Haryana

StateCommission

A/640/2019

LIBERTY GENERAL INSURANCE - Complainant(s)

Versus

CHIMAN LAL - Opp.Party(s)

PARAS MONEY GOYAL

29 Oct 2019

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HARYANA, PANCHKULA   

 

                                                 

                                                First Appeal No. 640 of 2019

                                                Date of the Institution: 16.07.2019

                                                Date of Decision: 29.10.2019

 

 

 

Liberty General Insurance Ltd., Unit No.13-B & 14, Ground Floor, Palm Court Building, MDI Chowk, Gurgaon through its Manager.

 

 

 

….. Appellant/Opposite Party

 

VERSUS

 

Chiman Lal, resident of House No.566/16, Civil Line, Tehsil and District Gurgaon.

 

…..Respondent/Complainant

 

 

 

CORAM:    Hon’ble Mr. Justice T.P.S. Mann, President.

                    

 

                  

                                     

Present:-    Shri Paras Money Goyal, counsel for the appellant.

                    

                  

 

                                                O R D E R

 

 

T.P.S. MANN, J.  

 

          The opposite party, namely, Liberty General Insurance Ltd., has filed the instant appeal against the order dated 13.5.2019 passed by learned District Consumer Disputes Redressal Forum, Gurgaon, whereby, it was directed to reconsider the case of the complainant in terms of the Liberty Health Connect Policy (hereinafter referred to as ‘the policy’) and to pay the claim amount to the complainant within 30 days from the date of receiving the copy of the order.

2.      According to complainant-Chiman Lal, he had obtained the policy for himself and his two children from the opposite party in the year 2018 for sum assured of `5,00,000/-, which covered the period from 22.6.2018 to 21.6.2019.  At the time of obtaining the Liberty policy, a premium of `15,486/- was paid by him to the opposite party after porting the earlier medical policy of New India Assurance Company Ltd. i.e. New India Floater Mediclaim policy. During the subsistence of the policy i.e. on 28.7.2018, he fell ill due to bleeding in stomach and taken to Medanta-The Medicity, Gurgaon, from where he was discharged on 2.8.2018. He had spent a sum of `1,54,768.15 on his treatment. Accordingly, he submitted his claim on 13.8.2018 but the same was repudiated by the opposite party on the ground that:

 

“We have scrutinized the documents submitted at the time of claims. As per the Hospital discharge summary submitted, Mr. Chiman Lal is suffering from Hypertension since last five years. However, the same was not disclosed in the proposal form submitted at the time of applying for the insurance.

We regret to inform you that your policy stands cancelled   ab initio on basis of the below Cancellation/Termination clause mentioned under General Terms and Conditions in policy working.

The policy shall be void and all premium paid hereon shall be forfeited to the company, in the event of misrepresentation, mis-description or non disclosure of any material fact.”

Subsequently, vide letter dated 24.10.2018, the claim was again rejected on the ground that:

“As per received documents it was observed that insured status is cancelled. Thus this claim is recommended for rejection.”

 

3.      Accordingly, the complainant filed the complaint praying for issuance of directions to the opposite party to reimburse the claim along with interest, compensation of `50,000/- on account of mental agony, harassment, humiliation etc. and `22,000/- towards litigation expenses.

4.      Upon notice, the opposite party filed written version stating therein that the complaint had been filed on false, frivolous and baseless grounds and without any cause of action as there was no deficiency in service on its part. It was also pleaded that from the medical records, it was revealed that the complainant was a known case of hypertension (HTN) for the last five years, whereas, in the proposal form, he had concealed this fact and the policy was obtained by concealment of material facts and/or by mis-representation. The opposite party received a request of reimbursement of the claim from the complainant on 13.8.2018 vide which he stated that he was hospitalized for the period from 28.7.2018 to 2.8.2018 in Medanta Hospital for treatment of    Grade-III Interno-external Piles and incurred expenditure of `1,54,768/- but as per discharge summary, the complainant was a case of past medical history-HTN.  Along with the claim form, the complainant submitted progress sheet dated 27.7.2018, wherein, it was mentioned that the complainant was “50 years old male HTN 05 years”. It was contended that no doctor would write and mention medical history in treatment records at his own and would mention only upon the information given by the patient or his relatives. From the medical record, it was established that the complainant was having HTN for the last five years. However, this fact was not disclosed by the complainant in the proposal form. The complainant was thus guilty of concealment of material facts. Accordingly, on 25.8.2018, the opposite party declared the policy issued to the complainant as void ab-initio. The claim was also not admissible and vide letter dated 24.10.2018, the claim of the complaint was repudiated. The conduct of the complainant clearly showed that history in medical records was as per information given by the complainant to the treating doctor and as regards medical tests, insurance contracts were based on utmost good faith.  As such, the opposite party considered information given by the complainant as true and correct. Accordingly, dismissal of the complaint was sought.

5.      After hearing learned counsel for the parties and on going through the record, learned District Forum held that the repudiation of the claim of the complainant was not justified and hence no reimbursement of the claim amount to the complainant tantamounted to deficiency in service on the part of the opposite party.  Accordingly, the opposite party was directed to reconsider the case of the complainant in terms of the policy and pay the claim amount within 30 days.

6.      Having heard learned counsel for the opposite party/appellant, this Commission finds that the earlier policy taken by the complainant from New India Assurance Company Ltd. was taken in the year 2006 and it was renewed from time to time and valid upto 21.6.2018. At the time of taking policy from New India Assurance Company Ltd. in the year 2006, the complainant had not stated about suffering from hypertension. It is another thing that the complainant suffered from hypertension only five years before the year 2018. The new policy was taken by way of porting, which was allowed by the opposite party-Liberty General Insurance Ltd. There was no enquiry made from the complainant while taking the new policy by way of porting. Rather, it was issued on the basis of the policy, which was taken by the complainant in the year 2006 from New India Assurance Company Ltd.  When the claim of the complainant was considered by the Liberty General Insurance Ltd.-opposite party, the statement of the complainant was recorded. There was no ground to conceal the fact about suffering from hypertension. It may also be mentioned here that the hypertension is not a disease and it varies at different stages of life of an individual and it can also be the result of the stress which an individual might be having and the individual may not notice symptoms of hypertension.

7.      In view of the above, the act of the opposite party in repudiating the claim of the complainant was not justified and as such the opposite party could be directed to reconsider the case in terms of the policy and to pay the claim amount to the complainant.

8.      Resultantly, the appeal is without any merit and, therefore, dismissed.

9.      The statutory amount of `25,000/- deposited by the appellant at the time of filing of the appeal be disbursed in favour of the complainant subject to decision of appeal/revision, if any and in accordance with rules.

 

 

Announced 29.10.2019

(T.P.S. Mann) President

D.R.