it is hard to believe that the repudiation of the claim is justified. Further the document Ex.OP/9 Reimbursement Insurance Claim Verification report, so relied upon by the Opposite Party is also incomplete report and it transpires that the said report is only an interim report, which has been not followed by any final report. The repudiation of the claim has been made on the basis of the recommendations made in the report, so referred wherein it is recorded that “Final remarks will be given after the statement by the family doctor.”

8.       In our considered opinion the repudiation made by the Opposite Party-Insurance Company regarding genuine claim of the complainant have been made without application of mind. It is usual with the insurance company to show all types of green pasture 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 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 seems 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.

9.       Now come to the quantum of compensation.  The complainant has claimed the amount of Rs.80,000/- for his treatment. But the final bill Ex.C11 placed on record by the complainant shows that he spent Rs.60,000/- during his stay in the hospital from 10.07.2021 to 12.07.2021. Hence, we allow the same.

10.     In view of the above discussion, we are of the opinion that the rejection of the claim of the complainant is not genuine. Opposite Party has committed deficiency in service by rejecting the claim of the complainant. Hence, the present complaint stands partly allowed and Opposite Party is directed to pay a sum of Rs.60,000/- (Rupees Sixty Thousand only) incurred by the complainant on his treatment. Opposite Party is also directed to pay compository amount of Rs.10,000/- (Rupees Ten Thousand only) towards compensation and litigation costs to the complainant. The compliance of this order be made by the Opposite Party within 30 days from the date of receipt of copy of this order, failing which, the Opposite Party is burdened with additional amount of Rs.20,000/- (Rupees Twenty Thousand only) to be paid to the complainant. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced on Open Commission