Complainant Vinod Kumar through the present complaint U/s 12 of the Consumer Protection Act, 1986 (hereinafter, ‘the Act’) has sought necessary directions to the titled opposite party: M/s Oriental Insurance Co. Ltd., Batala through its Branch Manager to release the Hospitalization Insurance Claim amount of Rs.75,815/- along with interest @ 18% PA from the date of the complaint till realization besides Rs.15,000/- as litigation expenses and another Rs.1,00,000/- as cost and damages (compensation) for having inflicted mental pain & agony plus any other relief as per their entitlement/eligibility etc., all  in the interest of justice.

2.       The case of the complainant in brief is that he in March’ 2012 purchased the insurance policy with validity from 15.03.2012 and brand name: ‘Happy Family Floater Health Insurance Policy’ from the OP insurers. The Policy with the duly paid premium covered the entire family for availing the cash-less medical treatment, as and when required, at the designated network Hospitals, throughout the country. Further, the same Policy was renewed annually and was valid up to 13.03.2015. Unfortunately, the Complainant fell ill on 12.04.2014 suffering from Liver and other ailments and was admitted to DMC & H, Ludhiana; where he was refused the cash less facility and thus he paid the treatment Bill of Rs.75,815/- that was duly claimed afterwards from the OP insurers, who however repudiated the same on flimsy grounds and thus prompted the present complaint with the relief as prayed, hereinabove.   

3.       Upon notice, the OP insurers appeared and filed its written reply through the counsel taking the preliminary objection that the complaint was against the duly accepted Terms and Conditions of the Policy that has been duly admitted along with its validity as on the date of occurrence i.e., hospitalization and also the cause of action etc but alleged/labeled the medical treatment taken qua the ailments caused by Genetic Disorders and thus hit by the applicable Exclusionary clauses of the Policy that resulted in the repudiation of the Claim. Non-submission of documents/ medical records by the complainant upon demand by the TPA has also been alleged. Lastly the complaint has been prayed to be dismissed with litigation costs along with any other relief etc., as applicable (found entitled). 

4.       Both the parties produced their documents in evidence to support their pleadings and their learned counsels also put forth their arguments to prove their respective assertions/claims. The complainants have produced the documents exhibited as: The Ex.CW1/A being the affidavit of the complainant deposing the pleadings averred in the complaint and the other supporting documents are exhibited as: Ex C1 to Ex C9. In reciprocation, the OP produced the documents exhibited as: Ex.OP1 being the affidavit of Rajesh Sharma Divisional Manager with the OP insurers duly deposing their assertions and objections to the complaint and the Ex OP2 being repudiation letters dated 18.05.2014.  We have examined all the documents/ evidence produced on record and have also duly considered and perused the essence of the heard arguments while adjudicating the present complaint.

5.       We find that the Policy in question has been continuing (by way of annual renewals) since March’2012, with its benefits having duly availed of by way of insurance claim for hospitalization in Fortis, Amritsar (on 16.03.2013) but only through the adjudicatory intervention of this very Forum (Orders of 26.03.2014). However, as the post-developments had it, the inter-se contract (Insurance Policy) was renewed afresh on 14.03.2014, extending its validity up to 15.03.2015. This time the complainant was hospitalized in the Dayanand Medical College & Hospital, Ludhiana on 12.04.2014 but for the recurrence of the same ailment ‘cirrhosis of liver’ and ended up with the familiar repudiation of insurance claim of Rs.75,815/- and the subsequent complaint. This time, the prime reason for repudiation of claim has been put forth by the OP insurers as ‘non-submission’ of required documents/medical treatment records etc by the complainant even at the express demand/asking of the TPA (Third Party Administrator) and the collateral objection for the ‘refusal’ to the cash-less facility was the ‘generic-disorder’ classification accorded to the ailment of cirrhosis of Liver making it fall under the ‘exclusions’. It is not understood as to why and how the Policy was consented to be renewed by the OP insurers if they were not inclined to cover the ‘known ailment’ of ‘cirrhosis of liver’ under the cash-less facility and why the same was not specifically and categorically removed from the ‘insurance-cover’. The ailment of ‘cirrhosis of liver’ was very much in their knowledge and its recurrence is a subject matter of common knowledge and when once they have refused the cash- facility for of the generic disorder why and what documents/medical records were being insisted upon and for what purpose. During the entire course of proceedings the ‘so-demanded’ documents have not been named and/or enumerated with the ‘purpose’ etc. It seems though sadly that the Policy in question was issued to earn the ‘premium’ only and the un-ethical proposition gets confirmed with the arbitrary ‘repudiation’ of the otherwise a valid ‘medical-treatment’ claim. And, it becomes more objectionable at the face of the Orders dated 26.03.2014 (Ex.C7) wherein the concept of ‘exclusionary clause’ was duly explained/ interpreted as: “This is also an implicit admitted factum that the quoted Exclusionary clauses are applicable only if the Policy in question (with the OP1) is taken up as a fresh Policy in isolation of the first Policy with the OP2 that dates back to 14.09.2010. The complainants have duly deposed that the first Policy with the OP2 Batala was shifted and renewed at the OP1 Kapurthala at the instant and instruction of the OPs only and the time period gap was the causal effect for which they cannot be held liable.” Thus, we find the OP insurers guilty of having intentionally repudiated the complainants’ otherwise a valid insurance claim (and also the cash-less facility) and in the process have duly infringed his valuable consumer rights through the displayed ‘unfair trade practice’ amounting to deficiency in service on their part.  

6.       In the light of the all above, we hold the OP insurers liable to settle the impugned claim in full and thus ORDER them to pay to the complainant the full eligible amount (under the Policy) besides Rs.5,000/- as compensation and Rs. 3,000/- as cost of litigation within 30 days of receipt of the copy of these orders otherwise the aggregate amount (so-settled) shall attract interest @ 9 % PA from the date of complaint till actually paid.

7.       Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.         

                                                                   (Naveen Puri)

                                                                       President.      

ANNOUNCED:               (G.B.S.Bhullar)                        (Jagdeep Kaur)

January 19, 2015.                      Member                                 Member

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