Haryana

Bhiwani

CC/70/2020

Sudha Gupta - Complainant(s)

Versus

Cholamandlam - Opp.Party(s)

Sanjiv Tanwar

24 Jul 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSASL COMMISSION, BHIWANI.

                                                                Complaint Case No. : 70 of 2020

                                                                Date of Institution    : 17.07.2020

                                                                Date of decision:      : 24.07.2024

 

Smt. Sudha Gupta wife of Parkash Chander Gupta R/o H.No.208,Chiranjiv Colony, Bhiwani, Tehsil and District Bhiwani.

                                                            ...Complainant. 

 

                                                    Versus.

1. Chloamandalam MS General Insurance Company Ltd., having its branch office at Indian Ban, Hansi Gate, Bhiwani through its authorized signatory and having its registrered office, 2^nd Floor Dare House, 2 NSE Bose Road, Chennai.

 

2. Oriental Bank of Commerce, Bhiwani through its Branch Manager.

 

....Opposite parties.

 

COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT, 1986.

Before: -       Mrs. Saroj Bala Bohra, Presiding Member.

                    Ms. Shashi Kiran Panwar, Member.

Present:        Sh. Neeraj Kumar, Advocate for complainant.

Sh. Rajender Verma, Advocate for OP No.1.

Ms. Sheela Tanwar, Advocate for OP No.2.

 

                                                  ORDER

 

SAROJ BALA BOHRA, PRESIDING MEMBER:

1.                 Brief facts of this case are that complainant  and her husband obtained a Group Health Insurance Policy bearing No.2842/00165789/0002/000/00 Family Floater/Arogya 500 from OP No.1, through OP No.2, by paying a premium of Rs.11012/-. The policy was effective for a period from 19.12.2018 to 18.12.2019. She further obtain a policy no. 2876/00037020/000001/000/01 of the abovesaid plan for a period from 19.12.2019 to 18.12.2020 by paying a premium of Rs.11012/-.  It is submitted that complainant was got medically examined by OP insurance company prior to issuance of the policy and no ailment was found.  Complainant in the month of December 2019 fell ill and taken outdoor patient treatment from Medical Care Centre Trust, Kashiben Gordhandas Patel Children Hospital, Vadodra, till 30.12.2019.Thereafter, she got admitted in Isha Multispecialty Hospital, Vadodra centra, Sarabhai Main Road, Vadodra, Gujrat on 04.01.2020 and was discharged on 05.01.2020 and incurred a sum of Rs.1,50,000/- on the treatment. Complainant claimed the amount from OPs by submitting all necessary documents but the claim was cancelled on the ground of pre-existing disease. Hence, the present complaint has been preferred by complainant alleging deficiency in service on the part of OPs resulting into monetary loss as well as mental and physical harassment.  In the end, complainant sought directions against the Ops to pay a sum of Rs.1,50,000/-, further to pay Rs.50,000/- as compensation for harassment, Rs.5000/- as cost of complaint and to restore/not to cancel the Group Health Insurance policy bearing No.2876/00037020/000001/000/01. Any other relief to which this Commission deems fit has also been sought.

2.                 Notices were sent to the OPs. OP No.1 filed written statement raising preliminary objections qua maintainability of complaint, locus standi, cause of action, jurisdiction and suppression of material facts by complainant.  On merits, it is submitted that the insured did not disclose true and material facts in the proposal form and concealed fact about their ill health. It is clarified that the complainant was suffering from hypertension and thyroid since 10 years and 5 years as per history mentioned in discharge summary. As such, the claim was not payable to the complainant and same was repudiated vide letters dated 15.02.2020 and 21.04.2020 and the policy was cancelled on 20.06.2020. In the end, denied for any deficiency in service and prayed for dismissal of the complaint with costs.

3.                 OP No.2 appeared through counsel and tendered reply submitting that it has not acted upon any deficiency in service as it has only deducted the amount from account of complainant and remitted the same to OP insurance company. In the end, denied for any deficiency in service on its part and prayed for dismissal of the complaint with costs.

4.                 In evidence of complainant, her affidavit Ex. CW1/A alongwith documents Annexure C-1 to Annexure C-20 were tendered and closed the evidence.

5.                 On the other side, in evidence of OP No.1, affidavit of Mr. Kuber Dutt Sharma, authorized person of OP No.1 alongwith documents Annexure R-1 to Annexure R-10 were tendered and closed the evidence.

6.                 In evidence of OP No.2, document Annexure C-11 was tendered and closed the evidence.

7.                 We have heard learned counsels for the parties and perused the record carefully.

8.                 Prima facie, claim of complainant has been repudiated by OP insurance company vide their letter (Annexure R-10) on the grounds that On perusal of the claim documents it is observed that the present ailment is diagnosed/diagnosable within first thirty days of inception of the policy hence, the claim is inadmissible as per General Exclusions 3.1.1 which reads as No indemnity is available or payable for claims directly or indirectly caused by, arising out of or connected to A waiting period of 30 days will apply to all claims from the commencement date of the policy except in case of hospitalization arising out of injuries caused by accidents. This exclusions does not apply for subsequent renewals with the company without a break. Further, the insured has hypertension and thyroid since 10 years and 5 years as per history recorded in the discharge summary, 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 the policy. Ld. Counsel for OP insurance company, in support of his case has placed reliance on case laws delivered by Hon’ble Rajasthan State Consumer Disputes Redressal Commission, Jaipur in case titled Kailash Chand Jain Vs. National Insurance Co. Ltd. & Ors. III (2016) CPJ 57 (Raj.) wherein it is observed that “Medical reimbursement-Denied on ground of suppression of pre-existing disease-Alleged deficiency in service-District Forum dismissed complaint-Hence appeal-Discharge ticket relied upon by appellant himself speaks that appellant was suffering from pre-existing disease-Repudiation justified.”   

9.                 The counsel for complainant has argued that the OP insurance company has arbitrarily and illegally repudiated the genuine claim of complainant on the ground of suppression of previous ailment by the insured while taking the insurance policy. The counsel has vehemently argued that in fact, the insured was not suffering from any disease as medical examination of the complainant was done prior to issuing of the policy.  The counsel has relied upon a case law delivered by Hon’ble State Consumers Disputes Redressal Commission, Punjab, Chandigarh, First Appeal N.125 of 2020 titled Life Insurance Corporation of India Vs. Sohan Lal, decided on 19.06.2020 wherein it is observed that "Mere non-mentioning of insured being a patient of hypertension did not amount to suppression of material facts, so as to entitle respondent to repudiation claim.  Hypertension is a common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension may have exact knowledge of same-Repudiation of claim set aside-claim allowed. (2) Diabetes is a life style disease and is so common in India that whole insurance claim cannot be rejected on this ground.” Further, the counsel has also placed reliance on a case law delivered by Hon’ble Punjab & Haryana High Court in CWP No.26178 of 2016 titled as National Insurance Co.Ltd. Vs. Sandeep & others reported in 2017 (1) RCR (Civil) Page 621 wherein it has been  held that “Insurance companies give lucrative offers to attract customers-However, the moment any insured puts even the most genuine claim, seldom said claim would be accepted by any insurance company.”

10.               Undisputedly, the complainant at the time of taking treatment was under the cover of insurance policy and the amount so incurred on the treatment is also not in dispute. The grounds for repudiation of claim to complainant are that the claim was within first thirty days of inception of the policy and that there was suppression of pre-existing diseased of hypertension and thyroid to complainant.   As is clear from record and pleading of the parties, it is clear that it was subsequent policy of the complainant, therefore, the denial of medical reimbursement on the grounds of early claim under the policy terms was not justified. Further, repudiation of claim to complainant on ground of suppression of hypertension, in our view, is also not justified rather the observations made the case Life Insurance Corporation of India (supra) are of much helpful in deciding the present case. Complainant to prove that she incurred Rs.1,34,729/- on her treatment has placed on record a consolidated bill (Annexure C-4).

10.               After hearing learned counsels for the parties and going through the record, we are of the view that OP No.1 insurance company has wrongly repudiated the claim of complainant just to cheat and harass the complainant which amounts to deficiency in service and mal-trade practice on their part resulting into monetary loss as well as mental and physical harassment.  Hence, the complaint is allowed and the OP No.1 is directed to comply with the following directions within 40 days from the date of order:-

(i)       To pay a sum of Rs.1,34,729/- (Rs.One lac thirty four thousand seven hundred twenty nine) to the complainant alongwith simple interest @ 9% per annum from the date of filing of complaint till actual realization.

(ii)      To pay Rs.10,000/- (Rs. Ten thousand) as compensation for harassment. 

3. To pay Rs.5500/- (Rs. Five thousand five hundred) as litigation expenses.

                    In case of non-compliance, all the awarded amounts shall attract simple interest @ 12% per annum for the period of default. 

                    Further, the complainant shall be entitled to the execution petition under section 71 of Consumer Protection Act, 2019 and in that eventuality, the opposite party no.1 may also be liable for prosecution under Section 72 of the said Act which envisages punishment of imprisonment, which may extend to three years or fine upto rupees one lac or with both.  Copies of this order be sent to the parties concerned, free of costs.  File be consigned to the record room, after due compliance. 

Announced.

Dated: 24.07.2024.