FINAL ORDER/JUDGEMENT
Smt. SAHANA AHMED BASU, Member,
The case of the Complainant, in a nutshell, is that, the Complainant started her Mediclaim Policy since May, 2004 under United India Insurance Co. Ltd and continuing the Policy by paying the yearly premiums without any break. In the year 2018 being allured by the representation of the OPs the Complainant agreed to port the existing policy with the OPs. Before porting to the Ops thorough medical tests were carried by the OP’s Doctor and on the recommendation by the authorized Doctor the policy was ported. Proposal form was filled up by the representative of the OPs and the Complainant just pot her signature on good faith. After satisfying from all respects the OPs issued Nowover/Portability Mediclaim Policy being No. PROHLRO10700873 for the period from 29.05.2018 to 28.05.2019 on payment of Premium of Rs.23,388/- and the sum assured for the Policy was Rs.4,50,000/-. Thereafter the Complainant took admission at Fortis Hospital on 13/11/2018 to 23/11/2018 for knee surgery under Dr. Rakesh Rajput and sought for cashless claim under Insurer Member ID No. 1000811174 to the OP. But the OP refused to allow cashless treatment. Therefore the Complainant filed claim for reimbursement furnishing all the treatment papers I original to the OP and the total bill amount was Rs.4,03,974/-. Despite acknowledged the claim as Claim No. 18527672 the OP repudiated the claim of the Complainant on the ground of non-disclosure of pre-existing disease of hypertension. On the other hand the Complainant received an email dated 28/12/2018 from the OP for depositing an additional loading of rs.3508/-. The Complainant sent several emails with request for reimbursing the cost of the surgery on 18/12/2018, 21/12/2018, 05/01/2019, 08/01/2019, 14/01/2019 and 16/01/2019. Finding no other option the Complainant approached before this Commission for relief/reliefs.
OP contested the case by filing WV contending inter alia that the instant complaint is false, malicious and incorrect. The case of the OP is that complainant had taken an Insurance Policy Bearing No.PROHLR010700873 in the name of the Complainant for the period from 29/05/2018 to 28/05/2019. At the time of taking abovementioned Policy the Complainant submitted the Proposal Form duly filled up and signed up by her and as per the Proposal Form the proposed insured person has to provide all information required therein correctly and/or truly. The Complainant deliberately concealed her previous illness in the proposal form and the Complainant and as such the OP did not have the opportunity to assess the risk before issuing the policy. Further the OP conducted a standard health checkup before issuing the Policy. Moreover the Complainant was asked a specific question regarding hypertension, its duration and medication, if any; however, the Complainant chose not to disclose her medical history. The Complainant made cashless request for proposed hospitalization on 123/11/2018 in Fortis Hospital due to pain in both knees and instability. On scrutiny of the documents it has been observed from the OPD consultation paper from the said Hospital that the Complainant has history of Hypertension. Therefore the OP requested the Complainant to provide exact duration of hypertension. In response the Complainant through her mail confirmed that she had been suffering from hypertension since 2008 and has been on medication for the same. As such the OP denied the cashless request under Clause VIII.1 of the Policy Terms and Conditions and was duly intimated to the Complainant vide rejection letter dated 09/11/2018 and repudiated the claim of reimbursement for non-disclosure of material information vide repudiation letter dated 18/12/2018. The Complainant cannot expect more than what is permissible under the scope and purview of the Policy Terms and Conditions. Hence, there is no deficiency on the part of the OP.
Both parties have tendered evidence supported by affidavit. We have gone thoroughly evidence adduced by the parties including documents on record and gave careful consideration to the arguments advanced by the Ld. Lawyers for the parties. On scrutiny of the record it is found that OP has filed WV as MANIPAL CIGNA HEALTH INSURANCE COMPANY LIMITED (FORMERLY KNOWN AS CIGNATTK HEALTH INSURANCE COMPANY LIMITED). But no amendment is made by the Complainant in this regard. Therefore we may go with the Cause Title of the Complaint Petition.
Admitted fact is that, the Complainant had taken an Insurance Policy (ProHealth-Protect) bearing No. PROHLR010700873 from the OP for the period from 29/05/2018 to 28/05/2019. Fact also remains that the Complainant had undergo through Knee Surgery at Fortis Hospital under Dr. Rakesh Rajput for which the Complainant was admitted at the said hospital for the period from 13/11/2018 to 23/11/2018 and the hospital bill was amounting to Rs.3,66,798/- and Pre-surgery testes, medicines and physiotherapy sessions cost was amounting to Rs.37,166. There is also no doubt that the Complainant made a cashless request to the OP for the proposed surgery on 13/11/2018 which was denied by the OP on 09/11/2018under Clause VIII.1 of the Policy stating that:
As per the available documents patient is a known case of Hypertension since 2008, that is before policy inception. It was not disclosed during policy inception. As per policy condition non-disclosure of any medical history in the proposal form leads to repudiation of claim under VIII.1.
Thereafter the Complainant made a reimbursement request for hospitalization on 13/11/2018 to the OP which was also repudiated by the OP on 18/12/2018 stating that:
On scrutiny of the documents it has been observed that As per the mail from patient during pre authorization, it was found that the patient is having hypertension since 2008. Since the said ailment was not disclosed at the time of Policy inception, hence the claim stands repudiated under Policy Clause VIII.1.
Ld. Advocate for the Complainant submitted that the Complainant was not a patient of Hypertension at the time of inception of the said policy and was not taking any medicines for that. Therefore question of non-disclosure of the pre-existing disease does not arise.
Ld. Advocate for the OP alleged that the Complainant did not disclose in the Proposal Form that she had already suffered from Hypertension (HTN) since 2008 and the same was realized by the OP from the pre authorization mail sent by the Complainant at the time of Claims. Photocopy of the said email sent by the Complainant reveals that the Complainant intimated the OP answering the Queries of them stating: take pressure medicine in very low dose since 2008.On perusal of the documents on record it is found that Discharge Summary of the Fortis Hospital and the OPD Consultation dated 30/10/2018of the treating Doctor also pointed at the past history of Hypertension of the Complainant.
Ld. Advocate for the Complainant submitted that during her treatment under Dr. Rakesh Rajput she was enquired about the medicines she took in the past to which the Complainant could not recollect name of any medication and it was treating Doctor who made mistake by writing HTN+on the Pre-Anaesthetic Check-Up(PAC) Record with preoperative advice to continue Stamplo 5mg and Eltroxin. We find no logic in this submission and it is hard to digest that a skilled surgeon advices to continue medicines for Hypertension and Thyroid without any past history of the patient. Therefore we are not inclined to consider abovementioned submission on the part of the Complainant.
Ld. Advocate for the Complainant alleged that OP conducted a series of medical tests of the Complainant on 18.05.2018 which was certified by Dr. Ratan Samaddar and being satisfied with the report of the said medical tests portability of the said Mediclaim Policy was approved by the OP. Controverting this submission Ld. Advocate for the OP argued that on the basis of information provided by the Complainant the OP conducted standard medical tests before issuing such Policy in favour of the Complainant. As the Complainant deliberately concealed his previous illness in the Proposal Form the OP did not have the opportunity to conduct medical test on that line. Photocopies of the said Medical CheckList dated 18/05/2018showing that MER, CBC & amp, ESR, FBS, Lipid Profile, Sr. Creatinine, ECG was suggested and in the MEDICAL EXAMINATION REPORT FORM, there is a specific question in Clause 2. Medical History regarding Hypertension,its duration and Medication, if any, the complainant filled up that category with the answer NO.
Ld. Advocate for the Complainant cited the matter of Manmohan Nanda Vs. United India Assurance Co. Ltd & Anr (Civil Appeal No. 8386 of 2015 dated 06.12.21), Sulbha Prakash Matagaonkar Vs. LIC (Civil Appeal No.8245 of 2015 dated 05.10.2015), Sunil Kumar Sharma Vs. Tata AIG Life Insurance Co. (Revision Petition No.3557 of 2013 dated 01.03.2021), Hari Om Agarwal Vs. Oriental Insurance Company Ltd., Aviva Life Insurance Vs. Sharanjit Kaur V(2014) CPJ 124. In the matter of Manmohan Nanda Vs.United India assurance Co. Ltd & Anr the Hon’ble Apex Court observed that it is very relevant that whether the ailment of the insured has any connection with the alleged pre-existing disease. Hon’ble NCDRCin the case of Sunil Kumar Sharma Vs. Tata AIG Life Insurance CO.and Hon’ble Delhi High Courtin Hari Om Vs. Orientasl Insurance Company Ltd held that Hypertension is a Common Life Style disease which cannot be treated as a pre - existing disease.
On the other hand Ld. Advocate for the OP placed the judgement of Hon’ble Supreme Court of India in the Matter of SATWANT KAUR SANDHU VS. NEW INDIA ASSURANCE COMPANY LTD wherein the Hon’ble Supreme Court held that:
A mediclaim policy is a non-life insurance policy meant to assure the policy holder in respect of certain expenses pertaining to injury, accidents or hospitalization. Nonetheless, it is a contract of insurance failing in the category of contract uberrimae fidei, meaning a contract of utmost good faith on the part of the assured. Thus, it needs little emphasis that when an information on a specific aspect is asked for in the proposal form, an assured is under a solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge.
It is also held by the Hon’ble supreme Court that:
The upshot of the entire discussion is that in a contract of insurance, any fact which would influence the mind of a prudent insurer in deciding whether to accept or not to accept the risk is a “material fact”. If the proposer has knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal form. Needless to emphasise that any inaccurate answer will entitle the insurer to repudiate his liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a Contract of Insurance.
Another matter placed by the Ld. Advocate for the OP is the case of LIC OF INDIA VS NEELAM SHARMA before the Hon’ble NCDRC wherein Hon’ble NCDRC held that:
Undoubtedly, these were “material facts” and being within the knowledge of the Insured only, he was obliged to disclose the same correctly in the proposal form issued to him for the purpose of obtaining the policies in question.
In the matter of Relience Life Insurance Co Ltd & Anr Vs. Rekhaben Nareshbhai Rathod cited by the Ld. Advocate for the OP Hon’ble D. Y. Chandrachud, Chief Justice of Supreme Court observed that:
Disclosure of a pre-existing life insurance cover of the proposer is necessary to enable the insurer to assess the human life value of the proposer before the issuance of a policy. The consequence of non-disclosure of a pre-existing cover is that the insurer is unable to assess the real risk.
In this instant case the OP repudiate the claim of the Complainant under ClauseVIII.1 of the GENERAL TERMS AND CONDITIONS of the saidMediclaim in question which states that:
The policy shall be null and void no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, mis-description or non-disclosure of any material particulars in the proposal form, personal statement, declaration, claim form declaration, medical history in the claim form and connected documents, or any material information having been withheld by You or any one acting on Your behalf, under this Policy. You further understand and agree that We may at Our sole discretion cancel the Policy and the premium paid shall be forfeited to us.
The Complainant incept the policy on 29/05/2018 and she herself intimated the OP that she is having Hypertension since 2008. Discharge Summary of the Fortis Hospital and observation of the treating Doctor in OPD Consultation documents also evident that the Complainant has a past history of Hypertension. Hence this is not the case of repudiation on the ground of PRE-EXISTING disease, rather it is the case of repudiation on the ground of NON-DISCLOSURE OF THE MATERIAL INFORMATION.
In view of the above, we are of the opinion that the OP is justified in repudiating the claim of the Complainant.
As such, the Consumer Complaint is dismissed on contest without any cost.
