DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, EAST, Govt of NCT of Delhi
CONVENIENT SHOPPING CENTRE, 1st FLOOR, SAINI ENCLAVE, DELHI 110092
Consumer complaint no. 178/2017
Date of Institution 19/05/2017
Order reserved on 04/12/2019
Date of Order 06/12/2019
In matter of
Mr Sanjiv Wadhera
3, Basement, Jagruti Enclave
Karkarduma, Delhi 110092 ………………….……………...…………….Complainant
Vs
M/s The Manager,
Apollo Munich Health Insurance Co. Ltd.
204, Laxmi Deep Building
Laxmi Nagar Distt. Centre, Delhi 110092 ……………..….…………..Opponent
Complainant’s Advocate Mr. Ram N.Sharma
Opponent’s Advocate Mr Vibhore Agarwal
Quorum Sh Sukhdev Singh President
Dr P N Tiwari Member
Mrs Harpreet Kaur Member
Order by Dr P N Tiwari Member
Brief Facts of the case
Complainant took Easy Health Mediclaim Individual Standard policy at the age of 42 years from OP having tenure from 08/09/2010 to 07/09/2011 for a sum assured (SA) Rs. 5Lac for himself vide policy no. 110100/11001/1000109915 with terms and conditions (ExCW1/1) and was renewed thereafter in 2012 to 2013 (Ex CW1/1A).
The same policy was renewed from 08/09/2016 to 07/09/2017. The complainant had developed swelling over preputial skin with foul smelling discharges over groin region so got checked up by plastic surgeon on 28/01/2017 who diagnosed a case “Hydradentis Suppurativa” and advised admission immediately, so complainant got admitted at Sir Ganga Ram Hospital, Delhi on 07/03/2017 and was discharged on 11/03/2017 (Ex CW1/3). Hospital sent cashless request which was rejected even after informations were provided. He paid his hospital bill Rs 1,51,160/-(Ex CW1/6).
It has been stated that after submitting entire claim documents on 05/04/2017 for total expenditure of Rs 153660/-, did not get any reply from OP even visiting personally to OP office also. Later complainant received repudiation letter (Ex CW1/7) dated 12/04/2013 rejecting his claim under permanent exclusion based terms and conditions and based on discharge summary where it was diagnosed a case of “Hidradentis Suppurativa”. The discharge summary was marked as Ex CW1/4. Complainant filed this complaint alleging deficiency of services of OP and claimed for Rs 1,53,660/- with 24% interest per annum and compensation Rs 25,000/- for mental agony with litigation cost Rs 20,000/-
OP submitted written statement denying allegations of deficiency of OP. It was submitted that claim pertaining to medical treatment for a sum of Rs 1,53660/- was thoroughly checked by OP and it was found that “Hidradentis Suppurativa” was under permanent exclusion under section V(c) because insured/complainant had same disease in 2006 and 2008 for which he took treatment after getting admitted in Sir Ganga Ram Hospital whose old treatment documents were procured during investigation before repudiating claim.
It was also stated that complainant did not mention in Policy Proposal Form where every information had to be given as per IRDA Regulations, 2002, under Section 2(1)(d) of protection of policyholder’s Interest. OP’s vital document as Policy Proposal Form for issuing policy which said that “Policy Proposal Form (PPF)”, a form to be filled by the proposer for taking insurance and all required material as asked had to be furnished in order to enable the insurer to decide whether to accept or decline, to undertake the risk and in the event of acceptance of risk, of a cover to be granted” (Ex OPW1/2) vide no. 11006640479. As per PPF, para 6 of Medical & Lifestyle Information, answer in Section B (xvii) states as Undertaken any surgery or a surgery has been advised in the last 10 years or is a surgery still pending …,Section B (xviii) states as Suffered from any other disease/illness/accident/injury other than common cold or viral fever.” Under this column, proposer/complainant had written NO as answer. Based on good faith and declared medical history in PPF, OP issued first policy vide no. 110100/11001/1000109915 from 08/09/2010 to 07/09/2011 and renewed up to 07/09/2017 (Ex OPW1/3).
It was further submitted that cashless claim was reported from Sir Ganga Ram Hospital on 20/01/2017 with presenting symptoms as “Discharging Sinus from Scrotal Sac X 90 days with probable diagnosis Recurrent Lesion Hidradentis Suppurativa” as previously operated case (Ex OPW1/4) and asked to submit certain required documents. It was further submitted that hospital forwarded Cashless, refusal request was received from complainant (Ex OPW1/5&6) so cashless denial was sent to hospital. After receiving reimbursement of treatment bill of hospital with discharge summary, OP conducted proper investigation and procured previous admission and operation in same hospital pertaining to 2006 and 2008 (Ex OPW1/7) and repudiated claim based on non Disclosure of material fact as Hidradentis Suppurativa. Hence repudiation was justified under Section V (c) of policy terms and conditions which stated that …..plastic surgery or cosmetic surgery unless required due to accident….
OP submitted that complainant here in this case intentionally and with malafide intension suppressed material facts pertaining to his previous same illness (Hidradentis Suppurativa) before answering OP and also violated laws of contract between insurer and insured, hence complainant was not entitled for any relief and compensation and their claim repudiation was justified. To sustain their repudiation on non disclosure of material fact, OP had annexed policy terms and conditions and certain higher courts judgments as under-
- Prem Kumar Chhabra vs LIC Ltd., RP 3405/2017
- OIC Ltd. vs Sony Cherian, AIR 19099SC 3252
- Yeshashwini Wima Yojna vs Mumtaz Begum, NC RP 1173/2007
- UIICo. Ltd. vs Harchand Rai Chandan Lal, Appeal no 6277/2004 SC
- Sr Manager LIC of India vs Smt Satwant Kaur sandhu, RP 3138/2006 NC
- Dewan Surender Lal vs OIC Ltd., NC 1(2009) CPJ 117,
- Maya Devi vs LIC of India, NC III(2011)CPJ 43
- Lal Chand vs LIC of India, RP 2749/2006NC
- Pushpa Devi Babulalal Punamiya vs LIC of India, RP6566/2011NC
- Bajaj Allianz General Insurance Co. Ltd vs Patel Vitthalbhai Shivbhai, RP 1272/2014NC
- PC Chacko vs Chairman LIC of India, CA5322/2007
- LIC of India vs Neelam Sharma &
- LIC of India vs Asha Goel, 2SCC(160) 2001
It was stated in all above citations that non disclosure of material facts and putting incorrect information in policy proposal form by the policy seeker amounts willful non disclosure and in such situation, complainant could not claim any relief in term of compensation from opposite party.
Complainant submitted rejoinder to written statement and denied all facts submitted on record and stressed on all the facts and evidence were correct and true as per his complaint. He also submitted evidences through his own affidavit where he stated that OP had repudiated his claim illegally and with malafide intention and did not give cashless which was required. He also stated that his policy continued since 2010 without break. So, his claim be considered and claim be awarded.
OP also submitted their evidence on affidavit through Mr Vir Bhan, Sr. Divisional Manager at OP office and affirmed on oath that all the procedures adopted by them were as per the IRDA guidelines and rejection was done as per terms and conditions of the policy. So, there was no deficiency in their services and repudiation was justified based on policy terms and condition and various higher courts judgment which were on record. It was also submitted that Insurance company was bound by their policy terms and conditions as per IRDA guidelines and could not be overlooked. Hence, this complaint may be dismissed on non disclosure of material facts by the complainant/insured.
Both the party submitted their written arguments where complainant stressed his facts and claimed repudiation of claim was unjustified. OP also stressed that based on policy terms and conditions claim repudiation was justified on non disclosure of material fact which had permanent exclusion irrespective of continuation of policy renewal. OP also additional citations as Guddi Devi vs LIC of India, RP 828/2017,NC where complainant intentionally hided material fact of CKD and was on regular dialysis. This fact was material to OP and repudiation of claim was justified by OP. In another case, Lalit Kumar Garg vs UIICo. Ltd & others, RP 621/2017 NC, where complainant had CAD in k/c/o Unstable Angina and had stents but did not disclose this fact before OP, so claim was rightly repudiated.
Arguments were heard from both the parties and order was reserved.
By going to the facts and evidences from both the parties, it is evident that complainant intentionally hidden material fact of Hidradentis Suppurativa which he was having since 2006 and he did not disclose in the policy proposal form.
Hence, this complaint has no merit in proving deficiency of OP in rejecting his claim. So, this complaint deserves to be dismissed so dismissed without cost.
Copy of this order be sent to the parties as per the Regulations of the Consumer Protection Act, 1986 and file be consigned to Record Room.
(Dr) P N Tiwari Member Mrs Harpreet Kaur Member
Sukhdev Singh President
