Madhya Pradesh

StateCommission

A/21/529

ANIL KUMAR SURANA - Complainant(s)

Versus

APPOL UNIQUE HEALTH INSU. CO. LTD - Opp.Party(s)

MS.MONA PALIWAL

04 Jul 2023

ORDER

M. P. STATE  CONSUMER  DISPUTES  REDRESSAL  COMMISSION,

PLOT NO.76, ARERA HILLS, BHOPAL

 

                                      FIRST APPEAL NO. 529 OF 2021

(Arising out of order dated 28.10.2021 passed in C. C. No.51/2019 by District Commission, Neemuch)

 

ANIL KUMAR SURANA,

S/O SHRI MANGILAL SURANA,

R/O BUNGLOW NO. 36, JAIN COLONY,

TEHSIL & DISTRICT-NEEMUCH (M.P.)                                                         ….       APPELLANT.

 

Versus

 

1. APOLLO MUNICH HEALTH INSURANCE CO.LTD.

    NOW HDFC ERGO HEALTH INSURANCE CO. LTD.

    HEAD OFFICE CENTRAL PROCESSING CENTRAL,

    II 7 III FLOOR, I.L.A.B.S. CENTER PLOT NO.404-405,

    UDYOG VIHAR, PHASE-3, GURGAON, HARYANA-122016

 

2. PRAVEEN KUMAR SHARMA,

    R/O OPPOSITE HIGHER SECONDARY SCHOOL,

    SINDHI COLONY, TEHSIL & DISTRICT-NEEMUCH (M.P.)                         ….    RESPONDENTS.   

                     

BEFORE:

                  HON’BLE SHRI A. K. TIWARI                  :   PRESIDING MEMBER

                  HON’BLE DR. SRIKANT PANDEY          :   MEMBER                 

                              

COUNSEL FOR PARTIES :

                        Ms. Mona Paliwal, learned counsel for the appellant. 

                Shri Sushil Goswami, learned counsel for the respondent no.1.

                None for the respondent no.2.            

                  

                                                  O R D E R

                                       (Passed on 04.07.2023)

                   The following order of the Commission was delivered by A. K. Tiwari, Presiding Member:

                  This appeal by the complainant/appellant is directed against the order dated 28.10.2021 passed by the District Consumer Disputes Redressal Commission, Neemuch (for short ‘District Commission) in C. C. No. 51/2019 whereby the complaint filed by him has been dismissed.

 

-2-

2.                Facts giving rise to this appeal, in brief, are that according to the complainant, he via opposite party no.2, the agent of the opposite party no.1-insurance company had obtained a health insurance policy no. 191103/48/06/20/00000170500/11301/A.A.00763804 for the period w.e.f. 25.02.2018 to 24.04.2019 of which sum insured was Rs.10,00,000/-. According to the complainant earlier insurance was in another insurance company and on the assurance of the agent in continuation of the earlier policy obtained from another insurance company he had obtained insurance policy for the fourth year from the opposite party no.1 insurance company. During the currency of the policy, on 13.04.2018, when he had some pain in his chest he was referred to CIMS Hospital, Ahmedabad by the local private hospital, where he got admitted and after angioplasty stunts were inserted in which he incurred Rs.2,50,000/-. The complainant filed a claim with the insurance company along with requisite documents but the insurance company denied the claim on the ground that he was suffering from pre-existing disease. The complainant therefore alleging deficiency in service on part of the opposite party-insurance company, filed a complaint before the District Commission, seeking expenses incurred in treatment along with compensation and costs.

3.                Since, the reply filed by the opposite party no.1-insurance company was filed beyond prescribed period therefore was not taken on

-3-

record.  The opposite party no.2 remained absent before the District Commission.

4.                Heard learned counsel for the parties. Perused the record.

5.                Learned counsel for the appellant argued that before taking insurance policy from the opposite party no.1-insurance company, the complainant was taking health insurance policy from other insurance companies and he did not make any claim from them. Had the complaint any pre-existing disease, he could have claimed from the other insurance companies. The appellant did not sign any proposal form.  She further submits that the District Commission has committed grave error while passing the impugned order without sound reasoning and proper appreciation of evidence on record. She therefore prays that the impugned deserves to be set-aside and the appeal be allowed.

6.                Learned counsel for the opposite party/respondent-insurance company vehemently argued that at the time of taking the insurance policy, the complainant was suffering from heart disease which is evident from the Treadmill test conducted before taking the insurance policy. The complainant/appellant suppressed the material fact relating to previous disease at the time of submitting the proposal form for issuance of insurance policy in question. He further submitted that there was reasonable nexus between the previous disease concealed by the life assured and the

-4-

angioplasty underwent. Hence, the claim of the complainant/appellant has been rightly repudiated by the insurance company.  The impugned order passed by the District Commission does not call for any interference. The appellant has no legs to stand and the same is liable to be dismissed.

7.                To substantiate the complaint and defence, both the complainant and the opposite party no.1 filed their respective affidavits before the District Commission and on the side of the complainant, 28 documents marked as C-1 to C-28, while the documents of the opposite party no.1 were marked 8 documents D-1 to D-8.

8.                We have perused the material available on record. There is letter dated 13.04.2018 (at page no. 129) of the insurance company addressed to CIMS hospital regarding denial of cashless service, wherein it is stated that the admissibility of the claim would be decided post review of the documents and policy conditions. D-4 (at Page 121) is the Exercise Stress Test Report dated 06.09.2017 i.e. before five months of taking the policy in question, wherein it is stated that TMT (Treadmill test) positive. In the discharge summary (C-4) it is stated that he had complaints of on and off chest pain with uneasiness. Patient consulted to family physician and ECG, TMT was done which was positive for inducible ischemia and advised for CAG. This clearly goes to show that the complainant was having heart problem before taking the insurance policy.

-5-

9.                In D-1, the proposal form he has clearly denied the queries raised in Section C regarding health issues. It is also pertinent to mention here that the complainant/appellant had taken policy on 25.02.2018 and fell ill on 13.04.2018.  The insurance company has also filed the investigation report (D-6) wherein the investigator has clearly stated that the complainant/appellant refused to give the earlier prescriptions/papers, reports regarding his earlier treatment.

10.              Further from the record, we find that the insurance company repeatedly asked the documents from the complainant/appellant but the complainant/appellant did not provide the same to the insurance company. Thereafter vide final reminder letter dated 12 July 2018 (D-6), the insurance company asked the complainant/appellant to produce certain documents such as treating doctor’s certificate regarding duration and history of chest pain, first consultation letter and past treatment record of chest pain. Even then the complainant failed to supply the same to the insurance company. Thereafter the insurance company vide letter dated 16 Oct 2018 (D-5) rejected the claim stating that the claim is not payable under the policy on the basis of the documents submitted.

11.              Thus, evidence available on record clearly indicate that the complainant/appellant was suffering from pre-existing disease and had

 

-6-

suppressed the same while filling up the proposal form in order to obtain the insurance policy in question.

12.              For the foregoing reasons, we are of the considered opinion that the repudiation of claim by the respondent insurance company is justified. The District Commission has committed no error in dismissing the complaint. We do not find any illegality or infirmity in the impugned order passed by the District Commission.

13.              In the result, the appeal is dismissed. No order as to costs.

 

 

             (A. K. Tiwari)                          (Dr. Srikant Pandey)

            Presiding Member                              Member