Order by:

Sh.Mohinder Singh Brar, Member

1.       Complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that earlier complainant was taking insurance policies regularly from United India Insurance Company Ltd since 22.03.2014 to 21.03.2020. Due to Covid-19 pandemic restrictions, policy was not got renewed. Thereafter on the allurement of agent of the Opposite Parties, complainant took the insurance policy from opposite parties vide policy bearing no.P/211/222/01/2021/007262 for the period of two years w.e.f. 24.01.2021 to 24.01.2023. On 08.04.2021 complainant suffered some health problems due to which he was admitted in DMC & Hospital, Ludhiana where he came to know that he has symptoms of heart disease. The complainant was admitted in the hospital from 08.04.2021 to 14.04.2021. The complainant presented the above said policy to the officials of the hospital, as it is a cashless policy and estimate for expenses for the medical treatment was sent to Opposite Parties no.1 & 2 by the hospital, but the Opposite Parties repudiate the claim on 15.11.2021. Further alleged that the doctor of Hero DMC Heart Institute i.e. Dr.Bishav Mohan issued a certificate on 21.07.2021 regarding the fact that complainant has no prior history of Cardiac illness. The complainant spent Rs.3 lakh on his treatment in DMC and Hospital, Ludhiana. Thereafter complainant approached the Opposite Parties a number of times and request them to make they payment of medical expenses, but to no effect. Hence this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to pay an amount of Rs.3 lakh alongwith interest @18% per annum till the date of payment.

b)      To pay an amount of Rs.2,00,000/- lakh as compensation on account of harassment and deficiency in service.

c)       To pay an amount of Rs.55,000/- as litigation expenses.

d)      And any other relief which this Commission may deem fit and proper be granted to the complainants in the interest of justice and equity.

2.       Opposite Parties appeared through counsel and contested the complaint by filing written version taking preliminary objections therein inter alia that the complaint is filed without any cause of action, as the claim of the complainant was denied by Opposite Parties on the ground of pre-existing disease and non disclosure of material facts. The insured/complainant by not disclosing the pre existing disease before procuring the policy has violated the policy document/contract. The present complaint pertains to insurance claim under Star Comprehensive Insurance Policy bearing no.P/211222/01/2021/007262 valid from 24.01.2021 to 23.01.2023 covering the Complainant self for a sum of Rs.5,00,000/-. However the aforesaid insurance policy was issued to the insured by the answering Opposite parties subject to the terms and conditions of the insurance policy. The said terms and conditions were handed over and supplied to the insured at the time of the contract. Moreover the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same were served to the complainant along with policy schedule. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Therefore it is submitted that in case if any liability would arise against the answering Opposite parties, then it would be subject to the terms and conditions of the insurance policy. Further submitted that the insured requested for a cashless authorization for the treatment on dated 08.04.2021 for treatment of ACS IE Acute Coronary Syndrome at Dayanand Medical College and Hospital, Ludhiana. On scrutiny of the cashless claim documents as provided by the insured, it was found and observed by the answering insurance company and its medical team that the insured patient had a long standing heart ailment and the company is unable to ascertain the duration of the disease based on the documents and details submitted by the insured and it required further evaluation. Thus the cashless authorization was rejected on dated 10.04.2021. Subsequently, the insured has submitted the documents for reimbursement and on the scrutiny of the said documents it has been observed from Echo Report that ‘severely compromised left ventricular function, triple vessel disease, previously blocked vessel RCA collateralized which indicated previous infraction, which is prior to inception of medical insurance policy and this medical history was not disclosed at the time of inception of the policy. Hence, it is a pre existing disease. Further submitted that the complainant had a duty of disclosure of information related to all kinds of pre-existing disease i.e. Heart Disease which the complainant had prior knowledge, to commencement of the policy. The complainant had a duty to disclose as the complainant had agreed to abide by the terms and conditions of the policy. Further submitted that as per III Exclusions- Pre Existing Disease- code Exc1-01 of the policy, expenses related to the treatment of a pre existing disease and its complications shall be excluded until the expiry of 36 months. Hence the reimbursement claim was rejected and same was informed to the insured vide letter dated 01.10.2021. Further submitted that as per new IRDA guidelines, if the non disclosed disease is other than the disease from the list of permanent exclusions, then the insurer can incorporate additional waiting period of non exceeding 3 years for the said undisclosed disease or condition from the date of the disease was found out and it has been incorporated in the insurance policy of the insured complainant as pre existing disease by passing endorsement. The above decision was taken as per the policy terms and conditions and new IRDA guideline and based on the document submitted by the claimant. Further submitted that disclosures made by the proposers facilitate the insurance company to take decision whether to give coverage to the proposer and what the premium would be. In the present case, had the fact of Heart Disease had been disclosed at the time of taking policy, either the coverage would have been denied totally or policy would have been issued with condition or permanent exclusion of ailments relating to the ailment he was suffering from. However, the complainant chose not to disclose the ailments and obtain the policy. This act of the complainant amounts to fraud under the Indian Contract Act and as such the contracts becomes voidable. The complainant has got no cause of action and locus-standi to file the present complaint. The instant complaint is false, malicious, incorrect and with malafide intent and is nothing but an abuse of the process of law and is an attempt to waste the precious time of this Commission, as the same has been filed by the complainant just to avail undue advantage. The instant complaint is neither maintainable in law nor on facts. This Commission has got no jurisdiction to try and decided the present complaint. No deficient services have been rendered by answering Opposite Parties. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       In order to prove his case, complainant tendered in evidence his affidavit Ex.CW1/A along with copies of documents Ex.C1 to Ex.C42.

4.       To rebut the evidence of complainant, Opposite Parties tendered in evidence affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1 to 3/A alongwith copies of documents Ex.OP1 to 3/1 to Ex.OP1 to 3/19.

5.       The case of the complainant is that he obtained an insurance policy bearing policy no.P/211/222/01/2021/007262 for the period of two years w.e.f. 24.01.2021 to 24.01.2023 from Opposite Parties. During the policy period, on 08.04.2021 he suffered some health problems due to which he was admitted in DMC & Hospital, Ludhiana where he came to know the he has symptoms of heart disease. The complainant was admitted in the hospital on 08.04.2021 and remain admitted there upto 14.04.2021. As it is a cashless policy, the complainant presented the above said policy to the officials of the hospital and the hospital sent the medical expenses estimate to Opposite Parties, but the Opposite Parties repudiated his claim.

6.       Ld. counsel for the opposite parties repelled the aforesaid contention of ld. counsel for the complainant on the ground that the insured requested for a cashless authorization for the treatment on dated 08.04.2021 for treatment of ACS IE Acute Coronary Syndrome at Dayanand Medical College and Hospital, Ludhiana. On scrutiny of the cashless claim documents as provided by the insured, it was observed by Opposite parties company and its medical team that the insured patient had a long standing heart ailment and the company is unable to ascertain the duration of the disease based on the documents and details submitted by the insured and it required further evaluation. Thus the cashless authorization was rejected on dated 10.04.2021. Subsequently, the insured has submitted the documents for reimbursement and it has been observed from Echo Report that ‘severely compromised left ventricular function, triple vessel disease, previously blocked vessel RCA collateralized which indicated previous infraction, which is prior to inception of medical insurance policy and this medical history was not disclosed at the time of inception of the policy. Hence, it is a pre existing disease. Further contended that as per III Exclusions- Pre Existing Disease- code Exc1-01 of the policy, expenses related to the treatment of a pre existing disease and its complications shall be excluded until the expiry of 36 months. Hence the reimbursement claim was rejected and same was informed to the insured vide letter dated 01.10.2021.

7.       We have considered the rival contentions of ld. Counsel for both the parties and have carefully gone through the record. The perusal of contention of ld. Counsel for the Opposite Parties shows that as the complainant has not disclosed his previous medical history and in this way he has violated the terms and conditions of the policy and as per terms and conditions of the policy he is not entitled for any claim. But the Opposite parties could not produce any evidence to prove that whether terms and conditions of the policy were ever supplied to the complainant i.e. insured, when and through which mode? No document placed on record which shows that policy has been given to the complainant. It has been held by Hon’ble National Commission, New Delhi in case titled as The Oriental Insurance Company Limited Vs. Satpal Singh & Others 2014(2) CLT page 305 that the insured is not bound by the terms and conditions of the insurance policy unless it is proved that policy was supplied to the insured by the insurance company. Onus to prove that terms and conditions of the policy were supplied to the insured lies upon the insurance company. From the perusal of the entire evidence produced on record by the Opposite parties, it is clear that Opposite parties have failed to prove on record that they did supply the terms and conditions of the policy to the complainant/insured. As such, these terms and conditions, particularly the exclusion clause of the policy is not binding upon the insured.

8.       The plea taken by the Opposite Parties that complainant suffered from pre-existing disease is not genuine, as in the Certificate Ex.C4 duly issued by Dr.Bishav Mohan, who treated the complainant, it is mentioned that “Patient was presented with chief complaints of burning sensation in chest prior to admission. Coronory Angiography was done on 09.04.2021 which showed Triple Vessel Disease. PTCA with stenting to LAD was done on 10.04.21. As per hospital records there are no prior history of cardiac illness.” Meaning thereby that complainant has no any pre existing disease i.e. heart disease prior to issuance of the policy in question. Moreover, the Opposite Parties have not placed on record any document to rebut the aforesaid certificate. Moreover, once the policy was issued to the insurer, the plea taken by the Opposite Parties regarding pre-existing disease of the insured has not appears to be genuine. Moreover, if the complainant was suffering from any disease prior to issuance of the policy, in question, the same must not have escaped the notice of the empanelled doctors of the Insurance Company. However, no such investigation record has been produced by the opposite parties. In case Bajaj Allianz Life Insurance Co. Ltd. & Ors. Vs. Raj Kumar III (2014) CPJ 221 (NC), it was held by the Hon’ble National Commission that usually, the authorized doctor of the Insurance Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. It was held that the Insurance Company wrongly repudiated the claim of the complainant.

9.       In view of the above discussion, we hold that the Opposite parties-Insurance Company have  wrongly and illegally rejected the claim of the complainant.

10.     Now come to the quantum of amount to be awarded to the complainant. Vide instant complaint, the complainant claimed the amount of Rs.3 lakh, but the final bill placed on record by complainant Ex.C34 reveals that during the hospitalization complainant spent Rs.1,95,000/- only on the treatment. Hence we allow the same.

11.     From the above discussion, we partly allow the complaint of the complainant and direct the Opposite Parties to pay an amount of Rs.1,95,000/- (Rupees One Lakh Ninety Five Thousand only) to the complainant for the expenses incurred by him on his treatment. Further Opposite Parties are also directed to pay compository costs of Rs.10,000/-(Rupees Ten Thousand only) as compensation and litigation expenses to the complainants. The compliance of this order be made by the Opposite Parties within 45 days from the date of receipt of copy of this order, failing which, the Opposite Parties are further burdened with additional cost of Rs.10,000/-(Rupees Ten Thousand only) to be paid to the complainants for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced on Open Commission