Complainant Revti Raman Vig through the present complaint U/S 12 of the Consumer Protection Act 1986 (hereinafter for short the Act.) has prayed for issuance of necessary directions to the opposite parties (the OP insurers) to make the payments of Rs.2,92,800/- (i.e. Rs.1,95,000/-, Rs.77,800/- spent on his heart surgery as per the insurance policy dated 24.02.2014 and Rs.20,000/- on medicines after 2.6.2014) with interest thereon @ 18% P.A.  w.e.f. 12.5.2014 till the actual date of payment. Opposite parties be also directed to pay Rs.1,00,000/- as compensation for harassment and mental agony caused to him and Rs.22,000/- as costs of litigation, all in the interest of justice..

2.       The case of the complainant in brief is that he is account holder in Punjab National Bank, Batala since long. On the request of opposite party no.3 he obtained one Health Insurance Policy vide cover note No.233106/48/2014/844 dated 24.2.2014 from opposite parties no.1 to 3 commencing w.e.f. 24.2.2014 to midnight of 23.2.2015 and paid Rs.6830/- as premium from his bank account lying with the opposite party no.3. The insurance policy covered him and his wife Smt.Veena Vig as well.  At the time of obtaining the insurance policy he was not suffering from any sort of disease. On 12.5.2014 he got the routine check up from Tagore Hospital and Heart Care Centre (P) Ltd. Banda Bahadur Nagar Mahavir Marg Jalandhar-144008 due to sudden illness complaining against chest pain whereas he was not having any sort of health problem earlier and he had no previous history of heart problem. On 12.5.2014 the Coronary Angiography was done by the Doctors which revealed that there was coronary artery disease and ultimately on 15.5.2014 coronary artery Bypass Grafting X-2 was done. The above mentioned hospital had given him a package of Rs.1,95,000/- and charged the said amount from him against receipts duly issued by the hospital. He has next pleaded that for the post operation treatment he remained admitted in Tagore Hospital and Heart Care Centre (P) Ltd. Banda Bahadur Nagar Mahavir Marg Jalandhar-144008 (Punjab) India w.e.f. from 24.5.2014 to 02.06.2015 and he spent Rs.77,800/- for his treatment including the medicines expenses. He spent the amount of Rs.2,72,800/- for his treatment at Tagore Hospital and Heart Care Centre (P) Ltd. Banda Bahadur Nagar Mahavir Marg Jalandhar-144008 w.e.f. 12.05.2014 till 02.06.2014. Apart from the above amount of Rs.2,72,800/- he spent about Rs.20,000/- for his treatment. In total he spent Rs.2,92,800/- for his treatment. He filed health claim with the opposite party and completed all the required formalities and submitted all the necessary documents desired by the opposite parties. But the opposite parties have repudiated his legal and valid  health claim illegally, unlawfully and in violation of the terms and conditions of the policy vide repudiation letter dated 28.8.2014 of Rs.1,95,000/- and denial of the claim of Rs.77,800/-/. Thus, there is deficiency in service on the part of the opposite parties. Hence this complaint.

3.      Upon notice, the opposite parties no.1 & 2 insurers appeared through their counsel and filed their written reply taking the preliminary objections that the complainant is not entitled to any insurance claim as the complainant with held material information in respect to his pre existed disease at the time of taking abovesaid insurance policy. The claim of the insured does not fall within the purview of the policy terms and conditions. The claim is not covered/payable as per terms and conditions of PNB-Oriental Royal Medi claim Insurance Policy. The complainant took first policy on 24.02.2014 for a period from 24.02.2014 to 23.02.2015 under policy no.233106/48/2014/844 issued by B.O.Kapurthala.  Hence being the first insurance policy as the complainant is having waiting period of two years. The claim of the complainant was repudiated on 11.10.2014 by the Medi Assist India TPA Pvt.Ltd. on the ground that it falls under Exclusion 4.2 of the terms and conditions of PNB-Oriental Royal Medi claim Insurance Policy; the complaint is not maintainable and the complaint is without any cause of action, hence liable to be dismissed. On merits, it was submitted that it was incorrect that at the time of obtaining the insurance policy complainant was not suffering from any sort of disease. The complainant with held material information in respect to his pre existed disease at the time of taking insurance policy. The claim of the insured does not fall within the purview of the policy terms and conditions. The claim is not covered/payable as per terms and conditions of PNB-Oriental Royal Mediclaim Insurance Policy. The complainant took policy on 24.2.2014 for a period from 24.2.2014 to 23.02.2015 issued by B.O.Kapurthala. Hence being the first insurance policy as the complainant is having waiting period of two years. The claim of the complainant was repudiated on 11.10.2014 by the Medi Assist India TPA Pvt.Ltd. on the ground that it falls under Exclusion 4.2 of the terms and conditions of PNB-Oriental Royal Medi claim Insurance Policy. On scrutiny of the claim documents, Medi Assist India TPA Pvt. Ltd. Observed that claim is not admissible in view of the following:-

“On perusal of claim documents it is found that the claimant covered under the abovementioned policy was admitted at Tagore Hospital for the treatment of CAD, Hypertension, Post Cab, Chest Infection on 24.05.2014 and discharged on 2.6.2014. As per the policy terms and conditions, during the period of insurance cover, the expenses on treatment of ailment/diseases/surgeries for hypertension disease for specified periods of two years are not payable if contracted and/or manifested during the currency of the policy. The claimant was treated for CAD on 15.5.2014 by the way of surgery and now admitted for chest infection. Hence, we regret our inability to admit this liability under present policy conditions and the claim is being repudiated under exclusion 4.2 of above mentioned policy.”

All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.       Upon notice, the opposite party no.3 appeared through its counsel and filed its written reply taking the preliminary objections that the opposite party has not committed any default in service as no service on the part of the opposite party is required in the present case qua the complaint in question and as such the complaint is not maintainable against it and liable to be dismissed on this ground alone. On merits, it was submitted that opposite party is not to pay any amount and question of repudiation of the claim does not arise. The claim if any is to be paid the same has to be paid by opposite parties No.1 and 2 as per policy and opposite party is not liable to pay the same in any capacity. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

5.       Counsel for the complainant tendered into evidence affidavit of complainant Ex.C1 alongwith other documents exhibited as: Ex.C2 to Ex.C49 and closed the evidence;

6.       Sh.Suraj Mehta A.O. of Oriental Insurance Company tendered into evidence his own affidavit Ex.OP1,2/1 along with the other documents exhibited as: Ex.OP1,2/2 to Ex.OP1,2/9 and closed the evidence.

7.      Sh.Naresh Kumar Puri Chief Manager of opposite party no.3 tendered into evidence his own affidavit Ex.OP-3/1 and closed the evidence.

8.       We have carefully examined all the documents/evidence produced on record and have also judiciously considered and perused the arguments duly put forth by the learned counsels along with the incidental scope of adverse inference for some documents that have been somehow ignored to be produced by the contesting litigants. We observe that the prime dispute has prompted from the OP’s claim repudiation of 28.08.2014 (Ex.C29) in response to the complainant’s 2 nos. of insurance claims for reimbursement of the hospitalization expenses of Rs.1,95,000/- (Ex.C5) and Rs.77,800/- (Ex.C17) incurred by him upon his medical treatment. Further, the OP insurers have duly admitted in the written statement & in its affidavit (Ex.OP1& 2/1) that the impugned insurance claim was repudiated/refused at the instance of the Third Party Administrators M/s Medi Assist India TPA Pvt. Ltd., as it fell under the Exclusion clause 4.2 of the Policy Terms & Conditions (Prospectus Ex.OP1&2/2); and as per which the expenses on the treatment of ailment/diseases/surgeries for Hypertension disease for specified period of 2 years are not payable if contracted and/or manifested during the currency of the policy. However, the prospectus Ex.OP1&2/2 requires at its page ‘12’ the insured’s signatures accepting the terms and conditions along with his name, address, place and date etc. Somehow, the OP insurers have failed to produce the duly acknowledged (signed) prospectus (by the complainant) confirming the acceptance of the terms & conditions (including its ‘exclusionary’ clauses). In the absence of the above ‘acceptance’ (amounting to ‘pre-notice’) the complainant shall not be bound by any adverse terms of the Policy at the stage of claim settlement. The above legal proposition also derives its ‘legal-force’ from the orders of the honorable apex court in Modern Insulators Ltd., vs. Oriental Insurance Company Limited; (2000) 2 SCC 734 as: “9. In view of the settled position of law we are of the opinion that the view expressed by the NCDRC 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 cannot claim the benefit of the said exclusion clause. Therefore, the finding of the National Commission is untenable in law”. Finally, the impugned repudiation was first conveyed vide Ex.C29 of 28.08.2014 but the OP insurers and the TPA continued their inter-se correspondence till 11.10.2014 (Ex.OP1&2/9) and also with the complainant Ex.OP1&2/4 to Ex.OP1&2/6 (26.09.2014); whereas the written statement and the affidavit Ex.OP1&2/1 depose that the claim was repudiated on 11.10.2014 and the inconsistency has been left to stay as such, unexplained by the OP insurers. Thus, the OP insurers’ impugned repudiation of the insurance claim does not entail legality under the applicable law and need be set-aside.     

9.       In the light of the all above, we partly allow the present complaint and thus ORDER the OP insurers to settle and pay both the impugned insurance med-claim(s) with full Hospitalization Benefits as applicable under the related Policy to the complainant besides Rs.5,000/- as compensation (for the harassment inflicted) and Rs.3,000/- as cost (of litigation) within 30 days of the receipt of the copy of these orders otherwise the aggregate awarded amount shall attract interest @ 9% PA form the date of the orders till actual payment. 

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

                    (Naveen Puri)

                                                                                        President     

ANNOUNCED:                                                            (Jagdeep Kaur)

December 23, 2015.                                                              Member.

*MK*