Complainant Jai Dev Sharma, through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has prayed that the opposite parties be directed to reimburse Rs.1,25,662/- alongwith interest @ 18% P.A. from the date of due till its realization. Opposite parties be also directed to pay Rs.20,000/- for the pain, humiliation, tension he suffered in the hands of opposite party alongwith litigation expenses, in the interest of justice and fair play.

2.    The case of the complainant in brief is that he entered into Med Claim Policy with the opposite party in the year 2013 for the total insured sum of Rs.5,00,000/- as per the terms and conditions. The premium of the policy was Rs.6830/- and commenced from 7.1.2013 to 6.1.2014. Subsequently in the year 2014, he renewed the same policy with the opposite party for the sum of Rs.6830/- as premium which is renewed upto 6.1.2015. He has further pleaded that on 30.3.2014, he suffered a Cardiac arrest, resulted which he was hospitalized in Ravi Multi Specialty Hospital, Dalhousie Road, Pathankot where he got admitted and treated. He remained under their Hospital treatment and huge expenditure was incurred on the treatment and is still under treatment and bill for whole treatment amounting to Rs.1,25,662/- were borne by him. After treatment, he handed over all the original bills and other relevant documents to the opposite party for the reimbursement of med claim. Opposite party did not consider his request and flatly refused to admit his claim. A number of times, he visited the office of opposite party but of no use. Even the opposite parties have issued letter dated 15.7.2014 through registered post to him, whereby they repudiated his claim. There is clear cut unfair trade and malpractice on their part. Due to the illegal act and conduct of the opposite party towards him, he has suffered huge monetary loss, mental and physical harassment which act of the opposite parties is clear cut deficiency in services on the part of the opposite party. Hence this complaint.   

3.       Upon notice, the opposite parties appeared through their counsel and filed the written reply by taking the preliminary objections that complaint is bad for non joinder of necessary party; the present complainant is not entitled for any insurance claim as the complainant withheld material information in respect to his pre existed diseases at the time of taking above said 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 ORIENTAL ROYAL MEDICLAIM POLICY. The claim of the claimant was repudiated by the Medi Assist India TPA Pvt.Ltd. 47/1, Sri Krishna Arcade, 1^st Main, 9^th Cross Sarakki Industrial Layout, J.P.Nagar, 3^rd Phase, Bangalore on 9.10.2014 on the ground that it falls under Exclusion 4.2 of the terms and conditions of PNB-Oriental Royal Mediclaim Insurance Policy. On scrutiny of the claim documents, Medi Assist India TPA Pvt.Ltd. observe that claim is not admissible in view of the following:- ‘On perusal of claim documents it is found that the Claimant covered under the above mentioned policy admitted at Raavi Multi specialty Hospital for the treatment of Hypertension, Diabetes, Tripathy, DCM, Severe Left Systolic Dysfunction on 30.3.2014 & discharged on 6.4.2014. As per the policy terms and conditions, during the period of insurance cover, the expenses on treatment of aliment/diseases/surgeries for hypertension & diabetes disease for specified periods of 2 years are not payable if contracted and/manifested during the currency of the policy. Hence, we regret our inability to admit this liability under present policy conditions and the claim is being repudiated under exclusion 4.2 of terms and conditions of the above mentioned policy. We also reserve the right to repudiate the claim under any other grounds available to us subsequently’. The claim of the complainant was repudiated under exclusion 4.2 of terms and conditions of the above mentioned policy. That as per terms and conditions of Exclusion 4.2 pre existing diseases not declared in the proposal form, when the cover incepts for the first time are excluded upto two years of this policy being in force continuously. But the abovesaid claim of the insured is in respect to second year of taking the policy, so the opposite party is not liable to pay any claim to the complainant as per Exclusion 4.2 of terms and conditions of the above mentioned policy; the complaint is not maintainable and is liable to be dismissed, no cause of action has been accrued to the complainant against the opposite parties for filing the present complaint. On merits, the same contentions have been repeated while denying and rebutting the other allegations made in the complaint and prayed for dismissal of the complaint.    

4. Complainant tendered into evidence his own affidavit Ex.C1 alongwith other documents Ex.C2 to Ex.C96 and closed the evidence. 
5. Sh.Makiat Singh, Branch Manager of the opposite parties tendered into evidence  his own affidavit Ex.OP-1, alongwith other documents Ex.P-2 to Ex.OP4 and closed the evidence.

6.       We have duly considered the pleadings of both the parties; heard the arguments advanced by their counsels and have also appreciated the evidence produced on record with the valuable assistance of the learned counsels for the purpose of adjudication of the present complaint.

7.       We find that the complainant’s hospitalization claim has been repudiated by the OP insurers vide the Repudiation Letter (Ex.C96) of 15.07.2014 duly followed by the Third Party Administrator (TPA)’s Denial of Claim (Ex.OP2) intimation letter of 09.10.2014 both having prompted on the strength of Exclusion clause 4.2 (Ex.OP3) the related relevant part of which reads as: The expenses on treatment of following ailment/diseases/surgeries for the specified periods are not payable if contracted and/or manifested during the currency of the policy: xvii) Hypertension for 2 years; and xviii) Diabetes again for 2 years. We, further find that the complainant was diagnosed vide the Hospital’s Discharge Summary (Ex.OP28) to have suffered from the following 7 diseases, namely: i) COAD ii) HTN iii) Type II DM iv) DCM v) Severe LV Systolic Dysfunction vi) Acute LVF with carcinogenic shock and vii) Electrolyte Imbalance (since Recovered); and that shows on record that the complainant patient was not only treated for 2 nos. of ailments at # ii) & iii) but also for all other ailments at # i) and iv) to vii) with that at # vii) getting cured. The Resume of History, Examination & the Hospital Course duly supported by other exhibits on diagnosis & treatment (Ex.C6 to Ex.C35) further confirm the indications of serious ailments other than HTN & DM warranting urgent medical treatment and that was duly provided at the attending Hospital. A simple study of all these exhibits even by an English-literate layman shall let him know that the subjected medical treatment had been for some serious Heart Dysfunction etc and not for the commonly attracted HTN & Type II DM etc that are treated through oral-medication and the more complex angiography and other procedures need not be associated. The onus of proof lay heavily upon the OP insurers to prove that the complainant received medical treatment only for the ailments/ diseases falling under the exclusionary clause 4.2 and for no other ailment etc of whatsoever; but they failed to produce any such cogent evidence on record. We are of the considered opinion that the medical treatment received by the complainant at the attending Hospital from 30.03.2014 to 06.04.2014 was primarily for the treatment of ailments/diseases not falling under the exclusionary clause 4.2 and thus he was fully entitled to receive full reimbursement of the amount spent on his treatment. We respectfully concur with the legal proposition transpiring out of the honorable National Commissions’ Orders in RP # 852 of 2013 titled: Col. T S Bakshi vs Star Health & Allied Insurance Co. Ltd.; but that does not absolve the OP insurers of its legal liability, here since the ‘issue’ in question in that case pertained to the alleged non-disclosure of the exclusionary clause by the insurers to the complainant whereas in the present complaint the ‘issue’ in question is of the reimbursement of medical treatment of the ‘ailment/ disease’ not falling in the ‘list of ailments/diseases’ included under the exclusionary clause 4.2.        

8.       In the light of the all above, we hold the OP insurers’ claim repudiation-decision as arbitrary, and thus ORDER them to settle and pay to the complainant the full insurance-claim amount as eligible under the extant terms of the Policy in force at the time of his hospitalization, besides to pay him Rs.5,000/- as compensation 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 become payable with interest @ 9% PA form the date of the orders till actually paid.

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

                                                                                           (Naveen Puri)

                                                                                                President.                                                                                   

ANNOUNCED:                                                             (Jagdeep Kaur)

June 22, 2015                                                                          Member.

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