Chandigarh

DF-I

CC/207/2022

Vijay Chauhan - Complainant(s)

Versus

Cholamandalam MS General Insurance Co. Ltd. - Opp.Party(s)

Ashok Kumar Chauhan

06 Mar 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/207/2022
Date of Institution	:	15/02/2022
Date of Decision	:	06/03/2024

 

1.     Vijay Chauhan aged 62 years s/o Sh. Mangat Ram

2.     Veena Chauhan aged 52 years, w/o Sh. Vijay Chauhan

        Both residents of House No.74/6, Subhash Nagar, Manimajra, Chandigarh.

… Complainants

V E R S U S

1.     Cholamandalam MS General Insurance Company Ltd., through its Authorized Signatory, New No.319, Old No.154, Shaw Wallace Building, 2nd Floor, Thambu Chetty Street Parry's Corner, Chennai-600001.

2.     Cholamandalam MS General Insurance Company Ltd., through its Manager/Authorized Representative, SCO No.2463-2464, Second Floor, Sector 22-C, Chandigarh.

3.     Deepak Sachdeva, Agent of Cholamandalam MS General Insurance Company Ltd., SCO No.2463-2464, Second Floor, Sector 22-C, Chandigarh.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                               

ARGUED BY	:	None for complainants
	:	Sh. Kaveesh Kailey, Advocate for OPs (through VC)

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Vijay Chauhan and another, complainants against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that on 30.8.2019, complainant had purchased a group health insurance policy namely “Family Floater/AROGYA” (hereinafter referred to as “subject policy”) for himself, his spouse and upto three dependent children on payment of premium of ₹7,866/- and the same was valid w.e.f. 30.8.2019 to 29.8.2020. The subject policy (Ex.C-1) was issued by the OPs to the complainant after completion of requisite formalities.  In the second week of October 2021, Smt.Veena Chauhan (complainant No.2) suffered from “Subacute Intestinal Obstruction (Amoebic Colitis) with dengue fever” as a result of which she was admitted at Dhawan Hospital, Panchkula on 10.10.2021 where she remained admitted for five days and was discharged on 15.10.2021.  A copy of medical/treatment summary of complainant No.2 is Ex.C-4. Complainants had spent an amount of ₹55,925/- on treatment of complainant No.2 vide receipts (Ex.C-5 to C-8) and discharge summary is Ex.C-9.  Thereafter the complainants approached the OPs and intimated about medical treatment taken by complainant No.2 and submitted all the documents required for the settlement of the claim.  However, vide letter dated 30.10.2021 (Ex.C-10) OPs had repudiated the claim of the complainants on the ground that the insured patient i.e. complainant No.2 was suffering from diabetes since four years and hypertension since 15 years, which fact was not disclosed in the proposal form and the same is violation of the terms and conditions of the subject policy. The aforesaid objection raised by the OPs was baseless as the complainant was treated for “Subacute Intestinal Obstruction (Amoebic Colitis) with dengue fever”, which has no connection with the pre-existing disease as alleged by the OPs.  Not only this, complainant No.2 was not even suffering from the aforesaid alleged diseases even at the time when the subject policy was purchased and in this manner, OPs have wrongly repudiated the claim and the said act 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, cause of action and suppression of material facts.  On merits, admitted that the subject policy was purchased by the complainants from the OPs and the same was valid at the relevant time, but, alleged that as the complainants had suppressed material facts qua the pre-existing disease from which complainant No.2 was suffering at the time of obtaining the subject policy and on account of fundamental breach of the terms and conditions of the subject policy, the claim was rightly repudiated as complainant No.2 was suffering from diabetes since 4 years and hypertension since 15 years before obtaining the subject policy. On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainants is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainants re-asserted 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, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the OPs 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 purchased the subject policy from the OPs which was valid w.e.f. 30.8.2019 to 29.8.2020, as is also evident from the certificate of insurance (Ex.C-1), coupled with the policy schedule (Ex.A-1) and also that complainant No.2 namely Smt. Veena Chauhan (hereinafter referred to as “insured patient”) was treated at Dhawan Hospital, Panchkula where she remained admitted from 10.10.2021 to 15.10.2021, as is also evident from discharge summary (Ex. C-9) and the claim of the complainants was repudiated by the OPs on the ground of non-disclosure of material facts by the complainants about the pre-existing diseases from which the insured patient was suffering prior to obtaining the subject policy, as is also evident from the copy of repudiation letter (Ex.A-2), the case is reduced to a narrow compass as it is to be determined if the OPs/insurers are unjustified in rejecting/repudiating the genuine claim of complainants on the said ground and the complainants are entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainants, or if the OPs/insurers have rightly repudiated the claim of the complainants and the instant consumer complaint is liable to be dismissed, as is the defence of the OPs. 
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, medical record of the insured patient and the repudiation letter and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Perusal of subject policy/certificate (Ex.C-1) clearly indicates that the same was valid w.e.f. 30.8.2019 to 29.8.2020 and copy of policy schedule (Ex.A-1) further indicates that in case of non-disclosure of material facts by the policy holder, insurer has right to cancel the subject policy.  Ex.C-9 is the discharge summary (which has also been relied upon by OPs by placing on record copy of the same as Ex.A-3), which clearly indicates that the insured patient was diagnosed with “Subacute Intestinal Obstruction (?Amoebic Colitis) with dengue fever”.  The relevant portion qua the final diagnosis, past history and hospitalisation summary of the insured patient is reproduced below for ready reference :-

“Present Complaint

C/O   Acute Severe pain abdomen

Recurrent vomiting (Greenish & Yellowish Colour)

Headache

Low oral intake           x 3-4 days

Obstipation

Generalised Bodyache

Past History

K/C/O-HTN x 15 years on Tab Amlip 5mg 1 tab once daily

Hospitalization Summary

52years female presented in emergency in this hospital with Acute sever pain upper abdomen, Recurrent vomitings, Obstipation, Inability to take orally. All Relevant investigations were done and patient diagnosed as a case of Subacute intestinal obstruction (? Amoebic colitis) with Dengue fever with Thrombocytopenia Patient managed conservatively by keeping NPO with RTA, IV fluids, IV antibiotics, IV analgesic, IV PPI, IV Antiemetic, RBS Monitoring along with other supportive treatment. RT removed on 13/10/21. Patient responded well to the treatment, remained stable, accepting orally liquid, passing flatus, stool passed, afebrile and now patient is discharged under satisfactory condition.”

 

4. Ex.A-2 is copy of letter dated 30.10.2021, which clearly indicates that the claim of the complainants was repudiated for non-disclosure of material facts and the relevant portion of the same is reproduced below for ready reference :-

“On perusal of the claim documents, it is observed that the insured is suffering from Diabetes since 4 years and Hypertension since 15 years as per the history recorded in the submitted documents and 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 clause 4.2.”

5. The contention of the complainants is that as it stands proved on record that the insured patient was treated for “Subacute Intestinal Obstruction (Amoebic Colitis) with dengue fever”, which has no nexus with alleged diseases of diabetes or hypertension, OPs have wrongly repudiated the claim of the complainants and the consumer complaint be allowed.
6. On the other hand, contention of OPs is that since the complainants had suppressed material facts and had not disclosed about the insured patient being suffering from Diabetes since 4 years and Hypertension since 15 years, claim was rightly repudiated and the instant consumer complaint be dismissed.
7. However, there is no force in the contention of the OPs as it stands proved from the record that the insured patient was treated for “Subacute Intestinal Obstruction (Amoebic Colitis) with dengue fever” from which admittedly insured patient was not suffering at the time of obtaining subject policy. For argument’s sake, even if it is believed that the insured patient was suffering from diabetes since 4 years and hypertension since 15 years, as recorded by the medical officer in the discharge summary, the same clearly has no nexus with the diseases/ailments for which the insured patient had taken treatment at the treating hospital.
8. Even otherwise, 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 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/insurers have not been able to connect the previous diseases/ailments with the present diseases/ailments, for which the insured patient had taken treatment from the treating hospital.  Hence, it is unsafe to hold that the OPs/insurers were justified in rejecting/repudiating the claim of the complainants and the present consumer complaint deserves to succeed. 
12. Now coming to the quantum of relief, since the complainants have proved the payment receipts/bill (Ex.C-5 to C-8) amounting to ₹55,925/-, it is safe to hold that OPs/insurers are liable to pay the said amount to the complainants alongwith interest and compensation etc.

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 ₹55,925/- to the complainants alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 30.10.2021 onwards.
2. to pay ₹10,000/- to the complainants as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainants as costs of litigation.

5. This order be complied with by the OPs within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

06/03/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Suresh Kumar Sardana] Member