Haryana

StateCommission

A/274/2018

APOLLO MUNICH HEALTH INSURANCE CO. - Complainant(s)

Versus

BALJIT SINGH - Opp.Party(s)

SACHIN OHRI

13 Aug 2024

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

 

                                                Date of Institution:05.03.2018

                                                         Date of Final Hearing:11.07.2024

                                                     Date of Pronouncement:13.08.2024

 

First Appeal No.274 of 2018

 

Apollo Munich Health Insurance, I Labs Centre, 2^nd & 3^rd Floor, I Labs Centre, Plot No. 404-405, Udyog Vihar, Phase-III, Gurgaon and First Floor, SCF-19, Sector 14, Gurgaon through Deepti Rustagi, Vice President Legal ad Compliance, Authorized signatory.                              

          .....Appellant

Versus

Baljit Singh son of Zile Singh, Resident of Village: Risalu Tehsil and District-Panipat

 

Argued by:-       Mr. Sachin Ohri, counsel for appellant.

None for respondent.

 

 

CORAM:             Mr. Naresh Katyal, Judicial Member

                             Mr. S.C. Kaushik, Member

 

                                                ORDER

NARESH KATYAL, JUDICIAL MEMBER:-

                    In this appeal; legality of order dated 30.01.2018, passed by learned District Consumer Disputes Redressal Commission-Panipat (In short “District Consumer Commission”) has been questioned by insurer. Vide this impugned order dated 30.01.2018; Complaint No. 50 of 2016, titled as Baljit Singh Vs. Appollo Munich Health Insurance Company Ltd. and another has been allowed and OP’s-insurer/appellant has been directed to make payment of Rs.95,138/- to complainant-Baljit Singh and also to pay Rs.4400/- for mental harassment caused to complainant and litigation expenses. 

2.                Factual matrix: Complainant-Baljit Singh obtained Health Insurance policy which was valid from 17.06.2015 to 16.06.2016 from OP/appellant. Sum assured was Rs. 3,00,000/- and risk of all members of complainant’s family was covered.  Premium amount of Rs. 8890/- was paid under this policy.  Complainant’s son- Anu Malik felt pain in his left knee in October-2015 and was taken to Doctors of Raghudeep Hospital-Panipat, where doctors advised him for MRI. After MRI of left knee of Anu Malik; doctors advised him for operation of left knee.  Complainant intimated OP/insurer vide intimation No. 75805 dated 29.10.2015 and his son (Anu Malik) was operated on his left knee. Rs. 95,138/- were allegedly spent by complainant.  Complainant, in order to get benefit of policy, contacted insurer-appellant and sent original bills to it.  However, insurer/appellant-repudiated complainant’s claim on ground that: knee problem/disease of Anu Malik is/was about ‘one and half year old’ which did not cover under policy.  Complainant’s sent legal notice dated 05.01.2016 to OP/appellant. It was not replied.  OP/appellant did not give single penny to complainant. By alleging negligent act and conduct of OP/appellant/insurer and deficiency in its service; complaint has been filed thereby seeking direction against OP/appellant/insurer to pay: Rs. 95,138/- along with 12% p.a. and Rs. 50,000/- on account of compensation and Rs. 10,000/- on account of litigation expenses. 

3.                OP/appellant-insurer resisted complaint.  In its written version; it is pleaded that: complaint is vexatious, misconceived and based upon misrepresentation of facts.  It is not maintainable.  No cause of action has arisen against OP/appellant-insurer.  Complainant filed claim with OP/appellant-insurer for treatment of disease/symptoms (of his son), which started before start of policy in question.  Pre-existing condition will not be covered, until 36 months of continuous coverage of policy with OP/appellant-insurer.  Disease/symptoms had started, one and half years back, policy started on 17.01.2015. Claim has been repudiated by OP/insurer/appellant under section 5 (c) of insurance policy and repudiation was informed to complainant.  There is neither any deficiency in service of OP/appellant-insurer, nor any unfair trade practice.  It is pleaded that: complainant’s son (Anu Malik) was suffering from ACL tear, before inception of policy and this material fact was never disclosed in enrolment form (Section 3), while taking policy.  In enrolment form it is mentioned that: Pre-Existing conditions has a waiting period for 36 months for any disease, illness or condition that existed prior to taking this policy.  It is admitted that: policy was issued for period between 17.06.2015 to 16.06.2016.  It is pleaded that: complainant submitted claim form for reimbursement of expenses incurred upon treatment of his son (Anu Malik).  It is pleaded that: treatment of Anterior Cruciate Ligament (ACL) tear of Anu Malik was done at Raghudeep Hospital-Panipat and estimated duration of stay was from 01.01.2015 to 03.11.2015.   On receipt of claim form and documents from complainant, it was found that claim is not payable under policy as treatment of disease/symptoms had started one and half year back, and policy start date is 17.06.2015.  Claim was repudiated and intimation of repudiation had been sent to complainant vide letter dated 04.01.2016.     

4.                Parties led their evidence, oral as well as documentary.  On analyzing the same learned District Consumer Commission-Panipat vide order dated 30.01.2018 has accepted the complaint in a manner referred hereinabove. Feeling dis-satisfied; insurer/appellant has filed instant appeal.  In proceedings of this appeal; vide order dated 26.04.2018; implementation of impugned order has been stayed.  On various dates fixed in this appeal from 20.11.2019, till 11.07.2024, (barring one date i.e. 11.07.2023); nobody represented respondent/complainant.  Final arguments in appeal were heard on 11.07.2024 and even on that date; complainant remained unrepresented.  It would be apt to mention that: Sh. Parveen Sharma, Advocate has filed memo of appearance on behalf of complainant on 27.02.2019.  It would legally imply that complainant (Baljit Singh) has knowledge about filing of this appeal by insurer.  Still, in his wisdom he has chosen, not to appear in this appeal’s proceedings.  

5.                Learned counsel for appellant/insurer, while contending for acceptance of this appeal has urged that: impugned order dated 30.01.2018 passed by District Consumer Commission-Panipat is grossly illegal on factual front.  It is contended that: son (Anu Malik) of complainant was already suffering from disease/ailment on his left knee, one and half year prior to inception of Health Insurance Policy, which started on 17.06.2015. This fact, as per contention, is proved from text of Discharge Slip and Case Summary of (Anu Malik). It is urged that this was the specific defense taken by insurer/appellant in its written version, which was proved too.  Learned District Consumer Commission, despite noticing this fact, has erred in law in not appreciating it in proper legal perspective.  It is urged that: per-existing disease is not covered, until 36 months of continuous coverage of policy with OP/appellant-insurer and this aspect is specifically mentioned in the terms and conditions of policy.  On these submissions, learned counsel for insurer/appellant has contended that insurer-appellant has no subsisting liability, under policy to reimburse amount of expenses allegedly incurred on left knee treatment/surgery of Anu Malik-son of complainant, so conducted at Raghudeep Hospital-Panipat from 01.11.2015 (date of admission in said Hospital) to 03.11.2015 (dated of discharge from said Hospital).  It is urged that exclusion clause contained in policy in question is attracted and insurer-appellant has rightly repudiated complainant’s claim vide letter 04.01.2016, in strict adherence to exclusion clause.     

6.                Admitted facts are that: complainant-Baljit Singh had obtained Health Insurance Policy Ex.R-2 from appellant, which has currency period from 17.06.2015 to 16.06.2016.  Sum assured under policy Rs. 3,00,000/- and entire family of complainant was covered.  Complainant’s son had obtained medical treatment regarding his left knee injury from Raghudeep Hospital-Panipat.  He was admitted in said hospital on 01.11.2015 and discharged on 03.11.2015.  On said treatment of his son; complainant had spent Rs. 95,138/-.  Further admitted fact is that complainant lodged claim on basis of Health Insurance Policy with appellant-insurer which was repudiated by OP/appellant vide its letter Annexure R-4 dated 04.01.2016.  Following is the reason of repudiation as mentioned in said letter:-

          “The submitted claim is for the treatment of a disease/symptoms which has been started before the start of the policy with us.  As per the terms and condition of the policy any pre-exiting condition will not be covered until 36 months of continuous coverage with us.  The disease/symptom started on one half years back and the policy start date is 17.06.2015.  Hence, we regret to inform you that your claim is repudiated under 5 (d) of the policy.”    

Meaning thereby, the insurer/appellant has invoked exclusion clause of its Health Insurance Policy held by complainant.  It is settled law that: burden to prove exclusion from policy, lay upon insurer alone.  It is trite to say that wherever such an exclusionary clause is contained in a policy, it would be for the insurer alone to show that the case falls within the purview of such clause.  In case of ambiguity, the contract of insurance has to be construed in favour of insured.  Reliance in this regard can be placed on judgment of Hon’ble Supreme Court in case titled as “National Insurance Co. Ltd. Vs. Vedic Resorts and Hotels Pvt. Ltd.” Civil Appeal No. 4979 of 2019 decided on 17.05.2023, and also on decision of Hon’ble Apex Court in case titled as ‘National Insurance Company Limited Vs. Ishar Das Madan Lal” (2007) 4 SCC 105. 

7.                While keeping in mind, the above referred legal adage, now moot question arises: As to whether insurer-appellant herein has rightly discharged its burden of proof from its exclusion from policy in question or not?  Answer to this moot proposition is in affirmative.  Reason in this regard is obvious.   Treatment of Anu Malik (son of complainant) was for left knee.  Injury on left of Anu Malik was already one and half year old when he landed in Raghubir Hospital-Panipat on 01.11.2015.  Phraseology of  discharge slip and case summary pertaining to Anu Malik, expressly and in unambiguous  terms recites under head ‘history of illness that: “patient (Anu Malik) has complained feeling of instability of left knee-pain and swelling left knee following minor twist.  Injury left knee about one and half year back.  He had sustained this injury due to jumping from height. He is having difficulty going downstairs and running”.

8.                Health Insurance Policy in question had commenced on 17.06.2015.  One and half year, down line, would be somewhere around January-2014.  Meaning thereby, injury on left knee of complainant son was pre-existing at that time, when health insurance policy got light of it day and begun to commence. Still, in his wisdom complainant has not mentioned a word about it in the enrolment form.   Instead, complainant has confirmed the declaration on behalf of all persons to be insured by confirming that: “I and other members proposed to be insured under this policy are in good health and have not suffered in last five years from any major disease/dis-order/ailment/deformity (other than infrequent common cold, fever, loose motion, headaches, acidity, high cholesterol, asthma, thyroid problem, diabetes without any complication or hypertension without any complication). I/We are neither availing any treatment medical or surgical nor attending any follow up for any disease/condition/ailment/injury/addiction not specified in this declaration.”  It was required on behalf of complainant is specify in exact terms about one and half year old knee injury of his son (Anu Malik) in the enrolment form but he (complainant) had withheld this fact, for reason best known to him.  Courts of law, over the centuries have frowned upon the litigants, who tend to approach it, with suppression of material facts.  Such litigants are not entitled to any equitable relief, owing to their malafide intention, accentuated by concealment of material facts. There can be no exception so far as present case is concerned where complainant-Baljeet Singh in guilty of concealment of material facts. It has been held by Hon’ble Apex Court in case titled as “Reliance Life Insurance Company Ltd. and Others Vs. Rekhaben Nareshbhai Rathod” 2019 (2) R.C.R. (Civil) 909 that: Suppression of facts made in proposal form will render Insurance Policy voidable by the Insurer.    In the case in hand insurer/appellant has rightly exercised its powers, within the ambit of insurance policy in question, to repudiate complainant’s claim.  There is absolutely no illegality committed by insurer/appellant, on that front.  

9.                Exclusions as enumerated in Health Insurance Policy under Clause 5 (c) reads as follows:-

          “pre-existing conditions will be covered after 36 months continuous coverage have elapsed since inception of the first Easy Health Group Insurance Policy with us.”    

                   Since period of 36 months had not elapsed after inception of health insurance policy in question, after its start date (17.06.2015), viz.-a-viz. left knee injury of complainant’s son which occurred somewhere in/around January-2014, therefore, insurer/appellant has rightly invoked the exclusion clause. Procedure on left knee of complainant son (Anu Malik) was performed in six months of operation of Health Insurance Policy. Repudiation of claimant’s claim for reimbursement of amount of expenses incurred on treatment of his son Anu Malik through its rejection letter dated 04.01.2016-Annexure R-4, was not a fallacy committed by insurer/appellant. 

10.              It is well settled legal adage that: Insurance policy is a contract between the parties.  Once, terms and conditions of policy are accepted, they acquire binding force between the parties. Hon’ble Apex Court in case titled as “United India Insurance Co. Ltd. Vs. M/s Harchand Rai Chandan Lal, IV (2004) CPJ 15 (SC)= AIR2004 Supreme Court 4794, has ruled “ that terms of policy have to be construed as it is and we cannot add and subtract something.  Howsoever liberally we may construe the policy but we cannot take liberalism to the extent of substituting the words which are not intended.”  This ratio of law is attracted to the facts of this case and while applying the same, the only inescapable conclusion is that: the complainant deserves to be non-suited and he is accordingly non-suited.             

11.              Learned District Consumer Commission-Panipat, despite having noticed all above facts in para 7 of its impugned order dated 30.01.2018, has not divulged into the same at all, critically and subjectively.  Absolutely no reason has been mentioned by Learned District Consumer Commission-Panipat, as to why and how, it has deviated from proved stand of insurer/appellant regarding its exclusion from policy.  In firm opinion of this commission; insurer/appellant has no liability under policy towards complainant in wake off given factual scenario. Consequently, it is held that: impugned order dated 30.01.2018, passed by Learned District Consumer Commission-Panipat suffers from patent illegality and perversity.  It is unsustainable in law and cannot be allowed to hold its light, any more.   Impugned order dated 30.01.2018 is accordingly set aside by allowing this appeal of insurer-appellant.  As a flowing consequence, the complainant’s complaint is dismissed.   

12.              Statutory amount of Rs. 25,000/-deposited by insurer/appellant  while filing its appeal (F.A. No.274 of 2018), be refunded to it after due identification and verification as per rules.  Registry of this Commission is accordingly directed.  

13.              Application(s) pending, if any stands disposed of in terms of the aforesaid judgment.

14.              Copy of this judgment/order be provided to all parties, free of cost, as mandated by the Consumer Protection Act, 1986/2019. This judgment/order be also uploaded forthwith on website of this Commission for perusal of parties.

15.              File of this appeal be consigned to record room.

                                    

Date of pronouncement: 13^th August, 2024

 

 

 

                             S.C. Kaushik                         Naresh Katyal                                          Member                                 Judicial Member

Addl. Bench                         Addl. Bench