Order by:
Sh.Amrinder Singh Sidhu, President
The complainant has filed the instant complaint under section 12 of the Consumer Protection Act, 1986 (as amended upto date) on the allegations that on the allurement of the agent of Opposite Party No.1, the complainant had purchased the medi claim policy bearing no. 36110034199500000017 from Opposite Party No.1 which was valid for the period w.e.f. 20.07.2019 to 19.07.2020 (11:59:59 PM) for a sum assured of Rs.1,50,000/- against the premium paid of Rs.11595/- which was duly paid by the Complainant and drawn on HDFC Bank Limited, Moga Branch. Copy of the cover note is enclosed herewith. However, the Opposite Party No.1 never supplied the policy in question or its terms and conditions to the Complainant till date. Further alleges, that as per the policy documents in question, admittedly the complainant was fully insured for any Indoor medical treatment upto the extent of Rs.1,50,000/-. During the policy period, the complainant felt uneasiness due to pain in her eyes. The Complainant immediately contacted Eye Specialist Dr.Rajesh Aggarwal, Amritsar Eye Hospital, New Town, Moga on 20.09.2019 who advised the Complainant to approach some super specialty hospital and thereafter, the Complainant approached Thind Eye Hospital, Model Town, Jalandhar. After thorough check up, the treating doctor of Thind eye Hospital, Model Town, Jalandhar opined that the Complainant is complained of diminution of vision in her both eyes. Her UCVA was finger counting at 1 meter in both eyes and BCVA was 6/6 in right eye with -7.50/Dsph-0.75/Dcy1 180/axis and 6/6 in left eye with -7.75/Dsph-0.50/Dcyl 180/axis and the treating doctor advised immediate operation.That as per the advice of the treating doctor of Thind eye Hospital, Model Town, Jalandhar, the Complainant immediately informed the Opposite Party No.1 about the said operation and the officials of the Opposite Parties told the Complainant that after completion of the operation, the expenses will be reimbursed. As per the instruction of the officials of the Opposite Parties, the Complainant admitted in Thind eye Hospital, Model Town, Jalandhar on 11.10.2019 for the treatment where the operation of both the eyes of the Complainant was conducted and on the same day, the Complainant was discharged from the hospital, where the Complainant spent Rs.83,039/- for the said treatment. Copy of the discharge summary is enclosed herewith. Beside this, the complainant also spent about Rs.20,000/- during admission at Thind eye Hospital, Model Town, Jalandhar. In this way, the complainant spent Rs.1,00,000/-. Beside this, the complainant also spent amount on her routine follow up check up in the treating hospital, which amounts to Rs.25,000/-. After discharge, the complainant submitted bills with Opposite Party No.1 for the reimbursement of her medical expenses and completed all the relevant formalities. The detail of the expenses paid by the Complainant is duly mentioned in claim form submitted by the Complainant with Opposite Party No.1 on 22.10.2019. After receiving the claim documents pertaining to captioned claim to avail the benefits of the policy in question, Opposite Party No.1 through Opposite Party No.2 (Raksha TPA Private Limited) has sought some documents and information regarding the claim vide letter dated 14.11.2019 from the Complainant and after receiving the said letter, the Complainant immediately supplied the required documents to the Opposite Parties which was duly received by Opposite Party No.2 from the Complainant on 02.12.2019. Thereafter, the complainant made so many visits to the Opposite Parties and requested to reimburse the mediclaim of the complainant, but the Opposite Parties repudiated the genuine claim of the complainant without assigning any reasonable cause mentioning some clause 4.4.4 of the policy vide letter dated 01.01.2020 which was investigated by Opposite Party No.2 i.e. Raksha TPA Private Limited. Said clause is not applicable to the present case. Moreover, as stated above, no such terms and conditions were ever supplied to the complainant at the time of issuance of the policy. Nor any such terms or condition was ever informed or delivered to the Complainant before issuance of the cover note. At the time of purchasing the policy, the officials of the Opposite Parties informed the Complainant that everything of all type of the medical claim in indoor campus is covered in this policy. Thereafter, the complainant made repeated requests to the opposite parties to make the payment of the claim of her medi claim bill as mentioned above, but to no affect. So there is deficiency in service on the part of the opposite parties for non redressal of the grievance of the complainant and they have illegally repudiated the genuine and legal claim of the complainant taking the false and frivolous ground. Due to non payment of the genuine and legal medi claim by the opposite parties without any rhyme and reason, the complainant remained under mental tension and harassment. Vide instant complaint, the complainant has sought the following reliefs.
- To direct the Opposite Parties to reimburse the remaining medi claim bill worth Rs.83,039/- of the complainant which was wrongly and illegally retained by the Opposite Parties without any reasonable cause.
- And also to pay Rs.1,50,000/- as compensation for causing her mental tension and harassment besides Rs.30,000/- as costs of litigation and
- Any other relief which this Hon’ble District Forum may deem fit and proper may be awarded to the complainant.
2. Upon notice, Opposite Party No.1 appeared through counsel and contested the complaint by filing written reply taking certain preliminary objections therein inter alia that the complaint is not maintainable; that the Complainant is estopped by his own act and conduct to file the present complaint. The intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure under the Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court. The complainant has not approached this District Consumer Commission with clean hands, rather he has wilfully concealed the material and patent facts from this District Consumer Commission which ipso-facto disentitles the complainant to seek any relief against the Opposite Party. In fact the claim of the complainant is non payable under clause 4.4.4 of the insurance policy. The claim of the complainant has been rightly repudiated as per the letter dated 01.01.2020 of Raksha Health Insurance TPA Private limited who observed that “Patient has undergone ilasik with custom vue. Claim for correction of eye sight. As refractive error of patient is 2.0 for right eye and 1.75 let eye which is far less than actual refraction error required for lasik surgery and not covered in policy terms and conditions. Hence claim is recommended for repudiation as per clause 4.4.4”. Thereafter, the claim was repudiated on the recommendation of Raksha Health TPA Private Limited vide letter dated 01.01.2020. Hence, there is no deficiency in service on the part of the Opposite Party. On merits, the Opposite Party took up the same and similar pleas as taken up by them in the preliminary objections. Hence, the complaint is pre mature for want of requisite information/ documents from the Complainant side and as such, the complaint may be dismissed. On merits, the Opposite Party No.1 took all most same and similar pleas as taken up by them in the preliminary objections and hence, there is no deficiency in service on the part of the Opposite Party No.1. All other allegations made in the complaint have been denied and a prayer for dismissal of the complaint with special costs has been made.
3. On the other hand, none has put in appearance on behalf of Opposite Party No.2-TPA, hence, Opposite Party No.2 is proceeded against exparte vide order dated 18.06.2021.
4. In order to prove her case, the complainant has tendered into evidence her affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C17 and closed his evidence.
5. On the other hand, to rebut the evidence of the complainant, Opposite Party No. 1 tendered into evidence affidavit of Sh.Sanjiv Kalia Ex.OP1/1 alongwith copies of documents Ex.OP1/2 to Ex.OP1/22 and closed the evidence.
6. We have heard the ld. counsel for the parties and have carefully gone through the evidence on record.
7. Ld.counsel for the complainant has reiterated the averments as narrated in the complaint and contended that first of all, the written version filed on behalf of the Opposite Party No.1 has not been filed by an authorized person. Therefore, the written version so filed is not maintainable. The Opposite Party No.1 is limited Company and written version has been filed on the basis of special power of attorney given to ld.counsel for the Opposite Party No.1.Further, no such terms and conditions were ever supplied to the complainant at the time of issuance of the policy by the Opposite Parties-Insurance Company nor any such terms or condition was ever informed or delivered to the Complainant before issuance of the cover note. At the time of purchasing the policy, the officials of the Opposite Parties informed the Complainant that everything of all type of the medical claim in indoor campus is covered in this policy. Moreover, the claim of the complainant was rejected on the report of Raksha (TPA), but said TPA has no authority to reject the claim of the complainant. Further contended that the complainant had purchased the medi claim policy bearing no. 36110034199500000017 from Opposite Party No.1 which was valid for the period w.e.f. 20.07.2019 to 19.07.2020 (11:59:59 PM) for a sum assured of Rs.1,50,000/- against the premium paid of Rs.11595/- which was duly paid by the Complainant and drawn on HDFC Bank Limited, Moga Branch. Copy of the cover note is enclosed herewith. However, the Opposite Party No.1 never supplied the policy in question or its terms and conditions to the Complainant till date. Further alleges, that as per the policy documents in question, admittedly the complainant was fully insured for any Indoor medical treatment upto the extent of Rs.1,50,000/-. During the policy period, the complainant felt uneasiness due to pain in her eyes. The Complainant immediately contacted Eye Specialist Dr.Rajesh Aggarwal, Amritsar Eye Hospital, New Town, Moga on 20.09.2019 who advised the Complainant to approach some super specialty hospital and thereafter, the Complainant approached Thind Eye Hospital, Model Town, Jalandhar. After thorough check up, the treating doctor of Thind eye Hospital, Model Town, Jalandhar opined that the Complainant is complained of diminution of vision in her both eyes. Her UCVA was finger counting at 1 meter in both eyes and BCVA was 6/6 in right eye with -7.50/Dsph-0.75/Dcy1 180/axis and 6/6 in left eye with -7.75/Dsph-0.50/Dcyl 180/axis and the treating doctor advised immediate operation.That as per the advice of the treating doctor of Thind eye Hospital, Model Town, Jalandhar, the Complainant immediately informed the Opposite Party No.1 about the said operation and the officials of the Opposite Parties told the Complainant that after completion of the operation, the expenses will be reimbursed. As per the instruction of the officials of the Opposite Parties, the Complainant admitted in Thind eye Hospital, Model Town, Jalandhar on 11.10.2019 for the treatment where the operation of both the eyes of the Complainant was conducted and on the same day, the Complainant was discharged from the hospital, where the Complainant spent Rs.83,039/- for the said treatment. Copy of the discharge summary is enclosed herewith. Beside this, the complainant also spent about Rs.20,000/- during admission at Thind eye Hospital, Model Town, Jalandhar. In this way, the complainant spent Rs.1,00,000/-. Beside this, the complainant also spent amount on her routine follow up check up in the treating hospital, which amounts to Rs.25,000/-. After discharge, the complainant submitted bills with Opposite Party No.1 for the reimbursement of her medical expenses and completed all the relevant formalities. The detail of the expenses paid by the Complainant is duly mentioned in claim form submitted by the Complainant with Opposite Party No.1 on 22.10.2019. After receiving the claim documents pertaining to captioned claim to avail the benefits of the policy in question, Opposite Party No.1 through Opposite Party No.2 (Raksha TPA Private Limited) has sought some documents and information regarding the claim vide letter dated 14.11.2019 from the Complainant and after receiving the said letter, the Complainant immediately supplied the required documents to the Opposite Parties which was duly received by Opposite Party No.2 from the Complainant on 02.12.2019. Thereafter, the complainant made so many visits to the Opposite Parties and requested to reimburse the mediclaim of the complainant, but the Opposite Parties repudiated the genuine claim of the complainant without assigning any reasonable cause mentioning some clause 4.4.4 of the policy vide letter dated 01.01.2020 which was investigated by Opposite Party No.2 i.e. Raksha TPA Private Limited. Said clause is not applicable to the present case. Moreover, as stated above, no such terms and conditions were ever supplied to the complainant at the time of issuance of the policy. Nor any such terms or condition was ever informed or delivered to the Complainant before issuance of the cover note. At the time of purchasing the policy, the officials of the Opposite Parties informed the Complainant that everything of all type of the medical claim in indoor campus is covered in this policy. Thereafter, the complainant made repeated requests to the opposite parties to make the payment of the claim of her medi claim bill as mentioned above, but to no affect. So there is deficiency in service on the part of the opposite parties for non redressal of the grievance of the complainant and they have illegally repudiated the genuine and legal claim of the complainant taking the false and frivolous ground.
8. On the other hand, ld.counsel for the Opposite Party No.1 has repelled the aforesaid contention of the ld.counsel for the Complainant on the ground that the Complainant is estopped by his own act and conduct to file the present complaint. Further contended that the intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure under the Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court. The complainant has not approached this District Consumer Commission with clean hands, rather he has wilfully concealed the material and patent facts from this District Consumer Commission which ipso-facto disentitles the complainant to seek any relief against the Opposite Party. In fact the claim of the complainant is non payable under clause 4.4.4 of the insurance policy. The claim of the complainant has been rightly repudiated as per the letter dated 01.01.2020 of Raksha Health Insurance TPA Private limited who observed that “Patient has undergone ilasik with custom vue. Claim for correction of eye sight. As refractive error of patient is 2.0 for right eye and 1.75 let eye which is far less than actual refraction error required for lasik surgery and not covered in policy terms and conditions. Hence claim is recommended for repudiation as per clause 4.4.4” . Thereafter, the claim was repudiated on the recommendation of Raksha Health TPA Private Limited vide letter dated 01.01.2020. Hence, there is no deficiency in service on the part of the Opposite Party.
9. Perusal of the contention of the ld.counsel for the shows that the written version filed on behalf of the Opposite Party has not been filed by an authorized person. Therefore, the written version so filed is not maintainable. The Opposite Party is limited Company and written version has been filed on the basis of special power of attorney given to ld.counsel for the Opposite Party. In this regard, Hon’ble Supreme Court of India in a judgment (2011)II Supreme Court Cases 524 titled as “State Bank of Travancore Vs. Kingston Computers India Pvt. Ltd.” and in para no.11 of the judgment, has held that
“the plaint was not instituted by an authorized person. On the plea that one authority letter dated 02.01.2003 was issued by Sh. R.K.Shukla in favour of Sh. A.K.Shukla. Further plaint failed to place on record its memorandum/articles to show that Sh. R.k.Shukla has been vested with the powers or had been given a general power of attorney on behalf of the Company to sign, verify and institute the suit on behalf of the Company.”
Similar proposition came before the Hon’ble Delhi High Court in “Nibro Ltd. Vs. National Insurance Co. Ltd.”, 2 (2005) 5SCC 30 that the
“bear authority is not recognized under law and ultimately, it was held that the plaint was not instituted by an authorized person. Here also appellant has not placed on record any resolution passed by any Board of Director in favour of Mr. Soonwon Kwon and that he was further authorised to delegate his power in favour of any other person. Further there is no memorandum/articles of the Company to show that Mr. Soonwon Kwon is one of the Director of the Company. In the absence of that evidence on record we cannot say that the special power of attorney given by Director Soonwon Kwon is a competent power of attorney issued in favour of Sh. Bhupinder Singh. In the absence of any resolution of the Company or any memorandum/articles of the Company to show that Sh. Soonwon Kwon is Director and that he was further authorised to issue power of attorney in favour of Sh. Bhupinder Singh.”
Recently our own Hon’ble State Commission, Punjab Chandigarh in FAO No.1235 of 2015 decided on 25.01.2017 in case titled as L.G.Electronics India Private Limited Vs. Sita Ram Chaudhary also held that the plaint instituted by an unauthorized person has no legal effect.
10. For the sake of arguments, for the time being, if the written reply filed by Opposite Party is presumed to be correct, the next plea raised by Opposite Party is that the complainant has violated the terms and conditions of the policy in question and as per the terms and conditions of the policy, the complainant is not entitled to the claim as claimed. But the Opposite Party could not produce any evidence to prove that terms and conditions of the policy were ever supplied to the complainant insured, when and through which mode? It has been held by Hon’ble National Commission, New Delhi in case titled as The Oriental Insurance Company Limited Vs. Satpal Singh & Others 2014(2) CLT page 305 that the insured is not bound by the terms and conditions of the insurance policy unless it is proved that policy was supplied to the insured by the insurance company. Onus to prove that terms and conditions of the policy were supplied to the insured lies upon the insurance company. From the perusal of the entire evidence produced on record by the Opposite Party, it is clear that Opposite Party has failed to prove on record that they did supply the terms and conditions of the policy to the complainant insured. As such, these terms and conditions, particularly the exclusion clause of the policy is not binding upon the insured. Reliance in this connection can be had on Modern Insulators Ltd.Vs. Oriental Insurance Company Limited (2000) 2 SCC 734, wherein it is held that “In view of the above settled position of law, we are of the opinion that the view expressed by the National Commission is not correct. As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclosed to the appellant, the respondent can not claim the benefit of the said exclusion clause. Therefore, the finding of the National Commission is untenable in law.” Our own Hon’ble State Commission, Punjab, Chandigarh in First Appeal No.871 of 2014 decided on 03.02.2017 in case titled as Veena Mahajan (Widow) and others Vs. Aegon Religare Life Insurance Company Limited in para No.5 has held that
“Counsel for the appellant argued that copy of insurance policy was not supplied to the appellant and hence, the exclusion clause in the contract of the insurance policy is not binding upon him. He further argued that no proof of sending of insurance policy was ever produced by the respondent despite specific contention raised by the complainant that the insurance policy was never received by him. He argued that though there is an averment of the OP that the policy in question was delivered through Blue Dart Courier to the complainant. In order to prove their contention, no affidavit of any employee of Blue Dart was produced who would have made a statement to have the effect that the policy was delivered to the complainant nor any acknowledgement slip for having received the article by the complainant through courier company was produced by the insurance company. He argued that since no policy document was received by the insured and argued that the terms and conditions as alleged to be part of the insurance policy were not binding upon the insured. He argued that policy was issued in the name of deceased Sh.Vijinder Pal Mahajan with his wife Mrs.Veena Mahajan as beneficiary and the same was never refused by the OP and the proper premium for insurance was paid by late complainant. He argued that as per the specific allegations made in the complaint in para No.4, no rebuttal to that contention was specifically there in their written reply in para No.2 and para No.4 in the reply filed by OP in the District Forum. He argued that Hon'ble National Consumer Disputes Redressal Commission, New Delhi in case of "Ashok Sharma Vs. National Insurance Co. Limited", in Revision Petition No. 2708 of 2013 held in para No.8 to the point of non-delivery of terms and conditions of the policy. He also cited Hon'ble Supreme Court's decision given in the matter of "United India Insurance Co. Limited Vs. M.K.J.Corporation" in Appeal (civil) 6075-6076 of 1995 (1996) 6 SCC 428 wherein the Apex court held that a fundamental principle of Insurance Law makes it that utmost good faith must be observed by the contracting parties. Good faith forbids either party from concealing what he privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary. Just as the insured has a duty to disclose, "similarly, it is the duty of the insurers and their agents to disclose all material facts within their knowledge, since obligation of good faith applies to them equally with the assured and further argued that since the terms and conditions were not supplied even on repeated requests the same cannot be relied upon by the opposite party in order to report to repudiate the genuine claim of the wife of the deceased policy holder.”
11. Further question is that whether TPA is competent to repudiate the claim of the complainant?. The answer is ‘No’. A bare perusal of the repudiation letter Ex.Op1/13 reveals that the same was issued by Opposite Party No.2-TPA. Except the above mentioned letter, nothing has been placed on record by Opposite Parties-Insurance Company vide which the claim has been considered and rejected by it.
12. Health Services to be provided by the TPA have been specified in IRDAI (THIRD PARTY ADMINISTRATORS-HEALTH SERVICES) REGULATIONS, 2016, issued vide Notification F. No.IRDAI/REG/ 5/117/2016, Dated 14.3.2016 and the same read as under:-
“Health services by TPA
3. (1) A TPA may render the following services to an insurer under an agreement in connection with health insurance business:
a. servicing of claims under health insurance policies by way of pre-authorization of cashless treatment or settlement of claims other than cashless claims or both, as per the underlying terms and conditions of the respective policy and within the framework of the guidelines issued by the insurers for settlement of claims.
b. servicing of claims for Hospitalization cover, if any, under Personal Accident Policy and domestic travel policy.
c. facilitating carrying out of pre-insurance medical examinations in connection with underwriting of health insurance policies: Provided that a TPA can extend this service for life insurance policies also
d. health services matters of foreign travel policies and health policies issued by Indian insurers covering medical First Appeal No.99 of 2017 12 treatment or hospitalization outside India
e. servicing of health services matters of foreign travel policies issued by foreign insurers for policyholders who are travelling to India:
Provided that such services shall be restricted to the health services required to be attended to during the course of the visit or the stay of the policyholders in India.
f. servicing of non-insurance healthcare schemes as mentioned in Regulation 22 (3) of these Regulations
g. any other services as may be mentioned by the Authority.
(2) While performing the services as indicated at Regulation.
3 (1) of these regulations,
a TPA shall not a. Directly make payment in respect of claims
b. Reject or repudiate any of the claims directly
c. Handle or service claims other than hospitalization cover under a personal accident policy
d. Procure or solicit insurance business directly or indirectly
e. Offer any service directly to the policyholder or insured or to any other person unless such service is in accordance with the terms and conditions of the policy contract and the agreement entered into in terms of these regulations.
(3) A TPA can provide health services to more than one insurer. Similarly an insurer may engage more than one TPA for providing health services to its policyholders or claimants.”
13. A perusal of Regulation 3(2)(b) of the above health services to be provided by TPA specifically reveals that while performing the services as indicated at Regulation 3(1)(b) of these Regulations, a TPA shall not reject or repudiate any of the claims directly. In the present case the claim has been repudiated by opposite party No.2- TPA, Ex.OP-1/13, which is in violation of the above said Regulations of the IRDAI. The duties and responsibilities of the Insurance Companies and TPA were also discussed by the Hon’ble Bombay High Court, in Public Interest Litigation No.12 of 2011 (Gaurang Dinesh Damani vs. Union of India & Ors.) in orders dated 05.03.2015 and 13.08.2015. It is a common practice that the TPA gives daily targets to its staff for approving claims, where they sanction total money in a day for and all the claims should not exceed particular limit. The hospital bill cannot be settled on the basis of targets fixed by the Insurance Companies. Otherwise, the TPAs have no authority to reject the claim. Such power lies, exclusively with the Insurance Companies. The TPA can only process the claim and forward the same to the Insurance Company and the competent authority of the Insurance Company is to decide about the same.
14. Thus, we are of the opinion that the claim of the complainant was illegally and arbitrarily rejected by the TPA, against the aforesaid instructions of the IRDA. Since the Insurance Companies use the PPN or hospitals empanelled by the TPA and, resultantly, TPA ask the hospital to give commission on every claim, if they want to be enrolled in PPN. This has been observed by the regulators. Resultantly, the patients/consumers are over-charged by the hospitals, since they have to pay some commissions to TPAs to use the power on behalf of the Insurance Companies. They have no right to solicit business, like agents for the Insurance Companies. Their only job is to serve and process the claims. Accepting and rejecting the claims at their own by the TPAs is illegal, arbitrary, null & void and is not sustainable in the eyes of law. Hence, the answer to question no.(ii) posed above is given in the negative. In this regard, we also supported the judgement of Hon’ble State Consumer Disputes Redressal Commission, Punjab at Chandigarh in First Appeal No.820 of 2017 decided on 17.09.2018 in case The New India Assurance Company Limited Vs. Vikram Goyal.
15. There is no dispute inter se parties regarding the expenses incurred by the complainant on the treatment for which the complainant has also produced on record. In view of this, there is deficiency in service on the part of the Opposite Party and they have illegally repudiated the claim of the Complainant.
16. In such a situation the repudiation made by Opposite Party regarding genuine claim of the complainant appears to have been made without application of mind. It is usual with the insurance company to show all types of green pesters 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 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.
17. In view of the above discussion, we are of the opinion that Opposite Parties-Insurance Company has wrongly and illegally repudiated the claim of the complainant. Consequently, we allow the complaint and Opposite Parties-Insurance Company is directed to reimburse the medical bill of the Complainant amounting to Rs.83,039/- (Rupees eighty three thousands and thirty nine only) alongwith interest @ 8% per annum from the date of filing the present complaint i.e. 29.01.2020 till its actual realization. Opposite Parties-Insurance Company is also directed to pay the lump sum compensation to the complainant to the tune of Rs.10,000/- (ten thousands only) on account of harassment, mental tension and litigation expenses. The compliance of this order be made by Opposite Parties-Insurance Company within 45 days from the date of receipt of this order, failing which the complainant shall be at liberty to get the order enforced through the indulgence of this District Commission. Copies of the order be furnished to the parties free of cost. File be consigned to record room after compliance.
18. Reason for delay in deciding the complaint.
This complaint could not be decided within the prescribed period because the government has not appointed any of the Whole Time Members in this Commission for about 3 years i.e. w.e.f. 15.09.2018 till 27.08.2021 as well as due to pandemic of COVID-19.
Announced in Open Commission.
Dated: 08.03.2022.
