DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

 

Complaint Case No : CC/163/2021

Date of Institution : 10.08.2021

Date of Decision : 13.09.2023

Raj Rani wife of Krishan Lal son of Hans Raj resident of Bagh Colony, Ward No. 3, Tapa Mandi, District Barnala.   

                  …Complainant

Versus

1. Cholamandlam MS General Insurance Company Limited, through its Manager, registered office at 2nd floor, Dare House, 2, N.S.C. Bose Road, Chennai.

2. Oriental Bank of Commerce, now Punjab National Bank, through its Manager Branch Office at Tapa, District Barnala. 

              …Opposite Parties

Complaint under Section 35 of the Consumer Protection Act, 2019

Present: Sh. Nitin Bansal Adv counsel for complainant.

Sh. AK Jindal Adv counsel for opposite party No. 1.

Sh. J.K. Kapil Adv counsel for opposite party No. 2.

Quorum.-

1. Sh. Jot Naranjan Singh Gill : President

2. Sh. Navdeep Kumar Garg : Member

(ORDER BY JOT NARANJAN SINGH GILL, PRESIDENT):

    The complainant Raj Rani filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Cholamandlam MS General Insurance Company Limited and others. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that complainant husband purchased policy from the opposite party No. 1 through opposite party No. 2 of intermediary code 2021451866343275 on the name of OBC1237 UDBHAV Gurgaon/Group Health Insurance UIN:IRDA/NL-HL/CHSGI/P-H/V.I/48/13-14 of opposite parties No. 1 and the details as under:-

Policy Number: 2876/00049435/000156/000/01

Validity Period: 01.03.2020 to 28.02.2021

Premium:          Rs. 7,866/- per annum

Whereby the complainant alongwith her husband Krishan Lal are having the medical insurance claim upto the sum of Rs. 3,00,000/- in case of medical emergencies. It is further alleged that on 4.9.2020 the complainant was suffered from Severe B/L Pneumonia which is covered under the policy and discharged on 9.9.2020 having claim of Rs. 1,33,779/- has been spent on the medical treatment of complainant at Indrani Hospital, Bathinda. The complainant had applied for mediclaim under the policy issued by the opposite party No. 1 and in return instead of issuing the claim Query Revert Claim No. 2876022217 OBC Tapa 0641 to complainant, the opposite party No. 1 has asked complainant to deposit “need treating doctor certificate any history of co morbidity DM/HT/CAD with its duration related to patient”. It is further alleged that the required documents were submitted by the complainant to opposite party No. 1 but they revert back to complainant through email on 1.12.2020 Claim Repudiated- On the perusal of document, the insured is suffering from Diabetic and Hypertension since 4-5 years as per the history recorded in the submitted documents, this information is not disclosed in the proposal form while proposing for insurance. In view of this non-disclosure of material information, the contract of insurance becomes void and no claim is payable under this policy. It is further alleged that the complainant sent legal notice dated 28.9.2020 to the opposite parties but all in vain. The above said act of the opposite parties amounts to deficiency in service and unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.-

1)The opposite parties may kindly be directed to pay Rs. 1,33,779/- collectively or severally alongwith interest at the rate of 12% per annum from the date of claim lodged.

2) To pay Rs. 1,00,000/- on account of compensation for mental agony and harassment and Rs. 5,000/- as litigation expenses.

3. Upon notice of this complaint, opposite party No. 1 filed written reply taking legal objections that the intricate question of law and facts are involved in the present complaint which require documents and evidence which is not possible in the summary procedure. The  complainant has concealed material facts from this Commission. Further, on scrutiny of claim documents submitted it was observed that the claim is not admissible for the following reasons:

“On perusal of the documents, it is observed that the insured is suffering from diabetes and hypertension since 4-5 years as per history recorded in the submitted documents. The said information was not disclosed in the proposal form while proposing for insurance”. 

On merits, it is submitted that the letters dated 19.10.2020 and 3.11.2020 were sent seeking documents in order to process and decide the claim and on the perusal of submitted documents claim was repudiated vide letter dated 27.11.2020. Other allegations of the complainant are denied and it is also denied that there is deficiency in service and unfair trade practice on their party and lastly prayed for the dismissal of complaint. 

4. The opposite party No. 2 also filed separate written reply by taking legal objections interalia on the grounds that complainant has got no locus-standi or cause of action, present complaint is frivolous, vexatious and liable to to be dismissed. Complainant is not consumer of answering opposite party etc. On merits, it is submitted that act and conduct of answering opposite party not comes within the definition of unfair trade practice as well as deficiency in service. Complainant is not entitled to any relief against the opposite party No. 2. However, complaint is admitted to the extent that complainant has sent legal notice. All other allegations are denied and prayed for the dismissal of complaint. 

5. In support of her complaint, the complainant tendered into evidence her own affidavit Ex.C-1, copy of policy Ex.C-2, copy of report Ex.C-3 (containing 24 pages), copy of health claim query letter Ex.C-4 (containing 2 pages), copy of repudiation letter Ex.C-5, copy of legal notice Ex.C-6, copies of postal receipts Ex.C-7 & Ex.C-8 and closed the evidence. 

6. To rebut the case of the complainant the opposite party No. 1 tendered in evidence copy of health claim repudiation letter dated 27.11.2020 Ex.O.P.1/1, copy of health claim reminder letter dated 3.11.2020 Ex.O.P.1/2, copy of health claim query letter Ex.O.P.1/3, copy of Group Health Insurance Policy Ex.O.P.1/4 (containing paged 1 to 29), copy of discharge summary Ex.O.P.1/5 (containing pages 1 to 2), copy of claim form Ex.O.P.1/6 (containing pages 1 to 2), self declaration Vidhi Passi Ex.O.P.1/7. 

7. The opposite party No. 2 tendered into evidence affidavit of Maninderjit Singh Ex.O.P.2/1 and closed the evidence. 

8. We have heard learned counsel for the parties and have gone through the record on file. Written arguments filed by the complainant and opposite party No. 1. 

9. Ld. Counsel for the complainant argued that the complainant's husband purchased policy from the opposite party No. 1 through opposite party No. 2 on the name of OBC1237 UDBHAV Gurgaon/Group Health Insurance UIN:IRDA/NL-HL/CHSGI/P-H/V.I/48/13-14 of opposite parties No. 1 vide Policy Number: 2876/00049435/000156/000/01 with the validity period from 01.03.2020 to 28.02.2021 with premium of Rs. 7,866/- per annum (Ex.C-2). It is further argued that the complainant alongwith her husband Krishan Lal are having the medical insurance claim upto the sum of Rs. 3,00,000/- in case of medical emergencies. It is further argued that on 4.9.2020 the complainant was suffered from Severe B/L Pneumonia which is covered under the policy and discharged on 9.9.2020 having claim of Rs. 1,33,779/- has been spent on the medical treatment of complainant at Indrani Hospital, Bathinda (Ex.C-3). It is argued that the complainant had applied for mediclaim under the policy issued by the opposite party No. 1 and in return instead of issuing the claim the opposite party No. 1 made Query Revert Claim No. 2876022217 OBC Tapa 0641 to complainant and asked complainant to deposit “need treating doctor certificate any history of co morbidity DM/HT/CAD with its duration related to this patient” (Ex.C-4). It is further argued that the required documents were submitted by the complainant to opposite party No. 1 but they revert back to complainant through email on 1.12.2020 and claim repudiated on the following grounds:-

Claim Repudiated- On the perusal of document, the insured is suffering from Diabetic and Hypertension since 4-5 years as per the history recorded in the submitted documents, this information is not disclosed in the proposal form while proposing for insurance. In view of this non-disclosure of material information, the contract of insurance becomes void and no claim is payable under this policy.

It is further argued that the complainant sent legal notice dated 28.9.2020 (Ex.C-6) to the opposite parties but all in vain. 

10. Ld. Counsel for opposite party No. 1 argued that an intricate question of law and facts are involved in the present complaint which require documents and evidence and the same is not possible in the summary procedure. It is also argued that on scrutiny of claim documents submitted it is observed that the insured is suffering from diabetes and hypertension since 4-5 years as per history recorded in the submitted documents and the said information was not disclosed in the proposal form while proposing for insurance. In view of this non-disclosure of material information, the contract of insurance becomes void and no claim is payable under this policy (Ex.O.P1/1). It is argued that the letters dated 19.10.2020 and 3.11.2020 (Ex.O.P.1/2 & Ex.O.P.1/3) were sent seeking documents in order to process and decide the claim and on the perusal of submitted documents claim was repudiated vide letter dated 27.11.2020.

11. Ld. Counsel for opposite party No. 2 argued that act and conduct of opposite party No. 2 not comes within the definition of unfair trade practice as well as deficiency in service, however complaint is admitted to the extent that complainant has sent legal notice and the opposite party No. 2 denied all other allegations and prayed for the dismissal of complaint.  

12. It is not disputed between the parties that the complainant's husband purchased policy from the opposite party No. 1 through opposite party No. 2 vide Policy Number: 2876/00049435/000156/000/01 which was valid period from 01.03.2020 to 28.02.2021 with premium of Rs. 7,866/- per annum. It is also not disputed between the parties that the complainant alongwith her husband Krishan Lal are having the medical insurance claim upto the sum of Rs. 3,00,000/- in case of medical emergencies. It is further admitted case of the complainant that on 4.9.2020 the complainant was suffered from Severe B/L Pneumonia which is covered under the policy and discharged on 9.9.2020 having claim of Rs. 1,33,779/- has been spent on the medical treatment of complainant at Indrani Hospital, Bathinda. 

13. The case of the opposite party No. 1 is that on the perusal of document, the insured is suffering from Diabetic and Hypertension since 4-5 years as per the history recorded in the submitted documents, this information is not disclosed in the proposal form while proposing for insurance. In view of this non-disclosure of material information, the contract of insurance becomes void and no claim is payable under this policy. 

14. In order to prove her case the complainant has placed on record Ex.C-3 (Page 5) discharge summary. From which it is proved that the patient was admitted on 4.9.2020 and discharged on 9.9.2020. Further, in the column of Diagnosis it is mentioned “K/C/O DM/HTN/ Severe B/L Pneumonia” and the patient comes with complaint i.e. “C/o difficulty in breathing, chest heaviness, shortness of breath Cough x 3 days” and in the column of Hospital course it is mentioned as “In our hospital patient is treated with antacids, antiemetics, antibiotics, antivirals, bronchodilators, diuretics, nebulization and high flow mask with O2 support and other PPI supportive measures completed course of REMEDESIR (6 vials)”. So, from the course of hospital it is not found that the hospital has given treatment to the patient for diabetes and hypertension and there is relevancy of the treated disease with the pre-existing disease.  Even, the opposite party has failed to place on record Proposal Form vide which it is mentioned that the patient had pre-existing disease of diabetes and hypertension and the same was signed by the insured at the time of taking policy. We are of the view that the insurance company had not been able to prove beyond doubt that the patient was suffering from diabetes before filing of the proposal form. The insurance company had given insurance to a person of about 64 years of age without any preliminary medical examination which could have definitely revealed whether the proposer was suffering from diabetes or not. However, it is commonly known that a person of 64 years of age has a high probability of suffering from common lifestyle diseases like diabetes and hypertension and if the company is ready to take the risk at this age of the proposer, without any preliminary medical examination, then the company should be ready to honour the claim. As such, we are of the view that the insurance company has also failed to place on record any corroborated evidence in order to repudiate the claim of the complainant. Moreover, the opposite party No. 1 has failed to place on record the evidence/affidavit of doctor who had prepared the case history/summary of patient. Therefore, we are of the view that the insurance company has not been able to prove that the complainant suppressed material facts pertaining to pre-existing diseases and had breached the contract of utmost good faith. 

15. Ld. Counsel for complainant has relied upon the judgment In R.P. No. 4461 of 2012 in case titled Neelam Chopra Vs Life Insurance Corporation of India & Ors., decided on 8.10.2018 (NC) vide which it was held in Para No. 11 that;-

“From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases. The person insured may suffer consequences in terms of the reduced claims”. 

16. The Ld. Counsel for complainant further relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and  others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that it seems that the insurance companies are only interested in earning the premiums. 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 company in such cases reply upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy.

17. So, from the above discussion, it is established that the claim of the complainant was repudiated by the insurance company on unreasonable and unjustified grounds and there is clear cut deficiency in service on the part of opposite party No. 1. Therefore, the present complaint is partly allowed against the opposite party No. 1 and the opposite party No. 1 is directed to pay Rs. 1,33,779/- alongwith interest @ 7% per annum to the complainant from the date of filing of the present complaint till realization. The opposite parties are further directed to pay Rs. 5,000/- on account of consolidated amount of compensation as well as litigation expenses to the complainant.

18. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order.

19. Copy of this order be supplied to the parties free of costs as per rules. File be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN COMMISSION:

       13th Day of September, 2023

 

            (Jot Naranjan Singh Gill)

            President

 

(Navdeep Kumar Garg)

Member