State Consumer Disputes Redressal Commission
Ranjan Mohapatra vs Star Health & Allied Insurance Co. Ltd. on 8 July, 2022
STATE CO N SU M E R D IS PUTES It E D R ESSALCO MM ISS I ON,O DISIIA, CUTTACK
CONSUMER COMPLAINT NO. 1.9 OF 2018
Ranjan Mohapatra, aged about 68 years,
S/o Late Radhakanta Mohapatra,
Flat No.A /D - 7 - 1, Block - A
Chandrama Housing Cornplex,
Kharavela Nagar, Unit - 3,
Bhubaneswar, Odisha
Complainant
Vrs.
Star Health & Allied lrtsurance Co.Ltd.,
Represented through its Authorised
Signatory - Claims, No. l-5, Sri Sri Balaji
Comptex, l-'t Floor, Whites Lane, Royapettah,
Chennai - 600014
... Opp.Party
For the cornplainant : M/s R.l(.Pattnaik & Associates
For the Opp.party : M/s N.C.Misra & Associates
PRESENT:
HON,BLE DR. JUSTICE D.P.CHOUDHURY, PRESIDENT,
DR P.K.PRUSTY, MEMBER
AND
MISS S.L.PATTNAIK, MEMBER
{
DATED THE ogtn JULY , zozz
ORDER
DR. D.P. CHOUDHURY J., PRESIDENT The captioned complaint case is fited u/s LT of the consumer Protection Act (hereinafter called the 'Act' in short) by the complainant against'the opposite party seeking direction to the opposite party to pay a sum of Rs.3,2o,ooo/- along with all allied benefits with interest at the rate of LZ% per annum from the date of claim till the date of realisation, to pay Rs.25.00 lacs as compensation for causing loss of credibility, harassment and mental agony etc. along with litigation cost of Rs.25,000/- to the complainant.
FACTS
2. The factual matrix leading to the case of the complainant is that the complainant being allured by the advertisement of the oP insurer has purchased the Medi-claim policy for sum assured of Rs.10.00 lacs u.nder the plan 'senior citizens Red carpet Health lnsurance policy' vide policy No. Pl7oooo2lo1,/2o18l000106. The Policy was valid from 5.4.2afl to 4.4.2018. lt is alleged inter alia that the complainant while filling up of the proposal form. has admitted to have suffered from diabetic and hypertension. However, ofi 10.1.201g complainant having suffered from high fever got him admitted to the Apolto Hospital and after necessary treatment discharged on 18.1.2018. During hospitalisation, he has informed about his hospitalisation to the OP - insurer for cashless facitities. But the insurer raised the issue with regard to two more diseases i.e. Rheumatoid Arthritis and copD which he has not disclosed during filling up of the proposal form. Therefore, the op refused to provide cashless facilities but asked to submit documents to settle the medical expenses on reimbursement basis.
3. lt is alleged by the complainant further that the op issued a letter on 14.2.20!8 to produce the treatment records and hospitalisation records qua his treatment at sAAoL Heart centre on 21'.5.201,6. The complainant alleged to. have replied on 2L.2.2018 that he was never treated by hospital at sAAoL Heart ,i ;., j 4 I 1 .1 I i i j Centre but he has taken the therapy for better health. He i I . neither got any medical treatment nor undergone any I l I hospitalisation at sAAoL Heart centre. lnstead of paying I l attention to such letter, the OP remained silent. Then the I I 1 complainant sent legal notice on 9.3.2018 to the Op and they I I also replied on 24.3.201,8 through their advocate. However, on t'I l 20.3.2018 the OP issued a letter of repudiation stating that they t I ' have called for additional informations with regard to SAAOL ,1 il 1 j Heart Centre and the previous treatment etc. undergone by the :j i complainant, but due to non-submission of said clocuments, i ), there is clear violation of condition no.4.4 of policy in question 1 ,:i by the complainant for which they have repudiated the claim. i ;
Challenging the said repudiation the complainant filed the I
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' complaint alleging about deficiency in service and unfair li
trade 1j
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practice on the part of the Op. i,
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4- OP filed written version admitting about purchase of i t Senior Citizens Red Carpet Health lnsurance Policy from them by .1 rr , . I . the complainant. lt is also admitted that the comptainant was i i )rn /v\ -, :, hospitalised on 10.1.2018 in Apollo Hospital and informed the oP for cashless facilities. op further averred that the complainant has not disclosed about his previous hospitalisation while suffering from copD with sero positive rheumatoid arthritis for which they denied the cashless facilities but at the same time, asked the complainant to claim the reimbursement of the medical expenses. After receiving the application the op enquired into the matter and found not only complainant has become adamant to produce the hospitalisation records of sAAoL Heart centre but also failed to produce his cr rest report dated 27.9.201,6 undertaken in opD and his USG report dated 25.9.2017 held in AHC. As the complainant did not comply the letter of the oP dated rq.zt.zotg, 1.3.201g and 16.3.201g, they found violation of policy condition no.4.4 of the policy and accordingly, repudiated the claim on 20.3.201g. lt is the case of the oP that they have got information that the complainant was hospitalised for sero positive Rheumatoid Arthritis and copD but unfortunately, that was not included in the proposal form of policy by complainant, the reasons of same is,best known to the complainant. since the additional information was not received, there was no other way than to repudiate the claim. Therefore, there is no deficiency in service and unfair trade practice on the part of the oP. As such, the op prayed to dismiss the complaint as case of complaint is not covered by condition no.4.4 of the policy. on the other hand,,the insurer is not riabre to pay any amount to the complainant.
POINTS FOR DISCUSSION
5. Having gone through the complaint and the written version six points emerge for determination.
i) Whether the complainant case is maintainable?
ii) whether there' is cause of action to file the complaint?
iii) whether the complainant has proved compliance of clause no. 4.4 of the policy condition?
iv) whether there is deficiency in service and unfair trade practice adopted on the part of the Op?
,l ',.] ,l "l '7j l I I j I I
v) Whether the complainant is entitled to medical l I expenses and compensation, if so'quantum of such I I l compensation? I I
vi) Whether the complainant is entitled to any other l f relief? i DISCUSSIONS 1 1 I I Point No.3 I I 1
6. lt is well settled in law that the complainant has to prove j I i its case but in the instant cdse, it is admitted by the OP that the j i complainant has purchased the Senior Citizens Red Carpet I ;1 Health lnsurance Policy for the period from 5.4.2017 to 4.4.ZALB I ..
forsumaSSuredofRs.10.00lacs.ltisalsoadmittedbytheoP :
that the complainant had filed the proposal form where he I t, to i admitted have suffered from diabetes mellitus anci :
li i hypertension. lt is also admitted by the OP that the complainant t :
t.
had submitted the claim alleging about his hospitalisation in i ) Apollo Hospital from 10.1.2018 for treatment of DM/LOBAR ;
;
PNEUMONIA, DCM and asked for cashless treatment. lt is admitted by both parties that the cashless facility was refused : and the complainant was asked to submit the reimbursement of medical expenses. The facts.admitted need not be proved.
7. However, complainant has produced the policy which shows that senior citizens Red carpet Health lnsurance policy for sum assured of Rs.10.00 lacs was purchased by the complainant for the period from 5.4.2017 to 4.4.2018. ln that policy, it is averred that the insurance under the policy is subject to conditions, clauses, warranties, exclusions etc. attached to the policy. complainant has proved such policy vide Ext. t. complainant has also proved the copy of the discharge summery of his hospitalisation on L0.L.zor} to 18.1.2018 issued by the Apollo Hospital vide Ext. - 2. From the discharge summery, it appears that the complainant was hospitalised for diabetes mellitus (DM), LOBAR PNEUMONtA and DCM. The entire Ext. - 2 series disclosed that the complainant has been discharged after being cured. complainant has proved the letter dated 1,4.z.zotg vide Ext. - 4 issued by the oP. The letter itself shows that the complainant has already made claim with the documents but i {, ,.) the oP asked to produce additional documents in following manner:-
i) Patient has beeri admitted in saaol Heart centre on 21.5.2016. Kindly submit its complete hospitalisation records with reports.
ii) Patient has taken CT Chest on 21.9.2016 in OpD and USG on 25.9.2017 in AHC. Kindly submit its consultation paper and admission records.
iii) As per submitted indoor case papers patient is a known case of sero positive Rheumatoid Arthritis. Kindly get a letter from treating doctor regarding the duration of RA, DCMP and copD and submit first and all past consultations since diagnosis of RA an copD with RA Factor report when RA was first diagnosed, past chest X-ray report and treatment taken for teh same.
iv) All previous hospitalisation records. 10 complainant proved Ext. - 5, copy of the reply dated 21".2.201,9 which is as follows:-
"xxx xxx xxx Any way L^ onr,*ering to youryuur,r, just because you asked, which ore unreloted to my diseose and claim.
1-. sAAoL is not o hospitol. lt is qn qlternative treoting centre for improving heart functions for both people with comprqints ond without ony issues also. Pleose check with them. I went on my own ofter they presented the benefits of this in our oportment to oll members. So it is unreloted to my cose. 2.1 connot get you previous checkup and history os I do not keep ony records of thot when t am told thot there is no problem. lf you have got that then ptror,, show me in contest of my getting admitted with high groded fever.
i.You moy be knowing thot copD is on irreversible stote of teh lungs. lt connot be reversed. you hove got my chest x-RAy on scon film and report olso. Does it mention CO\D? No, so you ore wrong.
I never had Rheumqtoid orthritis. pleose produce the evidence, by which Doctor and I sholl immediotely get it cleqred by the sqme Doctor. Some time in IDC popers i onty presume thqt innocent doubt/remarks may be there but hqs anybody concluded? Anywoy I do not recollect nor have ony such finding with me.
4.1 om sorry, I cannot do your :iob of my previous hospitalisotion records because t do not hqve any. tf you hove ond it relates to present cloim, produce the evidence. ;11 , 11
5. There is no record with me for consultation of Hypertension. I hove hypertension long bock, ond have been toking medicotion from Doctor when I wqs employed ond always it is within control till dote. Also there ore Doctors who ore my relatives ohd they advise me.if ifeel so."
8. The aforesaid reply clearly shows that he was neither treated nor hospitalised for rheumatoid arthritis because he was never suffering from such disease. Further, he has made it clear in the said reply that he had been to sAAoL Heart centre for therapy but not for any treatment of disease. He submitted that he has already submitted all the documents such as scan report, X-ray and discharge report but no previous history of copD was there. The reply of the complainant is very clear that he was neither suffering from rheumatoid arthritis nor copD. Rather being disgusted with the conduct of the op, he requested to settle the claim as soon as possible.
9. complainant has proved the copy of the legal notice sent by him on 9.3.2018 vide r*a. - 6. op sent a reply again asking the documents as asked under letter dated .t4.z.zo!g in their letter dated 243.2a18 vide Ext. - 7. There is no whisper anything 12 about the reply of the complainant date d zr.z.zo1g vide Ext. -
5. Then the complainant was sent the letter of repudiation vide Ext. 8 where they have not only added about the non- submissions of records of sAAoL Heart centre dated 21".s.2a1,6 but also cast aspersion on the complainant but not having submitted the cr rest report dated 27.9.201,6 and ultrasound report dated 25.9.2017. ln that letter they clearly mentioned that since condition no.4 of the above policy has not been complied, they have repudiated the claim.
10. Complainant has filed the complaint with affidavit where under all the documents have been exhibited. since the Evidence Act would not apply strictly to the consumer cases but the principle of evidence would apply. Moreover, the documents more or less admitted by the op except the document dated 21'.2.20!8 sent by the complainant. on perusal of written version of the oP, it appears that at para - .LZ of the written version, he has refuted the allegations made in para 10 of
-
complaint where facts under the Ext. - 5 has been described. on h 13 the other hand, written version is totally silent about letter dated 21".2.2018 sent by the complainant to the OP. lt is settled in law that if the written version does not deny specific fact alleged in complaint or made evasive denial, such facts as alleged in the complaint are deemed to have.been admitted by the adverse party under the provisions of c.P.c. Therefore, the letter dated 2L.2.2oL8 vide Ext. - 5 is deemed to have been admitted by the OP and proved by the complainant. 1.1. Condition no.4.4 of the policy is as follows:-
"xxx xxx xxx 4.4 The insured person/s sholl obtqin ond furnish the Compony with oll ciriginot bills, receipts ond other documents upon which o claim ls bosed ond shall also given the Compony such odditionol informotion ond assistonce os the Compony moy require in dealing with the cloim.,, The aforesaid condition no.4.4 only states that the complainant if asked for filing of the documents or additional document the insured shall furnish the same to the op. ln the instant case, the complainant has been asked to produce the additional documents but not the documents because he has already ,_1, t4 submitted documents while submitting the claim. When the complainant has already admitted that he was not hospitalised at sAAoL Health centre and he was not suffering from any sort of disease except DM & hypertension prior to this policy in question, the query made by the Op seems to have been complied because a person without any hospitalisation cannot be forced to have the documents from the concerned hospital.
Thus, we are of the opinion that the complainant has proved the compliance of the letter dated 1.4.2.2008 and further reminders by the oP were not necessary. Therefore the compliance of policy condition no. 4.4 is found to have been proved by the complainant.
12. The oP in order to prove its plea has adduced evidence on affidavit and the documents. when both parties have adduced evidence, the importance of onus probandi is receded. on the other hand, both parties are to prove their pleas through their respective evidence. Now the OP has to prove that their action was justified. No doubt the op has adduced their authorised ,t, 15 signatory as opposite party witness No.1. we have gone through the same. oPW t has produced the pre-authorised requisition form and other documents vide Ext. - A series for proving their plea. opw L has arso stated that they have received the claim form but during enquiry, it was found that the complainant has got earlier treatment, in sAAoL Health centre on 21,.5.2016 and there was also cr scan of the chest of complainant on 27.9.201,6 and usG conducted on 25.9.2017 in Acharya Harihar Regional cancer Research centre. lt is also revealed from their statement that the complainant was a known patient of sero positive Rheumatoid Arthritis and as such, they have asked for the additional documents from the complainant on 1,4.2.2oL8 vide Ext. - B series. The statement of oPW 1, is also clear to show that they have repudiated the cashless facility but agreed to settre the claim on reimbursement medical expenses basis. lf it is so then what was the necessity of asking for the additional documents. I 16
13. lt is also admitted by OPW 1 that they have called for the documents from the SAAOL Heart Centre and accordingly, the letter dated t\.3.2O18 of concerned Heart Centre is available which is exhibited under Ext. - A series is as follows:-
"xxx xxx TO WHOM SO EVER IT MAY CONCERN This is to inforrn tht Mr Ronjan Mohopatro, oged 67 years, wos given theropy'ot our centre on 27.5.20L6. He did not hove any oliments during the time of theropy. He was given theropy to increase his normol stamina. This therapy is olso given to heolthy persons for enhancement of their health."
The aforesaid letter is clear to show that the complainant has no any ailment during the time of therapy, he was given therapy to increase his normal stamina and it is also given to the healthy person for enhancement of health. such letter of sAAoL Heart centre clearly proves that the complainant was not admitted in the Heart centre for any disease but took therapy as healthy person. On the other hand, OP has not been able to prove through this letter that the complainant had been hospitalised at sAAoL Heart Centre for any disease. Not onty this but also the oP has also admitted in. their written statement that the ,"1 17 complainant's wife has clearly denied vide Ext.A series about any pre-existing disease of her husband. The OP has not adduced any document to show there necessity for calling for CT Chest report of the complainant made on 27.9.201,6 or USG conducted on 25.g.20t7. Unless there is clear and cogent evidence adduced by oP to prove suppression of disease whose proof is asked for, oP is fou.nd to have not proved any suffering of the complainant due to sero positive Rheumatoid Arthritis or COPD. Moreover, the OP has not been able to prove any hospitalisation of the complainant at sAAoL Heart centre on 21,.5.20t6. when onus lies on the oP to prove the plea taken by them, no burden can be shifted to the complainant. on the other hand, we are of the opinion that the op in order to cover up their inaction have called for the additional documents from the complainant instead of considering the documents already called for by them.
L4. lt is also reported in the case of Mithoolal Nayak vrs. Life lnsurance corporation of lndia AIR 1902 supreme court 914, 18 satwant Kaur sandhu vrs. New rndia Assurance company Ltd. in civil Appeal No. 277G of Life lnsurance corporation of .z0oz, lndia and others vrs. Asha Goel, ArR (2001) scw 161 that whenever oP has taken plea of any suppression of material fact of pre-existing disease, it is for the op to prove the same. lt is reiterated that the oP has failed to prove their plea that the complainant was required to file the additional documents but he failed to submit the same. At any rate, op has failed to prove his plea.
15. Bereft of above balancing the evidence of both parties and considering the contentions of both parties, we are of the view that the complainant has proved the compliance of condition No. 4.4 of the policy condition in question. lssue is answered accordingly.
POINT NO.4
16. This point is dependent on lssue No.3. we have already held in the aforesaid para that the complainant has proved the compliance of condition no. - 4.4 of the policy whereas the op 11, 19 I has failed to prove their plea that the complainant's claim is liable to be rejected due to non-compliance of poticy condition No.4.4 of the policy.
17. Complainant has alleged that due to repudiation of the claim for no fault of the complainant, there has been deficiency in service and unfair trade practice adopted by the op to which the oP denied. section 2(g) of the Act defined the "deficiency" in the following manner:-
oxxx xxx xxx
(g) "deficiency" meqns any fault, imperfection, shortcoming or inodequacy in the quolity, nature and manner of performonce which is required to be mointoined by or under any law for the time being in force or has been undertaken to be performed by o person in pursuonce of a controct or otherwise in relation to any se.rvice;"
From the aforesaid definition, it is clear that if any shortcoming or any negligence on the part of the service provider or. any harassment made by the service provider in spite of notice to the service provider, the latter would be found to have 20 deficiency in service. ln the instant case, already we have observed above that the op for no reason has repeatedly asked the complainant to produce additionar documents whereas the comptainant has already denied to have got the documents asked for because he has never been hospitalised nor have undergone any treatment except therapy which is taken up for the healthy person. Therefore, we are of the view that the asking for the documents ignoring the letter dated 21".2.20Lg by the oP is undoubtedly not only harassment or negligence but also a great shortcoming for providing service to the insured by the oP - insurer. Hence, complainant has proved the deficiency in service on the part of the Op.
18. complainant has alreged about unfair trade practice adopted by the op whereas op denied about such fact. section 2 (r) of the Act defines "unfair trade practice,,. clause
- (6) of said section 2 (r) is as follows:-
XXX XXX XXX I 21 (6) monufacturer of spurious goods or offering such goods for sole or adoptina deceptive proctices in the provision of servicet"
Keeping in mind the above provisions let us see whether the complainant has been able'to prove alr the elements to attract unfair trade practice adopted by the op. No doubt the .
complainant has clearly stated in the complaint along with affidavit that the insurance contract is based on ,,uberrima fides" i.e. based on most abdudant good faith and trust, and the insured must observe most perfect good faith towards the insurer. lt is revealed from para - 20 ofthe complaint along with affidavit that the op insisted the comptainant with regard to its prior hospitalisation, when the complainant has never been hospitalised prior to taking up of the policy as per discussions made in above para. Thus, the op by taking higher premium and on the other hand denied to pay the insurance benefit. Although the complainant has already admitted towards suffered from diabetic and hypertension but he denied to have suffered from any other pre-existing disease. so taking the higher premium by ,l
-) -) the OP from the complainant and on the other hand denied the cashless facility or the reimbursement is certainly unfair trade practice on the part of the OP because OP has adopted deceptive practice.
1-9. More so, it is stated ,n O, ra - 21, of the complaint with affidavit that the oP repudiated claim while issuing the policy has given to the complainant high sound word that they are with the complainant for 24 hours multiplied by 7 days as and when it is necessary by providing cashless benefit to the insured doing hospitalisation and emergency but in reality, they are adopting different yard sticks to the policy holders by forcing the policy holder not to go for a particular way of treatment when the same is required as per the opinion of the treating doctors. This fact has also been denied by the op but as per the facts proved above, we are of the view that in spite of denial of any pre-hospitalisation or pre-existing disease the op went on asking the pre-hospitalisation and treatment records without proving them, thus it is nothing but the deceptive trade practice by the t' 23 OP. Therefore, we are also of the view that the complainant has proved the unfair trade practice on the part of the op. This issue is answered accordingly.
2A. POTNT NO.s ln view of answer to point Nos. 3 and 4 now it is for the complainant to prove that he is entitled to compensation as asked for in the comptaint. It has been prayed to pay hospitalisation bills amounting to Rs.3,20,000/- with interest at the rate of 12% per annum, compensation for mentat agony and harassment amounting to Rs.25,00, OO0/- due to illegal repudiation and cost of litigation amounting tb Rs.25,000/_. lt is revealed from the complaint accompanied with affidavit that the complainant has spent Rs.3,20,000/- as hospital bills. when there is deficiency in service and unfair trade practice adopted by the oP for not paying the hospital bills and the op failed to prove the violation of policy condition No. 4.4, the complainant is entitled for payment of hospital expenses which are not disputed by oP. Not only this but also the entire medical papers 'l 24 vide Ext. - 2 series proved that the complainant is entitled to the hospital expenses for Rs.3,2 O,AOOI -. 21'. The complainant in his compraint coupred with the affidavit at Para - 2t and 22 ctearly stated in following manner:-
"xxx xxx xxx 2L. Thqt the opp.porty ot the time of iisuance of the poticy hove given the comprainant high sound word that they are with the comploinont for 24 hours 7 days as and when it is necessory by providing coshress benefit to the insurer doing hospitolisotion ond emergency but in reority they ore odopting different yord sticks to the poficy horders by forcing the policy holder not to go for o porticurar way of treotment when the some is required os per the opinion of the treoting doctors.
22. Thot for the'oforesaid action of the opp.parties have illegally repudioted the croim of the comproinant and therefore ore lioble to poy the entire hospitor expenses os per the bill raised by the Apolro Hospitor which hos arreody been poid by the complainant ond because of iilegat rejection of cloim they ore otso fiobre to poy compensation and cost of litigotion qs indicqted in the schedule mentioned below.
SCHEDULE 1-. Payment of Hospitol bitts Rs.3,20,000/-
2. lnterest on the oforesaid omount from the dote of poyment tilt reolization @12% p.a. to be quantified by the Commission 25
3. Compensation for mentologony and Harassment due to illegol repudiation Rs.25,00,a0A/-
4. Cost of litigotion Rs. 25,000/-
Totol Rs.28,45,000/:'
22. oP in their written submission and the evidence on affidavit at para -22 and 23 stated in following manner:-
'xxx xxx xxx
22. Thqt the coshless benefit ond reiimbursement of the
complainont were denied due to his non-cooperotion ottitude in not submitting additional document ond informotion osked for by the compony to settle the claim. so the allegation that the company adopted different ottitude to the policy horders by forcing the policy holders not to go for o particulor woy of treotment when teh same is required os per the opinion of thot roting doctor is not correct. The compony never disputed thot he wos odmitted in Apollo Hospitol for treotment, but 'diseoses when some new were found white adntitted in Apollo Hospitol ond his odmission in saqol Heart Centre for Therapy treotment, the compony osked him provide additionol documents/information qbout such diseoses qnd information regording the odmission in sqoor Heort centre. As no response from the side of the comploinont the claim wos repudiated by the compqny.
23. Thqt it is totally wrong on the port of the complainont to say thot the compqny illegolly repudiated the cloim of the complainont. Rqther it con be sqid thot due to non submission of relevant odditionol documents/informqtions in 26 order to settle the cloim qnd as the complqinant remqined silent without ony informotion osked for by the company, so the claim was repudiated and by that there is no deficiency in service on the part of the compony ond unfair trade proctice as alleged. As such the complainqnt is not entitted to get the hospitolisotion qmount ond compensotion cloim in the present opplication ond the ssme is liobte to be dismissed."
23. while evaluating the pleading and evidence of both parties, we are of the view that the compldinant has already proved the deficiency in service and unfair trade practice as per discussions made in the above paras and in such circumstances, the asking for the hospitalisation and other medical documents of sAAoL Heart centre is certainly blow to the body and mind of the complainant, particularly when the cornplainant has become a senior citizen and ran' from pillar to post for a bill of Rs.3,20,000/- which is genuinely asked for and the same has been denied on flimsy grounds as per discussion made above. Thus, the mental agony and harassment to the complainant cannot be denied as proved by complainant. lt is reported in Gurumel singh vrs. Brarrch Manager, Nationat lnsurance co.Ltd )-7 ,rl in civil Appeal No. 4071 of zo2z disposed. of on zo.s.zozz which is as follows:-
"xxx xxx xxx 4.1 rn the present case, the insurance company hos become too technical while settling the clqim and has qcted orbitroriry. The oppellqnt hqs. been asked to furnish the documents which were beyond the control of the oppeilont to procure and furnish. once, there was o vorid insurance on poyment of huge sum by way of premium ond the Truck wos stolen, the insurqnce compony ought not to hove refused to settle the claim on non-submission of the duplicate certified copy of certificate of registration, which the appeltant could not produce due to the circumstances beyond his control.
rn mqny coses, it is found that the insuronce componies ore refusing the crqim on frimsy grounds ond/or technicar grounds. while settling the cloims, the insurqnce cofttpany should not be too technicql and ask for the documents, which the insured rs not in a position to produce due to circu msta nces beyond his control.,,
24. with due regard to the aforesaid decision of the Hon,ble supreme court of lndia when a ctaim is repudiated on flimsy ground the complainant is entitted to heavy compensation, so that in future they would not dare to repudiate such claim. rn the facts and circumstances of the case as discussed in the 28 above paras and at the cost of repetition we are of opinion that oP has repudiated the claim for non-submission of additional documents which are beyond the reach of complainant for being not hospitalised at sAAoL Heart centre, we hereby hold that the complainant is entitled to the hospital bill of Rs.3,20,000/- and the compensation. Not only this but also he is entitled to the compensation but also in such cases punitive damages must be awarded to the complainant. Therefore, we are of the opinion that the comptainant being a senior citizen is entitled to compensation of Rs. l-5,00,000/- and Rs.5,00,000/- for punitive damages. point No.5 is answered accordingly. 25. POINT NOS.I.. 2 AND 6
From the forgoing discussions, there lies cause of action to file the case and as such the complaint IS maintainable. lt needless to observe that section - 3 of the consumer protection Act, 1986 clearly spelt out that in addition to any other law for time being in force, the compraint can be made under the Act for hospitalisation expenses and compensation as per the i 29 ,t' { provisions of the Act. Therefore, in view of above discussion the complaint is maintainable.
26. we have already held in the above paras that the complainant has proved the deficiency in service and unfair trade practice on the part of teh op. Apart from this, we have already observed ln the above paras that the complainant is entitled to hospitalisation expenses for Rs.3,20,000/- and for compensation and punitive damages dll together for Rs.20,00,000/' (Twenty lacs). comptainant has prayed the !itigation expenses for Rs.25,000/-. when complainant is dragged to file case for inaction of op., he is entitled to such amount of cost. Besides above complainant is not entitled for any other relief. Hence ordered.
ORDER In view of above discussion, we hereby ailow the complaint by directing the oP to pay Rs.3,20,000/- (Three tacs twenty thousand) as hospitalisation expenses, Rs.15,00,000/- (Fifteen lacs) towards compensation and Rs.5,00,000/- (Five lacs) as 30 II punitive damages and cost of Rs.25,ooo/- (Twenty thousand) to complainant within 45 days fairing which ail payments wourd carry interest at the rate of 120/: per annum from the date of this order till the date of payment.
supply free copy of this order to the respective parties or the copy of this order be downtoaded from confonet or website of this commission to treat same as copy suppried from this Commission.
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