Delhi

North East

CC/42/2020

Sh. Amit Singhal - Complainant(s)

Versus

Care Health Insurance Limited - Opp.Party(s)

09 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION: NORTH-EAST

GOVT. OF NCT OF DELHI

D.C. OFFICE COMPLEX, BUNKAR VIHAR, NAND NAGRI, DELHI-93

 

Complaint Case No.42/20

In the matter of:

 

	Sh. AmitSinghal, S/o Sh. MangalSainSinghal, R/o: H.No. B-50, East Jyoti Nagar, Loni Road, Shahdara, Delhi 110094	Complainant
	Versus
	Care Health Insurance Ltd., Through its Managing Director,, Formerly Known As: Religare Health Insurance Co. Ltd., Registered Office: 5th Floor, 19 Chawla House, Nehru Place, New Delhi 11001	Opposite Party

 

DATE OF INSTITUTION:         JUDGMENT RESERVED ON:                         DATE OF ORDER  :

23.09.2020 10.07.2023 09.10.2023

 

CORAM:

Surinder Kumar Sharma, President

Anil Kumar Bamba, Member

Adarsh Nain, Member

ORDER

Anil Kumar Bamba, Member

 

The Complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019.

Case of the Complainant

1. The case of the Complainant as revealed from the record is that the Complainant has earlier filed a complaint vide CC No. 940 of 2017 in the Hon'ble State Commission and the same was disposed of by the Hon'ble Commission in which the Hon'ble  Commission gave direction to the Opposite Party to decide the claim of the Complainant within 3 months vide order dated 24.07.2019, and also gave permission to Complainant to file a fresh complaint against the Opposite Party in case Opposite Party repudiate the claim. It is his case that Opposite Party had not complied with the above mentioned order and after the expiry of 3 months period i.e. 23.10.2019, a legal notice dated 23.10.2019 was sent to the Opposite Party. It is his case that Opposite Party rejected the claim and the reason given in the letter dated 04.12.2019 was “Non-disclosure of cancer at the time of policy inception” “Permanent Exclusion- Act of self-destruction or self-inflicted injury, attempted suicide while sane or insane or any illness or injury attributable to consumption, use misuse or se of tobacco intoxicating drugs and alcohol or hallucinogens of smoking addiction”. Complainant took an insurance policy from the Opposite Party vide policy no. 10121133 for a sum of Rs. 50 lacs. The period of the said policy was from 01.07.2014 to 30.06.2017. Complainantcontinuously paid a premium of Rs. 1,46,711/-. On 26, June 2015, during the validity of Insurance Policy, the Complainant had undergone a surgical procedure at PushpanjaliCrosslay Hospital, Vaishali, Ghaziabad, U.P and the same is covered according to the terms and condition of the policy. Complainant informed the Opposite Party about the surgery and Opposite Party deputed Mr. Suresh Kumar to look after all the medical procedure and for collecting all the relevant documents and angioplasty CD from the hospital. It is his case that after discharge from the hospital, the Complainant filed the claim application of Rs. 50,00,000/- along with all the relevant documents. The executive of the Opposite Party assured the Complainant that within 15 days they would settle the claim. After that the Complainant approached the Opposite Party numerous times through phone, e-mail and even personally visited the office of Opposite Party but all in vain.On 14.04.2016, Complainant also sent a legal notice to the Opposite Party. On 27.05.2016 Opposite Party sent a reply in which Opposite Party was ready to pass the claim of Rs. 50lacs but claimed some OPD prescriptions and angioplasty CD to the Complainant and the angioplasty CD was provided by the Complainant to the Opposite Party. After that on 18.06.2016, Complainant sent a reply mentioning that such old documents demanded by the Opposite Party were nowhere required for the claim process. Moreover, the Complainant had “Sudden Onset Chest pain associated with suffocation and choking and sensation and there was no past history of Hypertension, Diabetes Mellitus or same ailment”. It is his case that Opposite Party demanded 05 years old OPD prescriptions. The Complainant had no such records available with him so Complainant had shown his inability to provide such documents. Therefore, Opposite Party did not pass the claim. Hence, this shows the deficiency of service on the part of Opposite Party. Complainant has prayed for Rs. 50,00,000/- along with interest @ 18 % p.a., Rs. 25,00,000/- mental harassment and Rs. 5,00,000/- on account of litigation expenses.

Case of the Opposite Party

2. The Opposite Party contested the case and filed its written statement. It is stated that the case was adjudicate upon by Hon'ble State Commission, New Delhi vide CC No. 940/17 dated 24 July 2019, wherein the Hon'ble State Commission ordered the Opposite Party to re-evaluate the claim within 3 months in accordance with the policy terms and conditions and gave Complainant further liberty to file fresh complaint, if not satisfied by the decision of Opposite Party. It is stated that the Opposite Party received copy of the order in the month of October 2019 and accordingly the claim was rejected vide claim rejection letter 04.12.2019 on the ground that on non-disclosure of Cancer and Permanent Exclusion: Smoking. It is stated that the rejection of claim was also informed vide reply to legal notice dated 02.01.2020 to the Complainant. It is stated that the present complaint of the Complainant is not maintained and is liable to be dismissed because there is no deficiency in service on the part of Opposite Party No. 1 in rejecting the claim of the Complainant. It is stated that the Complainant had purchased health insurance policy bearing no. 10121133 insuring himself for a period ranging from 01.07.2014 till 30.06.2017 for a sum insured of Rs. 50 lacs. It is stated that the insurance policy was obtained from ReligareFinvest Ltd against the loan amount of Rs. 75 lacs. It is stated that the sum insured of Rs. 50 lacs was not mentioned in the Policy Certificate, it is only mentioned in the Proposal Form. It is stated that the Complainant approached the Opposite Party for reimbursement claim for hospitalization for the treatment of Myocardial Infarction (Critical Illness). It is stated that the claim was not rejected till the matter was adjudicated upon by Hon'ble State Commission, Delhi and was pending for submission of necessary documents, sin quo non for assessment of the claim. It is stated that upon the receiving the orders from the Hon'ble State Commission, Delhi, the claim was reassessed/investigated and accordingly rejected for non-disclosure of Cancer/Permanent Exclusion of Smoking. It is stated that the Complainant incurred hospitalization from 26.06.2015 till 29.06.2015 at PushpanjaliCrosslay Hospital, Ghaziabad, for treatment of Coronary Artery Disease and subsequent surgery for the same. It is stated that the Complainant approached Opposite Party for hospitalization mentioned above. It is stated that on receipt of claim documents, Opposite Party raised a query on 19.09.2016 and subsequent Reminder letter – 1 and Reminder letter 2 to provide for complete Indoor case papers along with Doctor notes pre post hospitalization prescription/bills and certificate from treating doctor cause of ailment or any other past history of HTN and DM original ECG report and also provide any other insurance company policy and also provide recent photograph. It is stated that a query reply was received on 13.10.2015 from the Complainant. It is stated that Opposite Party raised on 23.12.2015, 01.01.2016, 18.03.2016, 22.03.2016 and 02.04.2016 to the Complainant to provide for OPD prescription dated 13.11.2010 referred by Dr. Ashok Grove, OPD prescription dated 25.11.2010 referred by Dr. Vijay Arora, OPD prescription dated 06.12.2010 referred by self, OPD prescription dated 07.12.2010 referred by self, OPD prescription dated 07.12.2010 referred by Dr. R Ganesh Kumar, OPD prescriptions of AmitUpadhayay dated 16.12.2010, 07.12.2010, 30.12.2010, 19.01.2011 and 13.07.2011, OPD prescription dated 18.02.2011 and 12.03.2012 by Dr. Anil Arora, OPD prescription dated 22.03.2012, 31.03.2012, 19.04.2014 and 19.05.2014 and also provide for angioplasty CD. It is stated that the documents received included invoices related to tests from 2010 suggested cancer however such medical tests were not supplied. Further there was ample proof towards Smoking habit of the Complainant. However, claim was denied for non-submission of necessary documents. It is stated that post order of the State Commission, the claim was reinvestigated and according denied for Non Disclosureof Cancer and Permanent Exclusion of Smoking Habit and which is evident as follows:

Non Disclosure Cancer:

3. It is stated Opposite Party had received invoices for the period 20.10.2014 via Investigation which was suspected to be pertaining to cancer related tests which the Complainant concealed from Opposite Party at the time of filing the Proposal form. It is stated that the invoices received (of 2010) had cancer specific tests (like bone marrow etc) mentioned in them and invoices pertaining to treatment/OPD/prescription of the Complainant between 2010-2014 at Max Health Hospital, Patparganj. It is stated that in addition to the invoices received of 2010 of cancer specific tests, further following test documents were retrieved through investigation which are envisaged as under:

• The vitals and parameters of investigation tests including Blood Count, Lactate Dehydrogenese Test, Liver Function etc dated from the year 2010, 2011 and 2012 (prior to policy inception) are suggestive of cancer.
• That the said tests were perused and supplemented with a second opinion of Dr. (Major) Durgesh Sharma, which duly states that the “Other investigations like BRC Mass, JAK 2 Mutation, AGB, CSCT Chest, Serum EPO Levels, Bone Marrow Analysis Etc with Personal history of smoking would have been sublime to clinch the diagnosis of Polycythemia Vera…. (Note: Polycythemiavera is a type of blood cancer)”
• That Dr. AmitUpadhaya, treating doctor of the Complainant and who has suggested/referred some of tests specially Complete Blood Count dated 30.12.2010 and Lactate Dehydrogenese Test dated 19.01.2011, affirmed in his statement, signed and stamped and dated 17.10.2019 that after seeing the reports the Complainant is probably suffering from Polyeythemia Vera and all the investigations were done to RO other causes.

4. It is stated that additional medical opinion of Dr C.H. Asrani was also taken which suggested that Complainant had cancer with following observation: “The deranged parameters in all 3 reports (very high haemoglobin, PCV and RBC) help establish the diagnosis of Polychythemia Vera which is a rare type of blood cancer and has myelofibrosis and leukemia as potential complications”. Further Dr. AmitUpadhyaya, who had ordered those tests, in his statement dated 17.10.2019 also suggested Cancer confirms (PolycythemiaVera).It is in this light that the test reports and medical opinions confirmed Cancer (Polycythemia Vera) however the same was not disclosed in the proposal form Therefore the claim was rejected for non-disclosure of cancer and same was communicated through claim denial letter dated 04.12.2019. It is stated that the Complainant was duty bound to disclose each and every fact related to the health status of the Complainant in the proposal form dated 26.06.2014 however same was not disclosed by the Complainant. It is stated that the non-disclosure with respect to cancer by the Complainant is as follows:

Medical & Lifestyle Details

Please answer each of the following questions for and on behalf of the insured (You means the “Insured Person”). Each question need to be answered in “Yes” or “No” unless other options are provided:

Have you ever been aware or told you have the following:-

Cancer

The Answer to this question is “NO”

The requisite Clause is reproduced as under

Clause 6.1 Disclosure to Information Norm & Fraud

If any untrue or incorrect statements are made or there has been a misrepresentation, mis-discrimination or non-disclosure of any material particulars or any material information having been withheld or if a claim is fraudulently made or any fraudulent or devises are used by the Policy holder or the Insured or any one acting on his/their behalf, the Company shall have no liability to make payment of any claims and the premium paid shall be forfeited to the Company.

Smoking: Permanent Exclusion

5. It is stated that the Complainant was in habit of Smoking Tobacco and same is excluded as per the Policy Terms and Conditions. The following documents suggest smoking habit of the Complainant:

• That in the pertinent case, investigation was conducted wherein the Complainant made the following disclosures:-

Do you take smoking or tobacco? If, yes since when and quantity?

The Complainant disclosed that he has been “smoking cigarettes since 3 years on and off basis”

• The initial assessment sheet, prepared by Pushpanjali hospital dated 26 June 2015 clearly mentions the Complainant to be “Chronic Smoker”.
• The Referral form of Pushpanjali hospital dated 26 June 2015, clearly mentioned “Reason for referral:- For addiction (Smoking)
• That the Physician’s progress notes dsated 27 June 2016, it was clearly mentioned the Complainant to be reviewed by “Dr. Ajay Nimalin for smoking addiction”.

That from the above mentioned documents, it was clearly concluded that the Complainant was a smoker and was covered under the following clauses:

Clauses 3.4 Permanent Exclusions applicable to all benefits

Any claim in respect of any insured person for arising out for or directly or indirectly due to any of the following shall not be admissible unless expressly stated to the contrary elsewhere in the Policy Terms and conditions:

(d) Acts of self-destruction or self-inflicted injury, attempted suicide or suicide while sane or insane or any illness or injury attributable to consumption use, misuse or abuse of tobacco, intoxicating drugs and alcohol or hallucinogens.

6. It is stated that since heart ailments was directly relating to chronic smoking, therefore it fell under the clause of Permanent Exclusion and same was mentioned in the Claim Denial letter dated 04.12.2019. It is further stated that there is no deficiency in service on the part of Opposite Party in rejecting the claim of the Complainant and the present complaint is liable to be dismissed on this ground alone. It is stated that as per the decision of the Hon’ble Supreme Court in Export Credit Guarantee Corpn. Of India Ltd. Vs. M/s. Garg Sons International 2013(I) Scale 410, it is stated that legal proposition that while construing the terms of the contract of Insurance the words used therein must be given paramount importance and it is not open for the court ot add, delete or substitute any words. It is also well settled that since upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the policy, its terms have to be strictly construed in order to determine the extent of the liability of the insurer. Further the insured cannot claim anything more than what is covered by the insurance policy. The terms of the contract have to be construed strictly without altering the nature of the contract as the same may affect the interest of the parties adversely. The clauses of an insurance policy have to be read as they are consequently the terms of the insurance policy, that fix the responsibility of the insurance company must also be read strictly. Accordingly, the present complaint is liable to be dismissed on this ground alone.

Rejoinder to the written statement of Opposite Party

7. The Complainant filed rejoinder to the written statement of Opposite Party wherein the Complainant has denied the pleas raised by the Opposite Party and has reiterated the assertion made in the complaint.

Evidence of the Complainant

8. The Complainant in support of his complaint filed his affidavit wherein he has supported the averments made in the complaint.

Evidence of the Opposite Party

9. To support its case Opposite Party has filed affidavit of ShriSahilChauhan, wherein, he has supported the case of the Opposite Party as mentioned in the written statement.

Arguments & Conclusion

10. We have heard the Ld. Counsels for the Parties.We have also perused the file and written arguments filed by the Complainant and Opposite Party. The case of the Complainant is he took an insurance policy from the Opposite Party for a sum of Rs. 5 lacs. The period of the said policy was from 01.07.2014 to 30.06.2017. On     26, June 2015, during the validity of Insurance Policy, the Complainant had undergone a surgical procedure at PushpanjaliCrosslay Hospital, Vaishali, Ghaziabad, U.P and the same is covered according to the terms and condition of the policy. Complainant informed the Opposite Party about the surgery and Opposite Party deputed a  representative to look after all the medical procedure and for collecting all the relevant documents and angioplasty CD from the hospital.  After discharge from the hospital, the Complainant  filed the claim  application of Rs. 50,00,000/- along with all the relevant documents. The Complainant approached the Opposite Party numerous times through phone, e-mail and even personally visited the office of Opposite Party but all in vain. Complainant sent a legal notice to the Opposite Party and in reply to the legal notice Opposite Party asked for OPD prescriptions and other documents related to his claim. Complainant sent a reply to the Opposite Party mentioning that all documents demanded by the Opposite Party were  nowhere required for the  claim process of the claim and also he had no such record available and shown inability to provide the said documents. Since, Opposite Party  did  not pass the claim  hence this shows the deficiency of service on the part of Opposite Party.
11. The case of the  Opposite Party is that it is  admitted that  the  Complainant having an insurance policy and  had  surgery during the validity of the policy period. It is further stated by the Opposite Party that the Complainant  approached the Opposite Party for payment of reimbursed for surgery undergone for Myocardial Infarction (Critical Illness). On receipt  of  the  claim  document claim,  Opposite Party raised a query   and    sent   subsequently two reminders letters to provide for complete Indoor case papers along with Doctor notes pre post hospitalization prescription/bills and certificate from treating doctor cause of ailment or any other past history of HTN and DM original ECG report and also provide any other insurance company policy and also provide recent photograph. It is stated by the Opposite Party that Opposite Party raised a query on various dated to the Complainant to provide the OPD prescription dated 13.11.2010 referred by Dr. Ashok Grove, OPD prescription dated 25.11.2010 referred by Dr. Vijay Arora, OPD prescription dated 07.12.2010 referred by Dr. R Ganesh Kumar, OPD prescriptions of AmitUpadhayay dated 16.12.2010 and further various dates, OPD prescription dated 18.02.2011 and 12.03.2012 by Dr. Anil Arora and OPD prescription dated 22.03.2012, 31.03.2012, 19.04.2014 and 19.05.2014 of Dr. Anil Arora. It is stated that the documents received included invoices related to tests from 2010 suggested cancer however such medical tests were not supplied. Further there was ample proof towards Smoking habit of the Complainant. Hence, claim was denied for non-submission of necessary documents. During the investigation by the Opposite Party denied for Non Disclosureof Cancer and Permanent Exclusion of Smoking Habit was came into the knowledge of the Opposite Party and which is evident as follows:

Non Disclosure Cancer:

12. It is stated by the Opposite Party that they have received invoices for the period 20.10.2014 via Investigation which was suspected to be pertaining to cancer related tests which the Complainant concealed from Opposite Party at the time of filing the Proposal form. It is further stated by the Opposite Party that the invoices received had cancer specific tests mentioned in them and invoices pertaining to treatment/OPD/prescription of the Complainant between 2010-2014 at Max Health Hospital, Patparganj. In addition to the invoices received of 2010 of cancer specific tests, further following test documents were retrieved through investigation which are envisaged as under:

• The vitals and parameters of investigation tests including Blood Count, Lactate Dehydrogenese Test, Liver Function etc dated from the year 2010, 2011 and 2012 (prior to policy inception) are suggestive of cancer.
• That the said tests were perused and supplemented with a second opinion of Dr. (Major) Durgesh Sharma, which duly states that the “Other investigations like BRC Mass, JAK 2 Mutation, AGB, CSCT Chest, Serum EPO Levels, Bone Marrow Analysis Etc with Personal history of smoking would have been sublime to clinch the diagnosis of Polycythemia Vera…. (Note: Polycythemiavera is a type of blood cancer)”
• That Dr. AmitUpadhaya, treating doctor of the Complainant and who has suggested/referred some of tests specially Complete Blood Count dated 30.12.2010 and Lactate Dehydrogenese Test dated 19.01.2011, affirmed in his statement, signed and stamped and dated 17.10.2019 that after seeing the reports the Complainant is probably suffering from Polyeythemia Vera and all the investigations were done to RO other causes.

 

13. In addition to above medical opinion of Dr C.H. Asrani was also taken which suggested that Complainant had cancer with following observation: “The deranged parameters in all 3 reports (very high haemoglobin, PCV and RBC) help establish the diagnosis of Polychythemia Vera which is a rare type of blood cancer and has myelofibrosis and leukemia as potential complications”. Further Dr. Amit Upadhyaya, who had ordered those tests, in his statement dated 17.10.2019 also suggested Cancer confirms (PolycythemiaVera).It is in this light that the test reports and medical opinions confirmed Cancer however the same was not disclosed in the proposal form therefore the claim was rejected for non-disclosure of cancer and same was communicated through claim denial letter dated 04.12.2019. The Complainant was duty bound to disclose each and every fact related to the health status of the Complainant in the proposal form dated 26.06.2014 and the same was not disclosed by the Complainant. It is stated that the non-disclosure with respect to cancer by the Complainant is as follows:

Medical & Lifestyle Details

 

Please answer each of the following questions for and on behalf of the insured (You means the “Insured Person”). Each question need to be answered in “Yes” or “No” unless other options are provided:

Have you ever been aware or told you have the following:-

 

Cancer

 

The Answer to this question is “NO”

 

Clause 6.1 of disclosed however is known as fraud:

Clause 6.1 Disclosure to Information Norm & Fraud

 

If any untrue or incorrect statements are made or there has been a misrepresentation, mis-discrimination or non-disclosure of any material particulars or any material information having been withheld or if a claim is fraudulently made or any fraudulent or devises are used by the Policy holder or the Insured or any one acting on his/their behalf, the Company shall have no liability to make payment of any claims and the premium paid shall be forfeited to the Company.

 

 

Smoking: Permanent Exclusion

14. It is stated that the Complainant was in habit of Smoking Tobacco and same is excluded as per the Policy Terms and Conditions. The following documents suggest smoking habit of the Complainant:

• That in the pertinent case, investigation was conducted wherein the Complainant made the following disclosures:-

Do you take smoking or tobacco? If, yes since when and quantity?

The Complainant disclosed that he has been “smoking cigarettes since 3 years on and off basis”

• The initial assessment sheet, prepared by Pushpanjali hospital dated 26 June 2015 clearly mentions the Complainant to be “Chronic Smoker”.
• The Referral form of Pushpanjali hospital dated 26 June 2015, clearly mentioned “Reason for referral:- For addiction (Smoking)
• That the Physician’s progress notes dated 27 June 2016, it was clearly mentioned the Complainant to be reviewed by “Dr. Ajay Nimalin for smoking addiction”.

 

That from the above mentioned documents, it was clearly concluded that the Complainant was a smoker and was covered under the following clauses:

Clauses 3.4 Permanent Exclusions applicable to all benefits

Any claim in respect of any insured person for arising out for or directly or indirectly due to any of the following shall not be admissible unless expressly stated to the contrary elsewhere in the Policy Terms and conditions.

 

12. Since the reimbursement of the claim for treatment of heart ailments was directly relating to chronic smoking, therefore it fell under the clause of Permanent Exclusion and same was mentioned in the Claim Denial letter dated 04.12.2019.

13. In the case of Export Credit Guarantee Corpn. Of India Ltd. Vs. M/s. Garg Sons International 2013(I) Scale 410, Hon’ble Supreme Court held that while construing the terms of the contract of Insurance the words used therein must be given paramount importance and it is not open for the court to add, delete or substitute any words. It is also well settled that since upon issuance of an insurance policy, the insurer undertakes to indemnify the loss suffered by the insured on account of risks covered by the policy, its terms have to be strictly construed in order to determine the extent of the liability of the insurer. Further the insured cannot claim anything more than what is covered by the insurance policy. The terms of the contract have to be construed strictly without altering the nature of the contract as the same may affect the interest of the parties adversely. The clauses of an insurance policy have to be read as they are consequently the terms of the insurance policy, that fix the responsibility of the insurance company must also be read strictly.

14. In the present case, the policy in question for the payment of sum insured in terms of para 2.1 of the terms and conditions of the policy, in the case of any critical illness, medical events and surgical procedures of the Complainant and not for the reimbursement expenditure incurred by the Complainant on the treatment. The Complainant was duty bound to disclose each and every fact related to the health status of the Complainant in the proposal form and the same was not disclosed by the Complainant.

15. In view of the above, the Complainant case fall in the category of non-disclosure of pre-existing disease and medical and lifestyle details. We are of the considered opinion that there is no deficiency of service on the part of Opposite Party. Hence, the complaint is dismissed.

16. Order announced on 09.10.2023.

Copy of this order be given to the parties free of cost

File be consigned to Record Room.

(Anil Kumar Bamba)	(Adarsh Nain)	(Surinder Kumar Sharma)
(Member)	(Member)	(President)