Complainants Shunila and Victor Bhatti have filed the present complaint against the opposite parties U/S 12 of the Consumer Protection Act (for short, C.P.Act.) seeking necessary directions to the opposite party no.1 to honour their claim and make the payment of insured amount immediately in terms of the Insurance Policy in question alongwith interest @ 18% P.A. from the date of due till actual realization. Opposite parties be further directed to pay Rs.50,000/- as compensation besides the amount in question on account of mental agony, physical harassment and deficiency in service on the part of the opposite parties alongwith Rs.5,000/- as litigation expenses, in the interest of justice.

2.       The case of the complainants in brief is that they obtained insurance policy from the opposite party no.1 through the opposite party no.2 under the policy ‘PNB-Oriental Royal Mediclaim Policy Schedule” vide policy no.233106/48/2018/413 valid from 03.07.2017 to Midnight of 02.07.2018 was issued to them. They paid the premium of the policy through cheque through opposite party no.2. The policy in question is continuing and still the same is in force. As per the terms of the policy three members of the family are covered under the policy. The complainant no.1 has duly nominated the complainant no.2 and her daughter Shahnaz Bhatti for availing benefits of this policy.  They have further pleaded that as per the policy schedule, the opposite party no.1 has to pay medical claim upto 5,00,000/- which is evident from the schedule of policy. All of sudden husband of complainant no.1 suffered from heart problem on 5.7.2017 and he was taken to Nayyar Hospital Amritsar where the complainant no.2 was admitted on 5.7.2017 at 01.37 P.M. and discharged on 10.07.2017 at 2.10 P.M. The complainant no.2 spent more than Rs.1,40,000/- on his treatment. Thereafter, they submitted claim to the opposite party no.1 for making payment of the same supported with all medical bills and other necessary documents but, the opposite party no.1 repudiated their claim which is totally illegal, null and void. They are also entitled for compensation to the tune of Rs.50,000/- besides the amount of claim for the mental torture, physical harassment and financial loss caused by the opposite party no.1 for no fault on their part. Thus, there is deficiency in service on the part of the opposite parties. Hence, this complaint.

3.       Notice of the complaint was issued to the opposite parties. Opposite party No.1 appeared through their counsel and filed their written reply taking the preliminary objection that the complaint filed by the complainants is not maintainable; all allegations made in the complaint, which are not specifically denied herein, are denied being false and baseless. The complaint is absolutely false, frivolous; at the very outset the replying opposite party denies all the allegations, facts and averments stated in the complaint filed by the complainant except to the extent it is expressly admitted therein and no cause of action has ever arisen in favour of the complainant against the replying opposite party to file the present complaint and hence, the complaint under reply is an abuse of the process of law and as such the same is liable to be dismissed, with exemplary cost. On merits, it was submitted that complainant got PNB-Oriental Royal Mediclaim Policy bearing no.233106/48/2018/413 effective from 03.07.2017 to 02.07.2018 from the opposite party no.1 through opposite party no.2. Complainant no.2 Victor Bhatti was Hospitalized from 05.07.2017 to 10.07.2017 at Nayyar Hospital Amritsar for getting treatment of CAD DVD and claim was lodged by complainant before opposite party regarding expenses on treatment of Victor Bhatti husband of insured Shunila. The claim file alongwith all the treatment record was sent to M/s.RAKSHA HEALTH INSURANCE TPA PVT.LTD., SCO 359/360, Ist Floor Sector 44 D, Chandigarh 160047 for investigation and admissibility of claim on 27.09.2017. M/s.RAKSHA HEALTH INSURANCE TPA PVT.LTD., Chandigarh sent a letter on 13.10.2017 to complainant Shunila regarding query and vide its letter dated 27.10.2016 declared that the claim of the complainant is not admissible. Opposite party further stated that the opposite party vide its letter dated 30.10.2017 closed the claim file of the complainant as NO CLAIM reason violation of policy conditions not covered in the policy duly conveyed to the complainant. So the opposite party no.1 is not liable to pay any claim to the complainant as per the terms and conditions of policy vide EXCLUSION CLAUSE 4.1 of the policy.  The opposite party No.1 has rightly repudiated the claim of the complainants as per the terms and conditions of the policy. Thus, there is no deficiency in service on the part of the insurance company. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.       Opposite party no.2 appeared through its counsel and filed its written statement taking the preliminary objection that the complaint filed by the complainants is not maintainable in the present form as no services were ever hired by the complainant from the opposite party at any point of time relating to the alleged matter in question and thus there is no deficiency in service on the part of the opposite party. On merits, it was submitted that there is no dispute that the complainants are having account with the opposite party. It is absolutely incorrect and wrong that the complainant was compelled to take the policy as alleged, however it is a fact that the other party had only introduced the complainant about the policy to the complainant and after understanding its pros and cons the complainant availed the policy from opposite party no.1 with her own will and consent and without any compulsion and force as alleged.  All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

5.       Ld. counsel for the complainant has tendered into evidence affidavit of complainant Ex.C-1 alongwith other documents Ex.C-2 to Ex.C-6 and closed the evidence.

6.       Ld. counsel for the opposite parties no.1 tendered into evidence affidavit of Sh.Karam Singh, Sr.D.M. Ex.OP-1/1 alongwith other documents Ex.OP-1/2  to Ex.OP-1/9 and closed the evidence.

7.       Sh.Sanil Kumar Maingi, Sr.Manager P.N.B. opposite party no.2 tendered into evidence his own affidavit Ex.OP-2/1 and closed the evidence.

8.       Written arguments not filed by the parties.

9.       We have carefully gone through the pleadings of counsels for the parties; arguments advanced by their respective counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsels for the purposes of adjudication of the present complaint.

10.     From the over all circumstances as enumerated in respective pleadings of the parties, It reveals that the complainants obtained insurance policy from the opposite party no.1 through the opposite party no.2 under the policy ‘PNB-Oriental Royal Mediclaim Policy Schedule” vide policy no.233106/48/2018/413 valid from 03.07.2017 to Midnight of 02.07.2018 and paid the premium of the policy through cheque through opposite party no.2. The policy in question is continuing and still the same is in force. As per the terms of the policy three members of the family are covered under the policy. That as per the policy schedule, the opposite party no.1 has to pay medical claim upto 5,00,000/- which is evident from the schedule of policy. All of sudden husband of complainant no.1 suffered from heart problem on 5.7.2017 and he was taken to Nayyar Hospital Amritsar where the complainant no.2 was admitted on 5.7.2017 at 01.37 P.M. and discharged on 10.07.2017 at 2.10 P.M. The complainant no.2 spent more than Rs.1,40,000/- on his treatment. Thereafter, complainants submitted claim to the opposite party no.1 for making payment of the same supported with all medical bills and other necessary documents but, the opposite party no.1 repudiated their claim.Thereafter complainant filed the present complaint. whereas the opposite party no.1 argued that the claim file alongwith all the treatment record was sent to M/s.RAKSHA HEALTH INSURANCE TPA PVT.LTD., SCO 359/360, Ist Floor Sector 44 D, Chandigarh 160047 for investigation and admissibility of claim on27.09.2017. Opposite party further argued that the opposite party vide its letter dated 30.10.2017 closed the claim file of the complainant as NO CLAIM as per the terms and conditions of policy vide EXCLUSION CLAUSE 4.1 of the policy, and rightly repudiated the claim of the complainants as per the terms and conditions of the policy.

11.    The Repudiation of the claim has been done on the ground that the insured suffered from pre-existing ailment under clause 4.1 of the policy. There is no evidence produced by the opposite party to establish this fact. Neither the medical examination report nor the proposal form has been placed on file.  It is pertinent to mention here that the opposite party has also quoted that the complainant was holding the similar policy previously upto 11.05.2013 and thereafter it was renewed as a fresh policy from 03.1.2017. Had it been pre-existing, as claimed by opposite parties even then there was a similar policy existing upto 05/2017. Moreover, the opposite parties have failed to put on record the evidence of terms and conditions of this policy showing that clause 4.1 is equally applicable in this insurance policy also. Therefore, it is not clear on what basis the opposite party has concluded that complainant was a pre-existing ailment. Moreover it was the duty of the Opposite Party to check the health condition of the Insured before issuing the Health Policy. The reason for repudiation of the claim was therefore, not based on medical evidence but on a surmise which cannot be a valid ground for repudiating the claim. Hence the repudiation of the claim of the complainant by the opposite party No.1 is not justified.

12.     Therefore, as a sequel of the above discussion, this commission is of considered opinion that the complaint in hand is partly allowed and the repudiation letter dated 30.10.2017 (Ex.C2) is hereby set aside. Further, opposite party no.1 is   directed to pay Rs.1,40,000/- along with interest @ 6% P.A. from filling of the present complaint i.e. 06.12.2017 till its realization within 45 days from the date of receipt of copy of this order, failing which opposite party no.1 shall pay the said amount along with interest @ 9% P.A. to the complainants , in addition to this opposite party no.1 is directed to pay Rs.5000/- in lump sum as deficiency in services  and  litigation charges to the complainants.

13.     The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.

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

                                                                    (Kiranjit Kaur Arora)

                                                                                 President.

Announced:                                                 (B.S.Matharu)

March 15, 2023                                                  Member

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