BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.528 of 2019
Date of Instt. 04.11.2019
Date of Decision: 23.08.2024
Prem Kumar Kohli S/o Late Shri Ved Prakash R/o 75, Green Park, Jalandhar, Punjab.
..........Complainant
Versus
1. Apollo Munich Health Insurance Co. Ltd., Regd. Office:-Apollo Hospitals Complex, 8-2-293/82/J III/DH/900 Jubilee Hills, Hyderabad, Telanganan-500033 Through its Directors/Principal Officer/Secretary.
2. Apollo Munich Health Insurance Co. Ltd., Branch Office:- Satnam Complex, BMC Chowk, Jalandhar-144001 Through its Branch Manager/Principal Officer.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Atul Malhotra, Adv. Counsel for the Complainant.
Sh. V. K. Gupta, Adv. Counsel for the OPs.
Order
Jyotsna (Member)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the complainant had been taking medical insurance policies regularly and continuously for the last five years starting from 31-3-2014 from OPs for self and for his family Lastly, After receiving the due premium, OP issued a policy bearing no.180200/11001/AA00067557-04 which was valid from 20-4-2018 to 19-4-2019 The complainant was not supplied with any terms and conditions since insurance policy was being renewed after 2015 and insurance policy was received by Complainant online and were printed through computer printer. Complainant had downloaded the insurance policy online through computer. OP had issued the original insurance policy on 31-3-2014 after complete medical examination of Complainant and his family from the panel of Doctors appointed by OP. On 9-11-2018, during the pendency of the said policy, Complainant felt some problem and consulted Patel Hospital Jalandhar, Shrimann Hospitals, Jalandhar and Sir Ganga Ram Hospital, New Delhi for the first time. It was diagnosed that Complainant had developed blockage in one of the arteries. Complainant and his relatives refused to get operated and refused to implant stents. Rather Complainant opted for other methods like diet control, daily routine controls, exercises and medicines for treating the disease. The complainant had to spend about Rs.2,00,000/- on the treatment, operation, special diet, traveling expenses, consultations etc. till present date and are still undergoing treatment and expenses regularly Complainant through his relatives had informed OP about the problem and had raised the cashless claim with OP immediately without any delay and had submitted all of the required documents as and when demanded by OP. But initially, OPs illegally and arbitrarily refused to make the payment of cashless insurance claim to complainant on the ground of pre existing disease on 28-1-2019. The complainant had never suffered heart problem or disease earlier and had no knowledge of such disease or problem earlier. Further Complainant had never taken any medicine or treatment of the heart disease earlier to taking policies. Due to the above said facts there is deficiency in services, negligence, unfair trade practices and restrictive trade practices on the part of OPs and as such necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay a compensation of Rs.5,00,000/- for causing mental tension and harassment to the complainant and further OPs be directed to make payment of Rs.1,67,991/- alongwith interest @ 18% per annum from 09.11.2018 till date of payment of entire sum and Rs.11,000/- as litigation expenses.
2. Notice of the complaint was given to the OPs, who filed reply and contested the complaint by taking preliminary objections that the complainant is not entitled to any claim or to get any relief claimed therein. It is further averred that the complaint is barred by the Section 3 of the Consumer Protection Act, 1986 and the same is liable to be relegated to the Civil Court of competent jurisdiction since the adjudication of the matter requires recording of elaborate evidence, oral, documentary and medical and the same is not possible by way of summary trial. It is further averred that the complaint is ex-facie misconceived, vexatious, untenable and devoid of any merits. The complainant has approached this Forum with unclean hands and has filed this complaint in order to raise a premeditated, false and frivolous dispute to harass the OPs. It is further averred that there is no deficiency in service or negligence or unfair trade practice on the part of the OPs. It is further averred that as per investigation and available record it was found that complainant had past history of Diabetes since 10 which was not disclosed by the complainant in proposal form at the time of taking policy. So, this case was also rejected on 1st February under Non-disclosure of Diabetes. On merits, the factum with regard to taking insurance policy by the insurance policy by the complainant is admitted and it is also admitted that the complainant lodged the claim and the same is repudiated, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder not filed by the complainant.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.
6. It is not disputed that the complainant had taken the mediclaim insurance policies regularly since 31.03.2014. The last policy No.180200/11001/AA00067557-04 was valid for a period 20.04.2018 to 19.04.2019. The complainant has alleged that on 09.11.2018 he felt some problem and consulted Patel Hospital Jalandhar, Shriman Hospital, Jalandhar and Sir Ganga Ram Hospital, New Delhi for. It was diagnosed that the complainant had developed blockage in one of the arteries and the complainant was admitted in Shrimann Super Speciality Hospital Jalandhar on 09.11.2018 and was discharged on 15.11.2018. The complainant was admitted in Sir Ganga Ram Hospital, Delhi on 21.11.2018 and was discharged on 23.11.2018. However he was denied cashless treatment by the insurance company in both above cases. Later on, he submitted his insurance claim for Rs.84,324/- on 21.12.2018 and Rs.68,244/- on 21.11.2018 which were rejected by the OPs on the ground that ‘the medical history details of non case of DM since 10 years that is before policy inception was not revealed in the proposal form while taking the policy’. Ex.C-49 and Ex.C-50 are the rejection letters.
7. In the written reply, the OP had not denied the above claims of the complainant. The OP had submitted in written reply that the claim of the complainant were sent for verification and post verification, it was observed from the medical records of Shrimann Hospital that complainant was having history of diabetic mellitus for last 10 years and thereafter, taking medical opinion, the claim of the complainant was rejected vide letter dated 31.01.2019 Ex.C-7 stating the following reasons:-
‘The medical history details of known case of DM since 10 years i.e. before policy inception was not revealed in the proposal form while taking the policy. Hence the policy is cancelled and claim is repudiated due to non-disclosure and concealment of facts under Section 5 c viii of policy terms and conditions.’
The above said fact shows that the complainant was having Diabetes, but he was admitted with complaints of Chest Pain and was diagnosed blockage in one of the arteries. It has nowhere been mentioned that he had suffered any chest problem earlier also or he was having heart problem. No document is on the record to show that his heart disease is old one and pre-existing.
8. It has been held by the Hon’ble State Commission, Delhi, in a case titled as ‘Pardeep Kumar Garg Vs. National Insurance Co. Ltd.’ in an Appeal No.A-482/2005, decided on 01.08.2008 that ‘claim of insured should not and cannot be repudiated by taking a clue or remote reference to any so called disease from the discharge summary of the insured’.
9. So, far as the ailment of diabetes is concerned. It has been decided by the Hon’ble National Commission in various judgments that Hypertension and Diabetes are not a disease, it is a general wear and tear of the life which occurred due to the pressure of the present life style and even otherwise the disease of Hypertension and Diabetes can be cured by taking medicine. It has been held by the Hon'ble National Commission in a case titled as ‘Neelam Chopra Vs. LIC (2018)’ that ‘common life style disease cannot be a ground to repudiate insurance claims. It has further been held that ‘the non-disclosure of information regarding common life style disease such as diabetes will not disentitle the insured from claiming the policy amount’. Similar view was taken by the Hon'ble National Commission in a case titled as ‘Reliance Life Insurance Co. Ltd. Vs. Tarun Kumar Sudhir Halder (2019)’ that ‘diabetes is a life style disease in India and the entire of insurance claim cannot be rejected only based on its non-disclosure.’
10. In view of the above detailed discussion, the repudiation letter Ex.C-49 and Ex.C-50 are held to be wrong and illegal and same are hereby set-aside. Thus, the complaint of the complainant is partly allowed and OPs are directed to pay claim Rs.1,52,568/- (Rs.84,324/- + Rs.68,244/-) with interest @ 9% per annum from the date of lodging of the mediclaim till its realization. Further, OPs are directed to pay a compensation of Rs.20,000/- for causing mental tension and harassment to the complainant and Rs.8000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
11. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
23.08.2024 Member Member President
