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 he purchased Corona Kavach Policy bearing No.P/211222/01/ 2021/002524 from the Opposite Party valid for the period 30.07.2020 to midnight of 11.05.2021 for 285 days against the paid up premium of Rs.2672/- for sum assured of Rs.5 lakhs. Further alleges that unfortunately, during the policy period on 20.08.2020, the complainant suffered from fever, cough and respiratory distress and general weakness and he found himself Corona Positive and as such, the complainant remained admitted in Mehar Super Speciality Hospital, Zirakpur, Mohali from 20.08.2020 upto 26.08.2020. The treating hospital charged Rs.2,04,862/- on account of treatment of the complainant. After discharge, the complainant lodged the claim for the reimbursement of his amount with the Opposite Party, but the complainant stunned to receive only Rs.58,662/- and retained the remaining amount of Rs.1,46,200/- out of the total medical expenses               without any valid reason.    In this way, said conduct of the Opposite Party 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 remaining insured amount of Rs.1,46,200/- alongwith interest  and also to pay Rs.3 lakhs as compensation on account of mental tension, physical harassment and Rs.11,000/- as costs of litigation.

2.       Opposite Party  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.  The intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure  under the Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court. The complainant has not approached this District Consumer Commission with clean hands, rather he has wilfully concealed the material and patent facts from this District Consumer Commission which ipso-facto disentitles the complainant to seek any relief against the Opposite Party. The complainant had purchased the Corona Kavach Policy bearing No. P/211222/01/2021/002524 for sum insured of Rs.5 lakhs valid for the period w.e.f. 30.07.2020 to 11.05.2021. At that time, the terms and conditions of the policy were explained to the complainant and the same were served to the complainant alongwith policy schedule and it is clearly stated in the policy schedule that the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. The insured preferred claim in the first month of the policy for Mehar Hospital, Zirakpur  with period of Hospitalisation from 20.08.2020 to 26.08.2020 with diagnosis of Covid 19 Positive and  claimed amount as per claim form Rs.2,04,862/- and based on the submitted reimbursement documents, the claim was processed and an amount of Rs.58,662/- was approved and paid to the insured through NEFT on 21.10.2020 which is the maximum payable amounts as per the terms and conditions of the policy and further on insured request of claim for value added benefits considered for settlement for an amount of Rs.15,000/- was paid to the insured through NEFT on 14.12.2020  and hence, there is no deficiency in service on the part of the Opposite Party.   On merits, the Opposite Party took up 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.CW1  alongwith copies of documents Ex.C2 to Ex.C70 and closed his evidence.

4.       On the other hand,  to rebut the evidence of the complainant,  Opposite Party tendered into evidence the copies of documents  Ex.Ops1/1 to Ex.Ops1/8 alongwith affidavit of Rajiv Jain Ex.Ops1/9 and closed the evidence on behalf of the Opposite Party.

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

6.       During the course of arguments, ld.counsel for the Complainant has  mainly reiterated the facts as narrated in the complaint and  contended that the complainant purchased Corona Kavach Policy bearing No.P/211222/01/ 2021/002524 from the Opposite Party valid for the period 30.07.2020 to midnight of 11.05.2021 for 285 days against the paid up premium of Rs.2672/- for sum assured of Rs.5 lakhs. Further contended that unfortunately, during the policy period on 20.08.2020, the complainant suffered from fever, cough and respiratory distress and general weakness and he found himself Corona Positive and as such, the complainant remained admitted in Mehar Super Speciality Hospital, Zirakpur, Mohali from 20.08.2020 upto 26.08.2020. The treating hospital charged Rs.2,04,862/- on account of treatment of the complainant. After discharge, the complainant lodged the claim for the reimbursement of his amount with the Opposite Party, but the complainant stunned to receive only Rs.58,662/- and retained the remaining amount of Rs.1,46,200/- out of the total medical expenses without any valid reason. Further contended that at the time of issuance of the said policy  to the complainant, no term and conditions were ever explained or supplied by Opposite Party to the complainant and hence, the alleged terms and conditions are not applicable to the present case of the complainant.

7.       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 first of all, the  intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure  under the Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court. The complainant has not approached this District Consumer Commission with clean hands, rather he has wilfully concealed the material and patent facts from this District Consumer Commission which ipso-facto disentitles the complainant to seek any relief against the Opposite Party.  Admittedly, the complainant had purchased the Corona Kavach Policy bearing No. P/211222/01/2021/002524 for sum insured of Rs.5 lakhs valid for the period w.e.f. 30.07.2020 to 11.05.2021. At that time, the terms and conditions of the policy were explained to the complainant and the same were served to the complainant alongwith policy schedule and it is clearly stated in the policy schedule that the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. The insured preferred claim in the first month of the policy for Mehar Hospital, Zirakpur  with period of Hospitalisation from 20.08.2020 to 26.08.2020 with diagnosis of Covid 19 Positive and  claimed amount as per claim form Rs.2,04,862/- and based on the submitted reimbursement documents, the claim was processed and an amount of Rs.58,662/- was approved and paid to the insured through NEFT on 21.10.2020 which is the maximum payable amounts as per the terms and conditions of the policy and further on insured request of claim for value added benefits considered for settlement for an amount of Rs.15,000/- was paid to the insured through NEFT on 14.12.2020  and hence, there is no deficiency in service on the part of the Opposite Party.

8.       The first  plea  raised by the Opposite Party is that the intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure  under the Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court and this  District Consumer Commission has no jurisdiction to try and decide the present complaint. So far as the objection that complicated question of the fact is involved as such the Insured be relegated to go before Civil Court, is concerned, The Consumer Protection Act, 1986 (as amended upto date) (hereinafter referred to as the Act) was enacted with object to provide for better protection of the interests of the consumers and for that purpose, to make provision for the establishment of consumer council and other authorities for settlement of consumer disputes and other matter connected therewith. Section 13 (4) confers same powers upon the authorities under the Act, which are vested in Civil Court under Code of Civil Procedure, 1908, while trying a suit in respect of (i) The summoning and enforcing the attendance of any defendant or witness and examining the witness on oath, (ii) the discovery and production of any document or other material object producible as evidence, (iii) the reception of evidence on affidavits, (iv) the requisitioning of the report of the concerned analysis or test the appropriate laboratory or from other relevant source, (v) issuing of any commission for the examination of any witness and (vi) any other matter which may be prescribed. The authorities are conferred jurisdiction to decide the issue of “unfair trade practice” which has been defined under Section 2 (r) of the Act. This definition is similar to the definition of “fraud” as given under Section 17 of Indian Contract Act, 1872. From these provisions it is clear that this Commission can hold a full trail as held by civil court or adopt summary procedure for decision of any complaint. Under the Act, although the jurisdiction of the authorities is limited to consumer complaint, but while deciding such complaint no limit has been fixed for adjudicating of the dispute. Three Judges Bench of Supreme Court in Dr. J.J. Merchant Vs. Shrinath Chaturvedi, (2002) 6 SCC 635, (paragraph-7) held that the object and purpose of the Act is to render simple, inexpensive and speedy remedy to the consumer with complaint against defective goods and deficient services and the benevolent piece of legislation, intended to protect a large body of consumer from exploitation. Consumer Forum is an alternate Forum, established under the Act, to discharge the function of Civil Court. Under the Act, the consumers are provided with an alternative efficacious and speedy remedy. As such the Consumer Forum is an alternative forum established under the Act to discharge the functions of Civil Court. Therefore, delay in disposal of the complaint would not be a ground for rejecting the complaint and directing the complainant to approach the Civil Court. The argument that the complicated question of fact cannot be decided by the Forum, has been specifically rejected (In paragraph-12). Similar view has been taken in Amar Jwala Paper Mills Vs. State Bank of India, (1998) 8 SCC 387, CCI Chambers Coop. Hsg. Society Ltd. Development Credit Bank Ltd. (2003) 7 SCC 233.  Hon’ble National Commission, New Delhi in CC No. 101 of 2009 titled as Mahalaxmi Dyes & Chemicals Ltd. Vs. New India Assurance Company Limited decided on 07.09.2021 also held so.  Hence, this District Consumer Commission is  not convinced with the aforesaid contention of the ld.counsel for the Opposite Party.

9.       Further contention of the ld.counsel for the Opposite Party is that  the insured preferred claim in the first month of the policy for Mehar Hospital, Zirakpur  with period of Hospitalisation from 20.08.2020 to 26.08.2020 with diagnosis of Covid 19 Positive and  claimed amount as per claim form Rs.2,04,862/- and based on the submitted reimbursement documents, the claim was processed and an amount of Rs.58,662/- was approved and paid to the insured through NEFT on 21.10.2020 which is the maximum payable amounts as per the terms and conditions of the policy and further on insured request of claim for value added benefits considered for settlement for an amount of Rs.15,000/- was paid to the insured through NEFT on 14.12.2020. But the contention of the complainant is that no such terms or conditions of the policy in question were ever conveyed or supplied to the complainant. Bare perusal of the record shows that the    Opposite Party 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.”

10.     It is not denial of the case that the complainant has lodged the claim for the reimbursement of his medical expenses for an amount of Rs.2,04,862/- and out of this medical expenses, admittedly, the Opposite Party has  paid an amount of Rs.58,662 through NEFT on 21.10.2020 and also paid Rs.15,000/- NEFT on 14.12.2020 and hence we hold that the complainant is entitled to the reimbursement of his remaining medical expenses.

11.     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.

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

13.     In view of the aforesaid facts and circumstances of the case,  we allow the complaint of the Complainant partly and direct Opposite Party-Insurance Company to reimburse the remaining medical bills of the complainant amounting to Rs.1,31,200/- (Rupees one lakh thirty one thousands two hundred only) alongwith interest @ 8% per annum from the date of filing the complaint i.e. 11.12.2020 till its actual realization. Opposite Party–Insurance Company is also directed to pay compensation to the complainant for causing him mental tension and harassment to the tune of Rs.10,000 (ten thousands only). The compliance of this order be made by Opposite Party-Insurance Company 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.

Announced in Open Commission.

Dated: 21.04.2022.