Chandigarh

DF-I

CC/429/2017

Roopinder Singh - Complainant(s)

Versus

Apollo Munich Health Insurance - Opp.Party(s)

Kashika Kaur

04 Sep 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

 

                               

Consumer Complaint No.	:	CC/429/2017
Date of Institution	:	30/05/2017
Date of Decision	:	04/09/2018

 

Roopinder Singh s/o Jaspal Singh r/o H.No.152, Sector 27A, Chandigarh.

… Complainant

V E R S U S

1.     Apollo Munich Health Insurance having its registered office at 1^st Floor, SCF-19, Sector 14, Gurgaon, Haryana through its authorised representative.

2.     Apollo Munich Health Insurance having its branch office at, 4^th Floor, SCO 50-51, Sector
34-A, Chandigarh through its authorised representative.

… Opposite Parties

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                    

ARGUED BY	:	Ms. Kashika Kaur, Counsel for complainant
	:	Sh. Pawan Kumar, Vice Counsel for Sh. Nitin Thatai, Counsel for OPs.

Per Rattan Singh Thakur, President

1.         The long and short of the allegations are, complainant including his family members i.e. wife and minor daughter had taken the Easy Health Floater Exclusive Policy on 13.9.2010 on payment of premium from the OPs. The policy was renewed continuously on yearly basis uptil 2012-13. Subsequent thereto, the complainant shifted to Optima Restore Floater Policy on payment of the premium which was valid from 13.9.2013 to midnight of 13.9.2014 and it was lastly renewed from13.9.2016 to midnight of 13.9.2017 for Rs.10.00 lakhs inclusive of Rs.5.00 lakhs as multiplier benefit. The premium of Rs.24,728.45 was paid to the OPs.

                The case is, the complainant fell ill and was hospitalized in Fortis Hospital Mohali from 24.1.2017 to 25.1.2017 because of acute abdomen pain which was later diagnosed as Gastric Outlet Obstruction with Non Rotation of Gut for which total amount of Rs.1,01,857/- was paid. The condition of the complainant did not improve and he was shifted to PGIMER, Chandigarh where he remained admitted from 26.1.2017 to 31.1.2017 and some non-surgical management treatment was followed. The complainant submitted claim in respect of both the hospitals, but, the same was repudiated vide letters dated 21.3.2017 and the policy was cancelled as there was concealment of material facts viz. diseases of diabetes, hypertension and CAD. Alleged, complainant was subjected to health examination by the OPs and, therefore, there was no concealment.  As such, there is deficiency in service on the part of the OPs and prayer is made to revive the policy, pay the amount of Rs.2,24,000/- alongwith interest, compensation and litigation expenses.

2.         OPs submitted their joint written statement and inter alia raised preliminary objections of complaint being not maintainable. On merits, admitted there was coverage of risk of health during the period, but, there has been reference in the treatment chart of pre-existing disease, known case of CAD and HTN. These facts were concealed, therefore, the claim was rightly repudiated and policy was cancelled. On these lines, the cause is sought to be defended.
3.         Parties led evidence by way of affidavits and documents.
4.         We have heard the learned counsels for the parties and gone through the record of the case.  After appraisal of record, our findings are as under:-
5.         Per pleadings of the parties, the undisputed facts are, the policy was taken by the complainant for himself and his family members i.e. wife and minor daughter initially w.e.f. 13.9.2010 and continuously without break the said policy was renewed on receipt of heavy premium by the OPs and, thereafter, in the year 2013 the policy was shifted to Optima Restore Floater Policy.  Again the said policy was renewed without objection. The complainant fell ill and was hospitalised from 24.1.2017 to 25.1.2017 at Fortis Hospital, Mohali because of acute abdomen pain, which was later diagnosed as gastric outlet obstruction with non-rotation of gut. Subsequently the complainant also remained admitted at PGIMER, Chandigarh from 26.1.2017 to 31.1.2017. The amount spent for the treatment in both the hospitals has not been disputed by the OPs, therefore, we do not feel any need to give details of the amount.
6.         The sole opposition of the OPs is, there was concealment of material facts with regard to the pre-existing disease of diabetes, hypertension and CAD which were concealed by the complainant at the time of filling up the declaration form in the year 2010. It is the case of the complainant, he was subjected to health examination by the OPs at the time of initial policy and subsequent renewal thereof. Right from the year 2010 onwards, for 7 long years hefty amount of premiums (last premium was Rs.24,728.45) were received by the OPs.
7.         Nevertheless, it is not the case of the OPs that on health examination such diseases were detected by their authorised medical attendant(s).   These are not the pleadings of the OPs at all.  Hypertension or diabetes or to say CAD could have been easily detected with blood samples regarding sugar and echo or some other tests regarding CAD, but, for 7 long years continuously the OPs slept over the matter and now, when the necessity of other disease surgery arose, they repudiated the claim on the ground of concealment of material fact of pre-existing disease by the complainant, and cancelled the policy for the remaining unexpired period.
8.         OPs had simply relied upon past history disclosed with the hospital regarding the aforementioned diseases. Who laid this information to the hospital has not been proved?  Not only this, no other authentic documentary evidence produced by the OPs to say, in the year 2009, prior to taking of the first policy, complainant was a known case of hypertension, diabetes and was suffering from Coronary Artery Disease.  Sleeping over the matter continuously for 7 long years and consecutive renewal of the policy definitely creates estoppel on the part of the OPs to say, there was concealment of material facts. The OPs had not produced any record to prove, complainant had been taking medicines for hypertension, diabetes and coronary artery disease. Simpliciter reliance was placed on the past history disclosed and OPs were not in possession of authentic medical records regarding the establishment of these diseases.
9.         Per record, it is not the case, the surgical problem, for which the complainant was operated upon, was on account of hypertension, CAD or say diabetes. The diagnosis of the disease, for which the medical reimbursement has been prayed for, is of Gastric Outlet Obstruction with Non Rotation of Gut.  This surgical problem has no nexus with hypertension, diabetes and CAD. 
10.         Reference has been made to the precedents, but, the OPs have not produced any record with regard to the establishment of these diseases prior to the year 2010 and were happily renewing the policy on yearly basis on receipt of hefty amount of premium which runs into more than Rs.one lakh.  It is worth mentioning here, a person takes health policy as a security measure.  However, after receipt of 7 continuous premiums from the complainant, OPs dealt him harshly with repudiation of his claim and cancellation of the policy.
11.         The learned counsel for the complainant has relied on case titled as Bajaj Alianz Life Insurance Co. Ltd. & Anr. Vs. Nasi Ban Begum, Revision Petition No.982 of 2011 decided on 1.8.2012 by the Hon’ble National Commission and the concluding paragraph of the same reads as under :-

“12.  The Supreme Court has held that since the respondents had come out with the case that the deceased did not disclose correct facts relating to his illness, it was for them to produce cogent evidence to prove the allegation. The respondents were found to have failed to produce any tangible evidence to prove that the deceased had withheld information about his hospitalisation and treatment.  Therefore, the claim under the policy was allowed.”

12.         Placing reliance on precedent supra, which is also based on the judgment of the Hon’ble Apex Court, we hold the act of repudiation of the claim alongwith cancellation of the policy by the OPs was unlawful.  Hence, the OPs are certainly proved to be deficient in rendering proper services.
13.         In view of the above discussion, the present consumer complaint deserves to succeed and the same is accordingly partly allowed. The OPs are directed as under:-

1. To immediately settle the claim and pay to the complainant the amount of Rs.1,01,857 + Rs.1,18,384 = Rs.2,20,241/- (as mentioned in the rejection letters dated 21.3.2017) alongwith interest @ 9% per annum from the date of rejection till realization.  The cancelled policy shall also be deemed to be in continuation till its validity period.
2. To pay Rs.50,000/- to the complainant as compensation for deficiency in service and mental agony and harassment caused to him;
3. To pay to the complainant Rs.15,000/- as costs of litigation.

14.         This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
15.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-	Sd/-
04/09/2018	[Suresh Kumar Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
hg	Member	Member	President