Punjab

Ludhiana

CC/14/850

Tarsem Kumar Garg - Complainant(s)

Versus

Cholamandlam MS Gen.Ins.Co.Ltd - Opp.Party(s)

Govind Puri Adv.

06 Jan 2017

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

 

 

Consumer Complaint No. 850 of 12.12.2014

Date of Decision          :   06.01.2017

 

Tarsem Kumar Garg s/o Harbans Garg r/o H.No.1133, Street No.5, Bhai Himmat Singh Nagar, Block-A, Dugri, Ludhiana.                                                                                                                                                    ….. Complainant

Versus 

 

1.Cholamandlam MS General Insurance Company Limited having its Branch Office at Rani Jhansi Road, Near Vohra Dental Clinic, Civil Lines, Ludhiana, through its Branch Manager.

2.Cholamandlam MS General Insurance Company Limited having registered office at 2^nd Floor, Dare House, 2 NSC Bose Road, Chennai-600001 through its Managing Director/Manager/Authorized Signatory.

..…Opposite parties

 

 

 (COMPLAINT U/S 12 OF THE CONSUMER PROTECTION ACT, 1986)

 

 

QUORUM:

SH.G.K.DHIR, PRESIDENT

SH.PARAM JIT SINGH BEWLI, MEMBER

 

COUNSEL FOR THE PARTIES:

For Complainant                     :         Sh.Govind Puri, Advocate

For Ops                         :         Sh.Vyom Bansal, Advocate

 

PER G.K DHIR, PRESIDENT

 

1.                          Shorn off unnecessary details, the case of the complainant is that agent of Ops approached complainant in January 2014 with a proposal for health insurance policy and on his allurement, complainant obtained medical health insurance policy by issue of cheque No.779551 dated 18.1.2014 for amount of Rs.6830/-. That amount was paid towards the premium of the insurance policy. Ops issued policy bearing No.2856/00132657/000/00 with validity period from 18.1.2014 to 17.1.2015. As per that policy, complainant along with his wife was insured for sum of Rs.5 lac in health floater scheme. Complainant was hale and hearty at the time of issuance of the policy in question. However, on 31.3.2014, he(complainant) all of a sudden, suffered chest pain and thereafter, consulted the doctor in OPD of CMC Hospital, Ludhiana on 1.4.2014. ECG was done and even other tests on the complainant were conducted. Blood pressure of the complainant at that time was in normal range of 110/80. Thereafter, the complainant started getting treatment in OPD for period from 1.4.2014 to 4.4.2014. On advise of doctor of CMC Hospital, Ludhiana, complainant got Cardiac Angiography done on 2.7.2014. After receipt of the report of CAG, it was found that there was blockage in the arteries of the complainant and his case was diagnosed as Triple Vessel Disease. Complainant was advised to undergo surgery and accordingly, he got the heart bye pass surgery from Hero DMC Heart Institute, Ludhiana by way of admission in that hospital for the period from 15.7.2014 to 23.7.2014. Amount of Rs.2,38,640/- were spent on this treatment. After discharge from the hospital on 23.7.2014, the complainant submitted the claim supported by original medical bills and other documents. That claim was duly registered vide claim No.2856000971. However, instead of paying the amount of genuine claim, the same was repudiated vide letter dated 15.10.2014. That repudiation alleged to be arbitrary and illegal. Repudiation took place on ground that ailment was existing for the last three months as disclosed by consultation advise dated 4.4.2014. It was observed that the ailment was since from 4.1.2014 and as such,the said treatment was pertaining to the pre-existing disease and the claim not admissible as per the exclusion general clause C-3. As far dyspnoea on exertion is concerned, the same can be experienced by anyone on exertion during winter season. So, non-disclosure of heart problem was on account of the fact that the complainant himself was not aware about his suffering from that problem. In the discharge summary of Hero DMC Hospital, Ludhiana, it was mentioned that patient complained of breathlessness for the last 20 days and he felt chest pain for the first time on 30.3.2014. Complainant was not suffering from pre-existing heart problem and by claiming that repudiation of claim is unjustified, prayer made for directing Ops to pay the claim amount of Rs.2,30,060/- along with compensation for physical harassment, mental pain and agony of Rs.50,000/-. Litigation expenses of Rs.11,000/- more claimed.

2.                In joint written statement by Ops, it is pleaded interalia as if complaint in the present form is not maintainable because cause of action has not arisen to the complainant within the territorial jurisdiction of this Forum; complainant has suppressed the material facts with motive of getting unjust money; there is no deficiency in service on the part of Ops; in view of involvement of intricate question of law and facts, matter need to be decided by the Civil Court. Besides, it is claimed that complainant instead of complying with the terms and conditions of the policy, approached this Forum without any rhyme or reason. Purchase of the policy in question not denied and nor submission of the claim denied. However, it is claimed that after receipt of the claim from the complainant, matter got investigated from Panel TPA and thereafter, verification and applying mind as well as scrutinizing the documents, the claim of the complainant was duly repudiated. It is claimed that Panel TPA found as if the complainant was having signs and symptoms of the present ailment existing just 3 months before date of consultation namely 4.4.2014 and as such, he was having such symptoms w.e.f.4.1.2014. However, inception of the policy took place w.e.f.18.1.2014. As per patient record dated 4.4.2014, he was suffering from dyspnoea on exertion for 3 months. That dyspnoea refers to the sensation of difficult or uncomfortable breathing. So, complainant was diagnosed with CAD/TVD for CABG. Ailment of the complainant was considered as a pre-existing disease on the basis of the received information and as such, claim alleged to be rightly repudiated vide letter dated 15.10.2014 in view of the general exclusion clause C-3 of the terms and conditions of the policy. Complainant concealed the factum of pre-existing disease while getting the policy because that fact was not mentioned in the proposal form and as such, on account of concealment of material facts, repudiation of claim alleged to be proper, particularly when contract of insurance is a contract arrived at with utmost faith. Moreover, complaint alleged to be filed after expiry of limitation period of 2 years.

3.                Complainant to prove his case tendered in evidence his affidavit Ex.CA along with documents Ex.C1 to Ex.C6 and thereafter, his counsel closed the evidence.

4.                On the other hand, counsel for OPs tendered in evidence affidavit Ex.RA of Sh.Ashutosh Kumar, Assistant Manager Claims (Legal) of OPs along with documents Ex.R1 to Ex.R3 and thereafter, Ops failed to conclude its evidence, despite availing of sufficient opportunities and as such, evidence of Ops was closed by orders of 23.7.2015. Application for additional evidence filed by Ops being vague was dismissed vide orders dated 27.1.2016 and as such, counsel for the Ops tendered in evidence policy wording Ex.R1, which was treated as part of Ex.RA.

5.                Oral arguments of counsel for the parties heard because written arguments not submitted by the parties. Records gone through minutely. 

6.                Only contentious point remains as to whether the disease of the complainant qua heart ailment was pre-existing or not?

7.                Undisputedly, the complainant purchased the medical health insurance policy from Ops vide Ex.C1=Ex.R1. Perusal of Ex.C3=Ex.R2 reveals that the complainant was found having dyspnoea on exertion for the last 3 months and even he complained of chest pain for the first time on 30.3.2014. In Ex.C3=Ex.R2, it is also mentioned that after complaint of chest pain for the first time on 30.3.2014, complainant did not make any complaint thereafter, This treatment record of complainant Ex.C3=Ex.R2 is of date 4.4.2014 and as such, in view of diagnosis of dyspnoea on exertion for last 3 months, it is vehemently contended by Sh.Vyom Bansal, Advocate representing Ops that actually the complainant was suffering from heart disease since from 4.1.2014. That submission of counsel for Ops has no force because in the written statement and affidavit Ex.RA of Sh.Ashutosh Kumar, it is specifically mentioned that dyspnoea refers to sensation of difficult or uncomfortable breathing. So, in view of this explanation given in written statement as well as in affidavit Ex.RA, it is obvious that the complainant complained of sensation of difficult or uncomfortable breathing on exertion just three months prior to the treatment on 4.4.2014. That difficulty or uncomfortableness in breathing may be felt even by a person not suffering from heart problem. So, just mention of word dyspnoea on exertion for the last three months in Ex.C3=Ex.R2 does not lead to the inference that the complainant actually suffered from heart ailment since from 4.1.2014. Policy in question commenced from 18.1.2014 as revealed by contents of Ex.C1=Ex.R1. Complainant himself was not aware of the disease of heart on 18.1.2014 and as such, question of disclosure of the heart disease by him at the time of submission of proposal form does not arise. There is no material produced on record to establish that the complainant got treatment for heart disease since from 4.1.2014 and as such, repudiation of claim on ground of pre-existing disease is quite improper. As complainant himself was not aware of heart disease at the time of purchase of the policy in question on 18.1.2014 and as such, non disclosure of that fact by the complainant on 18.1.2014 is not an act of concealment of the material  fact at all.

8.                Rather, after going through Ex.C3=Ex.R2, it is made out that acute coronary syndrome was recently detected. So, virtually sufferance of the complainant from coronary syndrome detected on 4.4.2014 and not before that and if that be the position, then certainly the complainant was not knowing about heart disease at all prior to 4.4.2014. Being so, there is no question of concealment of material facts qua sufferance from pre-existing disease by the complainant.

9.                Ex.C4 is the CAG report dated 2.7.2014 of the complainant. In Ex.C4, complainant was found to be suffering from Triple Vessel disease and as such, virtually the complainant was diagnosed as a case of heart disease during admission in CMC Hospital, Ludhiana on 4.4.2014 only and that is why he got his treatment from Hero DMC Heart Institute, Ludhiana in July, 2014. In view of this, repudiation of claim through letter Ex.C6 is quite improper.

10.              Perusal of Ex.R1 reveals that benefits of insurance scheme is not available for any pre-existing disease as defined in the policy until 48 months from the continuous coverage has elapsed since inception of the first policy with insurer. Pre-existing condition of heart disease was not known to the complainant until 4.4.2014 as discussed above and as such, repudiation of claim in view of general exclusion clause contained in Ex.R1 is quite improper. In view of this directions need to be issued to Ops to reconsider the claim of the complainant within 30 days from the date of receipt of copy of this order. In case, Ops will require any documents for settling the claim, then the complainant will submit the original to the extent available with him. However, in case, verification of the hospital records or of bills required by the Ops, then Ops can do the same at their own because as per law laid down in case of Avneet G Singh vs. ICICI Lombard General Insurance Company Limited and others-2014(2)CLT-374(Chandigarh State Consumer Disputes Redressal Commission, U.T.Chandigarh), the complainant if provides the available medical record with her, then beyond that the insurance company itself can collect the non available medical record from the hospital concerned also. In case, Ops required any documents from the complainant, then requisition in writing in that respect must be sent by the Ops to the complainant and thereafter, complainant will submit those required documents within 15 days of receipt of written requisition. As due to improper repudiation of the claim, complainant suffered lot of mental harassment and as such, he is entitled for somewhat hefty amount of compensation along with litigation expenses.

11.              Therefore, as a sequel of the above discussion, complaint allowed in terms that Ops will reconsider the claim of complainant because repudiation of the claim on ground of preexisting disease is illegal and improper. This reconsideration must take place within 30 days from receipt of copy of this order. On such reconsideration, if any amount found due, then same must be paid within 30 days of the order to be passed by Ops. However, compensation for mental harassment of Rs.20,000/- (Rupees Twenty Thousand only) and litigation costs of Rs.5,000/- (Rupees Five Thousand only)  more allowed in favour of complainant and against Ops. Liability of Ops to pay these amounts will be joint and several. Payment of these amounts be made within 30 days from the date of receipt of copy of this order. However, in case any documents will be required by Ops while settling/paying the amount, those will be submitted by complainant in original to the extent they are available. Verification of the hospital records or of the bills will be done by Ops at their own. Documents required will be submitted by complainant within 15 days on receipt of requisition in writing from Ops. Copies of order be supplied to parties free of costs as per rules.

12.                        File be indexed and consigned to record room.

 

                              (Param Jit Singh Bewli)           (G.K.Dhir)

                                     Member                               President

Announced in Open Forum

Dated:06.01.2017

Gurpreet Sharma.