Chandigarh

DF-I

CC/87/2024

RAGHBIR CHAND - Complainant(s)

Versus

CHOLA MANDALAM MS GENERAL INSURANCE COMPANY LTD, THROUGH ITS MANAGER - Opp.Party(s)

MOHD. YUSAF

30 Aug 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/87/2024
Date of Institution	:	9/2/2024
Date of Decision	:	30/08/2024

 

Raghbir Chand s/o jyoti ram resident of H. No. 133471, 1st Floor, Sector 21, Panchkula.

Versus

....Complainant

 

1. Chola Mandlam MS General Insurance Company Ltd, 2nd Floor, Dare House NSC Bos Road Channai through its Manager.

2. Chola MS General Insurance Company Ltd, SCO 2463-64, 2nd Floor, Sector 22-C, Chandigarh, through its authorised Manager.

.....Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Mohd. Yusaf,  Advocate for complainant
	:	Sh. Kaveesh, Advocate for OPs.

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by the complainant under Section 35 of the Consumer Protection Act 2019 against the opposite parties (hereinafter referred to as the OPs). The brief facts of the case are as under :-

1. It transpires from the averments as projected in the consumer complaint that the complainant purchased group health insurance policy Annexure C-1 (hereinafter referred to be as subject policy) from OPs for himself and his family members  on payment of premium amount of Rs.34844/- valid w.e.f. 7.10.2022 to 6.10.2023  with sum insured to the tune of Rs.10,00,000/-  At the time of issuance of policy, the complainant was 70 year old  and was not having any medical problem at all and was living very normal and healthy life. On 6.8.2023, the complainant suddenly felt pain in his chest and was immediately admitted  in the Alchemist Hospital, (hereinafter referred to be as treating hospital) Panchkula, where he was diagnosed with acute inferior wall myocardial infraction and had undergone medical procedure of cardiology angioplasty multi vessel (PTCA/Stent to LAD and RCA). The medical certificates issued to this effect is annexed as Annexure C-2 and C-3. The complainant spent more than 3 lacs on his treatment and even has also been spending amount for the follow up treatment.  Thereafter the complainant applied for reimbursement  of the mediclaim with the OPs but vide letter Annexure C-4,  the OPs have repudiated the claim of the complainant wrongly and illegally on the ground that  the complainant had not disclosed material facts with  regard to diabetes from which he was suffering for the last 13 years  prior to issuance of the subject policy and the contract of insurance becomes void and no claim is payable under clause 4.15  of the subject policy. However, as the complainant had disclosed all the material facts in the proposal form before obtaining the subject policy, the OPs had wrongly rejected the claim of the complainant. The complainant applied for the copy of proposal form under RTI vide Application Annexure C-5 with the OPs which was never supplied by the OPs to the complainant. Moreover, the diabetes and heart disease are different from each other and have no nexus  with each other and the Ops have wrongly repudiated the claim of the complainant.  The aforesaid act  of OPs amounts to deficiency in service and unfair trade practice on their part. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, concealment of material facts. It is alleged that in fact the complainant was suffering from diabetes mellitus-II  at the time of issuance of the subject policy for the last 13 year, which was never disclosed by the complainant in the proposal form and the complainant has violated the terms and condition of the subject policy and as such the OPs have rightly repudiated the claim of the complainant. On merits, the facts as stated in the preliminary objections have been re-iterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainant reiterated  the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, complainant tendered/proved their evidence by way of affidavit and supporting documents. However, as OPs failed to file evidence despite grant of sufficient opportunity, therefore, vide order dated 19.6.2024 of this Commission, opportunity to file the same was closed
3. We have heard the learned counsel for the parties and also gone through the file carefully.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had obtained the subject policy for himself and his family members valid w.e.f.7.10.2022 to 6.10.2023  with sum insured to the tune of Rs.10,00,000/- as is also evident from the  certificate of insurance Annexure C-1 and during the currency of the policy the complainant had undergone PTCA/Stent to LAD and RCA procedure  in the treating hospital  on 6.8.2023  and was discharged on 9.8.2023  as is evident from Discharge Summary Annexure C-2 and the treating hospital has raised bill of Rs.2,86,404/- which has been paid by the complainant from his own pocket as is also evident from bill Annexure C-3  and the claim of the complainant was repudiated by the OPs vide Annexure C-4  on the ground that the complainant was suffering from diabetes since 13 years prior to the inception of the subject policy, the case is reduced to a narrow compass as it is to be determined if the Ops are unjustified in repudiating the claim of the complainant and the complainant is entitled for the relief as prayed for as is the case of the complainant or if the complaint of the complainant being not maintainable is liable to be dismissed as is the defence of the OPs.
   2. In the back drop of the foregoing admitted and disputed facts on record, it is clear that the entire case of the parties is revolving around the subject policy, medical record and repudiation letter having been placed on record by the parties.
   3. Perusal of  Annexure C-1 clearly indicates that the subject policy was issued by the OPs in favour of the complainant which was valid w.e.f. 7.10.2022 to 6.10.2023  covering the complainant and his family members. Annexure C-2  is the discharge summary  which clearly indicates  that the complainant was admitted in the treating hospital on 6.8.2023 where he was finally diagnosed  with heart related disease  and was treated  for the same.  The relevant portion of final diagnosis, procedure done and past history  is as under:-

Final Diagnosis:

ACUTE INFERIOR WALL MYOCARDIAL INFARCTICTION CART- TRIPLE VESSEL DISEASE. PTCA/STENT TO LAD AND RCA DONE

              NORMAL LV SYSTOLIC FUNCTION (EF=55%)

DIABETES MELLITUS II

Procedure Done: (06.08.2023)

|CART-TRIPLE VESSEL DISEASE

PTCA/STENT TO LAD AND RCA DONE

UNDER ΤΡΙ COVER

Past History: K/C/O-DM II.

4.  Annexure C-3 is the medial bill  which indicates that the treating hospital has raised  bill of Rs.2,86,404/-. Annexure C-5 is copy of application filed under RTI by the complainant through his counsel with the Ops for supply of proposal form  but the same was never supplied by the OPs to the complainant. Annexure C-6  is the medical record issued by Shelly Hospital  which indicates that the complainant was treated for diabetes on 12.7.2022.  Copy of certificate at page 31 of the paper book of complainant clearly showing that the  treating hospital issued certificate to the complainant  to the effect that the complainant is having diabetes mellitus since 13 months  instead of 13 years.
5. Learned counsel for the complainant submitted that as it stands proved that the complainant was hale and hearty at the time of issuance of policy and was not suffering from any disease  and the OPs have wrongly repudiated the claim of the complainant on the ground that the complainant has concealed material fact about the previous ailment i.e. diabetes, the complainant is entitled for relief.
6. On the other hand the counsel for Ops submitted that the as it stands proved on record that the complainant was suffering from diabetes mellitus-II for the last 13 years prior to the inception of policy,  the complaint of complainant is liable to be dismissed as is the defence of the Ops, however, the said defence of the OPs stands demolished from the certificate available at page 31 of the paper book of the complaint which was issued by the treating hospital, clarifying that the patient has diabetes mellitus  II since 13 months instead of 13 years.
7. Moreover, as it stands proved on record that in fact  the complainant had taken treatment for heart related disease where he was finally diagnosed with acute inferior wall myocardial infraction and underwent medical procedure of cardiology angioplasty multi vessel (PTCA/Stent to LAD and RCA) and the OPs have failed prove on record that the diabetes mellitus has any nexus with the  aforesaid disease,  it is clear that the OPs have wrongly repudiated the claim of complainant.  
8. It has been, held by the Hon’ble State Commission, Delhi, in the case titled S.S. Jaspal Vs. National Insurance Co. Ltd. & Ors., IV (2022) CPJ 26 (Del.) that common lifestyle disease like diabetes and hypertension, cannot be treated as pre-existing diseases and cannot be a ground of repudiation of claim by Insurance companies. The relevant portion of the order is reproduced as under:-

 “Consumer Protection Act, 1986 - Sections 2(1)(g), 14(1)(d), 15 - Insurance (Mediclaim) -Angioplasty and Stenting - Suppression of pre-existing disease alleged - Repudiation of claim Deficiency in service - District Forum dismissed Complaint - Hence Appeal - Complainant experienced pain in chest and remained admitted in Hospital from 24.6.2004 to 30.6.2004, where he had undergone Angioplasty and Stenting, by incurring Rs.3,20,126 on treatment - Previous medical history is based upon information provided by family of patient - Respondents failed to show any evidence regarding pre-existing disease suffered by insured at time of getting policy - Common lifestyle disease like diabetes and hypertension, cannot be treated as pre existing diseases and cannot be a ground of repudiation of claim by Insurance companies - Respondents failed to show any evidence that any medical tests or examination was done, before issuing said policy in question - Respondents are directed to pay a sum of Rs.3,20,126 (Cost of Medical Expenses) to Appellant along with interest @ 6% p.a.”

9. Similarly, the Hon’ble National Commission in the case titled Sunil Kumar Sharma v. Tata AIG Life Insurance Company and Ors., Revision Petition No.3557 of 2013 decided on 1.3.2021, while dealing with the issue of pre-existing disease, has held as under:-

“14. Moreover the claim had been repudiated only on the ground that the insured was suffering from diabetes for a long time. So far as life style diseases like diabetes and high blood pressure are concerned, Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., W.P.(C) No.656 of 2007, decided on 17.09.2007 held as under:

"Insurance – Mediclaim -Reimbursement-Present Petition filed for appropriate directions to respondent to reimburse
expenses incurred by him for his medical treatment, in accordance with policy of insurance - Held, there is no dispute that diabetes was a condition at time of submission of proposal, so was hyper tension - Petitioner was advised to undergo ECG, which he did - Insurer accepted proposal and issued cover note. It is universally known that hypertension and diabetes can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications depending upon varied factors. That implies that there is probability of such ailments, equally they can arise in non-diabetics or those without hypertension. It would be apparent that giving a textual effect to Clause 4.1 of policy would in most such cases render mediclaim cover meaningless. Policy would be reduced to a contract with no content, in event of happening of contingency. Therefore Clause 4.1 of policy cannot be allowed to override insurer's primary liability. Main purpose rule would have to be pressed into service. Insurer renewed policy after petitioner underwent CABG procedure. Therefore refusal by insurer to process and reimburse petitioner's claim is arbitrary and unreasonable. As a state agency, it has to set standards of model behaviour; its attitude here has displayed a contrary tendency. Therefore direction issued to respondent to process petitioner's claim, and ensure that he is reimbursed for procedure undergone by him according to claim lodged with it, within six weeks and petition allowed."

10. Further, the Hon’ble National Commission in the case titled as Neelam Chopra Vs. Life Insurance Corporation of India & Ors., IV (2018) CPJ 321 (NC) while dealing with the question of suppression/ non-disclosure of material facts has held as under :-

     12. In the present case, clearly the cause of death is cardio respiratory arrest and this disease was not existing when the proposal form was filled. Clearly, there is no suppression of material information in respect of this disease, which is the main cause of death. The other disease of LL Hansen, which was prevailing for five weeks on the date of admission on 1.8.2003 was also not existing when the proposal was filed by the DLA. The fact of DLA having been treated in the year 2002 for LL Hansen is not supported from any direct evidence though PGI Chandigarh in its certificate has mentioned that disease was treated in 2002. Moreover, this disease does not have any correlation with the cause of death in the present case. Hon’ble Supreme Court in Sulbha Prakash Motegaonkar and Ors. v. Life Insurance Corporation of India, Civil Appeal No.8245 of 2015, decided on 5.10.2015 (SC) has held the following:

       “We have heard learned Counsel for the parties.

              It is not the case of the Insurance Company that the ailment that the deceased was suffering from was a life threatening disease which could or did cause the death of the insured. In fact, the clear case is that the deceased died due to ischaemic heart disease and also because of myocardial infarction. The concealment of lumbar spondylitis with PID with sciatica persuaded the respondent not to grant the insurance claim.

              We are of the opinion that National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim by the respondent. The death of the insured due to ischaemic heart disease and myocardial infarction had nothing to do with this lumbar spondylitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified.”

11. In view of the foregoing discussion and the ratio of law laid down above, it is clear that the OPs/insurer has not been able to connect the previous diseases/ailments with the present diseases/ailments, for which the insured had taken treatment from the treating hospital.  Hence, it is unsafe to hold that the OPs/insurers were justified in rejecting/denying the claim of the complainant and the present consumer complaint deserves to succeed. Thus the aforesaid act of OPs amounts to deficiency in service and unfair trade practice on their part. Hence, the instant consumer complaint deserves to be allowed.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹2,86,404/- to the complainant alongwith interest @ 9% per annum (simple) from the date of repudiation of the claim till onwards
2. to pay ₹20,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs jointly and severally within a period of 45 days from the date of receipt of certified copy thereof, failing which the amount(s) mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
6. Pending miscellaneous application(s), if any, also stands disposed off.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 30/08/2024 mp			[Pawanjit Singh] President
			[Surjeet Kaur] Member
			[Suresh Kumar Sardana] Member