The titled complainant Sh. Maninder Singh, aggrieved at the alleged arbitrary repudiation of his insurance-claim filed by him post-hospitalization and post-payment of Hospital Indoor-Bills @ Rs.4.0 Lac; by the titled opposite parties alleging inadmissibility in terms of the policy clause reading as: “Disclosure to information norms means the Policy shall be void and all premium paid hereon shall be forfeited to the Company, in the event of misrepresentation, mi-description or non-disclosure of any material fact. Breach of law with criminal intent we do not cover treatment directly or indirectly arising from Breach of Law by you with a criminal intent.” The complainant denies any such breach of law through any criminal act committed by him and addressing the repudiation as illegal, null and void has prayed through his present complaint for issuance of directives to the OP insurers to settle the impugned claim, in full, and pay the claim-amount to him with interest @ 12% PA from the date of admission till realization besides to pay him Rs.50,000/- as compensation and Rs.50,000/- for deficiency in service on their part along with litigation expenses etc., all in the interest of justice.
2. The Complainant had purchased the Health Policy (Complete Health Care Insurance Policy) Ex.C1 from the OP insurers on 06.11.2020 valid up to 05.11.2021 by paying the sum premium of Rs.16,486/-. However, on 14.01.2021 the insured had to be admitted to EMC Hospital, Amritsar to treat the serious Dog-bite Injury he got on his right-arm and could get the discharge on 12.02.2021 only, having paid the hospital-bills Ex.C2 to Ex.C18 for indoor medical-treatment amounting to Rs.400,000/-.
3. The complainant, after discharge, filed the requisite hospitalization insurance-claim # 244606 with the OP insurers, for reimbursement as per his entitlement under the policy. The OP insurers vide their letter dated 23.03.2021 Ex.C19 had requisitioned claim-related certain documents that were duly submitted. However, on 16.04.2021 the complainant did receive the insurers' letter Ex.C20 repudiating the hospitalization-claim illegally though inadvertently alleging breach of law by the complainant with a criminal intent. In response, the complainant refuted the allegation and further confirmed having not committed any breach of law with a criminal intent. As the OP insurers refused to relent and continued sticking to their repudiation the complainant filed the present complaint accompanied by his affidavit Ex.CW1/A and other exhibited documents in evidence Ex.C1 to ExC20 praying for the here-in-above sought relief.
4. The titled OP Insurers (the OP1 & the OP2), in response to the commission’s notice/summons appeared through their counsel who filed the written statement stating/raising therein preliminary as well as other objections (on merits) also as: The complaint was not maintainable in its present form; absence of any cause of action n locus-standee to the complainant to have filed the present complaint and further there has been no deficiency in service. Further, the insurance-contract being based on utmost good faith relieves the insurer upon breach of the same by the insured; and the parties are also bound by the terms of policy that cannot be altered post-execution.
5. Further, the OP insurers upon receipt, perusal and investigation of the said claim had found the therein narrated facts to be false and against the terms of the policy as the complainant had intentionally concealed the material facts and had misrepresented actual facts. Moreover, the complainant had also committed breach of law and as such the claim was rightly repudiated Ex.OP1,2/1 in accordance with the terms and conditions Ex.OP1,2/3 of the related policy. On merits, the OP insurers have formally repeated all their above objections and have also denied all the allegations as placed forth in the present complaint. Lastly, the OP have filed the affidavit Ex.OPW1,2/A of its authorized signatory and another document Ex.OP-1,2/2 praying for the dismissal of the complaint with costs, in the interest of justice.
6. We have examined the available documents/evidence on the records so as to statutorily interpret the meaning and purpose of each document and also the scope of adverse inference on account of some evidence/documents ignored to be produced by the contesting litigants against the back-drop of the arguments as put forth by the learned counsels for their respective litigants. We find that the present dispute has arisen for of the impugned repudiation of the complainant's hospitalization-claim on flimsy grounds and unfounded allegations/charges sans evidence. The OP insurers have failed to produce any cogent evidence to prove its allegations of breach of law and commission of criminal acts etc., and in its absence these amount to mere cum bare bald statements.
7. Thus, we do hereby disapprove the impugned repudiation in the present situation based merely on conjectures and presumptions only and manifesting an employ of unfair trade practices exhibiting deficiency in service at full swing and that for sure lines them up for an adverse statutory award under the herein applicable statute.
8. In the light of the all above, we set aside the OP insurers' impugned repudiation of the complainants’ hospitalization-claim being unfair, arbitrary (and in contravention to the laws of equity and natural justice) and amounting to ‘unfair trade practice cum deficiency in service’.
9. However, we partly allow this complaint and ORDER the OP insurers to pay the impugned claim, in full, as per the entitlement of the complainant in terms of the related policy, with interest @ 6% per annum from the date of the complaint till actually paid besides Rs.10,000/- in lump sum as compensation cum cost of litigation within 45 days of receipt of the certified copy of these orders, otherwise the entire awarded amounts shall attract additional interest upon these @ 3% PA form the date of orders till actually paid.
10. 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.
11. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.
(Naveen Puri)
President.
ANNOUNCED: (B.S.Matharu)
SEP. 15, 2022. Member.
YP.
