Complainant Sudhir Gupta through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has prayed that necessary directions may kindly be issued to the opposite parties to pay Rs.20,000/- as compensation to him for not deciding his claim within 30 days despite the submission of claim documents. He has further prayed that opposite parties be also directed to pay the claim amount of Rs.2,64,546/- along with 12% interest from the date 22.01.2014 till realization including Rs.10,000/- as litigation expenses, all in the interest of justice.

2. The case of the complainant in brief is that he had filed a complaint before this Hon’ble Froum against the opposite parties No.1 and 2 vide complaint No.232/14 which was decided on 12.02.2015 in which complainant was directed by this Hon’ble Forum to lodge the claim first before the opposite parties with all documents which were in his possession within 15 days from the date of receipt of copy of orders and opposite party was also directed to decide the claim within 30 days from the lodging of the claim and submitting of the documents by the complainant. It was pleaded that complainant complied with the orders of this Hon’ble Forum but the opposite party did not decide the claim within 30 days from lodging the claim, as such there is clear cut deficiency on the part of the opposite parties. It was pleaded that complainant got a Bank Medico Claim Policy in the year 2012 from opposite party No.1 vide policy No.2003004812410000213 which was valid from 30.04.2013 to 25.04.2014 and the sum insured as per the policy was Rs.5,00,000/-. It was further pleaded that suddenly complainant suffered from heart problem and was admitted in Medanta Medicity on 20.01.2014 and discharged on 29.01.2014 under the supervision of Dr.Naresh Tarhen and in the said hospital his bye pas surgery was got done. It was also pleaded that complainant came to know about this disease after 1.3/4 years, after getting the said policy and as such complainant submitted his medi claim with the opposite parties but the opposite parties did not decide the claim of the complainant despite the directions of this Hon’ble Froum. It was next pleaded that if the claim of the complainant illegally repudiated by the opposite parties then it will deficiency in service of the opposite parties, hence this complaint.

3. Notice of the complaint was served upon the opposite parties. Opposite parties No.1 and 2 appeared through their counsel and filed the written reply by taking the preliminary objection that present complaint of the complainant is not maintainable. It was stated that when claim was received from the complainant opposite parties i.e. Insurance Company referred the same to M/s. Paramount Health Services (TPA) Pvt. Ltd. Ludhiana for settling the claim as per terms and conditions of the policy and as per the required record/documents as M/s Paramount Health Services (TPA) Pvt. Ltd. is the claim settling authority who settles the mediclaim as per the terms and conditions of the policy. It was further stated that when Paramount Health Services Ltd. scrutinized the medical documents and policy they observed that patient Sudhir Gupta was suffering with pre existing disease and its related complications were not covered as per the policy terms and conditions. It was also stated that when complainant made request for cashless hospitalization under medical insurance policy to the third party administrator, the complainant had already given the detail of his past history of chronic illness in which he had admitted that he has been suffering with Diabetes since 8 to 10 years, Heart disease since 4 years and Hypertension since 3 years from which it was clear that he was suffering with pre-existing diseases which is not covered under the terms and conditions of the policy and as such opposite parties i.e. Insurance Company had rightly repudiated the claim of the complainant under the terms and conditions of the policy and it was conveyed to the complainant vide repudiation letter dated 09.02.2016. On merits, the contents of para no.1 of the complaint was admitted by the oppostie parties i.e. Insurance Company but it was denied that Company did not decide the claim within 30 days from lodging the claim and was also denied that there was deficiency in service on the part of the opposite party Insurance Company. It was admitted that complainant took the Medico Claim Policy in the year 2012 from opposite party No.1 which was valid from 30.04.2013 to 25.04.2014 for sum insured Rs.5,00,000/-. It was stated that Insurance Company settled the claim of the complainant under the terms and conditions of the policy as per the order of this Hon’ble Forum. It was further stated that Insurance Company had rightly repudiated the claim of the complainant under the terms and conditions of the policy. All other averments made in complaint have been denied and lastly prayed for dismissal of the complaint with exemplary costs.

4. Opposite party No.3 did not appear to contest the case of the complainant and was ordered to be proceeded against exparte vide order dated 22.4.2016.

5. Counsel for the complainant had tendered into evidence affidavit of complainant Ex.C1 along with other documents Ex.C2 to Ex.C7 and closed the evidence on behalf of complainant.

6. Counsel for the opposite parties No.1 and 2 had tendered into evidence affidavit of Sh.Surinder Singh D.M. Ex.OP-1,2/1 along with other documents Ex.OP-1,2/2 to Ex.OP-1,2/24 and closed the evidence on behalf of opposite parties No.1 and 2.

7. We have carefully gone through the pleadings of the parties, arguments advanced by the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of both the counsel for the parties.

8. We analytically observe with the judicial precision and find that the OP insurers have arbitrarily repudiated (vide Ex.OP1,2/12 dated 09.02.2016 followed by Ex.OP1,2/11 of 23.02.2016) the complainant’s insurance claim submitted/received by him on 15.05.2015 in compliance with the forum’s orders dated 12.02.2015 (pertaining to CC # 232/2014) vide which the OP insurers were also directed to decide the (so-submitted) claim within 30 days of its receipt. We further find that the OP insurers have attributed the ‘non-compliance’ of the forum’s referred orders within the prescribed time frame of ‘30’ days to the act of ‘non-submission’ of some documents by the complainant; but only to cover up the ‘8’ months delay with a number of deficiency letters sans an evidence of ‘dispatch’ etc. The last deficiency letter demanding the requisite deficient documents was dispatched from the OP insurers’ office only on 05.10.2015 (exhibited here as Ex.OP1,2/15) i.e., after 140 days of receipt of the claim in total violation and utter disregard of the forum’s orders. Moreover, out of the ‘2’ demanded documents, the first one (details of relevant consultations for Diabetes & HTN) has been invalid hence redundant in the light of the Proposal Form (Ex.OP1,2/2) and also as per the trite law that ‘one shall not depose against oneself unless admitting offence’. The other demand of second document i.e., ‘authority letter’ for the TPA representative to examine indoor case papers of treating Hospital has been all the more ‘fussy’ besides being arbitrary. The TPAs (Third Party Administrators) are always allowed limited access (though sufficient) to the Hospitals’ records for the purpose and moreover a post-discharged patient cannot delegate an authority that he himself never held/does not hold. At the best, the OP insurers have in order to establish ‘alibi’ to their otherwise unexplainable ‘delay’ in deciding the claim in question have undergone the futile exercise.

9. Finally, we find that the alleged misrepresentation/concealment/ non-disclosure of material facts etc do not stand proved. In such like repudiations the onus of proof always lay heavily upon the insurers but here they have miserably failed to legally discharge the same successfully. We are strengthened in our above proposition by virtue of the valuable comments as made out by the honorable Punjab State Commission in the FA # 537 of 2008 titled: LIC of India vs. Priya Sharma & ors., as: “…. in this case, there is no evidence on record to prove that the deceased life assured was suffering from any pre-existing disease at the time of purchasing the policy. …. There is no evidence to prove that the deceased was ever admitted or took any treatment from any hospital or the doctor regarding the alleged pre-existing disease. …”. The honorable National Consumer Commission has further elaborated the legal proposition in RP # 218 of 2008 titled United India Insurance Co. Ltd., vs. Anumolu Rama Krishan as: “7… Even if Respondent was suffering from these diseases which admittedly do not occur overnight, it is both possible and plausible that he was unaware of it since these can be ‘silent diseases’ and a person suffering from them may not even be aware until the condition aggravates and overt symptoms appear….”. Even, the OP insurer’s refusal to ‘pre-authorizations’ requests by the treating hospitals are not justified and the subsequent demands of ‘non-descript’ and ‘non-exist’ imaginary documents are all the more un-sustainable. We also find that the other two claims put forth by the complainant have been kept illogically deferred awaiting ‘settlement’ for collateral but arbitrary reasons. Even, the expert professional opinion pertaining to pre-existing disease cannot be taken as an evidence of its ‘non-disclosure/suppression’ by the insured since he may not be ‘himself’ aware of the disease present in its latent hibernating state.

10. In the light of the all above, we are of the considered opinion that the OP insurers have blatantly bruised the consumer rights of the present complainant by employing ‘unfair trade practice’ amounting to ‘deficiency in service’ (on their part) and that lines them up for an adverse statutory award under the applicable Consumer Protection Act’ 1986.

11. We, therefore, partly allow the present complaint and thus ORDER the OP insurers to settle the impugned ‘insurance claim’ as per the governing ‘terms’ of the applicable Health Insurance Policy (to its full benefits) but strictly in accordance with the IRDA guidelines on ‘settlement of claims’ to the present complainant besides to pay him a sum of Rs.5,000/- as cost and compensation within 30 days of receipt of the copy of the present orders otherwise the aggregate award amount shall attract interest @ 9% PA from the date of the orders till actual payment.

12. 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)

NOV. 17, 2016                                                              Member.

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