BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMRITSAR.
Consumer Complaint No. 289 of 2024
Date of Institution: 23.5.2024
Date of Decision:9.10.2024
Mr. Suresh Sondhi S/o Sh. Om Parkash R/o H.No. 80, Green Field, Majitha Road, Amritsar
Complainant
Versus
Care Health Insurance Limited through its Chairman/Managing Director/Principal Officer through its Branch Office at District Shopping Complex, Ranjit Avenue, Amritsar through its Branch Manager.
Opposite Party
Complaint under section 12 & 13 of the Consumer Protection Act, 1986 Now u/s 35 & 38 of the Consumer Protection Act, 2019
Result : Complaint Allowed
Counsel for the parties :
For the Complainant : Sh.Deepinder Singh, Advocate
For the Opposite Party : Sh. R.P. Singh,Advocate
CORAM
Mr.Jagdishwar Kumar Chopra, President
Ms. Mandeep Kaur, Member
ORDER:-
Mr.Jagdishwar Kumar Chopra, President :- Order of this commission will dispose of the present complaint filed by the complainant u/s 12 & 13 of the Consumer Protection Act, 1986 now u/s 35 & 38 of the Consumer Protection Act, 2019. Initially this case bearing RBT/CC No. 209 of 2018 was decided by District Consumer Disputes Redressal Commission, Barnala Camp Court at Amritsar and the same was dismissed vide order dated 16.8.2022 being time barred. Aggrieved by the decision , complainant preferred Appeal before the Hon’ble State Commission challenging the said order dated 16.8.2022 and vide order dated 6.5.2024 Hon’ble State Commission set-aside the order dated 16.8.2022 passed by District Commission Camp Court Barnala with direction to this Commission to decide the complaint on merits.
Brief facts and pleadings
1. Brief facts of the case of the complaint are that the complainant is getting health policy since long before the year 2008 from the United India Insu. Company Limited regularly and later got the same ported to Health Benefit Mediclaim Insurance to opposite party covering the risk from 21.7.2015 to 20.7.2016. Unfortunately complainant fell ill and was to; be hospitalized and under the treatment at Kidney Hospital & Lifeline Medical Institutions, Jalandhar from 25.9.2015 to 21.12.2015 and the treatment cost of the said hospitalization came to Rs. 481400/-. The opposite party was immediately informed about the said hospitalization and the treatment to be taken thereof as the said policy was issued on cashless basis and is worth mentioning over here that the sum insured for the medical benefit is for Rs. 5 lacs. It is pertinent to mention here that the complainant underwent organ transplant and as per the condition over the cover note issued to the complainant the donor is also entitled for Rs. 1 lac for which the complainant is entitled for reimbursement of the same. The opposite party instead of making the said payment issued letter dated 10.12.2015 that the complainant was have pre-existing diseases of Diabetes and Hypertension and was given 15 days to respond to the said letter. The complainant thereafter approached the opposite party in their office even in his unstable medical condition as he had underwent organ transplantation and made them known that he never taken any treatment nor was suffering from the said diseases as stated by the opposite party and requested to make the payment of his genuine claim, the opposite party assured to make the said payment but till the filing of the present complaint, the opposite party has not conveyed the status of the claim of the complainant. It is pertinent to mention here that no such policy terms and conditions were conveyed to the complainant even and the complainant was only provided with the cover note . The aforesaid act of the opposite party in not deciding the genuine claim of complainant is an act of deficiency in service, malpractice, unfair trade practice and has caused lot of mental agony, harassment, inconvenience besides financial loss to the complainant Vide instant complaint, complainant has sought for the following reliefs:-
(a) Opposite party be directed to pay the amount of Rs. 4,81,400/- and Rs. 1 lac alongwith interest @ 12% p.a. from the date of payment till realization ;
(b) Compensation to the tune of Rs. 50,000/- may also be awarded to the complainant .
(c ) Opposite party be also directed to pay adequate litigation expenses to the complainant.
(d) Any other relief to which the complainant is entitled be also awarded to the complainant
Hence, this complaint.
2. Upon notice opposite party appeared and filed written version taking certain preliminary objections therein interalia that present complaint is hopelessly time barred. The complaint was lodged for the admission in the hospital from 25.9.2015 till 21.12.2015, cashless request was made and the claim was repudiated vide letter dated 20.10.2015, thereafter notice of cancellation of policy was issued on 10.12.2015 which was duly received as admitted by the complainant in his complaint and thereafter policy was cancelled vide letter dated 6.1.2016 duly received by the complainant. The present complaint has been filed on 3.4.2018 after the expiry of two years, therefore, the present complaint is liable to be dismissed being time barred; that the complainant has not come to the court with clean hands and has suppressed the material facts from this Hon’ble Court. In this cashless request was made and same was rejected vide letter dated 20.10.2015 under clause 6.1. of the terms and conditions of the policy, but the complainant concealed these facts from this Hon’ble Court, therefore, he is not entitled for any claim. The correct facts of this case are that opposite party issued health Insu. policy to the complainant bearing No. 10124535 under the Plan “Care” w.e.f. 21.7.2014 to 20.7.2015 and subsequently renewed from 21.7.2015 to 20.7.2016 for the sum assured of Rs. 5,00,000/- subject to policy terms and conditions. During the abovesaid policy , complainant was admitted (planned hospitalization) on 26.10.2017 at Kidney Hospital & Lifeline Medical Institutions , for the treatment of surgery of kidney transplant. The complainant was diagnosed with CKD V Diabetes Mellitus and Hypertension . The complainant in respect to same approached the opposite party by filing a cashless claim. Upon receipt of claim and necessary documents the investigation was made who made following observations:-
. As per the cashless request form : it is clearly mentioned that the complainant has past history of Diabetes Mellitus since 1993 and hypertension since 2009 and provisional diagnosed with CKD V , DM, Hypertension (before the policy inception) The said cashless form is attached as Ex.OP2.
. As per consultation note of Dr.K.S.Chugh dated 21.6.2013 , it is clearly mentioned that the complainant has past history of Diabetes Mellitus for 10 years and he was shifted on insulin from last 4 years.
Decrease in vision of both eyes from last 4 years. The said consultation note is Ex.OP3.
. As per consultation note of Dr.K.S.Chugh dated 17.1.2014 it is clearly mentioned that the complainant was suffering from Diabetes Mellitus with neuropathy with nephropathy (before the inception of policy)
Nephropathy means kidney disease or damage Diabetic nephropathy is damage to your kidneys caused by diabetes. The said consultation note is Ex.OP4.
. As per consultation of Dr. K.S.Chugh dated 15.6.2015, it is clearly mentioned that the complainant was suffering from DM with neuropathy with nephropathy and he was on insulin. The said consultation note is Ex.OP5.
Basis the abovestated information, it was clear that the complainant was having history of Diabetes Mellitus since 1993 and Hypertension since 2009 which is prior to the inception of the policy and the complainant had deliberately concealed to fetch a health Insu. policy to gain unlawful gains. Accordingly the opposite party rejected the claim vide letter dated 20.10.2015 under clause 6.1 of the policy terms and conditions for non disclosure of material information. The complainant by not disclosing the correct health status of the patient at the time of proposal has acted in breach of terms and conditions of the policy. In the proposal form the question Has anyone been diagnosed/hospitalized or under any treatment for any illness/injury during the last 40 months or is suffering from any illness/disease ? The answer marked by the complainant Yes but only disclosed about the hospitalization of Jan. 2012 because of injury. Diabetes Hypertension/High Blood Pressure kidney disease other, the answer marked was No. Further at the time of pre policy medical exanimation, the complainant could have disclosed about the history of diabetes hypertension and decrease in vision of both eyes but he concealed this material information from the answering opposite party. Even in pre policy medical examination form he filled the column as under:-
Please select if you have suffered from any of the following:-
High Blood Pressure – No
Diabetes - No
Any disorder of eyes, ear nose throat or mouth – No
Have you ever been/or presently are on any kind of medication- No
Are you presently in good health, entirely free from any mental or physical impairments or deformity – Yes
In the last 5 years have you been medically examined, received medical advice or treatment or been hospitalized – No
Based upon the disclosures in the pre policy medical examination form the company provide the policy to the customer or not so it is the duty of the complainant to disclose correct information about his current health status.. Further the Insu. company took the medical legal opinion from Dr. Asrani that is Diabetes and Hypertension is directly related t the complainant’s present ailment of CKD V and the same was confirmed by Dr. CH Asrani in his opinion. The insured company believed the disclosures made by the patient in the proposal form issued the said policy. On merits it is admitted that cashless request was received and it was found that complainant was suffering from diabetes, hypertension so the claim was rejected under clause 6.1 of the terms and conditions of the policy and due intimation was given to the complainant vide letter dated 20.10.2015. Further notice for cancellation of policy was given to the complainant vide letter dated 10.12.2015 but no reply was given by the complainant so policy was cancelled and due intimation was given vide letter dated 6.1.2016. The terms and conditions of the policy were duly delivered to the complainant on 25.7.2014 (AWB No. 43718526154).It is further worthwhile to mention here that policy certificate contains the following note Ättached with this policy certificate are the policy terms and conditions and annexure. Please ensure that these documents have been received, read and understood. If any of these documents have not been received, please mail or write to the company. The complainant never approached the opposite party for alleged non receiving of policy terms and conditions. While submitting that there is no deficiency in service and while denying and controverting other allegations, dismissal of complaint was prayed.
Evidence of the parties and Arguments
3. In order to prove his case the complainant tendered in evidence has filed his affidavit Ex.C-1, copy of policy certificate Ex.C-2, copy of cancellation of policy Ex.C-3, copy of discharge card alongwith medical bills Ex.C-4 (colly), Copies of medical bills Ex.C-5 to Ex.C-14.
4. On the other hand opposite party tendered into evidence affidavit of Sh.Arvind Singh Naruka Legal Manager Ex.OP1, copy of policy 2014-15 Ex.OP2, copy of policy 2015-16 Ex.OP3, copy of terms and conditions Ex.OP4, copy of cashless request Ex.OP5, copy of OPD slip dated 21.6.2013 Ex.OP6, copy of OPD slip dated 17.1.2014 Ex.OP7, copy of OPD slip dated 15.6.2015 Ex.OP8, copy of pre-authorization request dated 20.10.2015 Ex.OP9, copy of proposal form Ex.OP10, copy of medical examination form Ex.OP11, copy of letter dated 10.12.2015 Ex.OP12, copy of policy cancellation dated 6.1.2016 Ex.OP13, copy of certificate issued by Dr. C.H.Asrani Ex,OP14, affidavit of Dr.H.S.Asrani Ex.OP15.
5. We have heard the Ld.counsel for the parties and have carefully gone through the record on the file . We have also gone through the written arguments submitted by the opposite party. Ld.counsel for the complainant stated at bar that he does not want to file written arguments and the contents of complaint alongwith exhibited documents be read as part of written arguments.
Findings
6. From the appreciation of the facts and circumstances of the case, it is not disputed that the complainant has been getting the health benefit mediclaim Insurance initially from United India Insurance company since 2009 and later on the same was ported with opposite party covering the risk from 21.7.2014 to 20.7.2015 and then from 21.7.2015 to 20.7.2016 and in this regard the complainant has placed on record copy of policy schedule Ex.C-2 and the opposite party has also placed on record policy schedule Ex.OP2 & Ex.OP3 which duly proves the aforesaid fact of having taking the policy from United India Insu. Company and then ported with opposite party for the period from 21.7.2014 to 20.7.2015 then from 21.7.2015 to 20.7.2016. There is also no dispute that during the subsistence of the policy period the complainant remained admitted at Kidney Hospital & Lifeline Medical Institutions, Jalandhar from 25.9.2015 to 21.12.2015 and the treatment cost of the said hospitalization came to Rs. 481400/-. The opposite party was immediately informed about the said hospitalization and the treatment to be taken thereof. But the opposite party instead of making the said payment issued notice/letter dated 10.12.2015 that the complainant was have pre-existing diseases of Diabetes and Hypertension and was given 15 days to respond to the said letter, copy of letter/notice is Ex.C-3. In this regard the complainant approached the opposite party and made them known that he never taken any treatment nor was suffering from the said diseases as stated by the opposite party and requested to make the payment of his genuine claim, the opposite party assured to make the said payment but till the filing of the present complaint, the opposite party has not conveyed the status of the claim of the complainant. It is pertinent to mention here that no such policy terms and conditions were conveyed to the complainant even and the complainant was only provided with the cover note .
7. On the other hand the only plea taken by the opposite party is that the claim was lodged for the admission in the hospital from 25.9.2015 till 21.12.2015 and the same was repudiated vide letter dated 20.10.2015 and thereafter notice of cancellation of policy was issued on 10.12.2015 which was duly received as admitted by the complainant in his complaint and thereafter policy was cancelled vide letter dated 6.1.2016 duly received by the complainant. The present complaint has been filed on 3.4.2018 after the expiry of two years, therefore, the present complaint is liable to be dismissed being time barred . It was submitted that during the abovesaid policy , complainant was admitted (planned hospitalization) on 26.10.2017 at Kidney Hospital & Lifeline Medical Institutions , for the treatment of surgery of kidney transplant, where the complainant was diagnosed with CKD V Diabetes Mellitus and Hypertension . The complainant in respect to same approached the opposite party by filing a cashless claim. Upon receipt of claim it was found that the complainant has past history of Diabetes Mellitus since 1993 and hypertension since 2009 and provisional diagnosed with CKD V , DM, Hypertension (before the policy inception) . As per consultation note of Dr.K.S.Chugh dated 21.6.2013 , it is clearly mentioned that the complainant has past history of Diabetes Mellitus for 10 years and he was shifted on insulin from last 4 years . Also thee is decrease in vision of both eyes from last 4 years. . As per consultation note of Dr.K.S.Chugh dated 17.1.2014 and 15.6.2015 the complainant was suffering from Diabetes Mellitus with neuropathy with nephropathy (before the inception of . Based on the aforesaid information, it was clear that the complainant was having history of Diabetes Mellitus since 1993 and Hypertension since 2009 which is prior to the inception of the policy and the complainant had deliberately concealed to fetch a health Insu. policy to gain unlawful gains. Accordingly the opposite party rejected the claim vide letter dated 20.10.2015 under clause 6.1 of the policy terms and conditions for non disclosure of material information. Whereas the complainant has given wrong answers to the questions in the proposal form as well as in pre policy medical examination form . In this regard Insu. company took the medical legal opinion from Dr. Asrani that is Diabetes and Hypertension is directly related t the complainant’s present ailment of CKD V and the same was confirmed by Dr. CH Asrani in his opinion. It was submitted that the terms and conditions of the policy were duly delivered to the complainant on 25.7.2014 (AWB No. 43718526154).
8. This Commission has given thoughtful consideration to the facts of the present case (i) whether the present case is time barred (iii) whether the ground taken by the opposite party in their written version as well as in the notice/letter of cancellation of policy dated 10.12.2015 of pre-existing ailment that complainant had history of diabetes since 1993 and Hypertension since 2009 is legal.
9. First of all before going to the merits of the case, point under discussion is whether the present case is time barred. It is the case of the complainant that till the filing of the present case the opposite party has not conveyed the status of the claim of the complainant. Whereas the plea taken by the opposite party is that policy was cancelled and due intimation was given vide letter dated 6.1.2016 and in this regard the opposite party has placed on record copy of letter of policy cancellation Ex.OP13. But we are not agreed with this plea taken by the opposite party as the opposite party has failed to prove on record that through which mode this letter was delivered to the complainant. It has been held by the Hon'ble State Consumer Disputes Redressal Commission , Punjab in First Appeal No. 1602 of 2012 decided on 22.1.2013 titled as ICICI Prudential Life Insurance Company Limited Vs. Jasjit Walia that where a person who delivered the shipment has not been produced nor his affidavit has been filed. Moreover, the document itself shows that shipment was not delivered to the complainant but it was received by one Kulwinder. There is no mention whether this Kulwinder is a male or female or what is the relationship of complainant with Kulwinder . Otherwise also , the delivery of the shipment to Kulwinder cannot be considered as the delivery of the policy to the complainant. Moreover it is settled principle of law that in case, two plausible views were available, under given set of facts, the court shall be obliged to the view which was favourable to the consumer. Reference in this regard can be had to “Kulwinder Singh Versus LIC of India “ 2007(1) CLT 303 (Punjab) wherein it has been held that “where two views are possible, the one, which favour the consumer should be taken” So once the complainant was not apprised regarding the cancellation of the policy as well as repudiation of the claim, it is a running cause of action till the claim is not decided. Reliance in this connection has been placed upon Delhi Development Authority Vs. Sh. Jagdeep Bali 2018(2) CLT 571 of the Hon’ble State Commission, Delhi in which it has been held that “Recurring cause of action- plea of OP that the claim of complainant is time barred-Held – it is trite law that in matters of the kind it is a recurring cause of action” .As such the plea taken by the opposite party that the complaint filed by the complainant is time barred is not sustainable in the eyes of law.
10. However, for the sake of arguments the ground taken by the opposite party in their written version as well as in the notice of cancelation of policy that the complainant had history of diabetes since 1993 and Hypertension since 2009 and relied upon photocopies of the consultation note of Dr.K.S.Chugh dated 21.6.2013 Ex.OP6, consultation note of Dr.K.S.Chugh dated 17.1.2014 Ex.OP7and 15.6.2015 Ex.OP8 that complainant was suffering from Diabetes Mellitus, Hypertension with neuropathy with nephropathy (before the inception of policy). But we are not agreed with this ground taken by the opposite party as the opposite party has placed reliance upon photocopy of some prescription slips of Dr.K.S.Chugh and the said doctor has not been examined as such these documents have no values in the eyes of law. Reliance in this connection has been placed upon Birla Sun Life Insurance Co. Ltd. & Anr. Vs.Arvind Kaur 2017(3) CLT 526 of the Hon’ble National Commission, New Delhi wherein it has been held that mere production of some unattested , unverified and unauthenticated photocopies, could not have been the basis of holding that the deceased was an alcoholic and was diagnosed with alcohol liver disease and its complications . Moreover diabetes as well as HTN is not a material disease, therefore, non disclosure thereof is not a concealment. We 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. Further reliance has been placed upon Reliance Life Insu. Co. Ltd. Vs. Subash Chander Aggarwal First Appeal 836 of 2016 of the Hon’ble State Commission wherein it has been held that DM and HTN is a common disease which can be controlled by medication.
11. Not only this the opposite party has neither filed affidavit of the said doctor who issued the prescription slips not made any effort to summon the said doctor Dr. K.S. Chugh , as such no evidentiary value can be attached to the photocopies of prescription slips Ex.OP6 to Ex.OP8 issued by Dr. K.S. Chugh. Reliance in this connection has been placed upon New India Assurance Co.Ltd. Vs. Ravi Narang II(2011) CPJ 241 of the Hon’ble Delhi State Commission, New Delhi wherein it has been held that “Medical examination reports filed- None contains name of examinee injured person or patient- cannot say report relates to complainant- No affidavit of the doctor filed to prove reports- Not substantiate contention that complainant was driving vehicle in drunken state at the time of accident.” Further reliance has been placed upon Manikant Vs. New India Assurance Co.Ltd. 1(2012) CPJ 88 (NC) of the Hon’ble National Commission wherein it has been held that the surveyor did not appear in court and subject himself to cross examination nor was any affidavit filed by him to prove his report . Producing a document in court does not by itself constitute proving the document. It has to be backed by credible evidence. In the instant case, no evidence was led to prove the surveyor’s report in the absence of which the surveyor’s report has little evidentiary value.
12. However, the opposite party No.2 only relied upon certificate issued by Dr. C.H.Asrani being expert opinion Ex.OP14. The said expert gave his report by sitting at Mumbai from the bear reading of these documents that patient was having pre-existing disease particularly when there are ample opportunity with the opposite party or the expert to visit and to trace out the documents and the medical evidence previously related to the complainant . But there is no independent enquiry which was required to be done to rule out whether this patient was having abovesaid pre-existing diseases which becomes the base of the repudiation. Had it been expert he must have conducted independent enquiry by visiting physically and then opined accordingly.
13. Moreover it is the duty of the Insurance company to get the medical test of the insured before issuing the policy .Reliance in this connection has been placed upon Bajaj Allianz Life Insu.Co.Ltd. & Ors Vs. Raj Kumar III(2014) CPJ 221 (NC) wherein it was held that usually the authorized doctor of the Insu.company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. Thus the repudiation of the claim on the ground of pre existing disease was held to be invalid. Not only this there was no bar on the Opposite Party/Insurance company to get the thorough medical check up at the time of issuance of the policy. The Opposite Party/Insu.company was within their right to cancel the policy if it doubted or found any information supplied by the life assured being false or wrong, but this has not been done by the Opposite Party. The investigation has been got done at the time when the claim was lodged by the complainant. It was for the Opposite Party/Insu. company to ensure about the health of the insured before issuance of the policy of such amount. Many times a person may not know himself/ herself if he/ he is suffering from any particular disease. Moreover, prior to issuance of the policy, it was required to check up life assured thoroughly. It was the bounden duty of the Opposite Party/Insu. company to make thorough investigation at the initial stage. It appears that the Opposite Party/Insurance company has different yard stick at the time of accepting the policy for procuring the business and different face at the time of discharge of its lawful liability. Not only this now-a-days it has become a business of almost all the Insu. Companies to deny the claim one or on another ground . Even otherwise in the fast growing business competition among the Insu. Companies unhealthy practice developed to get maximum benefits and profits. But in most of the cases he is left cheated when his claim is rejected with just a stroke of pen that his claim is against the terms and conditions of the policy or his claim has been deducted as per terms and conditions of the policy. Once accepting the premium and everything entered into an agreement the Insurance company cannot wriggle out of the liability merely by saying that repudiation has been made as per terms and conditions of the policy It is generally seen that the insurance companies are only interested in earning the premiums and find 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 111went on to hold as under:-
It seems 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.
14. Regarding the quantum of claim the complainant has sought relief for reimbursement of medical expenses of Rs.4,81,400/- for which the complainant has placed on record copy of medical bills Ex.C-4 to Ex.C-14 which was not denied by the opposite party, whereas the sum assured for the hospitalization expenses under the policy is Rs 5 lacs and for organ donor cover is Rs 1 lacs,as such the opposite party is liable to reimburse the medical expenses incurred on the treatment of the complainant i.e. Rs. 4,81,400/- as well as Rs. 1,00,000/- incurred on organ transplant as mentioned in the policy schedule Ex.OP2.
15. In view of the above discussion, we allow the complaint and the opposite party is directed to reimburse the amount of Rs. 4,81,400/- as hospitalization expenses and Rs. 1,00,000/- incurred by the complainant on organ transplantation alongwith interest @ 6% p.a. from the date of filing of the complaint till its realization So far as compensation is concerned , as the opposite party failed to decide the claim , whereas the opposite party is liable to settle the claim within 30 days from the date of lodging of claim. Reliance in this connection has been placed upon Oriental Insurance Company Ltd. Vs. Rajbir Kaur, in First Appeal No. 711 of 2013 decided on 27.2.2015 of Hon’ble State Commission, Punjab, Chandigarh wherein in similar case, the Hon’ble State Commission directed the Insurance company and stated that as per the regulations/instructed issued by the IRDA, the claims made under the Insurance policies are ordinarily be settled within one month of the submission of the claim. Not only this the complainant has to face the litigation not only before this Commission earlier but also filed Appeal before the Hon’ble State Commission and now for the third time before this Commission in the instant case for which the complainant suffered lot of harassment as well as financial loss, as such opposite party is directed to pay compensation to the tune of Rs.30000/- and litigation expenses of Rs.10000/- to the complainant. Compliance of this order be made within 45 days from the date of receipt of copy of this order ; failing which complainant shall be entitled to get the order executed through the indulgence of this commission. Copies of the orders be furnished to the parties free of costs. 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 commission.