Order dictated by:
Sh.Anoop Sharma,Presiding Member
1. Paramjit Singh, complainant has brought the instant complaint under section 11 & 12 of the Consumer Protection Act, 1986 on the allegations that complainant obtained a mediclaim policy namely Health Suraksha Policy Silver Plan from the opposite party bearing policy No. 2825100103744000000 for the period from 25.2.2016 to 24.2.2017 by paying premium of Rs. 15,058/- for the sum assured Rs. 3 lacs. It is worthwhile to mention here that the insured was taking policy of the opposite party for the last four years but due to negligence of agent of the opposite party, before this policy, the break occurred in continuation of the policy, therefore, the agent of the opposite party issued new policy. During the subsistence of the present policy, the complainant fell ill and was admitted in the hospital on 18.6.2016 for the treatment of cancer right kidney and incurred an expenditure of Rs. 1,83,225/0. Due intimation was given to the opposite party by submitted all the original medical record, complete bills for reimbursement. All the formalities required by the opposite party were fulfilled . Even the complainant was asked to submit the certificate from the treating doctor at Amritsar with regard to the disease , which was duly submitted. The complainant has received letter dated 5.9.2016 vide which the claim has been repudiated on the flimsy ground that the patient is known case of hypertension before the first inception of policy, since two years. The complainant never remained patient of hypertension and the repudiation on this ground is illegal, arbitrary and against the principles of natural justice. Vide instant complaint, complainant has sought for the following reliefs:-
(a) Opposite party be directed to pay claim amount to the tune of Rs. 1,83,225/- alongwith interest @ 18% p.a. alongwith other benefit as per policy to the complainant ;
(b) Compensation to the tune of Rs. 25000/- alongwith litigation expenses to the tune of Rs. 5000/- may also be awarded to the complainant.
Hence, this complaint.
2. Upon notice, opposite party appeared and filed written version in which it was submitted that after receiving the claim, the medical documents were examined and as per medical record of the complainant, the insured is a known case of hypertension before the first inception of the policy. There is history of hypertension since 2 years and complainant had not disclosed the ailment while procuring the policy. Hence, there is non disclosure of material facts and thus the claim was repudiated and intimation of the same was given to the complainant vide letter dated 5.9.2016. While denying and controverting other allegations, dismissal of complaint was prayed.
3. In his bid to prove the case complainant tendered into evidence his duly sworn affidavit Ex.C-1, copy of discharge summary Ex.C-2, copy of certificate Ex.C-3, copy of bill amounting to Rs. 172475/- Ex.C-4, copy of repudiation letter Ex.C-5, copies of bills dated 4.7.2016, 30.6.2016 and 15.6.2016 Ex.C-6 , Ex.C-7 and Ex.C-7A and closed his evidence. However, in additional evidence Sh.S.S.Channa,Adv.counsel for the complainant tendered into evidence copy of thanks letter dated 25.2.2017 issued by HDFC Ergo Ex.C-8, copy of policy for the period from 25.2.2017 to 24.2.2018 Ex.C-9 and closed the additional evidence on behalf of the complainant.
4. To rebut the aforesaid evidence Sh.R.P.Singh,Adv.counsel for the opposite party tendered into evidence affidavit of Sh.Pankaj Kumar, Legal Officer Ex.OP1, copy of investigation report Ex.OP2, copy of medical record Ex.OP3, affidavit of Dr. Nilutpal Bora Ex.OP4, copy of medical examination report Ex.OP5, copy of policy with terms and conditions Ex.OP6, copy of letter dated 22.7.2016 Ex.OP7, copy of letter dated 3.8.2016 Ex.OP8, copy of letter dated 20.8.2016 Ex.OP9.
5. We have heard the ld.counsel for the parties and have carefully gone through the record on the file.
6. Ld.counsel for the complainant has reiterated the facts narrated in the complaint and has submitted that he had obtained a mediclaim policy namely Health Suraksha Policy Silver Plan from the opposite party bearing policy No. 2825100103744000000 for the period from 25.2.2016 to 24.2.2017 by paying premium of Rs. 15,058/- for the sum assured Rs. 3 lacs. It was the case of the complainant that during the subsistence of the present policy, the complainant fell ill and was admitted in the hospital on 18.6.2016 for the treatment of cancer right kidney and incurred an expenditure of Rs. 1,83,225/-. The complainant has intimated the opposite party by submitting all the relevant bills as well as record of the treatment. The complainant was asked to submit the certificate from the treating doctor at Amritsar with regard to the disease , which was duly submitted. However, the complainant has received letter dated 5.9.2016 vide which the claim has been repudiated on the flimsy ground that the patient is known case of hypertension before the first inception of policy, since two years. The act of the opposite party in repudiating the claim of the complainant amounts to deficiency in service.
7. On the other hand opposite party has repelled the aforesaid contentions of the complainant on the ground the complainant was a known case of hypertension before the first inception of the policy and the complainant had not disclosed this fact to the opposite party before obtaining the policy, as such the claim was repudiated and intimation of the same was given to the complainant vide letter dated 5.9.2016. Ld.counsel for opposite party has prayed for dismissal of the complaint.
8. But, however, from the appreciation of the facts and circumstances of the case, it becomes evident that on 18.6.2016 i.e. during existence of the policy period the complainant fell ill and remained admitted in Tata Memorial Hospital and discharged from the said hospital on 25.6.2016. The complainant spent Rs. 1,83,225/- on his treatment. However, the complainant has produced on record copy of bill Ex.C-4 which was for Rs. 1,72,475/-. Thereafter the complainant filed claim with regard to reimbursement of his aforesaid claim . However, the complainant received a letter dated 5.9.2016 from opposite party in which the opposite party stated that the complainant was suffering from the disease of hypertension since two years from the first inception of the policy . But, however, the complainant never suffered from hypertension nevertheless no medical record showing such hypertension has ever been produced by the opposite party on the record. Vide instant complaint, complainant has sought for reimbursement of the expenditure incurred on the treatment of cancer right kidney to the tune of Rs. 1,83,225/-. But, the opposite party declined the claim of the complainant on the ground of concealment of material facts of ailment allegedly at the time of obtaining the policy in question by the complainant. It is also not disputed that the complainant has been continuously insuring himself with the opposite party since 4 years however last year policy there is gap in policy due to his visit to outside India, which fact has been clear by the opposite party in their investigation report Ex.OP2. As such,the opposite party cannot wriggle out from their liability . Hence, the opposite party is duty bound to continue the policy and reimburse the expenditure incurred on the treatment, duly covered under the policy. The ground on which the claim of the complainant has been repudiated has been that the complainant was suffering from hypertension since 2 years i.e. prior to the issuance of the insurance policy. However, the opposite party has not produced on record any evidence to show that the complainant was suffering from hypertension since 2 years from the first inception of the policy. The only evidence which the opposite party has produced is the treatment which the complainant has taken at the time of his admission in Tata Memorial Centre. In such a situation, it is preposterous to presume that said disease was pre-existing or that non disclosure thereof at the time of obtaining the insurance policy on the same amount to concealment. During these days, hypertension is not a material disease, therefore, non disclosure thereof does not amount to concealment. We draw support from Life Insurance Corporation of India Vs. Sushma Sharma from II (2008) CPJ 213 wherein Hon'ble State Commission has held as under:-
“So far as hypertension is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.
We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease.
9. Since the disease of cancer is covered under the terms and conditions of the policy in question and the complainant 1,83,225/- though the bill has been produced by the complainant to the tune of Rs. 1,72,475/- . As such, the complainant is entitled for reimbursement of the said amount under the terms and conditions of the Insurance policy in dispute. In such a situation the repudiation made by Opposite Party regarding genuine claim of the complainant appears to have been made without application of mind. It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
10. From the aforesaid discussion, it transpires that Opposite Party has wrongly repudiated the claim of the complainant . As such, opposite party is directed to reimburse the amount of Rs. 1,72,475/- incurred on the treatment of cancer of right kidney. The costs of the litigation are assessed at Rs.2,000/-. Compliance of this order be made within 30 days from the receipt of copy of the order; failing which, awarded amount shall carry interest @ 9% p.a from the date of filing of the complaint until full and final recovery. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
Dated: 6.6.2017.
