CONSUMER DISPUTES REDRESSAL COMMISSION-VII

DISTRICT: SOUTH-WEST

GOVERNMENT OF NCT OF DELHI

FIRST FLOOR, PANDIT DEEP CHAND SHARMA SAHKAR BHAWAN

CASE NO.CC/336/16

            Date of Institution:-    05.07.2016

          Order Reserved on:- 01.05.2024

                         Date of Decision:-      03.05.2024

IN THE MATTER OF:

Sh. OmDutt,

R/o House No.63,

V.P.O. Kakrola,

New Delhi - 110078

.….. Complainant

VERSUS

Apollo Munich Health Insurance Co. Ltd.

1^st Floor, SCF-19, Sector-14,

Gurgaon, Haryana - 122001

.…..Opposite Party

Suresh Kumar Gupta, President

1. The complainant has filed the complaint under section 12 of Consumer Protection Act, 1986 (hereinafter referred to as Act) with the allegations that in 2010, he has taken the health insurance policy on the assurance of Sh. Ashok Kumar, Agent of the OP, who even completed the formalities. The health insurance policy bearing no.110103/11119/1000101904-05 dated 10.08.2010 was issued. The basic cover was for Rs.4 lakh. The premium of the policy has been continuously paid till 2014 -15. The medical history was disclosed to the agent of the OP at the time of taking the policy who raised no objection at that time. The agent told that pre-existing disease will be covered. On 22.07.2015, he was admitted to Max Super Speciality Hospital, Saket, New Delhi. The OP did not extend the cashless facility but assured that medical expenses will be reimbursed. On 24.07.2015, he was discharged from hospital. A sum of Rs.2,50,000/- was paid though the actual bill was of Rs.2,87,189.15/-. He applied for the reimbursement of the medical claim. He received a letter dated 12.08.2015 to the fact that his claim has been repudiated on the grounds of non-discloser and concealment of facts. The repudiation is against the facts as no medical examination was conducted. The medical history was disclosed to the agent of the OP. He has been continuously paying the premium on the policy. A legal notice dated 24.10.2015 was sent to the OP which was duly replied by email that he will get response within 72 hours but in vain. Hence, this complaint.

2. The OP has filed the reply to the effect that there is no cause of action in favour of the complainant. The complaint filed by the complainant with the Ombudsman has been decided against him on 16.05.2016. The contract of insurance is based upon good faith and concealment of material fact is ground to reject the claim. There is no deficiency of service or unfair trade practice on the part of OP.

3. The complainanthas submitted a proposal form no.1100540085 dated 10.08.2010 for the issuance of easy health individual standard policy with OP for a insured sum of Rs.4 lakh. The details of the policy were explained by the complainant to the agent. The proposal form carries a medical and life style information at section 6 and each and every question has been answered in negative by the complainant. The information in the proposal form was believed to be true and accordingly policy was issued on 10.08.2010 to the complainant which has been renewed time and again and is now valid till 09.08.2015. The relevant documents were supplied to the complainant to read the policy so complainant is bound by the terms and conditions of the policy. On 22.07.2015, a cashless facility request was received from the complainant upon which certain queries were raised and documents were demanded. The reply to the queries was received which shows that complainant has been a known case of CAD since March, 2010 and this fact was not disclosed at the time of taking the policy so cashless facility was rejected. The complainant has submitted the claim on 03.08.2015. The complainant did not disclose the material fact at the time of taking the initial policy so OP has terminated the policy vide termination letter dated 26.07.2015. The complainant was having pre-existing disease at the time of taking the policy and this fact was duly suppressed by the complainant at the time of taking the initial policy. This fact led to the rejection of the claim and cancellation of policy. There is no deficiency of service on the part of OP.

4. The complainant has filed the rejoinder to the written statement of OP wherein he has denied the averment of written statement and reiterated the stand taken in the complaint.

5. The parties were directed to lead the evidence.

6. The complainant has filed his own affidavit in evidence and corroborated version of complaint and placed reliance on the documents Ex.CW-1/1 to 1/5 though exhibits are not put on the documents.

7. The OP has filed the affidavit of Sh.ParmanPreet Singh Gujral, in evidence and corroborated version of written statement and placed reliance on the documentsEx.RW1/1 to 1/9

8. We have heardthe Ld. Counsel for the parties and perused the entire material on record.

9. The material on the record shows that easy health individual standard policy Ex.RW1/3 was issued by the OP to the complainant on the basis of proposal form Ex.RW1/2 filled by the complainant. The plea of the complainant is that proposal form is filled by the agent of the OP and medical history was disclosed to him which he did not disclose in the proposal form for which he cannot be made to suffer. This plea does not hold water as he was supposed to read the form before signing the same.

10. The complainant has repeatedly renewed the policy which was continuously running till 2014-15.This fact is not is dispute and also clear from Ex.CW1/1 though exhibit is not put on the document.

11. On 22.07.2015, the complainant was admitted to Max Super Speciality Hospital, Saket where he was diagnosed with coronary artery disease and stent was used in LAD with non-critical disease of LAD/LCX. He was discharged on 24.07.2015. The discharged summary was issued. The complainant was paid a sum of Rs.2,50,000/- to the complainant and thereafter raised a claim with the OP which was repudiated vide letter dated 12.08.2015 Ex.CW1/4 though exhibit is not put on the document.

12. The plea of the OP is that complainant was having pre-existing disease. He was a patient of coronary artery disease and previously admitted to Max Super Speciality Hospital, Saket on 17.03.2010. The hospital adopted the procedure i.e. Primary PTCA + Stent to LAD. These documents were received from the complainant. The pre-existing disease was not disclosed which led to the rejection of the claim and repudiation of the policy.

13. The complainant has not disputed the facts that he was not admitted to Max Super Speciality Hospital, Saket on 17.03.2010 where he was diagnosed with CAD and undergone the procedure of Primary PTCA + Stent to LAD. This fact was never disclosed by the complainant at the time of taking the policy on 10.08.2010 which was valid till 09.08.2011.This was pre-existing disease at the time of taking the policy. The policy has been subsequently renewed time and again by the complainant. The renewal of the policy does not condone the pre-existing disease. The heart disease prior to the taking of the policy shall remain excluded from the policy as a pre-existing disease. The pre-existing disease means disease which was existingprior to the issuance of first policy on 10.08.2010.The complainant was suffering from disease before taking the policy for the first time. The contract of insurance is based upon good faith. The complainant is bound to disclose all the material facts which may affect the issuance of the policy. The complainant has not disclosed the material fact to the OP. He is guilty of suppressing the material fact from the OP. The OP has rightly rejected the claim of complainant and repudiated the policy. There is no deficiency of service or unfair trade practice on the part of OP in rejecting the claim and repudiating the policy.

14. In view of above discussion, the complainant has failed to substantiate the allegations as set out in the complaint and accordingly the complaint is dismissed.

• A copy of this order is to be sent to all the parties as per rule.
• File be consigned to record room.
• Announced in the open court on 03.05.2024.