Order by:
Smt.Aparana Kundi, Member
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that Opposite Party No.1 sold the complainant a health insurance policy bearing no.38466003 and paid a premium of Rs.15,228/-. During the policy period, the complainant met with an accident on April 13, 2022 at home when he got slipped and hospitalized for treatment from Goyal Hospital, Moga and then Mittal Hospital, Moga, where he has spent Rs.15,00,000/-. The complainant lodged the claim with Opposite Parties vide claim no.92268218-00 dated 19.05.2022, but however, the Opposite Parties vide letter dated 09.06.2022 rejected the claim of the complainant “due to non-disclosure of alcohol use, while it is baseless and the complainant had disclosed about his alcohol use at the time of buying the policy. Alleged that Opposite Parties had asked for some documents which the complainant had submitted with the Opposite Parties on 22.03.2023, but to no effect. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to disburse the amount of sum assured i.e. Rs.5,00,000/- alongwith interest @ 9% per annum from the date of investment till realization.
b) To pay a sum of Rs.10,00,000/- as compensation on account of mental tension, and harassment.
c) To pay Rs.11,000/- as litigation expenses.
d) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. It is pertinent to mention here that vide separate statement dated 10.08.2023, the complainant has withdrawn the complaint against Opposite Party No.1 i.e. Mr.Gurpreet Singh an Insurance Advisor.
3. Opposite Parties No.2 & 3 appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complainant has attempted to misguide and mislead this Commission; the complaint involves disputed question of facts which cannot be determined in summary jurisdiction of Consumer Commission; the complainant has filed the complaint with malafide intentions and has not come this Commission with clean hands; the complaint is false, frivolous and vexatious in nature; the complainant is stopped from filing the present complaint by his own act, conduct, omissions and acquiescence; the complainant has tried to challenge the veracity of decision of the Opposite Parties to repudiate the claim. The complainant should approach the Civil Courts in order to challenge the veracity of the decision of the Opposite Party Company; this Commission has no jurisdiction to entertain the present complaint. The complainant failed to demonstrate any deficiency in service on the part of Opposite Parties. Averred that the replying opposite party company issued a Health Insurance Policy No. 17499225 with bearing certificate of insurance No.38466003 namely "Group Care 360° (PNB-Platinum)" to Punjab National bank and the coverage was provided to the complainant and his family from 08.02.2022 to 07.02.2023 for a sum insured upto Rs. 5,00,000/- subject to policy terms and conditions. The terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. The Complainant has accepted the Policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form. No assurance was given to the Complainant beyond the terms and conditions of the Policy. Submitted the Policy kit containing all relevant documents was duly delivered to the Complainant from time to time and the complainant never approached the replying Opposite Party Company stating that any information given in the Policy Schedule was incorrect. Averred that a cashless request was received from M/s Goyal Hospital, Moga on behalf of the Complainant for his hospitalization for 23.04.2022. As per the pre- authorization form, he was provisionally diagnosed with Spine Decompression and Fusion. The replying opposite party company rejected the cashless request vide denial letter dated 23.04.2022 for the following reasons:
i. 2 year waiting period for spinal disorder, joint replacement surgery.
ii. 2 year waiting period: arthritis (if non-infective), osteoarthritis and osteoporosis, gout, rheumatism and spinal disorders, joint replacement surgery.
Thus, in light of the above noted observations the replying opposite party Company rejected the Cashless request of the Hospital according to Policy Terms and Conditions. Upon rejection of cashless request a reimbursement claim was received from the complainant for his hospitalization at Goyal Hospital, Moga from 23.04.2022 to 30.04.2022, where he diagnosed with Lumber Infective Spondylitis's (Tubercular). Upon receipt of the claim the replying opposite party Company triggered an investigation to check the veracity of the claim and on investigation the following points came to light:
i. That as per the previous discharge Summary provided by Rajeev Hospital vide dated 08-01-2022, the Complainant was diagnosed with HEP B and Alcohol related CLD cirhossis and the same was not disclosed by the Complainant at the time of policy inception.
Therefore, in the light of above findings, the respondent company rejected the reimbursement claim vide denial letter dated 09.06.2022 for the following reason:
Non-disclosure of alcohol related CLD prior to policy inception.
Thus, in light of the above noted observations the Respondent Company rejected the claim of the Complainant according to Policy Terms and Conditions. Averred further that another reimbursement claim was received from the complainant for his hospitalization at Mittal Hospital, Moga from 10.05.2022 to 16.05.2022, where he diagnosed with Upper G/B, Alcoholic Cirrhosis. Upon receipt of the claim, a query letter dated 05.06.2022 was raised to the Complainant for the following documents/information:
i. Treating doctor's certificate for ethology of present ailment.
ii. Treating doctor's certificate for alcohol / any other drug abuse.
iii. Pre hospitalization OPD treatment record.
When no reply was received from the Complainant, two reminder letters vide dated 12.06.2022 and 19.06.2022 was also raised to the complainant for the following documents/information:
i. Treating doctor's certificate for ethology of present ailment.
ii. Treating doctor's certificate for alcohol/any other drug abuse.
iii. Pre hospitalization OPD treatment record.
Therefore, in the light of above findings, the respondent company rejected the reimbursement claim vide denial letter dated 27.08.2022 for the following reason:
Deficiency Not Replied.
Thus, in light of the above noted observations the Respondent Company rejected the claim of the Complainant according to Policy Terms and Conditions. Averred further that the complaint is not at all maintainable since the complainant himself violated the terms and conditions of the policy and there is no deficiency in services on part of replying opposite party. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
4. In order to prove the case, complainant has placed on record his affidavit as Ex.C1 alongwith copies of documents Ex.C2 to Ex.C90.
5. On the other hand, Opposite Parties No.2 & 3 have placed on record affidavit of Sh.Deepak Mishra, Authorized Signatory, Care Health Insurance Co. Ltd. as OPs2 & 3/1 alongwith copies of documents Ex.OPs2 & 3/2 to Ex.OPs2 & 3/4.
6. We have heard the ld. counsel for both the parties and also gone through the record.
7. It is not disputed that complainant availed a health insurance policy bearing no.17499225 with certificate of insurance No.38466003 namely ‘Group Care 360 (PNB-Platinum) for the period 08.02.2022 to 07.02.2023 for a sum insured upto Rs.5,00,000/-. Complainant alleged in complaint that on 13th April, 2022, he got slipped and fell down when he was at home and got admitted in Goyal Hospital, Moga and then Mittal Hospital, Moga for his treatment. Alleged further that he spent Rs.15,00,000/- on his treatment and thereafter lodge the claim with Opposite Parties on 19.05.2022, but his claim was rejected.
8. On the other hand, counsel for the Opposite Parties No.2 & 3 contended that a cashless request was received from M/s Goyal Hospital, Moga on behalf of the Complainant for his hospitalization for 23.04.2022. As per the pre- authorization form, he was provisionally diagnosed with Spine Decompression and Fusion. However, the opposite parties rejected the cashless request vide letter dated 23.04.2022 on the grounds that 2 year waiting period for spinal disorder, joint replacement surgery and 2 year waiting period: arthritis (if non-infective), osteoarthritis and osteoporosis, gout, rheumatism and spinal disorders, joint replacement surgery, is required. Thereafter, reimbursement claim was received from the complainant for his hospitalization at Goyal Hospital, Moga from 23.04.2022 to 30.04.2022 and finally diagnosed with Lumber Infective Spondylitis's (Tubercular). Upon receipt of the claim, they got conducted an investigation to check the veracity of the claim and on investigation the following points came to light:
That as per the previous discharge Summary provided by Rajeev Hospital vide dated 08.01.2022, the Complainant was diagnosed with HEP B and Alcohol related CLD Cirhossis and the same was not disclosed by the Complainant at the time of policy inception.
Therefore, the Opposite Parties rejected the claim vide denial letter dated 09.06.2022 on the ground of “Non-disclosure of alcohol related CLD prior to policy inception”. Contended further that another reimbursement claim was received from the complainant for his hospitalization at Mittal Hospital, Moga from 10.05.2022 to 16.05.2022 and finally diagnosed with Upper G/B, Alcoholic Cirrhosis. On receipt of the claim, a query letter dated 05.06.2022 was raised to the complainant requiring following documents/information:
i. Treating doctor's certificate for ethology of present ailment.
ii. Treating doctor's certificate for alcohol / any other drug abuse.
iii. Pre hospitalization OPD treatment record.
When no reply was received from the Complainant, two reminder letters vide dated 12.06.2022 and 19.06.2022 was also issued to the complainant requiring the aforesaid documents/information, which the complainant failed to supply. Therefore, the Opposite Parties again rejected the claim of complainant, vide denial letter dated 27.08.2022.
9. We have carefully gone through the documents placed on record. Firstly, we have gone through the discharge card of Rajeev Hospital, Moga (attached with Ex.OPs2 & 3/4) for the hospitalization period from 06.01.2022 to 08.01.2022 duly placed on record by Opposite Parties, in which, complainant was diagnosed with HEP B and Alcohol related CLD Cirrhosis, Fortal Hypertension, DM-2, Hematoma Left Eye, Iron deficiency Anemial, Alcohol Withdrawl and Moderate Ascites. In common parlance, it says that:-
“The most common cause of ascites is cirrhosis of the liver. Drinking too much alcohol is one of the most common causes of cirrhosis of the liver.
Further we have gone through the Discharge Summary of Mittal Hospital, Moga Ex.C22, in which, it is mentioned against the heading Diagnose as UGIB, HCV, alcohol cirrhosis. The cause of Cirrhosis is chronic alcoholism in common parlance it states:-
“Cirrhosis is severe scarring of the liver. This serious condition can be caused by many forms of liver disease and conditions, such as hepatitis or chronic alcoholism.”
10. From the above documents, it is clear that complainant suffering from HEP B and Alcohol related CLD Cirrhosis, prior to inception of the policy, which was not disclosed by the complainant to the Opposite Parties, while availing the policy, whereas in his complaint, the complainant has averred that he disclosed this fact to the agent of the Opposite Parties before taking policy. But no document/evidence placed on record to prove this fact. Moreover, upon service of notice, Opposite Party No.1 i.e. agent of Opposite Party/ Insurance Company failed to appear before this Commission and thereafter complaint against that agent has also been withdrawn by the complainant. In the absence of any evidence, the averment of complainant cannot be considered. Hence, we find no deficiency in service on the part of the Opposite Party-Insurance Company because in this instant case, the insured/complainant has suppressed the material facts pertaining to his health condition and about his alcohol consumption prior to issuance of the policy and hence, violated the terms and conditions of the policy in question.
11. Another document placed on record by Opposite Parties i.e. Pre Authorization Form (Ex.OPs2&3/4) filled by the hospital concerned on behalf of the complainant clearly shows that complainant was suffering from ‘Lumbar Infective Spondylodiscitis’ and has been taking treatment from the doctor as date was mentioned as 08.04.2022 in pre authorization form which was before 13.04.2022. So, it is clear from this document that complainant has not only concealed the fact of his alcohol consumption but also concealed the fact that he has already been suffering from Spine problem and taking the treatment of the same from Goyal Hospital before 13.04.2022. Further perusal of Proposal Form (attached with Ex.OP2 & 3/4) reveals that in the questionnaires under the heading ‘Health and Lifestyle Information’ against the question “Does the insure member use any recreational drugs or consume more than 5 cigarettes and/or 4units of alcohol per day”, he choose/tick the option ‘NO’.
12. It is well settled principle of law that the parties are bound by the terms and conditions of the Insurance Policy, and none of the parties can seek any relief beyond those terms and conditions. In this regard reference may be made to the observation made by Hon’ble Supreme Court of India in case Branch Manager, Bajaj Allianz Life Insurance Company Limited and other Vs. Dalbir Kaur (Civil Appeal No.3397 of 2020) decided on 09.10.2020, wherein it was held that
“13. The medical records which have been obtained during the course of the investigation clearly indicate that the deceased was suffering from a serious pre- existing medical condition which was not disclosed to the insurer. In fact, the deceased was hospitalized to undergo treatment for such condition in proximity to the date of his death, which was also not disclosed in spite of the specific queries relating to any ailment, hospitalization or treatment undergone by the proposer in Column 22 of the policy proposal form. We are, therefore, of the view that the judgment of the NCDRC in the present case does not lay down the correct principle of law and would have to be set aside. We order accordingly.
In view of the judgement (supra), it has clearly been held that the insurer is justified in repudiating a claim wherever there is a suppression of material fact. In the instant case, the DLA/policy holder did not disclose even in the proposal form at the time of purchasing the policy regarding his addiction of alcohol and hence suppressed/ concealed the material facts from the Opposite Parties.
13. In view of the discussion above, the present complaint stands dismissed. However, keeping in view the peculiar circumstances of the case, the parties are left to bear their own costs. Copies of the order be furnished to the parties free of cost. File be consigned to record room after compliance.
Announced in Open Commission
