DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SANGRUR.
Complaint No. 245
Instituted on: 01.06.2017
Decided on: 27.10.2017
Surinder Singh son of Sardar Singh, resident of House No.149, Patiala Road, Ajit Nagar, Ward No.3, Sunam, Distt. Sangrur.
…Complainant
Versus
1. Canara Bank, Near Mata Modi Chowk, Sunam, Distt. Sangrur through its Branch Manager.
2. Apollo Munich Health Insurance Company Ltd. Central Processing Center, 2nd and 3rd Floor, ILabs Center, Plot No.404-405, Udyog Vihar, Phase-III, Gurgaon through Manager.
3. Apollo Munich Health Insurance Company Limited, Corporate Office: First Floor, SCF-19, Sector 14, Gurgaon through Director.
4. Apollo Munich Health Insurance Company Ltd. Regd. Office: Apollo Hospitals Complex, Jubilee Hills, Hyderabad through M.D.
..Opposite parties.
For the complainant : Shri Amit Aggarwal, Adv.
For Opp.party No.1 : Shri Gagandeep Bhagria, Adv.
For Opp.Party No.2to4: Shri Vinay Jindal, Adv.
Quorum: Sukhpal Singh Gill, President
Sarita Garg, Member
Vinod Kumar Gulati, Member
Order by : Sukhpal Singh Gill, President.
1. Shri Surinder Singh complainant (referred to as complainant in short) has preferred the present complaint against the opposite parties (referred to as OPs in short) on the ground that the complainant availed the services of the OPs number 2 to 4 through OP number 1 by getting a health insurance policy for Rs.5,00,000/-, as the complainant is maintaining a saving account with the OP number 1 and further the complainant was entitled for Rs.50,000/- on account of optional critical illness. The case of the complainant is that on 20.10.2016, the complainant felt some problem in his abdomen and ultrasound was conducted on the complainant and after that he was advised to consult with the doctors of reputed institution like DMC, PGI, CMC etc. , as such on 21.10.2016 the complainant consulted Dr. Jaspal Singh of Dayanand Medical College and Hospital Ludhiana, where tests were conducted and was found a case of infection in abdominal and as such the complainant admitted in the DMC Hospital Ludhiana on 24.10.2016 and remained admitted upto 2.11.2016, where he spent an amount of Rs.85,136/-. It is further averred that after discharge from the hospital, the complainant submitted all the documents to the OPs, but the complainant received a letter in the month of November, 2016 stating that the OPs number 2 and 3 have terminated the policy. Lastly, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.85,136/- along with interest @ 18% per annum and further claimed compensation and litigation expenses.
2. In reply filed by OP number 1, legal objections are taken up on the grounds that the complainant is estopped by his own act and conduct from filing the present complaint, that the complaint is not maintainable and that this Forum has got no jurisdiction to hear and try the present complaint. It is stated further that as per the policy it is a condition precedent that the customer is to execute the necessary documents and forms prescribed for that purpose and as per the terms of health policy, the customer is to given an undertaking that he is not suffering from any heart disease or any such like other disease which may be fatal to the life of the customer. It is further stated that the OP has every right to cancel the policy. As at the time of purchase of the policy, the complainant did not disclose about his disease. It is stated further that vide letter dated 8.11.2016 the policy of the complainant was cancelled. The other allegations levelled in the complaint have been denied in toto.
3. In reply filed by OPs number 2 to 4, preliminary objections are taken up on the grounds that the insurance is done on the basis of doctrine of uberrima fides and there was no reason for replying the Ops to verify the correctness of the facts stated in the application, that the complaint is not maintainable, that the complainant has concealed the material facts and documents from the Forum, however, it is admitted that the OPs had issued the policy in question bearing number 12100/12001/2015/A005425 for the period from 17.8.2016 to 16.8.2017 and all the documents containing the policy kit were supplied to the complainant. Further case of the OPs is that on 25.10.2016, a cashless request was received from Dayanand Medical College and Hospital for patient Surinder Singh who got admitted with c/o PSO Abscess and probable diagnosis of PSO with HTN with DMC and estimated duration of stay of 3 days and estimated cost of Rs.42800/-. It is stated further that as per the available documents, the Ops observed that there is a non disclosure of heart disease, which may have an impact on policy and hence cashless approval was not possible. It is stated further that the policy was terminated on 8.12.2016 and was subsequently cancelled as per the terms and conditions of the policy. On merits, it is admitted that the complainant had obtained the policy in question. However, it is denied that the policy was terminated wrongly as the same was done as per the terms and conditions of the policy. The other allegations levelled in the complaint have been denied in toto.
4. The learned counsel for the complainant has produced Ex.C-1 to Ex.C-15 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OP number 1 has produced Ex.OP1/1 to Ex.OP1/2 copies of documents and affidavit and closed evidence. The learned counsel for OPs number 2 to 4 has produced Ex.OP2to4/1 to Ex.OP2to4/8 copies of documents and affidavit and closed evidence.
5. We have carefully perused the complaint, version of the opposite parties and evidence produced on the file and also heard the arguments of the learned counsel for the parties. In our opinion, the complaint merits acceptance, for these reasons.
6. It is an admitted fact between the parties that the complainant was insured with the Ops number 2 to 4 through Op number 1 under mediclaim insurance policy for Rs.5,00,000/-. It is further an admitted fact that the complainant remained admitted in Dayanand Medical College and Hospital Ludhiana for the period from 24.10.2016 to 2.11.2016, where he spent an amount of Rs.85,136/- on his treatment, as is evident from the copy of the bills on record as Ex.C-16 to Ex.C-64 and thereafter the complainant submitted all the bills to the OPs number 1 to 3 for reimbursement of the claim amount. But, the grievance of the complainant is that the OPs repudiated the claim being not payable on the ground that the policy was terminated by the Ops on the ground that the complainant did not disclose the material facts as the complainant was suffering from heart disease CAD, CVD. The learned counself or the Ops number 1 to 3 has further contended that as per the available documents, the Ops observed that there was a non disclosure of the heart disease, which may have an impact on policy and hence cashless approval was not granted and thereafter the Ops terminated the insurance policy on 8.12.2016. The learned counsel for the OPs has contended vehemently that the claim has rightly been rejected as the complainant had concealed material facts of heart disease suffered by him.
7. It is worth mentioning here that though the stand of the Ops number 1 to 3 is that the claim is not payable to the complainant on the ground that he was suffering from pre existing disease, such as, heart disease, but no conclusive proof showing that the complainant was earlier suffering from any such disease has been produced by the Ops on record. There is no explanation from the side of the Ops number 1 to 3 that why they have not produced such evidence showing that the complainant was earlier suffering from any such heart disease. It is worth mentioning here that it is not open for the Ops number 1 to 3 to reject such a claim of the complainant without producing any cogent, reliable and trustworthy evidence on record. As such, we feel that the ends of justice would be met if the OPs number 1 to 3 are directed to pay to the complainant an amount of Rs.85,136/- spent by him on his treatment.
8. Another plea of the OPs number 1 to 3 that the policy in question was terminated on 8.12.2016 falls flat because the complainant had took the treatment for the period from 24.10.2016 to 2.11.2016 and spent the above mentioned amount. We may mention that it is not open for the Ops to cancel/reject the policy after taking the treatment by the complainant and lodging the claim thereof. As such, we are of the considered opinion that this averment of the OPs is not at all helpful to their case and we find it to be a clear cut case of deficiency in service on the part of the OPs number 1 to 3 in not settling the claim.
9. The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.
10. Accordingly, in view of our above discussion, we allow the complaint and direct the OP number 1 to 3 to pay to the complainant an amount of Rs.85,136/- along with interest @ 9% per annum from the date of filing of the present complaint i.e. 01.06.2017 till realisation. We further order the OP number 1 to 3 to pay to the complainant an amount of Rs.5000/- in lieu of consolidated amount of compensation and litigation expenses.
11. This order of ours be complied with within a period of thirty days of its communication. A copy of this order be issued to the parties free of cost. File be consigned to records.
Pronounced.
October 27, 2017.
(Sukhpal Singh Gill)
President
(Sarita Garg)
Member
(Vinod Kumar Gulati)
Member
