Punjab

Ludhiana

CC/19/352

sukhpreet Singh - Complainant(s)

Versus

Apollo Munich Health Insurance - Opp.Party(s)

Karam Singh Adv.

13 Oct 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 352 dated 18.07.2019.                                                        Date of decision: 13.10.2022.

 

Sukhpreet Singh Mangat aged 37 years son of S. Bhinder Singh, resident of V.P.O. Begowal, Tehsil Payal, District Ludhiana.

                                                                                      ..…Complainant 

•  

1. Apollo Munich Health Insurance Company Ltd., 2^nd & 3^rd Floor, ilabs Centre, Plot NO.404-405, Udyog Vihar, Phase III, Gurgaon, Haryana-122016, through its Director/M.D.
2. Apollo Munich Health Insurance Company Ltd., 2^nd Floor, SCO 146, Feroze Gandhi Market, Ludhiana-141001.                                                                                                                         …..Opposite parties 

Complaint under Section 12 & 14 of the Consumer Protection    Act, 1986.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Karan Singh, Advocate.

For OPs                          :         Sh. Ajay Chawla, Advocate.

 

ORDER

PER K.K. KAREER, PRESIDENT

 

1.                In brief, the case of the complainant is that the complainant availed Easy Health Floater Standard Policy No.110600/11051/AA00300526 from the OPs in the year 2015 for a sum assured of Rs.3,00,000/-. The policy was purchased through an agent of the OPs namely Jasdeep Singh. The complainant disclosed all the facts about his previous ailment of Myxopapillary ependymoma in the year 2000 and also provided all the relevant documents to agent Jasdeep Singh. The proposal form of the policy was filled by Jasdeep Singh and the signatures of the complainant were obtained by the said agent. The complainant presumed that the agent would act bonafide. The complainant has been paying the premium of Rs.11,239/- to the OPs continuously for the last three years without any default.

2.                It is further alleged that the complainant is suffering from Myxopapillary ependymoma and he was required to take treatment of the said disease from the hospital. The complainant sought the opinion of the OPs as to whether the disease was covered under the policy availed by him. However, to the surprise of the complainant, the OPs served false and frivolous letter dated 27.05.2019 to the complainant threatening to terminate the policy due to non-disclosure of pre-existing disease of Myxopapillary ependymoma. The complainant sent reply to the notice of termination issued by the OPs explaining true position that the proposal form was filled by the agent of the OPs and the agent did not fill the proposal form correctly and as such, the policy cannot be cancelled due to any lapse on the part of the agent. Even otherwise, the complainant has not lodged any claim with the OPs regarding the ailment of Myxopapillary ependymoma. The complainant had only raised a query as to whether the said disease was covered under the policy or not. Even otherwise, the query raised by the OPs could have been treated as information regarding pre-existing disease and the policy cannot be cancelled on this ground depriving the complainant of the benefits of insurance qua his other diseases. However, the OPs vide letter dated 27.05.2019 terminated the policy even after the reply was sent by the complainant and vide email dated 26.06.2019, the complainant has been informed about the termination. This amounts to deficiency of service and unfair trade practice on the part of the OPs and has also caused mental pain and agony and harassment to the complainant. In the end, it has been requested that the OPs be directed to revalidate the insurance policy and be also made to compensate the complainant to the tune of Rs.70,000/- for having caused mental pain and agony along with Rs.20,000/- as litigation expenses.

3.                The complaint has been resisted by OPs. In the written statement filed on behalf of the OPs it has been, inter alia, pleaded that the complaint is not maintainable and is nothing but an abuse of process of law. According to the OPs, the contract of insurance is a contract of bonafide and every material fact is required to be disclosed otherwise it would be a good ground for rescission of the contract. The OPs have further pleaded that the complainant was suffering from Myxopapillary ependymoma and had undergone surgery for the said disease in the year 2000 much before the inception of the policy. However, the complainant failed to disclose this pre-existing disease at the time of availing the policy from the OPs and, therefore, the OPs have rightly rejected the claim of the complainant. The OPs have further pleaded that the proposal for insurance submitted by the complainant on 06.10.2015 was accepted on standard rates based on the information supplied by the complainant and the policy dated 07.10.2015 was issued which commenced from 06.10.2015 and, thereafter, it was renewed on annual basis. The benefits of the policy were, however, on certain conditions and exclusions which had been given in the policy documents. It has further been pleaded that the OPs received request for cashless claim on 27.05.2019 through Ojas Medical Services Private Limited for complainant Sukhpreet Singh who was admitted with the complaint of Myxopapillary ependymoma with recurrence and the estimated cost was Rs.31,200/-. Myxopapillary ependymoma (MEPN) is a slow-growing ependymoma (a type of glioma, which is a tumor that arises from the supportive tissue of the brain and spinal cord). It tends to occur in the lower part of the spinal column and are usually considered to be benign, low-grade or grade I tumors. On reviewing the documents, it was found that the complainant was having history of surgery for the same ailment in the year 2000. Thus, the complainant was having pre-existing disease which was not disclosed at the time of inception of the policy. As a result, the cashless authorization was declined vide letter dated 27.05.2019 and the policy was rightly repudiated. The other allegations made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

4.                In evidence, the complainant submitted his affidavit Ex. CA along with documents Ex. C1 to Ex. C3 and closed the evidence.

5.                On the other hand, the counsel for the OPs tendered affidavit Ex. OPA of Sh. Manoj Kumar Prajapati of OPs along with Annexure-OP1 to Annexure-OP6 and closed the evidence.

6.                We have heard arguments advanced by the counsel for the parties and gone through the record.

7.                 During the course of arguments, the complainant has argued that the OPs are not entitled to terminate the policy. In this regard, it has been contended by the counsel for the complainant that all the relevant facts including the fact of the complainant suffering from Myxopapillary ependymoma was duly disclosed to the agent of the OPs namely Jasdeep Singh who, for the reasons best known to him, did not mention this fact in the proposal form. The counsel for the complainant has further contended that even otherwise on this ground, the policy cannot be ordered to be terminated as the OPs have been accepting annual premiums and renewing the policy regularly from 2015 onwards.

8.                On the other hand, the counsel for the OPs has argued that admittedly the complainant underwent surgery for Myxopapillary ependymoma in the year 2000. It is not disputed that the complainant has been suffering from the disease of Myxopapillary ependymoma since 2000 but this fact was not deliberately disclosed in the proposal form which amounts to suppression of facts. According to the counsel for the OPs, the contract of insurance is contract of utmost bonafide and non-disclosure of material facts is liable to render the contract void and the same has been rendered rightly terminated. The counsel for the OPs has further argued that the plea that the omission regarding the incidence of the disease in the proposal form took place due to lapse on the part of the agent namely Jasdeep Singh is not sustainable. That onus, to prove that the lapse, if any, was on the part of the agent Jasdeep Singh is not at all tenable especially when the agent has not been impleaded as party in this case. In support of his contentions, the counsel for the OPs has relied upon 2020(4) C.P.J. 229 in Senior Manager, Life Insurance Corporation of India Vs Rajesh Kumar whereby it has been held by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi that it is bounden duty of the insured to disclose all relevant information with respect to state of her/his health and truthfully answer the question he/she is required to answer in proposal form. It has further been held in this very case that if neither the agent was impleaded as party to the complaint nor was he examined as a witness to prove that proposal was filled up by him without instruction from insured and was not read over and explained by him to her, the repudiation of the claim cannot be said to be illegal or arbitrary.    

9.                We have weighed the contentions raised by the counsel for the parties and have gone through the record carefully.

10.              It is not disputed by the complainant himself that he has been suffering from the disease of Myxopapillary ependymoma since the year 2000. It is also not disputed that the complainant underwent some surgery for the said disease in the year 2000. As per the information available on internet an ependymoma is a mass of irregular cells (tumor) in the brain or spinal cord. It’s a type of primary central nervous system tumor. Ependymomas start in the brain or spinal cord instead of starting elsewhere and spread to the brain and spinal cord. Ependymomas tend to grow slowly and usually don’t spread to other parts of the body. An ependymoma is a type of gliom and it starts in the glial cells. Considering nature of the disease, in our considered view, it was necessary for the complainant to have disclosed the factum of suffering from this disease since the year 2000 in the proposal form. However, admittedly, in the proposal form Ex. OP1, the same has not been disclosed which is a serious lapse on the part of the complainant and amounts to suppression of the material facts. It is a settled proposition of law that if insured does not disclose a material fact that he has been suffering from a serious disease and if the nature of the information withheld is of such magnitude that it could influence the decision of the insurance company whether to give the insurance cover or not amounts to material suppression of facts and on this basis not only a claim can be repudiated but the policy can also be terminated. The complainant in this case has tried to put the entire blame on agent Jasdeep Singh but the said agent has neither been made a party nor has been examined as a witness. Therefore, as per the law laid down in Senior Manager, Life Insurance Corporation of India Vs Rajesh Kumar (Supra) this plea is of no avail to the complainant as the said agent was neither been impleaded as a party nor examined as a witness. Since the material fact of the complainant having been suffering from a serious ailment such as Myxopapillary ependymoma since the year 2000 was not disclosed in the proposal form, the repudiation of the cashless authorization and termination of the policy cannot be said to be illegal, arbitrary or unjustified.  

11.              As a result of above discussion, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

12.              Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:13.10.2022.

Gobind Ram.

Sukhpreet Singh Vs Apollo Munich Health Ins.             CC/19/352

Present:       Sh. Karan Singh, Advocate for complainant.

                   Sh. Ajay Chawla, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint fails and the same is hereby dismissed. However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:13.10.2022.

Gobind Ram.