Order by:

Sh.Amrinder Singh Sidhu, President

1.       The complainant  has filed the instant complaint under section 12 of  the Consumer Protection Act, 1986 (now under section 35 of the Consumer Protection Act, 2019)  on the allegations that Usha Goel wife of late Jagdish Kumar Goel was insured with ops for a sum of Rs.2 lakhs and during the policy period, she remained admitted in Dayanand Medical College & Hospital, Ludhiana on 01.09.2015 and where she got conducted surgery on 03.09.2015 and discharged on 21.09.2015. In the said hospital, the insured has to incur Rs.5,05,386/- on account of medical expenses. Lateron said Usha Goel has died and the complainant being his nominee has filed the present complaint. Thereafter, the complainant lodged the claim for the reimbursement of medical expenses with the Opposite Parties and also completed all the formalities,  but the Opposite Parties did not pay any heed to the request of the complainant.   In this way, said conduct of the Opposite Parties clearly amounts to deficiency in service and as such, the Complainant is left with no other alternative but to file the present complaint.  Vide instant complaint, the complainant has sought the following reliefs.

a)       Opposite Party may be directed to pay the amount of Rs.5,05,386/- spent on the treatment of the insured Usha Goel alongwith  @ 12% per annum and Rs.1,00,000/- as compensation on account of mental tension, physical harassment besides Rs.25,000/- as litigation expenses .

2.       Opposite Parties  appeared through counsel and contested the complaint by filing  the written version  on the ground inter alia that the complaint is not maintainable; that there is no deficiency in service on the part of the Opposite Parties and that the complaint is absolutely false and frivolous. True facts are that mother of the complainant namely Usha Goel got individual health policy  bearing No.2012002814P112235649 for the period w.e.f. 01.01.2015 to 31.12.2015 for a sum of Rs.1,50,000/-. The mother of the complainant lodged a claim with the Opposite Parties for Rs.5,05,386/- and thereafter the Opposite Parties  issued a letter dated 09.12.2015 seeking the submission of the required documents, but the insured failed to submit the documents and thereafter, due to non submitting the required documents, the claim file of the insured was closed on 30.01.2016.   On merits, the Opposite Party took up almost the same and similar pleas as taken up by them in the preliminary objections.    Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint was made.

3.       In order to  prove  his  case, the complainant has tendered into evidence his affidavit Ex.C1  alongwith copies of documents Ex.C2 to Ex.C15 and closed his evidence.

4.       On the other hand,  to rebut the evidence of the complainant,  Opposite Parties tendered into evidence affidavit of Sh.R.N.Bansal Ex.OPs1 alongwith copies of documents Ex.OP2 to Ex.OP4 and closed the evidence on behalf of the Opposite Parties.

5.       We have heard the ld.counsel for the parties, perused the written submissions filed by the parties and  gone through the documents placed  on record.

6.       During the course of arguments, both the ld.counsel for the Complainant as well as Opposite Parties have mainly reiterated the facts as narrated in the complaint as well as in the written reply  respectively. We have perused the rival contentions of  the parties and also gone through the record on file. The main contention of the ld.counsel for the complainant is that after completing all the formalities and submission of all the requisite documents, for the reimbursement of medical bills of the insured, the Opposite Parties did not pay any heed to the request of the complainant and rather repudiated the claim of the complainant. On the other hand, ld.counsel for the Opposite Parties has repelled the aforesaid contention of the ld.counsel for the complainant on the ground that  admittedly,   mother of the complainant namely Usha Goel got individual health policy  bearing No.2012002814P112235649 for the period w.e.f. 01.01.2015 to 31.12.2015 for a sum of Rs.1,50,000/- and during her life time, she  lodged a claim with the Opposite Parties for Rs.5,05,386/- and thereafter the Opposite Parties  issued a letter dated 09.12.2015 seeking the submission of the required documents, but the insured failed to submit the documents and thereafter, due to non submitting the required documents, the claim file of the insured was closed on 30.01.2016. But we do not agree with the aforesaid contention of the Opposite Parties. It is unbelievable that without the documents of the complainant, how the Opposite Parties considered the claim i.e. No.54522151640522 and how the Opposite Parties ascertained the said amount without going through the produced documents. The contention of the complainant is that mother of the complainant submitted the requisite documents during her life time thrice to the Opposite Parties, but the Opposite Parties did not settle the claim of the mother of the complainant during her life time and at last, due to the unnecessary harassment of the Opposite Party in July, 2017  the mother of the complainant died due to humiliation. Moreover, if the Opposite Parties ever raised the demand of requisite documents, what was the hitch for the insured not to supply the same and why a person will delay his/ her own claim by not submitting the requisite documents. Not only this, the Opposite Parties could not produce  any evidence to prove that alleged letters Ex.Ops3 and Ex.Ops4 were ever supplied to  the insured, when and through which mode? In view of the above discussions, we are of the opinion that Opposite Party was not justified in closing the case of the complainant  without any reason.

7.       In such a situation the repudiation made by the Opposite Party-Insurance Company regarding genuine claim of the complainant have been made without application of mind. It is usual with the insurance company to show all types of green pasters 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.

8.       In view of the above discussion, we hold that the Opposite Party-Insurance Company have wrongly and illegally rejected the claim of the complainant.

9.       Now come to the quantum of compensation. The complainant has lodged the claim of Rs.5,05,386/- for the reimbursement with the Opposite Parties.  Perusal of the insurance policy Ex.Ops2 shows that Ms.Usha Goel wife of late Sh.Jagdish Kr.Goel was insured  with Opposite Parties vide policy bearing No.2012002814P112235649 for the period w.e.f. 01.01.2015 to 31.12.2015 for a sum insured of Rs.1,50,000/- and during that policy period, she remained admitted in Dayanand Medical College & Hospital, Ludhiana  and got her treatment for the period w.e.f. 01.09.2015 to 21.09.2015 where she allegedly spent Rs.5,05,386/-, as such, at the most, the complainant can claim maximum Rs.1,50,000/- and we allow the complaint to that extent only.

10.     In view of the aforesaid facts and circumstances, we partly allow the complaint of the complainant and direct the Opposite Parties to make the payment of Rs.1,50,000/- (Rupees one lakh fifty thousands only)  to the complainant alongwith interest @ 8% per annum from the date of filing the present complaint i.e. 29.01.2020 till its actual realization.  The compliance of this order be made by the Opposite Parties within 60 days from the date of receipt of copy of this order, failing which the Complainant shall be at liberty to get the order enforced through the indulgence of this Commission. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

11.     Reason for delay in deciding the complaint.

          This complaint could not be decided within the prescribed period because the State 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 as well as due to pandemic of COVID-19.

Announced in Open Commission.

Dated:08.06.2022.