Complainant Harinder Singh through the present complaint filed U/s 12 of the Consumer Protection Act 1986 (hereinafter, called the Act) has prayed for issuance of necessary directions to the titled opposite parties to pay Rs.3,75,000/- alongwith interest till the final payment or any other relief to this Hon’ble Forum deems fit may kindly be granted, in the interest of justice.
2. The case of the complainant in brief is that he is insured vide policy No.90140844 for Rs.3,00,000/- of Annual Limit by adopting an insurance plan type name Family Floater with plan option is Silver with opposite parties and they issued a policy in his favour vide unique identification No.101 No.87V02 and also issued a Health Privilege card vide client ID No.85766047 in the year 2015. He has further pleaded that before issuance of policy certificate to him, the opposite parties checked his health from all aspect and found that he is hale and healthy and then he got insured by the opposite parties. Unfortunately, he remained under treatment due to health problem since February 2017 and incurred huge medical expenses in the shape of operation and other treatment and also spent more than Rs.13 lakh on the treatment and he intimated the opposite parties for his ill health and about his treatment. He has next pleaded that after discharge from the hospital, he approached to the officials of opposite parties and also submitted the detail of treatment and operation and requested them that his health policy is in operation and opposite party is liable to pay the amount of Rs.3,00,000/-, as per terms and conditions of the policy, but the officials of opposite parties refused to refund/pay a single penny to him with the false reason that he is suffering from diabetes and intentionally without any reason flatly refused to pay a single penny. Even after that he approach various time and submitted his report and requested that they had promised to pay the amount of Rs.3,00,000/- in the event of hospitalization and its medical treatment but no one listen. He served a legal notice dated 10.7.2017 vide postal receipt dated 14.7.2017 to the opposite party and claimed the health insurance amount of Rs.3,00,000/- but all in vain. Again a reminder was also served to the opposite parties through Regd. Post dated 22.8.2017 vide postal receipt dated 23.8.2017 and again requested to pay the amount of insurance but no reply is filed neither any official of opposite party ever tried to contact with him. The act and conduct of the opposite parties and its officials seems that firstly they allure the persons with dishonest intention and in fraudulent manner and got insured a health insurance policy after receiving huge amount and on demand and on cause of action and on maturity the opposite parties intentionally, deliberately and without any reasons flatly refused to pay the amount. Hence this complaint.
3. Opposite parties appeared through their counsel and filed their written reply taking the preliminary objections that the instant complaint is false, malicious, incorrect and malafide and is nothering but an abuse of the process of the law; the complaint is neither maintainable in law nor on facts and the same is liable to be dismissed in limine; the complainant has not approached this Hon’ble Forum with clean hands; the present complaint is liable to be dismissed on the ground that the Insurance being a contract of ‘uberrimae fidae’ (utmost good faith), the Policy Holder is duty bound to reveal all the relevant material facts to the insurer in order to avail the Insurance Policy. The claim was denied on the ground of non-disclosure and there is no deficiency in service on the part of the opposite parties. On merits, it was submitted that complainant concealed the material facts regarding his health at the time of taking policy and as such breach the utmost good faith. The policy has been issued on the basis of information provided by the complainant in the proposal form. As already stated the material a fact regarding the health has not been disclosed by the complainant at that time. It was next submitted that it was wrong and denied that any amount of Rs.13,00,000/- was spent on the treatment as already stated the claim has been repudiated due to non-disclosure of the material facts regarding his health which is the breach of terms and conditions of the policy. Further the coverage under the policy is only upto Rs.3,00,000/-. It was further submitted that the claim has rightly been repudiated on the ground that the complainant is suffering from hypertension and diabetes since 5 years, which is prior to the policy inception and the same has not been disclosed in the proposal form. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.
4. Complainant tendered into evidence his own affidavit Ex.CW1/A alongwith copies of documents Ex.C1 to Ex.C45 and closed the evidence.
5. Counsel for the opposite parties tendered into evidence affidavit of Sh.Arpit Higgins, Manager-Legal Ex.OP-1,2/1 alongwith other documents Ex.OP1,2/2 to Ex.OP1,2/7 and closed the evidence.
6. On carefully going through the file we have noticed that complainant was insured with OPs vide Policy No.90140844 for a sum of Rs.3,00,000/- of Annual limit under the Family Floater Plan. As per version of complainant he was duly checked by OPs that he is maintaining good health and only after that the policy was issued. He was assured that as and when in need, he will get full health insurance claim from OPs and unfortunately complainant remained under treatment in the year 2017 and spent a huge amount of Rs.13 lakh on the treatment but OPs rejected his insurance claim on the ground of concealment of material facts. The complainant is entitled to avail the amount of Rs.3 lakh as per policy conditions but the OPs have refused to do so.
7. On the other hand, OPs took plea that complainant is himself guilty of misrepresentation and supply of material facts and the claim was denied on the ground of non-disclosure of material facts. As per available documents, patient is a known case of diabetes and hypertension since five years which is prior to the policy inception and the same has not been disclosed in the proposal form. Hence the claim has been repudiated. OPs denied all other allegations and prayed for dismissal of complaint.
8. Now the main question to be decided is whether the OPs have rightly repudiated the claim of complainant or not? The main plea of OPs about rejection of claim is that the complainant did not disclose about the disease of hypertension and diabetes in the proposal form which is produced as Ex.OP-1,2/3. We have observed that this proposal form is neither signed by complainant nor by any official of OPs. It is an unsigned proposal form which bears no weight in the eyes of law. This document proves that the contents of this proposal form were not explained to complainant rather it is an after though of the Ops as it is not signed by any person. The OPs have referred another document OP-1,2/6 which is the record of treating hospital where the complainant got treatment for his ailment for which he is claiming the insurance claim. In this document past history of Hypertension and Diabetes is written as 5 years. Now if we see this document then the doctor has simply stated the history of these diseases. But OPs have not produced any document to prove that complainant took treatment for these diseases from any hospital or any prescription of any doctor is not placed on the file to prove that complainant took treatment of these diseases. Moreover, hypertension and diabetes are no longer considered as fatal disease. There are lifestyle diseases which can be cured after taking some treatment. There are plethora of judgments where in it has been observed that Hypertension and diabetes are only life style disease. In Bajaj Allianz General Insurance Co. Ltd. Vs. Valsa Jose, Hon’ble National Commission observed that the Hypertension is a lifestyle disease, thus repudiation on the ground of suppression of facts is not justified.
9. Hon’ble National Commission reported in II (2005) CPJ 32 titled as “Surinder Kaur & Ors. Vs. LIC of India & Ors.” has been referred, wherein it was observed that doctor’s opinion based on hospital history is not sufficient to prove suppression of material facts on the part of the insurance company.
10. Further Hon’ble National Commission observed “National India Assurance Company Ltd. V. Rakesh Kumar” wherein it has been observed that the people can live for months, rather years, without having any knowledge that they have any disease it’s often discovered accidentally after routine check-ups, it cannot be stated to be the concealment and the repudiation is not justified.
11. In view of the above all discussion, we think and observe that OP Insurance Company was not justified in repudiating the insurance claim of the complainant on the grounds mentioned. So, we hold that Insurance Company is liable to pay the amount spent by complainant on his treatment as per policy terms amounting to Rs.3,00,000/-. Further as the complainant felt harassed in getting his insurance claim, he is also entitled for compensation to the tune of Rs.15,000/- alongwith Rs.5,000/- as litigation. Entire compliance be made within 30 days from the date of receipt of copy of order, failing which opposite parties will be liable to pay interest @ 9% P.A. on the entire awarded amount from the date of orders till its realization.
12. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room. The complaint could not be decided within prescribed time due to rush of work.
ANNOUNCED: (Shri Raj Singh) (Rajita Sareen)
August 05, 2019. Member Presiding Member
MK
