| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BATHINDA C.C.No. 180 of 22-7-2019 Decided on : 05-06-2023 Sunil Kumar aged about 45 years, S/o Sh. Pyare Lal, R/o H.No.31918, St.No.4, Partap Nagar, Bathinda. ........Complainant Versus Apollo Munich Health insurance Co.Ltd., 2nd & 3rd Floor, iLABS Centre, Plot No.404-405, Udyog Vihar, Phase-III, Gurgaon through its Managing Director. Canara Bank, Branch Code-80155926, Amrik Singh Road, Bathinda through its Branch Manager. (Deleted vide order dated.25.7.2019)
.......Opposite parties Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh. Lalit Mohan Dogra, President Sh. Shivdev Singh, Member Present : For the complainant : Sh. Pardeep Sharma, Advocate. For opposite parties : Sh. Varun Gupta, Advocate. ORDER Lalit Mohan Dogra, President The complainant Sunil Kumar (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986, ( Now C.P. Act, 2019 here-in after referred to as 'Act') before this forum (Now Commission) against Apollo Munich Health insurance Co.Ltd & another (here-in-after referred to as opposite parties). Briefly stated, the case of the complainant is that complainant is holding a bank account with the opposite party No.2 and the opposite party No.2 induced the complainant to purchase a Group Medical Insurance Policy of the opposite party No.1 for the cashless medical treatment of the complainant himself and his wife in case of any type of ailment for a sum assured of Rs.2,00,000/- and further made tall claims regarding the benefits to be provided under the said policy. Being induced by the tall claims made by opposite party No.2, complainant bonafidely agreed to purchase the policy and the concerned insurance adviser of the opposite party No.1 and the officials of the opposite party No.2 obtained the signatures of the complainant on some blank & printed forms/documents without reading over and explaining contents of the same and also got deposited the premium of Rs.4332/- towards the said Group Assurance Health Plan, by deducting the same from A/c No.1623101015143 of the complainant with opposite party no.2, for the period from 20.8.2018 to 19.8.2019 and lateron, the complainant received the copy of the insurance policy from the opposite party No.1 vide Policy No. 140200/12586/2017/A012586, which was issued by the opposite parties after completion of all the formalities. It is alleged that the wife of the complainant fell ill, all of a sudden, on 21.10.2018 due to the severe head ache which was beyond control and the wife of the complainant was taken to Dr.Taneja, Gursharan Hospital, Bathinda and after about 4/5 hours, she was referred to DMC & Hospital, Ludhiana an Ambulance and was got admitted on 21.10.2018 vide Admission No. 2018069165 in Emergency where some clinical tests were conducted by Dr.Bishav Mohan and prescribed some medicines to the wife of the complainant. She was discharged from the hospital on 22.10.2018 and the complainant paid Rs.27,474/- to the said hospital vide bill dated 22.10.2018 and also spent approx. Rs.3,000/- for the medicines etc. Since there was no improvement in the condition of the wife of the complainant and as such she was referred to the PGI, Hospital Chandigarh on 23.10.2018. She was taken to PGI Hospital, Chandigarh in an Ambulance and from PGI, Chandigarh, she was got discharged on 24.10.2018. Thereafter the wife of the complainant was got admitted in Kaiser Neurosurgical Centre, 100 Ft. Road, Bathinda on 28.10.2018 as the wife of the complainant continued suffering severe head ache and she was also not feeling comfortable during her admission in the hospital rather was very restless and uncomfortable, she was got discharged from the said hospital on 28.10.2018 and ultimately wife of the complainant died due to the heart problem on 28.10.2018. The complainant spent approx. Rs.1,00,000/- for the treatment of his wife including the hospital charges, expenses of Ambulance, medicines, attendants and other misc. expenses. The complainant alleged that thereafter the complainant applied for the reimbursement of the medical claim with the opposite party No.1 regarding the amount spent by him for the treatment of his wife, vide Claim No.903098 for Rs.40,662/- and Claim No.903107 for Rs.21,000/- besides other misc. expenses as detailed above and furnished the original medical treatment record of the wife of the complainant which is still in possession of the opposite party No.1 but the opposite party no.1 has failed to honour the claim of the complainant rather the opposite party no.1 illegally and arbitrarily terminated the Group Health Individual Policy of the complainant vide letter dated 26.2.2019 on the basis of false and flimsy ground that "Ms. Isha Garg: Past history of coronary artery disease since January, 2018 i.e prior to the policy inception". The opposite party has repudiated the aforesaid both the claims of the complainant vide repudiation letters dated 28.2.2019 on the aforesaid false ground of "past history of Coronary Artery disease since January, 2018" and the amount of Rs.1745/- has been credited in the account of the complainant on 2.4.2019 through NEFT It is further alleged that the opposite parties have repudiated the lawful claim of the complainant wrongly, illegally, against law, facts and principles of natural justice although wife of the complainant was not suffering from any problem in the past as alleged by the opposite party No.1 and the opposite party No.1 has concocted a false ground of the alleged past history of Coronary Artery disease in order to repudiate the lawful claim of the complainant. Further more, the opposite party No.2 sold the said Group Health Insurance Policy to the complainant regarding the family of the complainant, after completion of the requisite formalities and the opposite party no.1 could have got the clinical tests conducted' upon the complainant and his family members but the opposite party no.1 never got conducted any such clinical test and now the claim of the complainant has been illegally repudiated on the basis of totally fasle and filmsy ground. Due to abovesaid illegal acts of the opposite parties, the complainant suffered great mental tension, agony, botheration, harassment and humiliation and huge financial losses for which he claims compensation. On this backdrop of facts, the complainant has prayed for directions to the opposite parties to pay medical claim of the complainant to the tune of Rs.1,00,000/- and pay compensation amounting to Rs.50,000/- in addition to Rs.11,000/- as litigation expenses. On the statement of learned counsel for the complainant, name of opposite party No. 2 was deleted from the array of the parties vide order dated 25-7-2019. Upon notice, opposite party No.1 appeared through counsel and contested the complaint by filing written reply raising preliminary objections that the complaint is not maintainable; complaint involves disputed question of facts which cannot be determined in summary jurisdiction and that complainant filed by this complaint with mala-fide intention; prima facie no cause of action has arisen in favour of the complainant to file the present Complaint; complaint is false, frivolous and vexatious in nature and that the complainant is estopped from filing the present complaint by his own acts, conduct, omissions and acquiescence. It has been pleaded that opposite party received a duly filled and signed EF from the Complainant, Mr. Sunil Kumar for availing health insurance Policy seeking to cover himself and her spouse namely Isha Garg. Believing the information and details provided by the Proposer including the medical history in the EF to be true and correct in all respects and giving due credence to the under writing norms of opposite parties Company, a Policy No.120100/12586/2018/PE01092599 was issued for a sum assured of Rs.2,00,000/- opted as per EF to the Proposer for the period between 20.082018 to 19.08.2019. The copy of Schedule bearing relevant details of the Policy along with policy bond having terms and conditions were duly sent and delivered to the Proposer. Further, no assurance was given to the Complainant beyond the terms and conditions of the Policy. Policy kit containing all relevant documents was duly delivered to the Complainant, thereby giving an opportunity to the complainant to verify and examine the benefits, terms and conditions of the policy taken by the complainant. Complainant never approached the opposite party stating that any information given in the Policy Schedule was incorrect. The claim under the policy received from the complainant for reimbursement as the complainant's wife was admitted in hospital on 05.12.2018 who got admitted in Kaiser Neurosurgical Centre and DMC & Hero Heart Hospital Ludhiana for C/o Subarachnoid Hemorrhage. Post Scrutiny of documents query had been raised. All Investigation Reports Supporting the Diagnosis Detailed discharge summary on the Hospital Letterhead From reply it was noted that member was also suffered from Ischaemic Cardiomy So query was again revised by waiving above and adding for documents related CAD In reply member provided us the multiple prescription mentioned about CAD but that was not seems to be the first so case was referred for investigation Investigation was done and H/o CAD detected at DMC in January 2018 was found before of policy inception Member in his declaration asked that CAD was diagnosed on 21 October 2018 but prescription provided by member of same date mentioning K/C/O CAD, hence it was crystal clear that member was manipulated the actual fact about his CAD duration. MU opinion had been taken on it and post MU opinion for policy termination under ND of CAD case got rejected on wordings Based on verification conducted past history of Coronary Artery Disease since January 2018 was noted i.e. prior to policy inception. Hence claim is repudiated due to incorrect good health declaration under terms and conditions 7 of the policy. The opposite party has pleaded that complaint was not at all maintainable since the complainant's claim do not not fall within the insurance as granted. On merits, the opposite party has pleaded that the complainant after duly understood and satisfied with the features and the policy terms & conditions of the policy had availed a Health Insurance Policy of the opposite party with sum assured of Rs.2,00,000/- covering himself and spouse. After understanding all the terms and conditions of all the plans only thereafter complainant opted to purchase the policy. For this, the complainant filled the Enrolment Form and at the time of filling the above said EF, the complainant opted to pay requisite premium against the Sum Assured of Rs.2,00,000/-. That soon thereafter the policy was dispatched to the complainant and the same was duly received by him. Before signing the Proposal Form, the complainant made declaration and had signed the same. After receiving the Proposal Form and going through the entire contents of the Enrolment Form, the Underwriters of the policy, had issued the Insurance Policy to the complainant and sent the Policy documents along with all terms and conditions of the Policy to the complainant on the given address and the same was received by the complainant and the same are in his possession and moreover the complainant relied upon the same. The policy terms and conditions were also sent along the policy documents in which the actual benefit of the policy has been explained in detail. It is specifically mentions: “To help you understand our services better, please go through the 'know your policy better' kit that accompanies this letter and constitutes the following details: • Policy Certificate • Premium Acknowledgment • Key Policy Information • Policy Terms and Conditions • Claim Process However, the complainant never raised any complaint to the company regarding non-receipt of any of the above mentioned documents, and hence the complainant is at a later stage making up concocted facts. It is specifically mentioned that as per the provisions of the Insurance Act, 1938 IRDA Act, 1999 and rules and regulations made there under the insured have an option to reconsider the policy under the garb of Free Look Period i.e. Free Look Period means "The insured have the option to cancel the policy within for 15 calendar days from receipt of this policy document by giving the opposite party, in writing the reason for such cancellation. In such a case, the premium paid after deducting the stamps duty charges shall be refunded to the policy holder. But the complainant by not applying for such a cancellation imperatively agreed to the policy terms and conditions and thus is now stopped from raising concerns as regards the policy terms. In further reply, the opposite party has reiterated its version as pleaded and detailed above. In the end, the opposite party prayed for dismissal of complaint. In support of his complaint, the complainant has tendered into evidence his affidavit dated 12.7.2019 (Ex. C-1) and documents (Ex.C-2 to Ex.C-21). In order to rebut the evidence of complainant, the opposite party No.1 has tendered into evidence affidavit of Deepti Rustagi dated 30.10.2019 (Ex. OP-1/1) and the documents (Ex. OP-1/2 to Ex. OP-1/4). The learned counsel for the complainant has argued that complainant has purchased group medical health insurance policy from opposite party No. 1 and complainant and his wife was insured upto Rs. 2,00,000/- in case of any illness. It is further argued that on 21-10-2018, wife of the complainant, all of a sudden, suffered from severe headache during the continuation of policy of insurance. It is further argued that wife of complainant was taken to Dr. Taneja. However, after 4-5 hours, she was referred to DMC & Hospital, Ludhiana and thereafter she remained admitted in Hero DMC & Hospital from 21-10-2018 and was discharged on 22-10-2018. The complainant had to pay Rs. 27,474/- to the said hospital and Rs. 3,000/- were spent on medicines. It is further argued that since there was no improvement in the health of wife of complainant, as such, she was referred to PGI Chandigarh on 23-10-2018 but since there was no improvement, she was got discharged on 24-10-2018 and thereafter she was again admitted in Kaiser Neurosurgical Centre, Bathinda, but even there was no improvement, she was got discharged from the said hospital on the same day and unfortunately, wife of the complainant expired on the same day. The complainant spent about Rs. 1,00,000/- on the treatment of his wife. It is further argued that when the claim was lodged with opposite party No. 1, the claim was repudiated by the opposite party vide letter dated 26-2-2019 on the false and flimsly grounds i.e. on verification conducted, past history of Coronary artery disease since January, 2018. It is further argued that wife of the complainant was not suffering from any problem when the policy of insurance was purchased. Moreover, it was the duty of the opposite party that they should have got complainant and his wife medically examined before issuing the policy of insurance. In support of his submissions, learned counsel for the complainant has placed reliance on following case law : Hon'ble Supreme Court of India - case titled D Srinivas Vs. SBI Life Insurance Co. Ltd., & Others: Civil Appeal No. 2216 of 2018 (Arising out of SLP (C) No. 14021 of 2017 Date of Decision 16-2-2018. Hon'ble State Commission, Punjab – case titled Rajesh Singla Vs. Max Bupa Health Insurance Co. Ltd., & Anr. - CC No. 100 of 2017 – Date of Decision 24-4-2018. Hon'ble National Commission – case titled Satish Chander Madan Vs. M/s. Bajaj Allianz General Insurance Co. Ltd., - Revision Petition No. 3619 of 2013 (Against Order dated 16-7-2013 in Appeal No. 305 of 2013 of the State Commission, Haryana) – Date of Decision 11-1-2016. Hon'ble Supreme Court of India – case titled New India Assurance Co. Ltd., Paresh Mohanlal Parmar - Civil Appeal No. 10398 of 2011 – Date of decision 4-2-2020. On the other hand, learned counsel for opposite party No. 1 has argued that wife of the complainant was admitted in Kaiser Neurosurgical Centre and DMC & H Hero Heart Hospital, Ludhiana for C/o Subarachnoid Hemorrhage. Post Scrutiny of documents query had been raised. All Investigation Reports Supporting the Diagnosis Detailed discharge summary on the Hospital Letterhead From reply it was noted that member was also suffered from Ischaemic Cardiomy So query was again revised by waiving above and adding for documents related CAD In reply member provided us the multiple prescription mentioned about CAD but that was not seems to be the first so case was referred for investigation Investigation was done and H/o CAD detected at DMC in January 2018 was found before of policy inception Member in his declaration asked that CAD was diagnosed on 21 October 2018 but prescription provided by member of same date mentioning K/C/O CAD, hence it was crystal clear that member was manipulated the actual fact about his CAD duration. MU opinion had been taken on it and post MU opinion for policy termination under ND of CAD case got rejected on wordings Based on verification conducted past history of Coronary Artery Disease since January 2018 was noted i.e. prior to policy inception. Hence claim is repudiated due to incorrect good health declaration under terms and conditions 7 of the policy. It is further argued that since the complainant concealed the disease when he purchased policy of insurance, as such, claim was rightly repudiated by the Insurance Company. It is further argued that complainant was supplied complete kit alongwith policy and was given 15 days free look period and if the complainant had any query regarding terms and conditions, complainant was having option to get the policy cancelled within 15 days of free look period but said option was not availed by the complainant and as such, complainant is bound by the terms and conditions of the policy. We have heard learned counsel for the parties and gone through the file carefully. It is admitted fact that complainant had purchased group health insurance policy from opposite party No. 1 vide policy Ex. C-2. It is further admitted fact that wife of the complainant was insured under the policy Ex. C-2 remained admitted in various hospital from 21-10-2018 to 28-10-2018 i.e. till her death. It is further admitted fact that complainant had to spent amount on the treatment of his wife. It is also admitted fact that claim for reimbursement, lodged by the complainant, was repudiated by opposite party No. 1 on the ground that as per terms and conditions of the policy and due to the reason that wife of the complainant was patient of hypertension since January, 2018 and thus she was patient of heart disease. The only question before this Commission is whether decision of opposite party No. 1 was right while repudiating the claim of the complainant for reimbursement. First of all, it is nowhere denied by opposite party No. 1 that complainant and his wife had refused to get themselves medically examined when they purchased the policy of insurance from opposite party No. 1 meaning thereby that when the opposite party No. 1 did not avail option to get the complainant and his wife medically examined, in that case, this Commission has no hesitation in holding that said condition is deemed to have been waived off by opposite party No. 1. Since the opposite party No. 1 has failed to get the complainant and his wife medically examined before issuance of policy of insurance, opposite party No. 1, at this stage, cannot take this plea that wife of the complainant was patient of hypertension since January, 2018. Moreover, the opposite party No. 1 has not placed on record any evidence in the shape of treatment of wife of the complainant since 2018 at DMC & Hospital, Ludhiana, except for one single document dated 24-10-2018 i.e. case history of Kaiser Neurosurgical Centre. This Commission is of the view that complainant is not bound by case history written at Kaiser Neurosurgical Centre, in the absence of any cogent evidence. Moreover, it has already been held by Hon'ble State Commission that mere reference in the record mentioned by doctor that she suffered from hypertension since, 2018, is not sufficient. It has further been held that hypertension is not a disease which is required to be referred in proposal form. It has also been held by Hon'ble National Commission that hypertension is a common ailment and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer from heart attack. Therefore, from the above discussions and evidence on record and by relying upon case law, it is fully proved that claim lodged by the complainant was repudiated by the opposite party vide repudiation letter Ex C-19, on flimsy grounds and without any evidence of previous ailment, which amounts to deficiency in service on the part of opposite party No. 1. Accordingly, present complaint is partly allowed and opposite party No. 1 is directed to settle and pay the claim in respect of expenditure made by complainant on the treatment of his wife, as per policy of insurance Ex. C-2, alongwith interest @9% p.a. from the date of filing of complaint till realization. The opposite party No. 1 is also directed to pay Rs. 5,000/- as compensation on account of mental tension, harassment and litigation expenses. The compliance of this order be made by opposite party No.1 within 45 days from the date of receipt of copy of this order. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record room. Announced:- 05-06-2023 (Lalit Mohan Dogra) President (Shivdev Singh) Member
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