The instant complaint has been filed by complainant Som Parkash against the opposite parties u/s 35 of the Consumer Protection Act, 2019 seeking insurance claim from the opposite parties along-with interest and costs.

FACTUAL ASPECTS

2                 The brief facts of the present case are that the complainant had purchased Group Health Insurance policy and accidental policy from the respondents on 14.09.2016 through respondent No.3. After that, both policy period 14.09.2016 to 13.09.2017 and after that both policies were renewed continuously from the period 2017 to 2018 and at last renewed for the period 2018 to 2019. The said policy was the group family insurance policy and four family members namely Som Parkash, Rekha Rani, Simran Sharma and Shubham Sharma were covered on the sum insured of Rs.7,50,000/-. For this policy, the complainant paid Rs.17,157.20/- towards premium inclusive of IGST. During the above said valid policy period, the complainant has got the injuries in a roadside accident on dated 18.06.2019, when he was on the motor cycle. The complainant approached Dr. Ved Parkash Gupta Hospital, Barsat road, Panipat and thereafter the complainant has gone to Virk Hospital, Karnal and at last he was admitted in A.R. Mittal Hospital, Gohana Road, Kishanpura, Panipat on 21.06.2019 and remained admitted in hospital upto 23.06.2019. The hospital authority has charged the amount Rs.67,887/-, besides this the complainant had taken medicines, total in amount Rs.79,685/-. Thereafter, the complainant lodged his claim with the respondents and also submitted all the relevant documents  but the claim of the complainant has been repudiated by the respondents on the ground of pre-existing disease. Thereafter, the complainant served a legal notice dated 20.01.2020 upon the respondents but till today the respondents did not release the claim amount of complainant. So, the complainant has come to this Commission with the prayer to direct the respondents to release the claim amount of Rs.79,685/- along with interest @ 18% per annum and Rs.25,000/- as compensation on account of mental pain and agony.

3                 Upon notice, respondents No. 1 and 2 appeared but none appeared on behalf of respondent No.3, hence respondent No.3 was proceeded against ex parte vide order dated 13.07.2020.

4                 In reply, respondents No. 1 and 2 took preliminary objections regarding maintainability, jurisdiction, locus standie and suppression of true and material facts. The respondents No. 1 and 2 in their written statement has submitted that after receiving the treatment record and laboratory reports, it was noted that patient had past medical history of Tibial fracture 16 years back and presented admission was for PCL fracture which was not disclosed by the complainant in proposal form at time of taking policy. As per the terms and conditions of the policy any pre-existing position will not be covered until 36 months of continuous coverage.  Thereafter, on the request of complainant, the respondents company reviewed the case once again and demanded some documents related to current hospitalization from complainant vide letter dated 30.01.2020 and final reminder letter was sent on 07.02.2020 but the complainant had not duly replied the queries of the answering respondents, then the answering respondents have rejected the claim of the complainant due to non-compliance of the demanded documents. Hence, the respondents company are not liable to pay any claim amount.

EVIDENCE LED BY COMPLAINANT

5                 Counsel for  complainant in support of case has filed affidavit of complainant as Ex.CW1/A and closed the evidence after tendering the following documents;

EVIDENCE LED BY OPPOSITE PARTIES

6                 On the other hand, respondents in evidence filed the affidavit

closed the evidence after tendered the following documents;

7                 After considering the arguments and perusing the whole documents placed on file by both the parties, the following points have been found to be made out:-

1       Whether the complainant is entitled to recover the alleged claim amount of insurance from the respondents along with interest and compensation etc? OPC

2       Whether the complaint of the complainant is not maintainable in the present form OPR?

STAND TAKEN BY THE COMPLAINANT

8                 Learned counsel for the complainant has contended that the complainant had purchased Group Health Insurance policy and accidental policy from the respondents on 14.09.2016 through respondent No.3. After that both policies were renewed.  The sum assured of the policy was Rs.7,50,000/-. During the above said valid policy period, the complainant has got the injuries in a roadside accident on dated 18.06.2019, when he was on the motor cycle. The complainant was admitted in A.R. Mittal Hospital, Gohana Road, Kishanpura, from 21.06.2019 to 23.06.2019. The hospital authority has charged the amount Rs.67,887/-, besides this the complainant had taken medicines and tests, total amounting to Rs.79,685/-. Thereafter, the complainant lodged his claim with the respondents and also submitted all the relevant documents but the claim of the complainant has been repudiated by the respondents on false grounds. Hence, the present complaint.

                    STAND TAKEN BY THE OPPOSITE PARTIES NO. 1 and 2

9                 Learned counsel for the respondent has contended that after receiving the treatment record, it was noted that patient had past medical history of Tibial fracture 16 years back and presented admission was for PCL fracture which was not disclosed by the complainant in proposal form at time of taking policy.  Thereafter, the respondents company reviewed the case once again and demanded some documents related to current hospitalization from complainant but the complainant had not duly replied the queries of the answering respondents. Hence, the claim was repudiated.

10               We have heard the arguments advanced by the learned counsel for the parties and perused the whole record available on file. Our point-wise findings with reasons thereof are as under:-

FINDINGS

                                                POINT NO.1

11               After considering the arguments and after perusing the documents, it is proved on the file that the complainant was insured on the date of accident. No DDR was got lodged by the complainant. But it is not going to the roots of the case rather the medical evidence Ex.R4 to Ex.R8 have proved that the complainant was admitted in A.R. Mittal Hospital and he also got treatment from Virk Hospital, Karnal. The medical evidence and discharge report proving that due to accident the complainant got injuries and it is also evident that on the day of accident, the complainant was duly insured with the respondents and respondents cannot deny for reimbursement of spent amount of the complainant on his treatment. The medical record of Dr. A.R. Mittal Hospital proved that he charged Rs.67,887/- which were paid by the complainant and as per the terms and conditions of the insurance policy, the reimbursement should have been made by the respondents instead of sending the repudiation letter. The necessary documents Ex.C1 to Ex.C8 and even the record furnished by the respondents has also supported the case of complainant. It is pertinent to mention here that contention raised by the respondents that there is past history of fracture to the complainant that has not been proved and established at the instance of the respondents. The complainant is only entitled for the reimbursement of the medical expenditure that was due to current accident and even complainant has not claimed any charges of previous injury, if any, there on the body of the complainant rather he has claimed the expenses spent on his treatment after the accident dated 18.06.2019. Hence, from all the corners it can be concluded that complainant has duly proved this point by leading cogent and convincing evidence. Hence, this point is hereby returned in favour of the complainant and against the respondents.

                                                 POINT NO.2

12               So far as the Point No.2 is concerned, having glance over the detailed finding on Point No.1, the Point No.2 become redundant rather the complainant has disproved this Point of respondents by way of leading cogent and convincing evidence and complaint of the complainant has been fully established and duly proved, so, this Point is hereby returned against the respondents and in favour of complainant.

FINAL ORDER

13               Having heard the rival contentions raised by learned counsel for both the parties and after perusing the whole record, this Commission is of the firm opinion that the complaint of the complainant is maintainable and well proved and respondents are hereby directed to make the payment of Rs.67,887/- along with  interest @ 9 % P.A. from the date of filing of this complaint till its actual realization. The respondents are further directed to pay Rs.5,000/- to the complainant on account of compensation as well as Rs.5,500/- as litigation expenses within a period of 45 days, failing which the complainant shall be entitled for seeking 12% interest from the date of award till its realization. All the respondents are jointly and severally liable to make the payment of above said amount to the complainant.

14                         In case, respondents failed to do so, then the complainant can file the execution petition under Section 71 of Consumer Protection Act, 2019 and in that eventuality, the respondents may also be liable for prosecution under Section 72 of the said Act.  Copies of this order be sent to the party free of costs, as per rules, and this order be promptly uploaded on the website of this Commission. File be consigned to the record room after due compliance.