This is an order arising out of Misc Application under Section 38(8) of C.P.Act, 2019 filed by the complainant Smti Meera Borah. The complainant submits that she obtained a “ HDFC ERGO Energy Silver ” policy no. 2814204355371100000 after payment of a premium amounting to Rs.30,291/- and inception of the policy was 23.10.21 issued on 26.10.21 and daughter of the complainant is policy holder and complainant is the insured.
It is in the knowledge of the complainant that she will get full coverage from day 1 from all hospitalization from diabetes and hypertension.
Therefore, on 29.10.21 the complainant had a pain on her right shoulder and she rushed to a Orthopedic doctor in Hayat Hospital. Doctor prescribed and advised few medication and observed as “Frozen shoulder” is a condition suffered by patient with high glucose and hypertension is one of the condition that fit of the policy. Subsequently, the complainant was admitted in Pratiksha Hospital where she has to under gone surgery for her issue and the concerned doctor issued a certificate for reference of the insurance company stating certain facts about having frozen shoulder etc. Thereafter, the daughter of the complainant Mrs. Mridusmita Borah, policy holder approached the insurance agent for re-imbursement of the policy for medical expenses incurred by the complainant . Therefore, a letter was also issued on 2.11.22 addressing the claim manager, HDFC Ergo mentioning the situation of the complainant .
The complainant stated that the exclusions of the policy describes the “standard waiting period” in the Section C of the Customer Information Sheet where it states that :
“ Section C Exclusions
1 Standard Waiting Period
All Illnesses and treatments shall be covered subject to the waiting periods specified below :
- Specified disease/procedure waiting period-code-Exc l02
a)Expenses related to the treatment of the listed conditions, surgeries/treatments as mentioned in the table below shall be excluded until the expiry of 24 months of continuous coverage after the date of inception of the first policy with us. This exclusion shall not be applicable for claims arising due to an Accident.”
However, to the contrary under the same Section C(ii) pre-existing Disease it says :
“Any condition or illness, complication or ailment arising out of or connected to the below mentioned conditions shall not be considered as part of this waiting period.
- Type 2 Diabetes Mellitus
- Impaired Fasting Glucose (IFG)
- Impaired Glucose Tolerance (IGT)
- Type 1 Diabetes
- Hypertension ”
The complainant further states that the above-stated points clearly denotes that the complainant falls under the exception from the exclusion section mentioned in the Customer Information Sheet thereby, subjected to be covered by the policy thereon and that the repudiation of the op.party no. 1 for reimbursement of the complainant’s claim stands to be unreasonable as well as the cancellation of the policy is in gross violation of insurance guidelines.
The complainant submits that this commission may allow interim relief to the complainant so that policy number 2814204355371100000 can be renewed with the opp.party no. 1 and also to direct the opp.party no. 1 to make necessary arrangements for the renewal of the said policy . The opp.party no. 1 against the above petition, filed written objection wherein it is stated that the complainant has no cause of action and it should be dismissed. The complainant being a diabetic patient opted the said policy after assurance from the authorized company agent though the premium of the policy was as high as Rs.30,251/- and she will get full coverage from day 1 for al hospitalization arising out of diabetes and hypertension etc. are false and baseless and made without any proof. There is no proof that the complainant has opted the policy being a diabetic patient and she will get benefit for her pre-existing diseases.
The opp.party further submitted that “Frozen shoulder” is one of the conditions suffered by patient with high glucose (diabetes) and prolonged or increased levels of stress and anxiety with one of the condition and therefore , is one of the conditions that fit in the above mentioned policy is false and baseless. The complainant had never disclosed that she was suffering from pre-existing diseases like hypertension and she was a diabetic patient. The policy of the complainant has been cancelled due to non-disclosure of the material facts that she was suffering from pre-existing disease like hypertension diabetes.
The opp.party again submitted that Section D subsection 3 of General Terms & Clauses it is mentioned as “ The policy shall be void and all premium paid thereon shall be forfeited to the company in the event of misrepresentation, mis description or non-disclosure of any material facts by the policyholder.”
The opp.party has cancelled the policy of the complainant as it is a void policy and as such renewal of the cancelled policy /void policy cannot be allowed. The same issue is involved in the main consumer case i.e. c.c. no. 134/2022 and the Misc. Application that whether the policy was a void policy and whether the complainant has not disclosed material facts before inception of the policy can only be decided by adducing evidence from the either side. Without giving opportunity to adduce evidence to the opp.party the issue cannot be resolved. The renewal of the policy can only be allowed when the complainant can prove that she has disclosed about her pre-existing disease before inception of the policy. The opp.party prays to frame a preliminary issue as to the maintainability of this petition, and reject the prayer of the complainant by dismissing this petition.
After due hearing to the parties it appears to us that a prima facie case is there to decide whether there is any concealment of material facts by the insured. Moreover, having pre-existing disease as already discussed there were exclusion u/s C (II) of the customer information Sheet, that there are some awaiting periods of 24 months after the date of inception of the policy, but however, some diseases like diabetes mellitus hypertension etc. are not considered in the awaiting period. But , we are not in a position to draw any opinion at this stage of the hearing in the Misc. Application filed under order 38(8) of the C.P.Act,2019. Moreover, the complainant have purchased the policy and definitely , if there were any pre-existing disease it may be the liability of the insured of this case, but at the same time it is also responsibility of the insurer to get all medical examination and report etc. for the purpose of their satisfaction, but at a later stage when the claim has come, the opp.party refused the claim and cancelled the policy of the insured . It is found to be not justified at this stage of the proceeding without any authenticated documents and evidence on record. We are of the view that the policy ought not be cancelled before decision of the original case no. 134/2022. As such, this mis application is allowed directing the op.parties to continue the policy till disposal of the original case No. 134/2022. Accordingly, this Misc. Application No. 16/2022 in C.C. case No. 134/2022 is disposed of.
