Delhi

West Delhi

CC/14/220

Anand Kumar Sharma - Complainant(s)

Versus

Religare Health Insurance - Opp.Party(s)

20 Sep 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-III: WEST

GOVT. OF NCT OF DELHI

C-BLOCK, COMMUNITY CENTRE, PANKHA ROAD, JANAK PURI

NEW DELHI

 

Complaint Case No.220/2014

 

In the matter of:

 

	Anand Kumar Sharma S/o Sh. G.S. Sharma R/o D-50 Sitapuri, P O Palam, New Delhi - 110045	......Complainant
	Versus

Religare Health Insurance Co. Ltd. &Ors.

Through its Director

Having its Branch at

401, 4^th Floor, Suneja

Tower-1, Distt. Center,

Janakpuri, New Delhi – 110058.                                        ......Opposite Party

 

 

DATE OF   INSTITUTION    :  JUDGMENT RESERVED ON:           DATE OF DECISION:

16.04.2014 05.09.2022 20.09.2022

 

Ms. Sonica Mehrotra, President

Ms.Richa Jindal, Member

Mr. Anil Kumar Koushal, Member

Order passed by Ms.Richa Jindal, Member

 

ORDER

 

1. The complainant has filed the present complaint against OPs u/s 12 of The Consumer Protection Act, 1986. Brief facts of the complaint are as follows :

1. The complainant, an employee of TECH MAHINDRA, got a Standard Group MediclaimPolicy bearing No. GIRL0103157078 through his company, in the month of March 2013 for a period commenced from 30-03-2013 to March 29-03-2014 from opposite party No. 1 through opposite party No. 2.

 

2. On 26.6.2013, the complainant approached Doctor ArunSetia's Clinic at Siri Fort Road as the complainant was aggrieved by swelling and pain in the lower gums of his mouth. After the complainant's initial check-up, the doctor suggested to the complainant that the problem that of  a was a lower jaw bone cyst which might need to be removed surgically and suggested the complainant to visit SIR GANGA RAM HOSPITAL on 28 06-2013 for a final check-up of the complainant. The complainant paid Rs. 1000/-(one thousand rupees only) as a consultation fee on 26-06-2013. On the very same day doctor advised the complainant to get the OPG X-ray done of his jaws for which the complainant visited City X-ray & Scan Pvt. Ltd. and paid Rs. 500/- for the same.
3. On 28.06.2013, the complainant visited the GANGA RAM HOSPITAL and paid Rs. 1000/-(one thousand rupees only) as a consultation fee. On the very same day doctor advised the complainant to conduct some other tests also for which the complainant visited Bhagat Hospitals Pvt. Ltd. at Janakpuri and paid Rs. 1600/- (sixteen hundred rupees only) for the same. That after the completion of all the tests, the complainant consulted his doctor and showed the report of all the tests to his doctor after going through the reports of the complainant the doctor advised him to go through surgery as soon as possible as the problem occurred in the jaws of the complainant is of serious nature and if the complainant will delay then it can be carcinogenic. The doctor explained that the problem occurred in the jaws of the complainant is a cyst that is formed from tissues, which is a kind of Tumour and after the excision of the Tumour,the gap is filled with bone marrow and Hydroxy apatite crystals. On the very same day after consultation with the doctor, the complainant via telephonic call informed the opposite party No. 2 about his surgery which has to be done on 02.07.2013 and requested the OP for the approval of the claim of the complainant and also sent an e-mail to the opposite party No. 2 to inform him about the urgent need of surgery which was suggested by the Doctor and requesting for the approval of the same.
4. On 01.07.2013, responding to the e-mail and telephonic call of the complainant, the official of the opposite party No. 2 sent an e-mail to the complainant and asked for the documents related to the treatment of the complainant for the opinion of the doctors of the opposite party No. 2. The complainant sent an e-mail and provided the documents and medical reports to the Opposite Party No.2 via e-mail as desired by the Opposite Party No. 2. That on the same day the HR of the company of the complainant sent an e-mail to the opposite party No. 2 to respond to the email of the complainant. But the opposite party No. 2 did not pay any heed to the e-mail of the complainant as well as the HR of the company of the complainant. On 01.07.2013 the doctor prescribed some medicine to the complainant which costs RS. 443.50/-.
5. On 02.07.2013, the complainant got admitted to SIR GANGA RAM HOSPITAL for surgery, as the doctor suggested the complainant to undergone surgery on the lower jaw and need to get operated for surgical removal of the cyst and bone grafting of the lower jaw. The surgery of the complainant was performed under General Anaesthesia at SIR GANGA RAM HOSPITAL on 02.07.2013 and the complainant got discharged from the hospital on 03.07.2013. During his stay in the hospital from 02.07.2013 to 03.7.2013, the hospital raised the bill of Rs.65867/-(sixty-five thousand eight hundred sixty-seven rupees only) vide bill No. 2013 2014/CA/1/0015371, which is duly paid by the complainant by way of credit card bearing No. 3292. The complainant spent Rs. 967.77/-, Rs. 575/- and Rs. 132/- for the prescribed medicines.
6. That on 09.07.2013 the complainant visited the SIR GANGA RAM HOSPITAL for the dressing of the surgery and todiscuss the Biopsy report with the doctor. The doctor confirmed that the problem of the complainant is not cancer. On the same day the complainant underwent OPG (Digital) test and paid Rs. 600/- for the said test.
7. On 10.07.2013, the complainant submitted an Insurance Claim of RS. 72,685/-(seventy-two thousand and six hundred eighty-five rupees only) with the representative of the opposite party No. 2 at his company premises and waited for the response of the opposite party No. 1 and 2. But the opposite party No. 2 take it in a very irresponsible manner and did not give any reply to the complainant about the status of the claim of the complainant which caused mental pain and agony to the complainant.
8. On 12.07.2013, the complainant again visited SIR GANGA RAM HOSPITAL to cut the stitches given to the complainant at the time of surgery and paid Rs. 1000/- (one thousand rupees only) as a consultation fee and purchased some medicine prescribed by the doctor which costs Rs. 638/- to the complainant.
9. On 17.07.2013, the complainant again visited SIR GANGA RAM HOSPITAL for cutting off the stitches which were given to the complainant at the time of surgery.
10. On 30.07.2013 the complainant again visited SIR GANGA RAM HOSPITAL to show post operation X-ray of the jaw bone and paid Rs. 2500/-(twenty-five hundred rupees only). On 04.08.2013, 14.08.2013 and 17.08.2013, the complainant purchased medicines as prescribed to him by the doctor.
11. On 19.08.2013 and 23.08.2013, the complainant again approached the opposite party No. 2 via email to enquire about the status of the claim of the complainant and requested him to kindly look into the claim of the complainant and to respond for the same. On the same day, Two HRs of the company of thecomplainant also approached the opposite party No. 2 via e-mail to enquire about the status of the claim of the complainant but did not get any response or satisfactory reply from the opposite party No. 2.
12. On 26.08.2013 the opposite party No. 2 turned up to the request of the complainant and the doctors of the opposite party No. 2 consulted with the doctor of the complainant i.e.Dr Arun P. Setia to enquire about the problem of the complainant and to reimburse the genuine claim of the complainant and after their conversation with the doctor of the complainant, they assured the complainant that the claim of the complainant will be reimbursed as soon as possible.
13. On 27-08-2013 the complainant again visited SIR GANGA RAM HOSPITAL for checking onthe formation of bones and nerves on the bone grafting as suggested by the doctor and paid Rs.1000/- (one thousand rupees only) as a consultation fee. On the same day, the doctor again advised him to get the OPG X-ray done to check the status of the bone grafting which was done at the time of surgery. On the same day, a certificate was also issued by the doctor of the complainant to show the treatment done by him.
14. On 27.08.2013, the HR manager of the company of the complainant again approached the opposite party No. 2 via e-mail and requested him to reconsider the matter for reimbursement. The opposite party No. 2 responded to the e-mail of the HR Manager of the company of the complainant and replied that the opposite party No. 2 required some additional documents regarding the surgery of the complainant and after getting the same the opposite party No. 2 will forward the claim file of the complainant to opposite party No. 1 for their opinion.
15. On 07.09.2013, the complainant again undergone to the OPG X-ray as suggested by the doctor and on 12.10.2013, the complainant visited SIR GANGA RAM HOSPITAL to show his OPG X-ray report to the doctor. The doctor suggested that the problem of the complainant is of a special kind and can be re-occurred so he has to be under treatment for two years and has been advised the complainant to visit and report to the doctor every few months for a check-up.
16. That after chasing the opposite party No. 2 for about 6 months, the complainant got an e-mail from the opposite party No. 2 on 20.12.2013 that the claim of the complainant has been denied as per policy terms & conditions.
17. According to theopposite party No. 2, the claim of the complainant is hit by exclusion clause 3.2 (iv) of the terms condition of the policy which states 'Any dental treatment or surgery unless necessitated due to injury. That the opposite party No. 2 in their email or any other mode did not give any explanation that why the claim of the complainant is declined. The mere saying of the opposite party No. 2 that the claim of the complainant is not covered under policy terms is not sufficient for the reimbursement of the claim. Opposite Party No. 2 has to give sufficient details that why the claim of the complainant is not covered while in actuality the problem of the complainant is covered under the exclusion clause of the policy. The opposite parties have defaulted on their part to reimburse the claim of the complainant and failed to explain the reason why the claim of the complainant has been denied by them.
18. In fact, the problem of the complainant is not a dental problem the problem of the complainant is a cyst that occurred in the bone of the lower jaw of the complainant, which reflects that the problem of the complainant is an Odontogenic cyst with no dental lesion which is similar to the Tumour for which the complainant got operated. The Odontogenic cysts are a group of jaw cysts that are formed from tissues.
19. The opposite party NO. 1 and opposite party No. 2 to not satisfying the genuine claim of the complainant and to take undue benefit of the same,intentionally and deliberately denied the claim of the complainant and are deliberately and intentionally avoiding the same, which has caused every sort of mental pain, agony and suffering to the complainant.22. That the opposite party No.1 & 2 had deliberately not provided the services as a matter of company policy and acted in deficiency of not attending the calls and emails of the complainant for which the complainant has severely suffered physically, mentally and economically.
20. The opposite parties worked in default of negligence in regard to the settlement of the insurance claim of the complainant that constitutesa deficiency in the service on the part of the opposite parties.
21. That the complainant is a consumer within the meaning of the consumer protection Act and the opposite parties have acted against the spirit of the act and had acted in deficiency of service. Hence this complaint wherein the complainant prayed for the following reliefs:-

1. Direct the opposite parties No. 1 and 2 to reimburse the claim of the complainant of Rs. 80,500/-(Rupees eighty thousand and five hundred only) approx. and other expenses incurred by the complainant till the expiry of the policy with interest @ 24% Per annum)
2. Direct the opposite parties to pay a sum of Rs. 1,00,000/- (Rupees one Lac only) to the complainant on account of mental torture, pain, agony and suffering caused by the irresponsible conduct of the opposite parties.
3. Direct the respondents/opposite parties to pay a sum of Rs. 30,000/- (Rupees Thirty thousand only) to the complainant being the cost of the present litigation.

2. After hearing the arguments on admission, the present complaint was admitted and accordingly notice was issued to the OP on 22-04-2014. Accordingly, OP appeared and sought an adjournment for filing a written statement.

 

3. The OP accordingly on 4/09/2014 filed a written statement taking preliminary objection that:-

1. Present claim of the complainant is not maintainable and is liable to be dismissed because after examination of the documents submitted by the complainant and terms and conditions of the Insurance Company, it was concluded that the claim pertained to tumour excision and Bone Grafting with G. Bone Mandible under General Anaesthesia for AmeloblastomaPeriapical Cyst, as per permanent exclusion clause 3.2.iv of the policy terms and conditions, any dental treatment or surgery unless necessitated due to an injury was not payable, accordingly the claim was not payable and was duly repudiated by the opposite parties. Under such circumstances, there is no deficiency in service on the part of Opposite Parties in repudiating the claim of the complainant and the complaint is liable to be dismissed on this ground alone.
2. The disputed and complicated question of facts are involved, which cannot be decided in a summary trial and can only be decided by leading detailed evidence and cross-examination accordingly the present claim under the Consumer Protection Act is not maintainable and is liable to be dismissed on this ground alone.
3. the complainant was insured under the Group Policy bearing no. 10020093 from March 30, 2013, to March 29, 2014 subject to the Policy Terms and Conditions. However, it is admitted that the complainant's claim was denied as the same was not payable as per Clause 3.2 (iv) of the PolicyTerms and Conditions. The Repudiation Letter is annexed as AnnexureClause (iv) of the Policy Terms and Conditions states that:

3.2 Any Claim in respect of any Insured Member for, arising out of or directly or indirectly due to any of the following shall not be admissible unless expressly stated tothe contrary elsewhere in the Policy terms and conditions:

iv. "Any dental treatment or surgery unless necessitated due to an Injury."It is submitted that since the claim of the complainant was not payable as per Clause 3.2 (iv) of the Policy Terms and Conditions, accordingly the same was duly repudiated by the opposite parties.

4. It is admitted that odontogenic cysts are a group of jaw cysts that are formed from tissues.Histopathology means the science concerned with the cytologic and histologic structure of abnormal or diseased tissue. As per the attached opinion taken by the OP,an Odontogenic cyst originates from dental system tissues. Also, dental treatment is defined as "Any of a variety of treatments of teeth and adjacent tissues to restore or maintain normal oral health and function" Therefore, the surgery undertaken by the complainant was infact a dental treatment which is excluded from the ambit of coverage of the Policy Terms and Conditions. It is submitted that repudiation by the Opposite Parties is correct and lawful.
5. It is wrong that the Opposite Parties have acted against the spirit of the Act and have acted in deficiency of service. It is submitted that the claim of the complainant squarely fell within the exclusion clause of the policy and therefore was not payable and was repudiated accordingly.
6. It is, therefore, most respectfully prayed that the present complaint of the complainant may please be dismissed with costs.

 

4. The complainant filed a rejoinder on 18/12/2017 to the reply of OP, wherein the complainant made the following submissions in rebuttal to the reply filed on behalf of the OPs:

1. After examination of the documents submitted by the complainant and by the terms and conditions of the Insurance company, it was concluded by the opposite parties that the claim pertained to tumour excision and Bone Grafting with G.Bone Mandible under General Anaesthesia for AmeloblastomaPeriapical Cyst, as per permanent exclusion clause 3.2(iv) of the policy terms and conditions, any dental treatment or surgery unless necessitated due to an injury was not payable, accordingly the claim was not payable and was duly repudiated by the opposite parties. It is submitted here that the opposite parties have completely overlooked the report of the consultant / Doctor Arun P. Sethia that the cyst was an odontogenic cyst with no dental lesion and the involvement of teeth was secondary to the origin of the cyst and after excision of the tumour, the gap was filled with Bone Marrow and hydroxyapatite crystals.
2. According to Dr Arun P.Sethia,the histopathology of an odontogenic cyst is similar to dental, although a dental cyst is smaller and associated with a carious tooth which has not been the case with the complainant. It is also submitted that the complainant and HR of the Company many times approached the opposite party but never got any satisfactory reply from their side.
3. The opposite party no.2 showed a very irresponsible manner and did not give any reply to the complainant about the status of the claim which caused mental pain and agony to the complainant.
4. The opposite parties have completely overlooked the report of the consultant / Doctor Arun P. Sethia that the cyst was an odontogenic cyst with no dental lesion and the involvement of teeth was secondary to the origin of the cyst and after excision of the tumour, the gap was filled with Bone Marrow and hydroxyapatite crystals. It is also submitted by the doctor Arun P.Sethia that the histopathology of an odontogenic cyst is similar to dental, although a dental cyst is smaller and associated with a carious tooth which has not been the case with the complainant.

 

5. The complainant filed evidence by way of an affidavit on 11-08-2015 testifying to all the facts stated in the complaint along with documents exhibit CW-1/1 to CW-1/26 affirming the facts alleged in the complaint. The complainant has filed his evidence as CW1/PW1 by way of his affidavit and he has proved the following documents: -

1. Photocopy of the insurance card issued by the opposite party No. 2 attached herewith and exhibited as Ex. CW-1/1,
2. Photocopy of the policy details is attached herewith and exhibited as Ex. CW-1/2(colly)
3. The copy of the consultation fee receipt dated 26-06-2013 is attached herewith and exhibited as Ex. CW-1/3.
4. Photocopy of a copy of the diagnosis sheetis attached herewith and exhibited as Ex. CW-1/4.
5. The copy of the fee forthe X-ray is attached herewith and exhibited as Ex. CW-1/5.
6. The copy of the consultation fee is attached herewith and exhibited as Ex. CW-1/6.
7. The copy of the Bill of the tests of the complainant vide receipt No. B13/038490 attached herewith and exhibited as Ex. CW-1/7.
8. the test report of the tests is attached herewith and exhibited as Ex. CW-1/8 (colly).
9. The copy of the claim intimation to OP is attached herewith and exhibited as Ex. CW-1/9.
10. The copy of the bill of the medicine is attached herewith and exhibited as Ex. CW-1/10.
11. The copy of the Diagnosis Report of Sir Ganga Ram hospital is attached herewith and exhibited as Ex. CW-1/11.
12. The copy of the discharge summary is attached herewith and exhibited as Ex. CW-1/12.
13. The copy of the bill and its receiving is attached herewith and exhibited as Ex. CW-1/13 (colly).
14. The copies of the bill of medicines are attached herewith and exhibited as Ex. CW-1/14 (colly).
15. The copy of the fee receipt for the OPG (Digital) test is attached herewith and exhibited as Ex. CW-1/15.
16. The copy of the Insurance Claim of RS. 72,685/- is attached herewith and exhibited as Ex. CW-1/16 (colly).
17. The copy of the receipt is attached herewith and exhibited as Ex. CW-1/17.
18. The copy of the medicine prescribed by the doctor which costs Rs. 638/- is attached herewith and exhibited as Ex. CW-1/18.
19. The copy of the receipt is attached herewith and exhibited as Ex. CW-1/19.
20. The copies of the bill of medicine amounting to Rs.346/- Rs.207/- Rs.198/- and Rs.902/- are attached herewith and exhibited as Ex. CW-1/20 (colly).
21. The copy of the e-mail is attached herewith and exhibited as Ex. CW-1/21.
22. The copy of the receipt is attached herewith and exhibited as Ex. CW-1/22.
23. The copies of the receipt for OPG X-ray done amounting to Rs.450/- and Rs.550/- are attached herewith and exhibited as Ex. CW-1/23 and Ex. CW-1/24 respectively.
24. The copy of a certificate issued by the doctor of the complainant is attached herewith and exhibited as Ex. CW-1/25.
25. The copy of the repudiation letter is attached herewith and exhibited as Ex. CW-1/26.

 

6. Sh. Anoop Singh, Authorized representative of Religare Health Insurance Co. Ltd. has filed his affidavit in evidence on behalf of the respondents.

1. Photocopy of the policy details is attached herewith and exhibited as Ex. R-1 (colly)
2. Photocopy of the Repudiation Letter is attached herewith and exhibited as Ex. R-2.

 

7. Written submissions have also been filed by both parties. Finally, oral arguments of both parties were heard on 5/09/2022 and the order was reserved.

 

8. We heard both the parties, and perused the record and the controversy in the present case is as to whether the complainant is entitled to the claim amount or not. The factual position is not in dispute OP categorically admitted the issuance of policy in the present case also a treatment given to the complainant and the period of admission is also not in dispute. The only issue raised by the OP is that the complainant had undergone a dental treatment and not dental injury which was permanently excluded as per policy term and condition.

 

9. Perusal of record shows that treating doctor, Dr Arun P. Setia, Dental Surgeon Oro Maxillofacial Surgeon of Sir Ganga Ram Hospital, New Delhi himself by his certificate dated 20/03/2017 clarified the context in which he made that remark, and explained the same. His certificate is reproduced herein as under:

 

“I wish to submit that the Jaw Cyst operated on Mr Anand Kumar Sharma was a Jaw Cyst may be of odontogenic cause but not due to any infected focus on teeth. As I see it in the X-ray, it has completely healed up and he has now been advised to get the rehabilitation of his lower jaw done with the help of dental implants.”

 

10. As against this another expert opinion was taken by the Insurance Company from Dr C H Ansari, Consultant Family Physician &Insurance claim Consultant from Mumbai, which is given as under:

“The histopathology of an odontogenic cyst is similar to dental. Odontogenic cyst originates from dental system tissues and any treatment falls under dental treatment. Hence claim is not admissible.”

 

11. Admittedly when we have Opinions of two different doctors having a different opinions, then in our opinion credibility should be given more to that doctor, whom himself treated the patient rather than that doctor who has given his opinion based on prescriptions and treatment records submitted by the complainant.

 

12. In our view, the Insurance Company has erroneously relied on the certificate of Dr C.H. Asrani, because it was based on medical texts and presumptions. He gave the final opinion only after the Insurance Company sent the case papers of the Complainant. The report given by Dr C.H. Asrani is based on the assumption elsewhere and is not proved by him or by the Insurance Company. We cannot rely on such assumptions and presumptions of experts. He has neither examined nor operated upon the insured and hence he cannot say that the insured was having histopathology of an odontogenic cyst. We have to rely on the documentary evidence produced by the Complainant supported by Certificate of the treating doctor which is not disproved by the Insurance Company.

 

13. Hence, in our view, the Insurance Company has erroneously repudiated the claim by relying upon the so-called certificates of Dr C.H. Asrani to whom they have paid fees. None of the aforesaid certificates by Doctors would establish that the histopathology of an odontogenic cyst is dental treatment.

 

14. Given of the above discussion and from the records available before us, in our opinion, the Complainant has proved his case beyond doubt and hence the Complaint is allowed.

 

16. The controversy in the present case is as to whether the complainant is entitled to the claim amount or not. The factual position is not in dispute that OP categorically admitted the issuance of policy in the present case, but the OP in their WS categorically stated that the complainant was insured under the Group Policy bearing no. 10020093 from March 30, 2013, to March 29, 2014 subject to the Policy Terms and Conditions. However, it is admitted that the complainant's claim was denied as the same was not payable as per permanent exclusion Clause 3.2 (iv) of the Policy Terms and Conditions. According to the OP odontogenic cysts are a group of jaw cysts that are formed from tissues. Histopathology means the science concerned with the cytologic and histologic structure of abnormal or diseased tissue. As per the attached opinion taken by the OP, an Odontogenic cyst originates from dental system tissues. Also, dental treatment is defined as "Any of a variety of treatments of teeth and adjacent tissues to restore or maintain normal oral health and function" Therefore, the surgery undertaken by the complainant was a dental treatment which is excluded from the ambit of coverage of the Policy Terms and Conditions. It is submitted that repudiation by the Opposite Parties is correct and lawful.Whereas in rebuttal the complainant categorically stated that opposite parties have completely overlooked the report of the consultant / Doctor Arun P. Sethia that the cyst was an odontogenic cyst with no dental lesion and the involvement of teeth was secondary to the origin of the cyst and after excision of the tumour, the gap was filled with Bone Marrow and hydroxyapatite crystals. According to the certificate (Exhibit Cw1/25) given by treating/consulting Doctor Arun P. Sethia certifies that the cyst was an odontogenic cyst with no dental lesion and the involvement of teeth was secondary to the origin of the cyst and after excision of the tumour, the gap was filled with Bone Marrow and hydroxyapatite crystals. It is also submitted by the doctor Arun P. Sethia that the histopathology of an odontogenic cyst is similar to dental, although a dental cyst is smaller and associated with a carious tooth which has not been the case with the complainant.

 

17. Thus, in this case, the OP has failed to procure any such conclusive evidence in respect of the surgery undertaken by the complainant beingsimilar to dental treatment which is excluded from the ambit of coverage of the Policy Terms and Conditions, which was not covered by the insured at the time of taking the mediclaim policy but has taken hyper technical ground to repudiate the claim.

 

18. We also rely on the following observation made in the judgement of the Honourable Supreme Court in the case of National Insurance Company Vs Swaran Singh & others, 2004 SCC 297.

"The proposition of law is no longer res Integra that the person who alleges breach must prove the same. The insurance company is, thus, required to establish the said breach by cogent evidence. In the event, the insurance company fails to prove that there has been a breach of conditions of policy on the part of the insured, the insurance company cannot be absolved of its liability."

 

4. Further Hon’ble Supreme Court in case title “Gurmeet Singh v. National Insurance Co. Ltd.” , decided on 20.05.2022 held that the Hon’ble Court believed that in many cases, it is found that the insurance companies are refusing the claim on flimsy grounds and/or technical grounds. It observed,

“The insurance company has become too technical while settling the claim and has acted arbitrarily. The appellant has been asked to furnish the documents which were beyond the control of the appellant to procure and furnish. Once, there was valid insurance on payment of a huge sum by way of premium and the Truck was stolen, the insurance company ought not to have become too technical and ought not to have refused to settle the claim on non-submission of the duplicate certified copy of the certificate of registration, which the appellant could not produce due to the circumstances beyond his control.”

 

19. Hon’ble Supreme Court in the case of "Lucknow Development Authority vs. M. K. Gupta" reported in [(1993) CPJ 7 (SC)] and other Judgments wherein it has been held that for deficiency in service in case of statutory duty also proceedings for the damages under the tort is maintainable against the statutory authorities.

 

20. In the case of "Lucknow Development Authority" (supra), the Hon'ble Supreme Court held that the legislative intent is clear to protect a consumer against services rendered even by statutory bodies. Considering the larger issue, the Apex Court held that a government or Semi-Government body or a local body is as much amenable to the Act as any other private body rendering a similar service. There can be no doubt that the OPs could be proceeded against under the Act.

 

21. Further, extraordinary suspicious approach without proof cannot be held to be justified. In this connection, reference may be made to a decision of the Hon'ble National Commission in the case of Life Insurance Corporation of India and others Vs. Dr. P.S. Aggarwal; I (2005) CPJ 41 (NC).

 

22.  From the totality of the facts and considering all the legal aspects, we are of the considered view that the repudiation of the claim merely on the ground of suspicion and in absence of any conclusive evidence in respect of the surgery undertaken by the complainant beingsimilar to dental treatment which is excluded from the ambit of coverage of the Policy Terms and Conditions., was unjustified.

 

23. Hence the claim petition of the claimant is very much maintainable in the eyes of law and the same is liable to be allowedsince the policy in question had been issued after verification and the complainant is entitled to the claim amount.It is a very well-settled issue law that once the company has issueda policy to any person then the company is liable to compensate him because of various Apex Court judgements Hence we hold that the OP is liable to reimburse the claim of the complainant of Rs. 80,500/-.

 

24. Therefore, we allow the complaint of the complainant and it is directed that:-

(i)    The OPs will reimburse the claim of the complainant of Rs. 80,500/-(Rupees eighty thousand and five hundred only) to the complainant within 30 days from the date of this order alongwith interest @ 6% p.a. on the above amount of Rs.80,500/- from the date of filing of the complaint i.e. 16.04.2014 till realization.

(iii)   The OPs will also pay a sum of Rs.7,000/- (Rupees Seven Thousand) towards the cost of litigation to the complainant.

(iv)   The OPs will also pay a sum of Rs.15,000/- towards harassment mental agony loss of time to the complainant.

23. Let the order be complied with by OPs within 30 days from the date of receipt of the copy of this order.

 

24. Let a copy of this order be sent to each party free of cost after receiving the application for the certified copy as per the direction received from the Hon’ble State Commission.

 

25. File be consigned to record room.

 

26. Announced on 20.09.2022. 

 

Richa Jindal                              Anil Kumar Koushal                   Sonica Mehrotra

(Member)                                   (Member)                             (President)