Charanjit Singh, President;
1 The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.
2 The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 12 and 13 against the opposite party on the allegations that the complainant got health benefit mediclaim insurance for himself and his wife from opposite party covering the risk period from 26.8.2016 to 25.8.2017 and he is the consumer as provided under the Act. The complainant unfortunately fell ill and was hospitalized at Life Care Hospital, Amritsar from 8.8.2017 till 13.8.2017 and the treatment cost of the said hospitalization and medicine and investigation came to Rs. 70,024/-. The opposite party was immediately informed about the said hospitalization and the cashless basis and it is worth mentioning over here that the sum insured for the medical benefit is for Rs. 2 Lacs. Opposite party instead of making the said payment repudiated the cashless claim of the complainant on the frivolous grounds vide their repudiation letter dated 10.8.2017 that the complainant was having diabetes which infact was totally wrong and against the true facts. The complainant later on filed the regular claim with the opposite party for the said hospitalization and claim which was verbally rejected by the opposite party citing the repudiation early made by them. The complainant made representations to the opposite party against the said wrongful repudiation but to no effect. No policy conditions were ever supplied to the complainant by the opposite party. The complainant has never suppressed anything from the opposite party. The aforesaid acts of the opposite party in repudiating the genuine claim of the complainant on frivolous grounds is an act of deficiency in services, malpractice, unfair trade practice. The complainant has prayed for the following reliefs against the opposite party:-
(a) The opposite party be directed to pay an amount of Rs.70,024/- alongwith interest @12% from 13.8.2017 till realization.
(b) The opposite party be directed to pay the compensation of Rs.50,000/- to the complainant.
(c) The opposite party be directed to pay the adequate cost of litigation.
3 After formal admission of the complaint, notice was issued to Opposite Party and opposite party appeared through counsel and filed written version and contested the complaint by interalia pleadings that the present complaint is gross abuse of process of law and filed without any cause of action. The present complaint is not tenable under the provision of law. The complainant has suppressed material facts and information which are essential and necessary for the adjudication of this matter the complainant has not approached this commission with clean hands. The complaint is bad due to acts, deeds, conduct and acquiescence of the complainant. The present complaint is very complex in nature, involves intricate questions of facts and law and requires perusal of voluminous documentary evidence for determination of dispute in hand. It is not possible to weigh the evidence properly in summary procedure as followed by this commission. Therefore, this complaint may please be returned to competent civil court for proper adjudication of the matter through a full fledged trial. The complainant has got no cause of action to file and maintain the present complaint against the opposite party. The complainant has approached the opposite party for Health Policy for himself and his wife. Accordingly, the opposite party explained the entire terms and conditions to the complainant. After understanding the terms and conditions, the complainant obtained insurance policy No. OG-17-1210-8408-00000008 w.e.f. 26-Aug-2016 to 25-Aug-2017 subject to policy terms and conditions. Thereafter, the insured / complainant had intimated 2 claims with the opposite party dated 6.5.2017 bearing claim No. OC-18-1002-8408-00000217 and thereafter, another claim by submitting claim documents in support with the claim form reimbursement of expenses incurred by the complainant/ insured on account of alleged hospitalization and medical expenses caused due to alleged hospitalization for a period from 8.8.2017 to 13.8.2017. The said claim was registered on 10-Aug-2017 as claim No. OC-18-1002-8408-00000814 by the opposite party. The claim of the complainant was duly processed by the opposite party by way of minutely going through the hospitalization details of the insured by examining the details of hospital records, register and treatment case history of the complainant/ insured and collected the details and related documents. The opposite party after scrutinizing documents submitted by the insured/ complainant alongwith hospital records and treatment details, observed as follows:
(i) Before the filing of present claim dated 10.8.2017, the complainant Gurbax Singh had filed a claim dated 6.5.2017 bearing claim No. OC-18-1002-8408-00000217, for admission in Care & Cure Medicity Hospital. However, it was found that the complainant was suffering from diabetes type II for last 10-12 years and which was duly mentioned in the hospital patient record provided by the complainant at that time and accordingly, the claim of the complainant was denied on the said observations and also the fact that the complainant had concealed/ suppressed material facts from the opposite party.
(ii) Further, this answering opponent observed that the complainant had again concealed/ suppressed the facts with regard to previous claim from this answering opponent. And moreover, in the present complaint also, the hospital patient record of Life Care Hospital duly shows that the complainant is suffering from CAB/DM-II/HTN, but these facts again have been concealed, therefore, the complainant is not entitled for any claim, as the complainant is suffering from pre-existing disease and which were and is in his knowledge.
Insurance policy is a contract and both the parties are under obligation to obey/ fulfill all the terms and conditions of the same in strict sense of the words written therein. As the terms and conditions of the policy are sacrosanct, the claim arrived is also processed within the precincts of the Policy only. As per clause C1 of policy terms and condition pre-existing disease is not covered under the policy. The opposite party rightfully rejected the cashless facility to the complainant. The complainant has concealed the material facts from this commission about his previous hospitlsiation details and also the pre-existing details of diseases diagnosed to complainant and has therefore, not come to the commission with clean hands, therefore, he is not entitled for any claim. As per terms and conditions of the policy, the complainant is not entitled for reimbursement for hospitalization, if he/she is diagnosed for any ailment which is or due to/ connected with pre-existing disease. In this case, the cashless claim was filed by the complainant and after going through the medical record, the cashless facility was denied vide letter dated 10.8.2017 and no reimbursement of the claim was ever filed by the complainant. There is no deficiency in service or unfair trade practice on the part of the Insurance Company to invoke the jurisdiction of this commission. The opposite party has denied the other contents of the complaint and prayed for dismissal of the same.
4 To prove the case of the complainant, Ld. counsel for the complainant tendered in evidence affidavit of complainant Ex. C-1, copy of heath card Ex. C-2, copy of the bill of hospital Ex. C-3, copy of the repudiation letter Ex. C-4, death certificate Ex. C-5, affidavit or Rattanjit Kaur Ex. C-6, copy of the bank passbook Ex. C-7 and closed the evidence. On the other hands, Ld. counsel for the opposite party tendered in evidence affidavit of Sh. Sarpreet Kaur Ahluwalia, Asstt. Manager Ex. OP1/A, copy of the power of attorney Ex. OP2, copy of the policy Ex. OP3, copy of terms and conditions Ex. OP4, copy of the proposal form Ex. OP5. Dr. Aprajit Sareen was examined and he placed on record treatment record of Gurbax Singh Ex. OP2/A
5 We have heard the Ld. counsel for the parties and have gone through the record on the file.
6 Ld. counsel for the complainant contended that the complainant got health benefit mediclaim insurance for himself and his wife from the opposite party covering the risk period from 26.8.2016 to 25.8.2017. The complainant fell ill and was hospitalized at Life Care Hospital, Amritsar from 8.8.2017 till 13.8.2017 and the treatment cost of the said hospitalization and medicine and investigation came to Rs. 70,024/-. The sum insured for the medical benefit is for Rs. 2 Lacs. Opposite party instead of making the said payment repudiated the cashless claim of the complainant on the frivolous grounds vide their repudiation letter dated 10.8.2017 that the complainant was having diabetes which infact was totally wrong and against the true facts. The complainant later on filed the regular claim with the opposite party for the said hospitalization and claim which was verbally rejected by the opposite party citing the repudiation early made by them. The complainant made representations to the opposite party against the said wrongful repudiation but to no effect. No policy conditions were ever supplied to the complainant by the opposite party. The complainant has never suppressed anything from the opposite party and prayed that the present complaint may be allowed.
7 Ld. counsel for the opposite party contended that the complainant has suppressed material facts and information which are essential and necessary for the adjudication of this matter the complainant has not approached this commission with clean hands. The present complaint is very complex in nature, involves intricate questions of facts and law and requires perusal of voluminous documentary evidence for determination of dispute at hand. It is not possible to weigh the evidence properly in summary procedure as followed by this commission. Therefore, this complaint may please be referred to competent civil court for proper adjudication of the matter through a full fledged trial. The complainant has approached the opposite party for Health Policy for himself and his wife. Accordingly, the opposite party explained the entire terms and conditions to the complainant. After understanding the terms and conditions, the complainant obtained insurance policy No. OG-17-1210-8408-00000008 w.e.f. 26-Aug-2016 to 25-Aug-2017 subject to policy terms and conditions. Thereafter, the insured / complainant had intimated 2 claims with the opposite party dated 6.5.2017 bearing claim No. OC-18-1002-8408-00000217 and thereafter, another claim by submitting claim documents in support with the claim form reimbursement of expenses incurred by the complainant/ insured on account of alleged hospitalization and medical expenses caused due to alleged hospitalization for a period from 8.8.2017 to 13.8.2017. The said claim was registered on 10-Aug-2017 as claim No. OC-18-1002-8408-00000814 by the opposite party. The claim of the complainant was duly processed by the opposite party by way of minutely going through the hospitalization details of the insured by examining the details of hospital records, register and treatment case history of the complainant/ insured and collected the details and related documents. The opposite party after scrutinizing documents submitted by the insured/ complainant alongwith hospital records and treatment details, observed as follows:
(i) Before the filing of present claim dated 10.8.2017, the complainant Gurbax Singh had filed a claim dated 6.5.2017 bearing claim No. OC-18-1002-8408-00000217, for admission in Care & Cure Medicity Hospital. However, it was found that the complainant was suffering from diabetes type II for last 10-12 years and which was duly mentioned in the hospital patient record provided by the complainant at that time and accordingly, the claim of the complainant was denied on the said observations and also the fact that the complainant had concealed/ suppressed material facts from the opposite party.
(ii) Further, this answering opponent observed that the complainant had again concealed/ suppressed the facts with regard to previous claim from this answering opponent. And moreover, in the present complaint also, the hospital patient record of Life Care Hospital duly shows that the complainant is suffering from CAB/DM-II/HTN, but these facts again have been concealed, therefore, the complainant is not entitled for any claim, as the complainant is suffering from pre-existing disease and which were and is in his knowledge.
Insurance policy is a contract and both the parties are under obligation to obey/ fulfill all the terms and conditions of the same in strict sense of the words written therein. As the terms and conditions of the policy are sacrosanct, the claim arrived is also processed within the precincts of the Policy only. As per clause C1 of policy terms and conditions, pre-existing disease is not covered under the policy. The opposite party rightfully rejected the cashless facility to the complainant. The complainant has concealed the material facts from this commission about his previous hospitalization details and also the pre-existing details of diseases diagnosed to the complainant and has therefore, not come to the commission with clean hands, therefore, he is not entitled for any claim. As per terms and conditions of the policy, the complainant is not entitled for reimbursement for hospitalization, if he/she is diagnosed for any ailment which is or due to/ connected with pre-existing disease. In this case, the cashless claim was filed by the complainant and after going through the medical record, the cashless facility was denied vide letter dated 10.8.2017 and no reimbursement of the claim was ever filed by the complainant. There is no deficiency in service or unfair trade practice on the part of the Insurance Company to invoke the jurisdiction of this commission and prayed for dismissal of the same.
8 The objection raised by the opposite party is that in the present complaint intricate question of laws and facts are involved, which cannot be adjudicated before this Commission. In case we go through the pleadings of the parties, that question involved in the present case is that the patient is known case of DM TYPE II and to prove its contention the opposite party examined witnesses and their cross examinations have been done. We do not find any complicated questions of law and facts are involved, which cannot be adjudicated by this Commission. In this regard, we are fortified by the judgment of ‘Dr.J.J.Merchant and Ors. V. Shrinath Chaturvedi’ 2002(6) SCC 635, wherein it was held that the State Commission and District Commissions are headed by retired High Court Judges and Officers of District Judge level and in our view, this is not such a case which cannot be decided by the ‘Consumer Fora' after obtaining evidence and if need be after getting an expert opinion.
9 The opposite party has repudiated the claim of the complainant on the ground that the complainant was known case of DM TYPE II for the last 10 to 12 years on regular treatment and the complainant has suppressed facts regarding the same from the opposite party at the time of taking the policy. According to opposite party the complainant was suffering from pre existing disease and which is in his knowledge. To prove the same the opposite party tendered in evidence Dr. Vaneet Sehgal of Life Care Hospital who proved on record Ex. OP1 Medical record of complainant showing history of DM TYPE II, HTN Post CABG and CAD. But in his cross examination the said doctor has admitted that I do not maintain the record of OP1. There are many reasons for CVA It is not necessary that CVA is caused by diabetes. This patient is not diagnosed CVA due to diabetes. He also admitted in his cross examination that there is nothing on the file Ex. OP1 that where the patient earlier took the treatment of diabetes. I am neuro-physician and not the endocrinologist. Further the opposite parties have examined other witness i.e. Dr. Nikhil Monga who stated in his statement that I was treating doctor of patient Gurbax Singh whose treatment record is Ex. OP2/A. the patient was known case of DM Type II for the last 10 to 12 years on regular treatment with the history of bypass CABG one year back. The patient was admitted in the hospital for the treatment of low respiratory disorder. But in his cross examination the said witness/doctor has admitted that I have not prepared the record myself which is OP2/A. I do not know from where the patient was taking the treatment DM GYPE II. There is no anti diabetic drug prescribed by me during my stay on the treatment record. As such, the statements and their cross examination do not corroborate the case of the opposite party. The diabetes is not a material disease, therefore, non disclosure thereof is not a concealment. We draw support from Life Insurance Corporation of India Vs. Sushma Sharma from II (2008) CPJ 213 wherein Hon'ble State Commission has held as under:-
“So far as hypertension and diabetes is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer 14 from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.
We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease. Moreover, as per proposal form Ex. OP5 the date of birth of Gurbkah Singh is 1.1.1961 and he was more than 45 years age at the time of taking the policy and it was the duty of the opposite partyn to medically examine the insured before issuance of insurance policy in question. In support of his contention Ld.counsel for the complainant placed reliance upon I.R.D.A.I Rules and Instructions with regard to thorough medical examination if the insured is more than 45 years which is reproduced as under:-
“As per instructions issued by the Insurance Regulatory and Development Authority of India (IRDAI), it was bounded duty of the insurer to put insured to thorough medical examination in case Mediclaim insured was more than 45 years and if insurance company failed to do so then insurance company has no right to decline the insurance claim on account of non disclosure of the facts of pre existing disease when the policy was taken. The above observations is supported by law cited in SBI General Insurance Company Limited Vs. Balwinder Singh Jolly” 2016(4) CLT 372 of the Hon’ble State Commission, Chandigarh.”
10 Ld. counsel for the complainant has contended that the opposite party has not explained the terms and conditions of the policy in question to the complainant and same are not supplied or explained to him at the time of inception of insurance policy. He placed reliance on citation 2001(1)CPR 93 (Supreme Court) 242 titled as M/s Modern Insulators Ltd Vs The Oriental Insurance Company Ltd, wherein Hon’ble Apex Court held that clauses which are not explained to complainant are not binding upon the insured and are required to be ignored.
11 In such a situation the repudiation made by the Opposite Party regarding the genuine claim of the complainant appears to have been made without application of mind. It is usual with the insurance company to show all types of green pesters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon‟ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This „take it or leave it‟, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and finding ways and means to decline claims. In similar set of facts the Hon‟ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
12 During the pendency of the present complaint, Gurbax Singh original complainant in this case has since died and after his death Harjinder Kaur is widow, Mr. Ratanjit Singh & Mr. Charanjit Singh are his sons and Ms. Gurjit Kaur, Ms. Harjit Kaur, Ms. Rajinder Kaur are his daughters and they have been brought on record.
13 In view of above discussion, the present complaint is allowed and opposite party is directed to pay Rs. 70,024/- to the complainants. The complainants have been harassed by the opposite party unnecessarily for a long time. The complainants are also entitled to Rs. 8,000/- as compensation on account of harassment and mental agony and Rs 7,000/- as litigation expenses. The complainants are entitled to the awarded amount as follows:-
Harjinder Kaur : 20%
Ratanjit Singh : 16%
Charanjit Singh : 16%
Gurjit Kaur : 16%
Harjit Kaur : 16%
Rajwinder Kaur : 16%
Opposite Party is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainants are entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation. Copy of order will be supplied by District Consumer Disputes Redressal Commission, Amritsar to the parties as per rules. File be sent back to the District consumer Disputes Redressal Commission, Amritsar.
Announced in Open Commission
03.11.2022
