Order dictated by:

Mr.Anoop Sharma, Presiding Member

1.       Sh.Sucha Singh has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, on the allegations that  the complainant alongwith his wife and two children get themselves insured from Opposite Party No.1 vide policy No.233300/48/2016/1691 which was issued from 26.6.2015 to midnight 25.6.2016 against the premium paid by them and Opposite Party No.2 is TPA of Opposite Party No.1 and as such, availed the services of Opposite Parties, hence they are consumer qua the Opposite Parties. On 19.9.2015, the complainant suddenly fell ill, suffering from perfused sweating and admitted in D.S.Hospital, Sultanwind Road, Amritsar  and remained admitted till 23.9.2015 and he as referred to Ivy Hospital, there he remained admitted on 23.9.2015 and discharged on the same day i.e. on 23.9.2015 after angiography. Due intimation to the Opposite Party No.1 was given and all the original medical bills, reports were supplied to Opposite Parties  for releasing the claim covered under the policy.  But the Opposite Party No.1 vide letter dated 12.4.2016 repudiated the claim of the complainants stating the flimsy ground i.e. the complainant was suffering from DM2 since 7-8 years and CAD, therefore, this particular ailment is found to be present prior to the inception of policy and going beyond the coverage of present policy and denied the claim. But however, the complainant was not suffering from DM2 since 7-8 years not CAD as mentioned in the repudiation letter. It is further submitted that when the complainant fell suddenly ill and admitted in the hospital, he was not suffering any ailment as mentioned in the repudiation letter and this fact was specifically  stated to Opposite Party No.1, but inspite of that the claim was repudiated on false and frivolous grounds. The complainant had spent Rs.62,822/- on his treatment and all the original bills alongwith original reports have already been sent to Opposite Party No.2 at the time of filing the claim to Opposite Party. The repudiation of claim is arbitrary, against the law, principles of natural justice and terms and conditions of the policy.          Vide instant complaint, the complainant has sought the following reliefs.

a)       Opposite Parties  may kindly be directed to reimburse the claim amount of Rs.62,822/- to the complainant with interest @ 24% per annum.

b)      Compensation to the tune of Rs.30,000/- may also be awarded to the complainant.

c)       The cost of the complaint may also be awarded to the complainant.

d)      Any other relief to which the complainant is found entitled under law and equity be also awarded to him. 

Hence, this complaint.

2.       Upon notice, Opposite Party No.1 appeared and contested the complaint by filing  written statement taking preliminary objections therein inter alia that the present complaint is not maintainable, since in the light of terms and conditions of the medi claim policy, it was found that the claim is not payable as per exclusion clause 4.1 which clearly mentioned in para No.1 of the preliminary objections of the written reply filed by the Opposite Party No.1.  On perusal of the claim documents by the competent authority of the Opposite Party, it was found that the complainant was admitted at D.S.Hospital on 19.9.2015, diagnosed as CAD and had undergone conservative management for the same. As it was the first year of policy coverage declared by the complainant in the claim form and inception of the policy was from 20.6.2015 and from the discharge summary of the hospital it was clearly  evident that the complainant was complaining of DM2 since 7-8 years and CAD. Therefore, this particular ailment was found to be present prior to the inception of the policy and going beyond the coverage of  the present policy. Hence, the liability under the present policy was considered inadmissible and claim was repudiated under exclusion clause 4.1 of the policy accordingly vide letter dated 23.5.2016. The disease in question being a pre-existing one and the significant past history of the complainant also being undisclosed, the claim of the complainant was considered as inadmissible due to Non disclosure of material facts and as per the terms and conditions of the present policy. Resultantly, the Opposite Party  intimated the complainant vide letter dated 23.5.2016 clearly stating that the present claim was not payable and the same was repudiated accordingly. Hence, the complainant is not entitled to the relief claimed for. On merits, it was averred that as per the terms and conditions of the policy in question, the claim has to be reported within 48 hours of admission in a hospital, but before discharge from the hospital. Moreover, the claim documents have to be submitted with the Opposite Party  within 7 days of discharge from the hospital, but the complainant failed on both the accounts, hence the complainant has violated the basic terms and conditions of the policy and is not entitled to the relief claimed for.  The Opposite Party  took same and similar pleas as taken up by them in the preliminary objections. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.

3.       On the other hand, none appeared on behalf of Opposite Party No.2, hence Opposite Party No.2 was proceeded against exparte vide order of this Forum.

4.       In his bid  to prove the case, complainant tendered into evidence  affidavit Ex.C-1 in support of the allegations made in the complaint and also produced copies of documents Ex.C2 to Ex.C37  and closed his evidence.

5.       On the other hand, to rebut the evidence of the complainant, the Opposite Party tendered medical record as Ex.Op1/A, affidavit of Gurdeep Singh, DM Ex.OP1/1, copies of documents Ex.Op2/1, Ex.Op3/1 and closed the evidence on behalf of the Opposite Party No.1.

6.       We have heard the ld.counsel for the parties and have carefully gone through the evidence on record.

7.       The complainant has submitted his affidavit Ex.C1 in which he has reiterated the facts as detailed in the complaint and submitted that the complainant alongwith his wife and two children get themselves insured from Opposite Party No.1 vide policy No.233300/48/2016/1691 which was issued from 26.6.2015 to midnight 25.6.2016 against the premium paid by them and Opposite Party No.2 is TPA of Opposite Party No.1 and as such, availed the services of Opposite Parties, hence they are consumer qua the Opposite Parties. On 19.9.2015, the complainant suddenly fell ill, suffering from perfused sweating and admitted in D.S.Hospital, Sultanwind Road, Amritsar  and remained admitted till 23.9.2015 and he as referred to Ivy Hospital, there he remained admitted on 23.9.2015 and discharged on the same day i.e. on 23.9.2015 after angiography. Due intimation to the Opposite Party No.1 was given and all the original medical bills, reports were supplied to Opposite Parties  for releasing the claim covered under the policy.  But the Opposite Party No.1 vide letter dated 12.4.2016 repudiated the claim of the complainants stating the flimsy ground i.e. the complainant was suffering from DM2 since 7-8 years and CAD, therefore, this particular ailment is found to be present prior to the inception of policy and going beyond the coverage of present policy and denied the claim. But however, the complainant was not suffering from DM2 since 7-8 years not CAD as mentioned in the repudiation letter. It is further submitted that when the complainant fell suddenly ill and admitted in the hospital, he was not suffering any ailment as mentioned in the repudiation letter and this fact was specifically  stated to Opposite Party No.1, but inspite of that the claim was repudiated on false and frivolous grounds. The complainant had spent Rs.62,822/- on his treatment and all the original bills alongwith original reports have already been sent to Opposite Party No.2 at the time of filing the claim to Opposite Party. The repudiation of claim is arbitrary, against the law, principles of natural justice and terms and conditions of the policy.

8.       On the other hand, ld.counsel for Opposite Party  has repelled the aforesaid contention of the ld.counsel for the complainant on the ground that on perusal of the claim documents by the competent authority of the Opposite Party, it was found that the complainant was admitted at D.S.Hospital on 19.9.2015, diagnosed as CAD and had undergone conservative management for the same. As it was the first year of policy coverage declared by the complainant in the claim form and inception of the policy was from 20.6.2015 and from the discharge summary of the hospital it was clearly  evident that the complainant was complaining of DM2 since 7-8 years and CAD. Therefore, this particular ailment was found to be present prior to the inception of the policy and going beyond the coverage of  the present policy. Hence, the liability under the present policy was considered inadmissible and claim was repudiated under exclusion clause 4.1 of the policy accordingly vide letter dated 23.5.2016. the disease in question being a pre-existing one and the significant past history of the complainant also being undisclosed, the claim of the complainant was considered as inadmissible due to Non disclosure of material facts and as per the terms and conditions of the present policy. Resultantly, the Opposite Party  intimated the complainant vide letter dated 23.5.2016 clearly stating that the present claim was not payable and the same was repudiated accordingly. Hence, the complainant is not entitled to the relief claimed for.

9.       From the entire above discussion, we have come to the conclusion that the complainant alongwith his wife and two children get themselves insured from Opposite Party No.1 vide policy No.233300/48/2016/1691 which was issued from 26.6.2015 to midnight 25.6.2016 against the premium paid by them and as such, availed the services of Opposite Parties, hence they are consumer qua the Opposite Parties. It is also not disputed that on 19.9.2015, the complainant suddenly fell ill, and remained admitted in D.S.Hospital, Sultanwind Road, Amritsar till 23.9.2015 and he was referred to Ivy Hospital, where  he remained admitted on 23.9.2015 and discharged on the same day i.e. on 23.9.2015 after angiography. Due intimation to the Opposite Party No.1 was given and all the original medical bills, reports were supplied to Opposite Parties  for releasing the claim covered under the policy.  But the Opposite Party No.1 vide letter dated 12.4.2016 repudiated the claim of the complainants stating the flimsy ground i.e. the complainant was suffering from DM2 since 7-8 years and CAD, therefore, this particular ailment is found to be present prior to the inception of policy and going beyond the coverage of present policy and denied the claim. But however, the complainant was not suffering from DM2 since 7-8 years not CAD as mentioned in the repudiation letter. It is further submitted that when the complainant fell suddenly ill and admitted in the hospital, he was not suffering any ailment as mentioned in the repudiation letter and this fact was specifically  stated to Opposite Party No.1, but inspite of that the claim was repudiated on false and frivolous grounds. The complainant had spent Rs.62,822/- on his treatment and all the original bills alongwith original reports have already been sent to Opposite Party No.2 at the time of filing the claim to Opposite Party. On the other hand, though  Opposite Party has produced on record the discharge summary of life insured regarding his admission in the hospital, but they   could not examine any medical practitioner/ doctor who has treated the complainant for the said disease nor the Opposite Party has filed any affidavit of any doctor who has medically treated the insured for the disease prior to taking of the policy. It has been held by the Hon'ble National Commission in case New India Assurance Co.Ltd & Anr Vs. Murari Lal Bhusri 2011(III) CPJ 198 (NC) that where the Insurance company failed to produce any evidence to show that respondent was aware of any pre-existing disease at the time when insurance policy was taken, opposite party was not justified in repudiating the claim of the complainant on the ground of pre-existing disease. It has been held by the Hon'ble Supreme Court of India in case P.Vankat Naidu Vs. Life Insurance Corporation of India & Anr 2011(3) CPC 350 that where no cogent evidence was produced by the respondent to prove that insured/deceased had concealed any fact about his illness or hospitalization, it was held that no material fact was suppressed by the deceased in this respect. It has been held by the Hon'ble State Commission of Punjab in case  Life Insurance Corporation of India Vs. Miss Veenu Babbar and another 2000(1) CLT 619 that repudiation on the basis of history recorded in the hospital records is illegal and arbitrary and the same could not be treated as substantive material to base any decision. Same view has been taken by the Hon'ble National Commission in case Life Insurance Corporation of India & Ors. Vs. Kunari Devi IV(2008) CPJ 89 (NC) that where no document has been produced in support of allegation of suppression of disease at the time of taking policy or revival of policy, history recorded in hospital's bed ticket, not to be treated as evidence as doctor, recording history not examined, suppression of disease not proved, insurer was held liable under the policy. It has further been held by the Hon'ble National Commission in case Sahara India Life Insurance Co. Ltd. & Anr Vs. Hansaben Deeepak Kumar Pandya IV(2012) CPJ 13(NC) that where the opposite party insurance company has failed to produce on record any evidence to show that deceased insured ever consulted doctor for taking treatment of heart disease, the repudiation of the claim on the ground of suppression of material fact is totally illegal. It has been  held by Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in case titled as Ashwani Gupta & Ors. Vs. United India Insurance Company Limited 2009(1) CPC page 561 that where the claim of the complainant has been repudiated on the ground that the assured had pre-existing disease of diabetes mellitus which was not disclosed- apparently, burden to prove lies  upon the insurer- If assured was suffering from pre-existing disease why insurer  had not checked it at the time when proposal form was accepted by its  staff-Respondent has failed to fulfill this requirement before repudiating the claim and the appellant was held entitled  to claim alongwith interest.

10.     In view of the above discussion, we are of the opinion that the Opposite Party  No.1  has wrongly repudiated the claim of the complainant. Consequently, we allow the complaint with costs and the Opposite Party No.1 is directed to pay the claim amount of Rs.62,822/- to the complainant, within one month from the date of receipt of copy of this order failing which the complainant shall be entitled to interest @ 6% per annum on this amount from the date of filing of the complaint till the payment is made to the complainants. Opposite Party No.1 is also directed to pay litigation expenses to the complainant  to the tune of Rs. 2000/-.  Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Announced in open Forum.

Dated: 05.04.2017.