ORDER

25.07.2024

Sh. Sanjay Kumar, President

1. The factual matrix of the present case is that complainant is having Optima Restore (The Unbelievable Health Plan) of Apollo Munich Health Insurance Policy for the last 3 or 4 years and regularly paying the premium of this policy since then and current policy would be expire on dated 12^th Feb. 2015.
2. It is stated that complainant’s Health insurance policy’s basic sum insured is Rs.5,00,000/- and paid the regular health insurance premium before the expiry of the policy. It is further stated that complainant was in vomiting and dihorrea when complainant went for the initial check up to Dr. R.K. Ghai. It is stated that the Dr. R.K. Ghai checked complainant and prescribed to admitted the hospital. It is further stated that the Dr. R.K. Ghai consulted complainant to admit the hospital because his health was becoming deteriorated the sugar level of complainant body accidentally shoot up and the vomiting and stool passing continuously so that complainant admitted to the concerned Genesis Hospital for his better health.
3. It is stated that complainant admitted to the hospital and consulted the doctors and told them that the sugar level abruptly shoot up so that they kept complainant in observation gave complainant proper medical intensive care. Complainant also told them that complainant is having Apollo Munich Health Insurance so that the staff consulted his insurance co. and gave assurance of non-payment of the medical expenses. It is further stated that as and when complainant’s health insurance company came to know about the claim of medical treatment they sent their authorized representative to confirm the claim and settle the medical issues with in the given time frame.
4. It is stated that the health insurance co. authorized representative came to the Genesis Hospital and consulted complainant after debating the claim the authorized representative demanded complainant some cash to settle the claim the complainant denied his demand and he warned complainant that you will face the dire consequences against the claim.
5. It is stated that the authorized representative asked complainant about diabetes history complainant showed him his first prescription of diabetes of Ganapathy’s Clinic dated 06.01.2014. It is further stated that Complainant was shocked when complainant heard that the health insurance co. demanded his diabetes history before one year but complainant became diabeted approx. one year. It is further stated that due to the harassment of authorized representative of health insurance co. complainant diabetes level and blood pressure level became so high. So that due to that reason complainant remained in Genesis Hospital for more 3 days. The harassment and the condition of complainant health remained very poor. The hypertension level and the blood pressure level remain not normal during those days.
6. It is stated that the Genesis Hospital administration informed complainant that complainant cashless policy became ineffective and your claim could not settle by the health insurance co. It is further stated that after non-payment of cashless facility complainant arranged the cash to pay the pending bills of the Genesis Hospital. It is further stated that the Apollo Munich Health Insurance Co. and their representative continuously talked complainant and gave false assurance for settling the claim. It is further stated that the health insurance co. suddenly denied to grant complainant the claim and gave the assurance of reimbursement of the claim.
7. The complainant is seeking direction against OP to pay Rs.55,872/- for hospital and medication, lab and visiting charges, to p ay Rs.55,872/- for harassment and tension claims.
8.  OP filed WS and taken preliminary objections that present complaint is false, malicious, incorrect, malafide and an abuse of process of law, therefore, liable to be dismissed under section 26 of CP Act, 1986. It is stated that complainant has concealded the material and correct facts and has not approached this Hon’ble District Forum with clean hands and present complaint suffers from the suppression of material facts, therefore, liable to be dismissed. It is stated that complainant was very well aware of his medical ailment and conditions and still choose to cheat the OP by non disclosure of correct facts in the proposal form. It is stated that OP pay claims out of common pool of funds belonging to all policy holders. It is stated that it is the statutory duty of proposal under the contract of insurance to disclose all material facts pertaining to status of his/her health including pre-existing medical conditions.
9. It is stated that complainant mislead the OP to issue the policy by concealment and suppression of material facts relating to his past medical condition. It is stated that if the complainant would have declared in the proposal form about his past medical condition (diabetes mellitus) than OP may not have issued the policy to the complainant in the manner and at the premium that was issued. It is stated that complainant is not entitled for any benefit under the policy. It is stated that there is serious non disclosure of material facts which is a violation of the terms and conditions of the insurance policy. It is stated that OP was unduly influenced by the complainant by misrepresenting the correct facts about his wife’s medical health condition in the proposal form, therefore, present complaint is liable to be dismissed.
10. OP stated brief submission stating that complainant had signed and submitted the proposal form bearing no.1100973373 dated 11.02.2011 for taking Easy Health Individual Standard Plan Insurance Policy. It is stated that on the basis of the information and the contents of the proposal form submitted by the complainant and believing the declaration, information and details provided by complainant including medical history in the proposal form to be true, correct and complete in all respect, giving due credence to the under writing norms of OP an Easy Health Individual Standard Policy No. 110101/11001/1000164629 was issued for sum assured as per proposal form to the complainant for the period between 11.02.2011 to 10.02.2012.
11. It is stated that complainant in the year 2012 before renewal of his policy submitted another proposal form bearing no.6100086905 dated 13.02.2012 for switching his Easy Health Policy Plan to Optima Restore Individual Health Insurance Plan of Apollo Munich Health Insurance. It is stated that the policy no. is 110101/11119/6000011788 and policy period was 13.02.2012 to 12.02.2013. It is stated that this policy was renewed. It is stated that the policy kit containing all relevant documents were duly sent and delivered to the complainant at various time, thereby giving an opportunity to complainant to verify and examine the benefit, terms and conditions of the policy taken. It is further stated that complainant never approached the OP stating that any information given in the policy kit documents was incorrect or any term and condition therein was not acceptable to complainant within free look period i.e 15 days from the receipt of the policy documents to review the terms and contract of the policy.
12. It is stated that on 04.09.2014 cashless request was received from the hospital Genesis Hospital, Delhi for patient Rajesh Ranjan Mishra who got admitted with c/o loose motions watery, recurrent vomiting and probable diagnosis of AGE with dehydration with uncontrolled DM with DOA 03.09.2014 with estimate cost of Rs.30,000/- for a duration stay of 5 to 6 days. It is stated that hospital also provided Hematology medical lab report and no further documents of treatment were sent by hospital it is stated that an additional information request dated 04.09.2014 was sent to hospital for providing casuality paper alongwith treatment documents prior to hospitalization and reports.
13. It is stated that the case sheet provided by the hospital specifically mentioned that patient is a non case of diabetes mellitus as recorded by treating doctor. It is stated that OP sent another letter dated 05.09.2014 asking the hospital for providing first consultation papers of diabetes since one year gap and thereafter reminder was sent on 06.09.2014. It is stated that hospital provided a prescription dated 06.01.2014. It is further stated that the case sheet dated 03.09.2014 provided by the hospital clearly mentions that patient is a non case of diabetes mellitus since one year. It is stated that prescription dated 06.01.2014 mentioned “Injection Insulin”. It is further stated that Insulin is always preceded by some medication and in no case insulin can be administered as first drug and this is clear from the prescription dated 06.01.2014 which is not the first prescription and complainant is trying to hide facts from the OP company.
14. It is stated that hospital replied to the letter dated 06.09.2014 and 07.12.2014 by stating that patient does not have any record prior to January 2014 and no documents available. It is stated that OP appointed an independent investigator in the cashless claim who submitted report. It is stated that during investigation it was found that consultation papers in which it was mentioned that patient is a non case of capital DM for last 15 years and on this the patient become annoyed and even tear the consultation paper into pieces and did not provide details. It is stated that looking into the discrepancies in the documents and non submission of first consultation papers of diabetes, the cashless services were denied vide letter dated 07.09.2014 and same was sent to hospital stating the reasons.
15. It is stated that on 24.09.2014 claim was submitted for Rs.40,300/- for reimbursement alongwith discharge summary alongwith final bill and various medical lab reports and prescriptions. It is stated that query was raised to complainant that attested copies of indoor case papers of hospitalization including admission note and duly progress note. It is stated that from hospital and from complainant documents were required regarding consultation record of diabetes since 15 years and also  required treating doctor certificate regarding need for psychiatric opinion.
16. It is stated that reminder letter dated 10.11.2014 was sent after query letter dated 29.10.2014 and subsequently on 12.12.2014 claim was closed due to non submission of desired mandatory documents. The OP referred the judgment of LIC Vs. Asha (2001) 2 SCC 160, Satwant Kaur Sandhu Vs. New India Assurance Co. Ltd. SC 2776 (2002), P.C. Chacko & Anr. Vs. Chairman LIC Ltd. AIR 2008 SC 424 and LIC of India Vs. Smt. G.M. Chanmaparsmma AIR 1991 SC 392.
17. On merit all the allegations are denied and contents of preliminary objections and submissions are reiterated. It is stated that complainant is not entitled to any relief.
18. Complainant filed rejoinder to the WS of OP and denied all the allegations made therein and reiterated contents of complaint.
19. Complainant filed evidence by way of his affidavit and reiterated contents of complaint. Complainant relied on copy of ID card Ex.CW1/1 (colly), copy of first prescription of diabetes of Ganapathy’s Clinic dated 06.01.2014 Ex.CW1/2 and copy of treatment papers and bill of Genesis Hospital Ex.CW1/3 (colly).
20. OP filed evidence by way of affidavit of Deepti Rustagi, Vice President-Legal & Compliance and reiterated contents of WS. OP relied on copy of application/proposal form Ex.DW1/A, copy of Easy Health Individual Standard Policy schedule Ex.DW1/B, copy of policy schedule along with policy wordings Ex. Ex.DW1/C (colly) and Ex.DW1/D (colly), copy of pre authorization form along with Hematology Medical Lab Report Ex.DW1/E (colly), copy of additional information request dated 04^th  Sep. 2014 and reply received from hospital alongwith case sheet Ex.DW1/F & Ex.DW1/G (colly), copy of letter dated 5^th  Sep. 214 and 6^th Sep. 2014 and reply received from hospoital Ex.DW1/H, Ex.DW1/I & Ex.DW1/J (colly), copy of letter dated 6^th Sep. 2014 and dated 7^th Sep. 2014 and reply received from hospital Ex.DW1/K, Ex.DW1/L & Ex.DW1/M, copy of investigator report Ex.DW1/N (colly), copy of denial of cashless service letter dated 7^th Sep. 2014 Ex.DW1/O, copy of claim form, discharge summary, final bill of Rs.40300/-, medical lab reports and prescriptions Ex.DW1/P, Ex.DW1/Q, Ex.DW1/R, Ex.DW1/S (colly), copy of reminder query letter dated 29^th Oct. 2014 and 10^th Nov. 2014 Ex.DW1/T & Ex.DW1/ U and copy of first prescription of patient Ex.DW1/V.
21. Written arguments filed by complainant as well as by OP.
22. We have  heard Sh. M.K Gill counsel for complainant and Ms. Charu Sachdeva counsel for OP. We have also gone through the record.
23. It is admitted case of the parties that complainant had signed and submitted the application/proposal form bearing no.1100973373 dated 11.02.2011 for taking Easy Health Individual Standard Plan Insurance Policy with OP insurance company for a period between 11.02.2011 to 10.02.2012. It is further admitted that complainant in the year 2012 before renewal of his policy submitted another proposal form bearing no. 6100086905 dated 13.02.2012 for switching his Easy Health Policy Plan to Optima Restore Individual Health Insurance Plan of Apollo Munich Health Insurance for period 13.02.2012 to 12.02.2013. It is admitted case that policy was renewed for period 13.02.2013 to 12.02.2015. As per OP the policy kit containing all the documents were duly sent and delivered to the complainant.
24. It is admitted case of the parties that on 04.09.2014 cashless request was received from the Genesis Hospital Delhi for complainant with C/o lose motions watery, recurrent vomiting and probable diagnosis of AGE with Dehydration with Uncontrolled DM with DOA 03.09.2014 with estimated cost of Rs.30,000/- with estimated duration of stay of 5 to 6 days. The Hospital also provided various lab reports. As per OP insurance company a letter was sent on 04.09.2014 seeking further treatment documents and history of prior hospitalization and reports but no document provided except a prescription dated 06.01.2014.
25. As per OP  insurance company the record of case sheet dated 03.09.2014 provided by hospital clearly mentioned that patient is non case of “Diabetes Mellitus” since one year and also prescription of January 2006, 2014 mention Injection of Insulin. The Genesis Hospital provide the information that patient does not have any record prior to January 2014 and no document available. The OP insurance company appointed  independent investigator and during investigation it was discovered that consultation papers of the complainant shows that he is a patient of diabetes mellitus from the past 15 years.
26. It is admitted case of the parties that on 24.09.2014 a claim was filed by complainant of Rs.30,300/- for reimbursement alongwith discharge summary, admission documents and final bills alongwith various medical reports of Genesis Hospital. The OP insurance company raised various clarification and queries from the complainant and sent letter dated 29.10.2014 and 10.11.2014 but complainant did not provide any clarification. The OP insurance company closed the claim on 12.12.2014.
27. The complainant admitted in the complaint that because of his sugar level his health condition is deteriorating and the sugar level accidently shoot up. Although he was admitted with history of diarrhea and vomiting. The complainant has not explained that why the doctor on January 2014 prescribed him insulin for disease diabetes mellitus. In the rejoinder and in the evidence filed by complainant the complainant has not disputed the investigation carried  out by OP Insurance company where it was found that complainant is a non case of diabetes mellitus for the past 15 years. The complainant also not replied any of the clarificatory letters filed by OP insurance company. The facts established that complainant had concealded the material and true facts with regard to his past medical history at the time of switching over the policy from Easy Health Policy Plan to Optima Restore Individual Health Insurance Plan in February 2013. The law is well settled in the case of present circumstance by the Hon’ble Supreme Court in the case of LIC Vs. Asha (2001) 2 SCC 160, Satwant Kaur Sandhu Vs. New India Assurance Co. Ltd. SC (2002) 2776, P.C Chacko & Anr. Vs. Chairman, LIC Ltd. AIR 2008 SC 424 and LIC of India Vs. Smt. G.M Chanmaparsmma AIR 1991 SC 392 held that the contract of insurance is “UBERRIMNA FIDES” and every fact of material must be disclosed otherwise there is good ground for recession of the contract. In this present case complainant violated this principle and suppressed the non material and true facts. In these circumstances complainant failed to establish any deficiency of service on the part of OP Insurance Co.
28. On the basis of above observations and discussions present complaint is dismissed. No order as to cost. File be consigned to record room.
29. Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving an application from the parties in the registry. The orders be uploaded on www.confonet.nic.in.

Announced in open Commission on  25.07.2024.

      SANJAY KUMAR                 NIPUR CHANDNA                       RAJESH

       PRESIDENT                             MEMBER                                MEMBER