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2.      The complainant has filed the complaint U/s 12 of The Consumer Protection Act, 1986 (in short, "the Act") against the OPs on the averments that OP no.2 insured the complainant for his medi-claim risk at Ludhiana i.e. medi-claim policy namely PNB-ORIENTAL ROYAL MEDICLAIM POLICY SCHEDULE. The complainant took medi-claim policy for himself and for his wife Parminder Kaur from OPs, vide policy bearing no. 233902/48/2014/3287 valid from 16.12.2013 to 15.12.2014. The complainant paid gross premium of Rs.6830/-, vide cheque dated 16.12.2013. OP no.2 issued policy and identity cards and except these documents, no other document was supplied by insured. The wife of the complainant developed sudden pain at midnight on 24.05.2014 and was taken for treatment to Fortis Hospital road Ludhiana. She was admitted and treated thereat and due intimation was given to OPs about admission and treatment of Parminder Kaur, wife of the complainant. The OPs noted the report/intimation of the complainant, vide reference no. 10185844 dated 24.05.2014 regarding confirming the intimation of her hospitalization and she was discharged from the hospital on 29.05.2014. All relevant documents together with medi claim policy duly signed by the complainant and attested by the Fortis Hospital were sent to OPs on 10.06.2014. The complainant requested the OPs to release the amount of Rs.1,25,308/-, but to no effect. The insurance claim of the complainant was repudiated by the OPs, vide letter dated 04.07.2014 on the ground that expenses on treatment of ailment/disease/surgeries for HERNIA for specified periods of 2 years from commencement of policy are not payable, if contracted and/or manifested during the currency of the policy. Parminder Kaur also suffered from Hypertension & Diabetes for the past two years prior to inception of the policy and hence in view of Exclusion Clauses 4.1 and 4.2 of the policy, the OPs repudiated the contract of insurance wrongfully. The terms and conditions of the insurance policy were not supplied to the complainant by OPs, as insurer. The complainant has, thus, filed complaint against OPs praying that OPs be directed to pay medical treatment expenses incurred by him on the treatment of his wife to the extent of Rs.1,25,308/- with interest, besides  Rs.50,000/- as compensation for mental harassment and Rs.11,000/- as costs of litigation.

3.      Upon notice, OPs appeared and filed written reply and contested the complaint of the complainant vehemently. It was averred in preliminary objections that complaint is barred under Section 26 of the CP Act and is not maintainable at all. PNB National Bank had obtained the medicalim policy for their account holders/employees of PNB and his/her spouse and two dependent children and policy called PNB Oriental Royal Mediclaim Policy was valid from 16.12.2013 to 15.12.2014. The case of the complainant falls under the Exclusion Clauses 4.1 and 4.2 of the terms and conditions of the policy, which is not admissible. The insured has not disclosed about above pre-existing ailments, when proposal form was filled and declaration was also signed by the insured in that regard. As per discharge summary issued by the hospital, Parminder Kaur was known k/c/o of diabetic mellitus and hypertension on regular treatment since two years, known case of erosive escophagitis, GERD on regular treatment and also had cholecystecomy in 1993 and hysterectomy in 2011 and was diagnosed with recurrent ventral hernia with intestinal obstruction, diabetic mellitus and hypertension. The TPA informed the OPs, after making an investigation to the matter, that claim was not admissible, as per terms and conditions of the policy. Parminder Kaur was treated for recurrent ventral hernia with intestinal obstruction, diabetics and hypertension and claim was, thus, not admissible for specified period of two years from inception of the policy. On receipt of letter dated 04.07.2014 from Medi Assist India TPA Pvt. Ltd, the OPs repudiated the contract of insurance and duly conveyed it to the complainant, vide letter dated 04.07.2014. The wife of the complainant Parminder Kaur was suffering from hypertension and diabetes for the past two years and claim was rightly inadmissible under Exclusion Clauses 4.1 and 4.2 of the insurance policy. The OPs admitted this fact on merits that policy was issued to insured on receipt of premium. This fact was denied by OPs that policy terms and conditions were not issued. The complainant and his wife are beneficiaries under medi claim insurance for their being account holder/ employees with their spouse and two children. The complainant intentionally withheld the production of the complete policy along with terms and conditions thereof, which were duly supplied to the complainant along with Annexure C-1. Parties are bound by the terms and conditions of the policy strictly. This fact was denied that complainant took his wife for treatment to Fortis Hospital Chandigarh Road Ludhiana. This fact was denied by OPs that on 27.05.2014, she was operated upon by the doctors of the above hospital. This fact was also denied that wife of the complainant was discharged from the hospital and thereby complainant incurred the expenses of Rs.1,25,308/- on her treatment. Parminder Kaur was admitted with the history of diabetes mellitus and hypertension on regular treatment since two years, being known case of erosive escophagitis, GERD on regular treatment and also had cholecystecomy in 1993 and hysterectomy in 2011 and was diagnosed with recurrent ventral hernia with intestinal obstruction, diabetes mellitus and hypertension. The claim of the complainant was rightly repudiated by OPs on account of violation of condition no.4.1 and 4.2 of the terms and conditions of the policy. Any deficiency in service was vehemently denied by OPs on their part and they prayed for dismissal of the complaint.

7.      It was further submitted that there is also violation of clause 4.2 of the terms and conditions of the policy for treatment of Hernia does not cover for first two years from the date of commencement of the policy. The complainant purchased medi claim policy for himself and his wife for the first time for the period 16.12.2013 to 15.12.2014. Parminder Kaur, wife of the complainant took treatment from Fortis Hospital Chandigarh Road, Ludhiana and was discharged on 29.05.2014 during first year of inception of the policy. It was further maintained by counsel for the appellant that parties are strictly bound by the terms and conditions of the contract of insurance and they cannot get out of the same.

It is, thus, evident from perusal of above clauses, that the expenses on treatment of above noted diseases ailment /diseases,/surgeries for the specified periods are not payable, if contracted and /or manifested during the currency of the policy. Surgery of Hernia has been excluded for a period of two years as per serial no.(iii) in the table. Hypertension has been excluded for a period of two years, as per serial no. (xvii) of the table and it has been excluded for a period of two years  being part of the clauses 4.1 and 4.2 of the policy. It lays down that if continuity of renewal is not maintained with the company, then subsequent cover shall be treated as fresh policy. Clauses 4.1 and 4.2 shall apply unless agreed to the contrary by the Company and suitable endorsement is passed of the policy. Similarly, if the sum insured is enhanced subsequent to the inception of the policy, the exclusions clauses 4.1 and 4.2 will apply afresh for the enhanced portion of the sum insured as well for the purpose of this section. The above clauses 4.1 and 4.2 of the policy lays down in clear terms that any disease, which was pre-existing disease in nature, is excluded for two years from the date of inception of the policy. The gist of clause 4.2 of the policy is that expenses incurred on the treatment of surgery for the specified period are not payable, if contracted and/or manifested during the currency of the policy. Surgery of Hernia is not admissible for two years from the date of inception of the policy. Similarly, diseases of hypertension and diabetes expenses are not admissible for a period of two years from the date of inception of the policy. The discharge summary on the record issued by Fortis Hospital Ludhiana has proved that Parminder Kaur was patient of diabetes mellitus and hypertension on regular treatment since two years prior to the date of her admission in the hospital. The Discharge Summary has, thus, proved it on the record that Parminder Kaur was a patient of Diabetes Mellitus and Hypertension on regular treatment since two years prior to her date of admission i.e. 24.05.2014.The symptom of surgery of Hernia also manifested within two years from the date of commencement of the policy in her. The Apex Court has held in Satwant Kaur Sandhu versus New India Assurance Company Ltd, reported in IV (2009) CPJ  8 (SC) that contract of insurance is UMBERRIMA FIDES. The insured is under obligation to make true and full disclosure of information, within his knowledge in the proposal form on the record. The complainant gave answers in positive regarding good health of the insured in the questionnaire in the proposal form. It is, thus, evident that material information has been withheld by the insured with regard to her state of health, when the proposal form was filled in. The National Commission has also held in United India Insurance Company Ltd versus Kanta Gupta, reported in II(2012) CPJ 191 (NC) that insured was patient of DM and CRF for last 15 years , as mentioned in discharge certificate of hospital. The Discharge Certificate issued by the hospital was duly relied upon by National Commission in the cited authority in proving that insured was a patient of above pre-existing diseases. Our own State Commission has also held in Sapna Arora versus Life Insurance Corporation of India and others, reported in I(2009) CPJ 588 that insured suffered from Diabetes Mellitus Type 2  prior to filling of the proposal form. This fact was not disclosed by the insured to the hospital. History given by insured himself, recorded in discharge certificate, can validly become basis of repudiation of the claim of insurance. The National Commission has also held in Komal Sharma and others versus Life Insurance Corporation of India and others, reported in I(2013) CPJ 606 (NC) that  assured is under solemn obligation to make true and full disclosure of information on subject, which is within his knowledge. The repudiation of the claim was, thus, justified. The discharge summary report issued by Fortis Hospital Ludhiana clearly proved this fact that Parminder Kaur was patient of Diabetes Mellitus and Hypertension for past two years. Meaning thereby, she was already patient of these health disorders prior to taking the policy in question. This is material fact, which has not been disclosed in the proposal form in this case by the insured. There is violation of Clauses 4.1 and 4.2 of the terms and conditions of the policy. It was PNB-ORIENTAL ROYAL MEDICLAIM POLICY SCHEDULE, which got insured its account holders and employees with their families. It is not credible to believe that documents were not supplied to the complainant in this case containing the terms and conditions of the policy. We find no substance on the record in this regard and reject the contention of the counsel for the complainant on this point of non-supply of terms and conditions of the policy.