Order by:

Sh.Amrinder Singh Sidhu, President

1.              The complainant  has filed the instant complaint under section 12 of  the Consumer Protection Act, 1986 (as amended upto date) on the allegations that he is retired employee of Punjab National Bank having Employee No.18621 and having account in the Punjab National Bank from where the amount of insurance was deducted from the account of complainant for the purpose of giving the premium of group insurance policy by the Punjab National Bank to the opposite parties. Further alleges that complainant has insured with a insurance policy which was specifically for the retired employees/employees of the Punjab National Bank and the said policy was purchased by employer of complainant i.e. Punjab National Bank for the medi-claim insurance of retired employees having group insurance policy having No.500100/48/15/41/00000/535 and the policy period is from 07-11-2015 to 01-10-2016 for one year and as per this policy the Punjab National Bank is the policy holder and the complainant is a primary beneficiary being a member and insured in the above said policy to the extent of Rs.3 Lac during the insurance period qua hospitalization and domiciliary treatment as mentioned in the schedule in the details of said Policy which was supplied by the policy holder bank to the complainant being a primary beneficiary of the policy after deducting the IBA account of the complainant in the said bank. It is also pertinent to mention here that in this regard an identity card was also issued by opposite no.1 and 2 by mentioning a I.D No.UIC54518621PNBR and the same is valid upto the policy period. It is also mention here that in this regard the premium has already been deducted through the account of complainant maintained in the Punjab National Bank, Moga. It is also pertinent to mention here that till today the policy is continue one and the opposite no.1 and 2 have already renewed the policy for the period of 2016-17 and 2017-18 also and premium was also deducted from the PNB account of complainant, in lieu of the renewal of the said policy. The Complainant further alleges that  unluckily complainant during the policy period suffered a abdominal pain on 07-06-2016 and in this regard complainant was admitted in the DMC & H Ludhiana vide CR No.116317 and having Admission No.27480 on 07-06-2016 and after admission the complainant was admitted there in the said hospital from 07-06-2016 to 14-06-2016 and diagnosis for Pancretitis disease and admitted in the gastro ward for the said treatment by the doctors of DMC & H Ludhiana and was discharged on 14-06-2016 by Dr.Ajit Sood of DMC & H, Ludhiana in a satisfactory condition. During that treatment said hospital and on medicine total expenses was paid by complainant i.e. Rs.96,000/- approxy from his own pocket for the above said treatment and other expenses on account of medical tests, medicines etc. and the details of same had already supplied to the opposite parties. It is also pertinent to mention here that earlier the complainant applied for cashless-hospitalization through DMC & H Ludhiana, but the same was denied by the opposite party no.3 on flimsy ground by mentioning that history of alcohol consumption is positive and cashless facility can not be accorded and also mentioned that ‘this is not the denial of treatment but only the denial of credit facility and the complainant can send his claim for re-imbursement for review’ through letter Dt.14-06-2016. So, after receiving this complainant pay all the expenses and medical charges from his own pocket. Copy of bill of taxi Dt.07-06-2016 and denial of cashless hospitalization charges by opposite party no.3 on 14-06-2016 and copy of all the medical bills from 07-06-2016 to 14-06-2016 and discharge summary are attached herewith.  Thereafter, on 23-06-2016 complainant lodged a claim with the opposite party no.1 and 2 for reimbursement of medical expenses regarding the above said treatment and they further send the same to opposite party no.3 by fulfilling all the formalities along-with the original final bills of DMC & H and the original receipts for giving payment to the said hospital on different dates from complainant to opposite party no.2 which was acknowledged by one its employee and assured the complainant to process and pay the claim as early as possible. Thereafter the said claim file was sent by opposite party no.1 through opposite party no.2 to opposite party no.3 and registered the claim of complainant vide claim No.54551617092710. Copy of application Dt.23-06-2016 and the letter Dt.18-07-2016 and reply to letter Dt.18-07-2016 by complainant are attached.   Thereafter, on number of times the complainant has received a letter from the opposite parties no.1 and 2 regarding the acknowledgement of claim & also mentioned a Claim Reference No. 54551617092710 and also mentioned that the claim has been registered vide above said number and also demand some documents from the complainant to process the claim which was given by the complainant as demanded.   But the    claim of complainant was repudiated by the opposite parties vide his letter Dt.16-08-2016 on the flimsy grounds which is otherwise not made out as per the said policy terms and conditions and repudiate the same only to forfeit the legal claim of complainant intentionally, even after receiving the all documents in original from the complainant. It is also pertinent to mention here that the complainant is not drunkard or a chronic alcoholic and he only takes a moderate quantity occasionally. Copy of repudiation letter Dt.16-08-2016 is Ex.C-20. Thereafter the complainant approached number of times local office of opposite party no.2 and also issued a letter Dt.23-06-2017 vide registered post to the Grievance Redressal Officer Chennai, but they have linger on the matter on the one pretext of the other without giving any satisfactory reply to the complainant and harassed the complainant who is an old age person near about 72 years. Copy of letter Dt.23-06-2017 and postal receipt Dt.23-06-2017 and reply Dt.04-08-2017 are attached herewith as Ex.C-21 to Ex.C-23.  But the  ground mentioned in the repudiation letter is a fake one and is made only to forfeit the genuine and legal claim of the complainant by mentioning that the complainant have history of alcoholic consumption for the last so many years, which is not made out as, now the said policy is again renewed for next years also and deducted the premium from the account of the complainant and send the same to the opposite party no.1 and 2 for renewal of the said policy. If the opposite party no.1 and 2 have already in the knowledge that complainant has a history of alcoholic consumption and his claim is not genuine one as per their policy terms and conditions then why the opposite parties no.1 and 2 renewed the said policy for next years i.e. 2016-17 and 2017-18 and from this it is clear that there is no ground as mentioned in the repudiation letter to repudiate the genuine claim of complainant and the same is repudiate only to harass and humiliate the complainant who is a continuing policy holder of the opposite party company due to which the complainant is physically and mentally harassed by the opposite parties and the complainant also reserve his right to claim compensation on account of that also in case the opposite parties not paid the genuine claim of the complainant.  That thereafter a number of times the complainant made requests to the opposite parties regarding the settlement of the claim, but the opposite parties kept mum and revealed nothing in this respect to the complainant.  That ultimately on 10-04-2018, the complainant issued a legal notice to the O.Ps vide registered post, but till today no reply has been received by the complainant and even no call has been received by complainant for the settlement of the said claim. Photo copy of the legal notice Dated;10-04-2018 along-with the postal receipts are attached herewith and are Ex.C-24 to Ex.C-27.     That in spite of providing all the necessary document and information sought by the opposite parties by the complainant, the opposite parties are not doing any needful in settlement of the claim, for which the opposite parties are jointly and severally liable to pay the same as per the terms and conditions of the policy in question.  As such, there is deficiency in service on the part of the Opposite Parties. Vide instant complaint, the complainant has sought the following reliefs.

a)       To pay an amount of Rs.1,10,000/- including the travelling expenses, medical treatment of the insured under the policy  alongwith interest .

b)      An amount of Rs.One lakh as compensation for mental tension, harassment and agony suffered by the Complainant.

c)       An amount of Rs.15,000/- as litigation expenses.

d)      Or any other relief to which this District Commission may deem fit be also granted to the Complainant in the facts and circumstances mentioned above.      

2.       Opposite Parties  No.1 and 2 appeared through counsel and contested the complaint by filing  the written version taking preliminary objections therein inter alia that the complaint being false and frivolous is not maintainable; that the Complainant has suppressed the material facts from this District Consumer Commission and that there is no deficiency in service on the part of the answering Opposite Parties. The claim in question has been repudiated vide repudiation letter dated 16.08.2016 after due application of mind in accordance with terms and conditions of the insurance policy in question on the ground that “patient suffered from pancreatitis as per indoor case papers (initial assessment sheet) patient is chronic alcoholic from 40 years. Alcohol is the cause of pancreatitis. Therefore, claim is not payable as per clause 4.5 of the policy. Pancreatitis history of alcohol consumption + VE.”  Thus, it indicates that  insured was in the habit of consuming liquor, which is the  major reason for his aliment i.e. pancreatitis and the alleged claim for the treatment is said self inflicted ailment is not payable as per the terms and conditions of the medi-claim policy.   On merits, the Opposite Parties No.1 and 2 almost taken up the same and similar pleas as taken up by them in the preliminary objections. Hence, the complaint of the complaint deserves dismissal.    

3.       None has come present on behalf of Opposite PartyNo.3 despite service, hence Opposite Party No.3 was proceeded against exparte vide order dated 06.07.2018 of this District Commission.

4.       In order to prove  his  case, the complainant has placed on record  his affidavit Ex.C1 alongwith copies of bills and other relevant documents Ex.C2 to  C28.

5.       On the other hand, to rebut the evidence of the complainant, Opposite Parties No.1 and 2 also placed on record affidavit of Sh.R.N.Bansal, DM Ex.OPs1 to 3/A alongwith copies of documents Ex.Ops1 to 3/1 to Ex.Ops1 to 3/6.

6.       We have heard the ld.counsel for the parties, perused the written arguments submitted by the Complainant as well as Opposite Parties No.1 and 2   and also  gone through the documents placed  on record.

7.       Perused the  written arguments submitted on behalf of the complainant which are on the lines of averments made in the complaint and during the course of arguments, ld.counsel for the Complainant has  mainly reiterated the facts as narrated in the complaint and contended that first of all, the written version  filed on behalf of the Opposite Parties has not been filed by an authorized person. Therefore, the written version so filed is not maintainable. Opposite Parties No.1 and 2 are limited Company and written version has been filed on the basis of special power of attorney given to ld.counsel for the Opposite Parties  No.1 and 2. Further contended that at the time of  issuance of the said card to the complainant, no term and conditions were ever explained or supplied by Opposite Parties to the complainant. On merits, it was contended that at the time of purchasing the policy, the Complainant was duly medically examined by the doctor of the Opposite Parties and in the proposal form (Ex.OP1 to 3/2)  it has duly been told  and filled as ‘Yes’ against the column of Alcohol or drug abuse meaning to say, that the Complainant has specifically told to the officials of the Opposite Parties that he is already taking alcohol in limit  and the Opposite Parties  issued the above mentioned policy in the name of the complainant after proper medical test and after completing other formalities and also receiving the premium amount. So the ground of repudiating the claim of complainant by the Opposite Parties  is fake one and is just to forfeit the genuine claim of complainant. Moreover, everything was explained at the time of taking policy by the complainant and after verifying each and everything the Opposite Parties  had issued the policy in question for medical illness & Procedure Policy. Even after receiving all the required documents and completing formalities by the complainant, the claim has been repudiated illegally and on false and frivolous grounds only to forfeit the genuine claim of the complainant. However, the Opposite Parties  are legally bound to pay the genuine claim of complainant.

8.       On the other hand, ld.counsel for the Opposite Parties No.1 and 2 has repelled the aforesaid contention of the ld.counsel for the Complainant on the ground that  the claim in question has been repudiated vide repudiation letter dated 16.08.2016 after due application of mind in accordance with terms and conditions of the insurance policy in question on the ground that “patient suffered from pancreatitis as per indoor case papers (initial assessment sheet) patient is chronic alcoholic from 40 years. Alcohol is the cause of pancreatitis. Therefore, claim is not payable as per clause 4.5 of the policy. Pancreatitis history of alcohol consumption + VE.” Thus, it indicates that  insured was in the habit of consuming liquor, which is the  major reason for his aliment i.e. pancreatitis and the alleged claim for the treatment is said self inflicted ailment is not payable as per the terms and conditions of the medi-claim policy.  To support its contention, the Opposite Parties have cited the judgements (i) R.Venkata Krishana Vs. United India Ins.CO 2016, CPR 353 (NC), (ii) Manohar lal Baghla Vs.National Ins.Co.Ltd. 2013 CPJ 156 (Punjab) and (iii) Shanti Devi Vs. Br.Manager Life Insurnce 2012 CPR 43 (Chatisgarh).

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 Parties  No.1 and 2 is presumed to be correct, the next  plea  raised by Opposite Parties  No.1 and 2  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 Parties  No.1 and 2 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 the repudiation of the claim of the Complainant was made specifically on the report of Raksha Health Insurance TPA Pvt.Limited Ex.OP1 to 3/5  with which the Complainant has no concern at all. But recently, our own Hon’ble State Commission, Punjab, Chandigarh in First Appeal No.1105 of 2014 decided on 25-04-2017 in case titled as Sukhdev Singh Nagpal Vs. New Karian Pehalwal Cooperataive Agriculture service Society & Others has held that TPAs have no authority to reject the claim- such power lies, exclusively with the Insurance Companies (Para No.25 to 27). 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. The claim of the complainant was illegally and arbitrarily rejected by the TPA, against the instructions of the IRDA. In view of this, the repudiation merely on the basis of report of the TPA is not legal.  

12.     As mentioned above, the policy in question was issued in the name of the life assured after proper medical tests conducted by the doctors of the Opposite Parties   and after completing all other formalities, but however, it also needs to be mentioned that when the policy is issued to the insured, prior investigations regarding health of the insured are duly done by the Insurance Company. If the complainant was suffering from any diseases prior to issuance of the policy, in question, the same must not have escaped the notice of the empanelled doctors of the Insurance Company. However, no such investigation record has been produced by the opposite parties. In case Bajaj Allianz Life Insurance Co. Ltd. & Ors. Vs. Raj Kumar III (2014) CPJ 221 (NC), it was held by the Hon’ble National Commission that usually, the authorized doctor of the Insurance Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. It was held that the Insurance Company wrongly repudiated the claim of the complainant.

13.     It also needs to be mentioned that Section 19 of the General Insurance Business (Nationalization) Act, 1972 states that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community. The denial of medical expenses reimbursement is utterly arbitrary on the ground that disease in question was pre-existing disease. It is mere an excuse to escape liability and is not bona fide intention of the insurance company. Fairness and non-arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State and public behavior. Any policy in the realm of insurance company should be informed, fair and non-arbitrary. When the insurance policy has exclusions/conditions to repudiate the claim or limit the liability, the same must be specifically brought to the notice of the insured and are required to be got signed to show that such exclusions and conditions have been brought to his/her notice.  Recently, our own Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in  First Appeal No. 50 of 2019 titled as Bajaj Alliance General Vs. Arjan Singh decided on 04.03.2021 also held so.

14.     The need for interpreting a contract always arises in two situations, (i) when a gap is needed to be filled in the contract and (ii) an ambiguity is needed to be resolved in the contract, then to find out correct intention of the contract, spirit behind it is required to be considered. Normally, the insurance policy is a contract of adhesion in which other party is left with hardly any bargaining power as compared to the insurer. Insurance contracts are standard form contracts and are drafted by the insurance company and as such, insurance company is at higher footing than the insured. The benefit of such clause, as exclusion clause, would go to the insured unless the same is explained in clear terms by the insurer. In such circumstances, the tribunal would be more oriented towards the interpretation which goes against the party who has inserted/drafted the disputed clause in the agreement/contract. The adjudicating authority is required to look into whether the intention of the party is to exclude or limit liability has been appropriately explained to the other party or not. This Commission while interpreting insurance agreement is to honour the intention of the parties, who have signed the agreement. Even if the agreement had general exclusion/condition for misrepresentation still fraudulent misrepresentation and non-disclosure may not be there. The innocent and negligent misrepresentations are to be ignored.  On the other hand, the rulings (i) Satwant Kaur Sandhu Vs. New India Assurance Company Limited, (ii) Murti Devi Vs. Birla Sun Life Insurance and (iii) Mamohan nanda Vs. United India Insurance Company Limited,   cited by the ld.counsel for the Opposite Parties  are not applicable and relevant  to the facts of the present case. 

15.     Not only this, the further stand of the Opposite Parties  is that insured was treated and suffered from pancreatitis as per indoor case papers (initial assessment sheet) patient is chronic alcoholic from 40 years. Alcohol is the cause of pancreatitis. Therefore, claim is not payable as per clause 4.5 of the policy. Pancreatitis history of alcohol consumption + VE.” Thus, it indicates that  insured was in the habit of consuming liquor, which is the  major reason for his aliment i.e. pancreatitis and the alleged claim for the treatment is said self inflicted ailment is not payable as per the terms and conditions of the medi-claim policy and said disease was never disclosed by the insured at the time of policy inception, but to prove this factum, the Opposite Parties  have failed to  prove its case by  examining any medical practitioner/ doctor who has treated the insured for the said disease nor the Opposite Party has filed any affidavit of any doctor who has medically treated the insured for the disease prior to taking of the policy. It has been held by the Hon'ble National Commission in case New India Assurance Co.Ltd & Anr Vs. Murari Lal Bhusri 2011(III) CPJ 198 (NC) that where the Insurance company failed to produce any evidence to show that respondent was aware of any pre-existing disease at the time when insurance policy was taken, opposite party was not justified in repudiating the claim of the complainant on the ground of pre-existing disease. It has been held by the Hon'ble Supreme Court of India in case P.Vankat Naidu Vs. Life Insurance Corporation of India & Anr 2011(3) CPC 350 that where no cogent evidence was produced by the respondent to prove that insured/deceased had concealed any fact about his illness or hospitalization, it was held that no material fact was suppressed by the deceased in this respect. It has been held by the Hon'ble State Commission of Punjab in case  Life Insurance Corporation of India Vs. Miss Veenu Babbar and another 2000(1) CLT 619 that repudiation on the basis of history recorded in the hospital records is illegal and arbitrary and the same could not be treated as substantive material to base any decision. Same view has been taken by the Hon'ble National Commission in case Life Insurance Corporation of India & Ors. Vs. Kunari Devi IV(2008) CPJ 89 (NC) that where no document has been produced in support of allegation of suppression of disease at the time of taking policy or revival of policy, history recorded in hospital's bed ticket, not to be treated as evidence as doctor, recording history not examined, suppression of disease not proved, insurer was held liable under the policy. It has further been held by the Hon'ble National Commission in case Sahara India Life Insurance Co. Ltd. & Anr Vs. Hansaben Deeepak Kumar Pandya IV(2012) CPJ 13(NC) that where the opposite party insurance company has failed to produce on record any evidence to show that deceased insured ever consulted doctor for taking treatment of heart disease, the repudiation of the claim on the ground of suppression of material fact is totally illegal. It has been  held by Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in case titled as Ashwani Gupta & Ors. Vs. United India Insurance Company Limited 2009(1) CPC page 561 that “where the claim of the complainant has been repudiated on the ground that the assured had pre-existing disease of diabetes mellitus which was not disclosed- apparently, burden to prove lies  upon the insurer- If assured was suffering from pre-existing disease why insurer  had not checked it at the time when proposal form was accepted by its  staff-Respondent has failed to fulfill this requirement before repudiating the claim and the appellant was held entitled  to claim alongwith interest”.

16.     In such a situation the repudiation made by Opposite Parties 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.     On the other hand, the judgements cited  by the Opposite Parties in their contention are not applicable to the facts of the present case and the same are distinguished.  

18.     In view of the above discussion, we are of the opinion that the Opposite Parties have wrongly and illegally repudiated the claim of the complainant. Consequently, we allow the complaint and  the Opposite Parties  No.1 and 2 are  jointly and severally directed to reimburse the medical bill of the Complainant amounting to Rs.1,10,000/- (Rupees one lakh ten thousands only)  alongwith interest @ 8% per annum from the date of filing the present complaint i.e. 29.05.2018 till its actual realization.  Opposite Parties No.1 and 2 are 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  No.1 and 2 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.

19.     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. Moreover, the President of this Commission is doing additional duties at District Consumer Commission, Faridkot and furthermore due to non-sitting of this District Commission virtually for a long period due to pandemic of COVID-19.

Announced in Open Commission.

Dated: 09.09.2021.

                   (Mohinder Singh Brar)                (Amrinder Singh Sidhu)

                                  Member                                        President