Order by:

Sh.Amrinder Singh Sidhu, President

1.       The complainant  has filed the instant complaint under section 35 of the Consumer Protection Act, 2019  on the allegations that the complainant purchased Cashless Family Health Optima Insurance Plan policy bearing No. P/211222/01/2021/0003225 for himself and his spouse Sneha Rani for a sum assured of Rs.6,25,000/- against paid up premium of Rs.11,198 valid for the period w.e.f. 12.09.2020 till 11.09.2021 and previously, the complainant also purchased the said policy  and the present policy is the  continuous policy. Further alleges that during the policy period in the third week of February, 2021 the complainant felt ill and suffered from shortness of breath and in a prevailing situation of pandemic, the family members of the complainant got worried and admitted the complainant  in Sham Nursing home & Heart Centre on 25.02.2021 where he remained admitted till 02.03.2021. On his treatment, the complainant spent total amount of Rs.1,25,651/- and paid the same to the treating hospital in cash. After discharge from the hospital,  the complainant lodged the claim for the reimbursement of his hospitalization charges and also completed all the formalities, but the Opposite Parties only reimbursed Rs.68,815/- and retained the remaining treatment charges without any reason and explanation.  Thereafter, the complainant made so many requests to the Opposite Parties to reimburse the remaining claim, but to no avail.  Hence, the said act of the Opposite Parties amounts to deficiency. Vide instant complaint, the complainant has sought the following reliefs.

a)       The Opposite Parties may be directed to reimburse the remaining medical claim of the complainant amounting to Rs.56,836/- alongwith interest @ 12% per annum from the date of filing the complaint till its realization and also to pay  Rs.1 lakh on account of compensation due to mental tension and harassment caused by the complainant besides cost of complaint amounting to Rs.22,000/- may please be allowed.

b)      And any other relief to which this Hon’ble Consumer Commission, Moga may deem fit be granted in the interest of justice and equity.       

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 of the complainant is liable to be dismissed. It is submitted that the complainant has already  paid upto the extent of Rs.68,815/- as per the terms and conditions of the policy and said amount of Rs.68,815/- was transferred in the bank account  of Treating Hospital directly through NEFT on 04.08.2021  and the alleged claim of Rs.56,894/- has been deducted as not payable as per the Exclusion clause of the policy as the insured underwent HCV, HFI, HIV, RBS and HBSAG test, which is irrelevant to the present diagnosis, i.e. viral pneumonia and as per the other excluded expenses No. 137, the charge towards Pulse Oxymeter is not payable and hence an amount of Rs.39,700/- was deducted. Similarly, as per the policy, the other excluded expenses the charges  towards DESREM maximum Rs.2360/- only payable. As per the AIIMS guidelines only 6 vials are payable for the insured having moderate covid infection and also the charges towards fabiflue and fluguard is not payable and hence, an amount of Rs.14,694/- was deducted. Further as per the other excluded expenses, the charges towards admission charge, file charge not payable and hence amount of Rs.1250/- is not payable and  hence deducted.  Not only this, as per the other excluded expenses, the charges towards CANFIX and FABIKIND are  not payable and an amount of Rs.1250/- was deducted. Thus, an amount of Rs.68,815/- settled to the insured after deducting an amount of Rs.56,836/- is the maximum amount payable to the insured and no further amount is payable to the insured in this claim.   On merits, the Opposite Parties took up almost the same and similar pleas as taken up by them in the preliminary objections. Hence, it is prayed that the   complaint may be dismissed with costs. 

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.C9 and  closed the evidence on behalf of the complainant.

4.       On the other hand,  to rebut the evidence of the complainant,  Opposite Parties No.1 and 2 also tendered into evidence the affidavit of Sh.Sumit Kumar Sharma Ex.Op1,2/A alongwith copies of documents Ex.OP1,2/1 to Ex.OP1,2/9 and closed the evidence.

5.       We have heard the ld.counsel for the parties and also  gone through the documents placed  on record.

6.       During the course of arguments, ld.counsel for the Complainant as well as ld.counsel for Opposite Parties   have mainly reiterated the facts as narrated in the complaint as well as in the written statements respectively. We have perused the rival contentions of  the parties and also gone through the record on file.

7.       It is not denial of the Opposite Parties-Insurance Company that the complainant has purchased the policy in question and it is the continuous policy. It is also denied by the Opposite Parties that the  ccomplainant has purchased Cashless Family Health Optima Insurance Plan policy bearing No. P/211222/01/2021/0003225 for himself and his spouse Sneha Rani for a sum assured of Rs.6,25,000/- against paid up premium of Rs.11,198 valid for the period w.e.f. 12.09.2020 till 11.09.2021,  copy of the policy is placed on record as Ex.C2 (5 pages). The main grouse of the Opposite Parties for retaining the remaining claim of the complainant is that the complainant has already  paid upto the extent of Rs.68,815/- as per the terms and conditions of the policy and said amount of Rs.68,815/- was transferred in the bank account  of Treating Hospital directly through NEFT on 04.08.2021  and the alleged claim of Rs.56,894/- has been deducted as not payable as per the Exclusion clause of the policy and thus, an amount of Rs.68,815/- settled to the insured after deducting an amount of Rs.56,836/- is the maximum amount payable to the insured and no further amount is payable to the insured in this claim because the  insured underwent HCV, HFI, HIV, RBS and HBSAG test, which is irrelevant to the present diagnosis, i.e. viral pneumonia and as per the other excluded expenses No. 137, the charge towards Pulse Oxymeter is not payable and hence an amount of Rs.39,700/- was deducted. Similarly, as per the policy, the other excluded expenses the charges  towards DESREM maximum Rs.2360/- only payable. As per the AIIMS guidelines only 6 vials are payable for the insured having moderate covid infection and also the charges towards fabiflue and fluguard is not payable and hence, an amount of Rs.14,694/- was deducted. Further as per the other excluded expenses, the charges towards admission charge, file charge not payable and hence amount of Rs.1250/- is not payable and  hence deducted.  Not only this, as per the other excluded expenses, the charges towards CANFIX and FABIKIND are  not payable and an amount of Rs.1250/- was deducted. But on the other hand, ld.counsel for the complainant has strenuously denied this contention of the Opposite Parties specifically pressing that the complainant  has never received any such terms or conditions or the Opposite Parties ever conveyed such terms or conditions to the complainant on the basis of which, now they have denied the remaining claim  on the excuse of some exclusion clause of the policy.  Bare perusal of the record shows that  Opposite Parties No-Insurance Company could not produce  any evidence to prove that such 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 so.

8.       We have heard the learned counsel for the parties at considerable length and have also examined the record of the case.  In the rejoinder filed rebutting the contents of the written reply of the Opposite Parties, the complainant has specifically mentioned that  the complainant never received any copy of the policy from the Opposite Party at the time of purchasing the policy. Moreover, the officials of the Opposite Parties told to the complainant that every disease is covered under the policy, but never handed over any policy terms and condition which shows that the above said treatment was excluded from the policy. On the other hand, to rebut the said contention raised by the complainant in  rejoinder, the Opposite Parties have failed to produce any iota of evidence to deny this factum of the complainant.     

9.       In such a situation the repudiation made by 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 seems 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.

10.     In view of the above discussion, we hold that the Opposite Parties No.1 and 2 -Insurance Company have  wrongly and illegally rejected the remaining claim of the complainant.

11.     To support their contention, Opposite Parties No.1 and 2 have cited the rulings, but these rulings are not applicable to the facts of the present case and are not supportive to the instant case.

12.     The complainant in his complaint has claimed the remaining medical claim upto the extent of Rs.56,836/- and on the other hand,  the Opposite Parties have nowhere denied the medical expenses borne by the complainant on his treatment and hence,  the claim of the complainant to that amount is genuine and we allow the claim of the complainant accordingly.  

13.     In view of the aforesaid facts and circumstances of the case,  we partly allow the complaint of the Complainant and direct Opposite Parties No.1 and 2 -Insurance Company to pay the remaining claim of Rs.56,836/- (Rupees fifty six thousands eight hundred thirty six only) to the complainant. The compliance of this order be made by Opposite Parties No.1 and 2- Insurance Company 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 in accordance with law. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced in Open Commission.