Chandigarh

DF-I

CC/259/2015

Rajesh Rana - Complainant(s)

Versus

Apollo Munich Health Insurance Co. Ltd. - Opp.Party(s)

Paras Money Goyal

28 May 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

========

 

                               

Consumer Complaint No.	:	CC/259/2015
Date of Institution	:	29/04/2015
Date of Decision	:	28/05/2016

 

1.     Rajesh Rana s/o Shri Krishan Gopal Rana

2.     Meenakshi Rana w/o Rajesh Rana

        Both residents of Hosue No.110, Kansal Enclave, Backside Club, Chandigarh.

…..Complainants

V E R S U S

1.     Apollo Munich Health Insurance Co. Ltd., Regd. Office : Apollo Hospitals Complex, Jubulee Hills, Hyderabad through its Authorised Representative.

2.     Apollo Munich Health Insurance Company Ltd., Regd. Office : SCO No.50-51, Fourth Floor, Sector 34, Chandigarh.

……Opposite Parties

 

 

QUORUM:	DR. MANJIT SINGH	PRESIDENT
	MRS.SURJEET KAUR	MEMBER
	SURESH KUMAR SARDANA	MEMBER

                                       

                                                                       

ARGUED BY	:	Sh. Gaurav Bhardwaj, Counsel for complainants
	:	Sh. Nitin Thatai, Counsel for OPs

                       

                 

PER DR. MANJIT SINGH, PRESIDENT

1.         Both the complainants have brought this consumer complaint under Section 12 of the Consumer Protection Act, 1986, against M/s Apollo Munich Health Insurance & another, Opposite Parties (hereinafter called the OPs), claiming medi-claim which has been denied by the OPs. 

                The complainants got themselves and their family members medically insured from the OPs for an amount of Rs.5.00 lakhs and as per the terms and conditions of the said policy, cashless facility was provided in the selective hospitals by the OPs. The said policy was valid from 20.7.2014 to 19.7.2015. In the month of November/ December 2014, complainant No.2 suffered from heavy bleeding per vagina every 15 days and she consulted Fortis Hospital, Sector 62, Phase VII, Mohali on 26.12.2014 where several tests were conducted and it was diagnosed that she was suffering from Adenomyosis Uterus and Total Abdominal Hysterectomy was required to be done.  Annexure C-2 to C-7 are the copies of consultation bills and laboratory report.  The complainants applied to the OPs for cashless medical facility in the Fortis Hospital.  The OPs requested the complainants to provide the duration and first doctor prescription of HTN vide email dated 3.1.2015 followed by another email dated 5.1.2015 which was responded by the complainants by an email of even date.  However, the cashless request of the complainants was denied by the OPs while mentioning that there was gross discrepancy in the documents provided by the complainants to the OPs.  Complainant No.2 was admitted in the Fortis Hospital on 8.1.2015 and discharged on 11.1.2015 and a bill to the tune of Rs.86,165/- was raised by the hospital.  As the cashless facility was not provided by the OPs, the complainants had to pay from their own pocket.  The complainants lodged a claim with the OPs for reimbursement of expenses suffered by them, but, ultimately the OPs refused to reimburse the said amount.  Hence, the complainants have filed the instant complaint. 

2.         OPs 1 & 2 resisted the claim of the complainants by taking the preliminary objections alleging that the complaint is liable to be dismissed as the complainants have attempted to misguide and mislead the Forum.  It is alleged that complainant No.2 has concealed material facts about her prior medical history of HTN, DM as she was on tab Glycomet and Rheumatoid Arthritis at the time of entering into contract of insurance with the OPs.  The said contract is in violation of the very fundamentals of law of contract i.e. uberrima fides and, therefore, is void ab-initio and is not binding on the OPs.  It is further alleged that no relief can be granted to the complainants on the basis of mis-statement/misrepresentation of facts, non-disclosure and concealment of material facts.  It is further pleaded that had the OPs known about the pre-existing disease of the insured i.e. HTN, DM and Rheumatoid Arthritis, it would have materially influenced the OPs in making the contract of insurance and in estimating the degree and character of risk, fixing the rate of premium and even declining the risk. It is further pleaded that in spite of a number of reminders sent to the complainants by the OPs to send the treating doctor certificate mentioning the duration of HTM, DM, if any (as the complainant was on tab Glycomet) and Rheumatoid Arthritis with first consultation paper and past treatment record, the same were not sent by the complainants and ultimately the OPs had to close the claim of the complainants. Though the complainants sent the certificate of a doctor certifying that Ms. Meenakshi Rana was on anti-hypertensions treatment from December 27, 2012, but, the same was not accompanied by first consultation paper and past treatment record which created a serious doubt in the mind of the OPs about the past medical history of complainant No.2.  Thus, the OPs prayed for dismissal of the complaint. 
3.         The parties led evidence in support of their contentions.  
4.         We have gone through the record and heard the arguments addressed by the learned Counsel for the parties.
5.         Annexure C-16 is the bill from Fortis Hospital which proves that complainant No.2, Mrs. Meenakshi Rana was admitted on 8.1.2015 and she was discharged on 11.1.2015. The complainants were charged a sum of Rs.86,165/-.  It is not disputed that both the complainants got themselves and their family members medically insured from OPs for an amount of Rs.5.00 lakhs.  The main controversy in this case is with regard to declining the reimbursement of the medical expenses by the OPs to the complainant due to past history and illness.  Ex.R-7 is the copy of the proposal form filled by complainant No.1, Mr. Rajesh Kumar Rana and the column No.6 deals with regard to the medical and life style information. A close scrutiny of the proposal form reveals that complainant No.1 did not disclose about any type of his illness or that of his wife/complainant No.2.  This proposal form clearly proves that at the time of seeking the insurance policy, no disease was disclosed by the complainants to the Insurance Company/OPs. This policy was obtained for the first time on 20.7.2012 when the requisite information was supplied. Ex.R-9 is the medical treatment obtained by complainant No.2. The complainant No.2 was admitted on 26.12.2014 and at that time the past medical history was disclosed by the complainant as K/C/O hypertension on medication K/C/O Rheumatoid Arthritis. After knowing the past history, the complainants were asked to submit the past medical history alongwith treatment obtained. The complainants only sent the certificate of doctor certifying that Ms. Meenakshi Rana was on anti-hypertensions treatment from December, 2012. The said certificate was not accompanied by the first treatment chart and the other treatment chart to prove that for the first time when the treatment was obtained. The complainants have not submitted any record regarding Rheumatoid Arthritis disease.  The policy was obtained in the month of July 2012 and the certificate submitted speaks of treatment from December 2012, which creates serious doubt about the genuineness of the same. The complainants were required to produce the record as and when for the first time the treatment of hypertension as well as Rheumatoid Arthritis was obtained.  As the OPs could not lay their own hands on the treatment obtained by the complainant No.2/Ms. Meenakshi Rana, so it was the duty of the complainants to produce the complete record regarding her treatment. Since, in spite of repeated requests, the first treatment chart or the first treatment advice has not been placed on record, so adverse inference has to be drawn against the complainants that at the time of obtaining the policy, the complainant No.2/Mrs. Meenakshi was suffering from hypertension and that fact was concealed. The complainants have failed to produce any record since when complainant No.2 was suffering from Rheumatoid Arthritis. So, it can be presumed that at the time of obtaining the policy, complainant No.2 was suffering from Rheumatoid Arthritis and this fact was concealed by her.
6.         Admittedly, the present disease of the complainant No.2 i.e. heavy bleeding per vagina every 15 days has no nexus with hypertension and Rheumatoid Arthritis, but, it is argued by the learned counsel for the OPs that it amounts to concealment of material facts influencing the policy.  The learned counsel for the complainants has argued that since the present diseases of complainant No.2 is not result of hypertension and Rheumatoid Arthritis, so it cannot be stated that the complainants have concealed material facts while obtaining the policy.  In this regard reliance has been placed on the judgment of Hon’ble State Commission, Rajasthan, Jaipur titled United India Insurance Co. Ltd. Vs. Sh. Narendra Kumar, bearing Appeal No.2079/2005 decided on 16.7.2009 wherein it was held that non-mentioning of the disease Hypertension in the declaration form by the complainant does not amount to suppression or concealment of material fact or mis-statement in real sense and, therefore, the appellants were not justified in repudiating the claim of the complainant on the ground of suppression of material facts regarding health.
7.         The contract of insurance falls in the category of the contract of ‘uberrima fides’ meaning thereby a contract of utmost good faith between the parties. When the information on a specific aspect is asked for, in the proposal form, the insured is under a solemn obligation to make a true and full disclosure of the same (information), on the subject, which is within his knowledge.
8.         Second part of Section 45 of the Insurance Act lays down three conditions which are as under :-

“(a)   the statement must be on a material matter or must suppress facts which it was material to disclose;

(b)    the suppression must be fraudulently made by the policy-holder; and

(c)     the policy-holder must have known at the time of making the statement that it was false or that it suppressed facts which it was material to disclose.”

Though the policy may be taken for the purpose of social security, but, the same should not be obtained with a fraudulent act by the insured.  Proposal can be repudiated if a fraudulent act is discovered.  The contracts of insurance, including contract of life insurance, are the contracts of uberrima fides and every fact of material must be disclosed otherwise, there is good ground for rescission of the contract. The duty to disclose material facts continues right up to the conclusion of the contract and also implies any material alteration in the character of the risk which may take place between the proposal and its acceptance.  If there are any mis-statements or suppression of material facts, the policy can be called into question.

9.         The diseases of hypertension and Rheumatoid Arthritis were definitely in the knowledge of the complainants at the time of obtaining the policy.  So, it can be said that the complainants have suppressed material facts while obtaining the policy. Had the complainants disclosed the diseases, then it might have been possible for the insurance company to charge much more amount from the complainants for high risk or the insurance company might have refused to insure the complainants. In the judgment Satwant Kaur Sandhu Vs. New India Assurance Company Ltd., (2009) 10 SCR 560, the Hon'ble Supreme Court observed that the term material in general terms means as any fact which would influence the judgment of a prudent insurer in fixing the premium or determining whether he would like to accept the risk. Any fact which goes to the root of the contract of Insurance and has a bearing on the risk involved would be material.  The Hon’ble State Commission, UT, Chandigarh in the judgment titled as Surinder Kaur Vs. ICICI Prudential Life Insurance Co. Ltd. & Ors, 2015 (1) CLT 365, did not agree with the submission of the counsel for the appellant that since the life assured had died on account of cardiac arrest and severe myocardial infarction, which had no nexus with the alleged ailments from which he had suffered or was suffering, much earlier to the signing of the proposal form and obtaining the policy, the claim could not be legally and validly repudiated.  In that case the insured had died with cardiac arrest which had no nexus with the disease suffered, but, the claim was declined.  The judgment United India Insurance Co. Ltd. Vs. Sh. Narendra Kumar (supra) is not applicable to the facts of the present case because in the present case it is proved that complainant No.2 was suffering from hypertension and Rheumatoid Arthritis and the complainants have concealed the material documents regarding her ailment to prove since when she was suffering from the said diseases.  So, an adverse inference has to be drawn against the complainants that complainant No.2 was suffering from the said diseases at the time of taking the policy.
10.         Taking into consideration all the facts and circumstances narrated above, we have no hesitation to hold that the complainants have suppressed material facts regarding the illness of complainant No.2 and committed a fraud at the time of obtaining the policy and, therefore, the OPs/Insurance Company have rightly repudiated the claim of the complainants.  Hence, this complaint is devoid of any merit and the same is hereby dismissed, leaving the parties to bear their own costs.
11.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

 

	Sd/-	Sd/-	Sd/-
28/05/2016	[Suresh Kumar Sardana]	[Surjeet Kaur]	[Dr. Manjit Singh]
hg	Member	Member	President