Chandigarh

DF-I

CC/195/2022

Bhajan Singh - Complainant(s)

Versus

HDFC ERGO General Insurance Co. Ltd. - Opp.Party(s)

Anirudh Gupta

01 May 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/195/2022
Date of Institution	:	14/02/2022
Date of Decision	:	01/05/2023

 

Bhajan Singh s/o Sh. Jalbir Singh, aged 41 years, office at Shop No.1, Ground Floor, Village Butraila, Star Complex, Chandigarh 160041.

… Complainant

V E R S U S

1. HDFC ERGO General Insurance Company Limited, having its registered office at SCO 124-125, Sector 8-C, Madhya Marg, Chandigarh 160008 through its Regional Manager.
2. HDFC ERGO General Insurance Company Limited, having its Corporate office at 1^st Floor, HDFC House, 165/166, Backbay Reclamation, H.T., Parekh Marg, Churchgate, Mumbai 400020 through its General Manager.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Anirudh Gupta, Counsel for complainant
	:	Sh. Vishal Sharma, Counsel for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Sh.Bhajan Singh, complainant against the opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that the complainant approached the OPs to get health insurance (Easy Health Floater Standard) (hereinafter referred to as “subject Policy”) for his parents and had obtained the same by paying premium of ₹38,814/- which was valid w.e.f. 21.11.2020 to 20.11.2021 (Ex.C-1). On 5.11.2021, father of complainant namely Sh.Jalbir Singh was admitted in Cheema Hospital when he was suffering from Biliary Cirrhosis and was discharged on 8.11.2021.  On account of medical treatment of his father, complainant had paid ₹68,491/- to the said hospital and thereafter had submitted the claim form (Ex.C-2) to the OPs for clearance.  However, the complainant was surprised on receiving letter dated 7.12.2021 (Ex.C-3) and another letter dated 8.1.2022 (Ex.C-4) from the OPs through which his claim was repudiated on the ground that the father of the complainant was diagnosed with a prolonged alcohol intake and with liver cirrhosis.  It is further alleged that in fact the OPs have wrongly repudiated the claim of the complainant despite of the fact that the said hospital had only mentioned in its report dated 23.11.2021 (Ex.C-5) that cause of liver cirrhosis possibly diabetes related and may be associated with alcohol.  Thus, the aforesaid act of the OPs amounts to deficiency in service which has caused mental agony to the complainant. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action, suppression of facts, non-joinder and mis-joiner of necessary parties and want of jurisdiction. On merits, admitted that the complainant had obtained the subject policy from the OPs which was valid w.e.f. 21.11.2020 to 20.11.2021 covering his father Sh. Jalbir Singh and mother Smt. Gurmeet Kaur, but, the liability of the OPs was strictly subject to the terms and conditions of the policy (Annexure R-1).  It is further alleged that in fact the patient was found with alcohol dependence with alcohol induced mood disorder half bottle per day and as per the statement of the doctor, the case was mentioned as etiology for liver disease cirrhosis is diabetes mellitus and alcohol both, which is clear violation of the terms and conditions of the policy and is covered under the exclusion clause of the same and the claim of the complainant was rightly repudiated by the OPs as per various judgments passed by the Hon’ble Courts.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In replication, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including the written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had purchased the subject policy covering his father and mother namely Sh.Jalbir Singh and Smt.Gurdeep Kaur which was valid w.e.f. 21.11.2020 to 20.11.2021 by paying premium of ₹38,814/- and also that the father of the complainant namely Sh.Jalbir Singh was admitted at Cheema Hospital on 5.11.2021 and was treated upon for liver cirrhosis and was discharged on 8.11.2021, the case is reduced to a narrow compass as it is to be determined if the OPs were unjustified in repudiating the claim of the complainant on the ground that the insured was diagnosed with liver cirrhosis which was diagnosed to be due to prolonged diabetes mellitus and prolonged alcohol intake and the complainant is entitled for the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs are justified in repudiating the claim of the complainant on account of violation of the terms and conditions of the subject policy by not disclosing about the factum of continuous intake of alcohol by the insured and the consumer complaint of the complainant is liable to be dismissed, as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy coupled with the medical report of the patient/insured issued by the Cheema Hospital, having been relied upon by both the parties.
   3. Annexure R-1 is the copy of the subject policy which clearly indicates that the same was valid w.e.f. 21.11.2020 to 20.11.2021 covering the father and mother of the complainant namely Sh. Jalbir Singh and Smt. Gurdeep Kaur and the first policy inception date is 21.11.2014, making further clear that the date of inception of the said policy was 21.11.2014 and it is only the subject policy which was renewed for the period from 21.11.2020 to 20.11.2021.  It is not the defence of the OPs that the said policy was ever discontinued by the insureds after its inception in the year 2014.
   4. Section VI(A)(iii) defines the pre-existing diseases which are covered under the exclusion clause and the same are reproduced as under :-

        “iii. Pre-Existing Diseases - Code – Excl01

a)     Expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 36 months of continuous coverage after the date of inception of the first policy with insurer.

b)     In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.

c)     If the insured person is continuously covered without any break as defined under the portability/migration norms of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage.

d)     Coverage under the policy after the expiry of 36 months for any preexisting disease is subject to the same being declared at the time of application and accepted by insurer.”

 

5. In addition to the aforesaid provision of pre-existing disease clause, the waiting period for specified disease/procedure are also defined under Section VI(A)(ii) of the subject policy which specifically mentions expenses related to treatment of the listed conditions etc. shall be excluded until the expiry of specified period and the relevant portion of the same is reproduced below :-

       “ii. Specified disease/procedure waiting period - Code – Excl02

a)     Expenses related to the treatment of the listed Conditions, surgeries/treatments 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 or underlying cause is cancer(s).

b)     In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.

c)     If any of the specified disease/procedure falls under the waiting period specified for pre-existing diseases, then the longer of the two waiting periods shall apply.

d)     The waiting period for listed conditions shall apply even if contracted after the policy or declared and accepted without a specific exclusion.

e)     If the Insured Person is continuously covered without any break as defined under the applicable norms on portability/migration stipulated by IRDAI, then waiting period for the same would be reduced to the extent of prior coverage.”

 

6. From the perusal of the aforesaid sections of the subject policy, one thing is clear that the case of the complainant is not covered under the exclusion clauses since the OPs have firstly failed to prove on record that the father of the complainant/insured was suffering from any pre-existing disease or the medical expenses claimed by the complainant are related to the treatment of the listed condition within 24 months of the continuous coverage after the date of inception of the first policy which was admittedly purchased in the year 2014 whereas the insured had taken treatment for the liver cirrhosis in the year 2021. The repudiation letter (Ex.C-4) sent by the OP clearly indicates that the claim of the complainant was repudiated on the basis of medical opinion expressed by the medical officer who has treated the insured and the relevant portion of the repudiation letter is reproduced below :-

       “1. As per the submitted documents, patient was admitted on 05/11/2021 with the diagnosis of Liver cirrhosis and was treated for same. However, it was found that the diagnosed is due to prolonged Alcohol intake. Thus, the claim is being repudiated under section VI A (ii) d of policy which excludes any treatment from the coverage which arises due to abuse or the consequences of the abuse of intoxicants or hallucinogenic substances such as drugs and alcohol, including smoking cessation programs and the treatment of nicotine addiction or any other substance abuse treatment or services, or supplies.”

7. However, the copy of medical certificate (Ex.C-5) issued by the treating doctor namely Dr. Sandeep Pal, which was obtained by the OPs from the said Cheema Hospital and annexed with the repudiation letter, clearly indicates that the medical officer had only expressed possibility of cause of liver cirrhosis may be diabetes related and may be associated with alcohol.
8. The OPs have heavily relied upon another medical document obtained by them from Dr. Sandeep Pal, annexed with the subject policy (Annexure R-1) and available at page 43 with the written version, which clearly indicates that the earlier medical officer had mentioned that etiology of cirrhosis related to diabetes and by making cutting on the words may be related to alcohol also had overwritten there “and alcohol both”.  Thus, even the medical officer has not given his concrete opinion that the cause of liver cirrhosis was only alcohol and the defence of the OPs is that as the insured was taking alcohol since long, the same was the cause for the disease i.e. liver cirrhosis and the same has been covered under the exclusion clause.  However, even the documents having been obtained by the OPs from the complainant with his signatures (available at pages 46 to 50) are of no help to the OPs as the medical evidence nowhere proves that due to consumption of alcohol by the father of complainant, same had caused liver cirrhosis especially when it is an admitted case of the parties that the date of first inception of the policy was in the year 2014 and the insured had been purchasing the same continuously till the purchase of the subject policy in the year 2020.
9. So far as the cause of the aforesaid disease may be diabetes mellitus, even the same cannot be treated as a pre-existing disease as it has already been held by the Hon’ble State Commission, Delhi, in the case titled S.S. Jaspal Vs. National Insurance Co. Ltd. & Ors., IV (2022) CPJ 26 (Del.) as under :-

“Consumer Protection Act, 1986 - Sections 2(1)(g), 14(1)(d), 15 - Insurance (Mediclaim) -Angioplasty and Stenting - Suppression of pre-existing disease alleged - Repudiation of claim Deficiency in service - District Forum dismissed Complaint - Hence Appeal - Complainant experienced pain in chest and remained admitted in Hospital from 24.6.2004 to 30.6.2004, where he had undergone Angioplasty and Stenting, by incurring Rs.3,20,126 on treatment - Previous medical history is based upon information provided by family of patient - Respondents failed to show any evidence regarding pre-existing disease suffered by insured at time of getting policy - Common lifestyle disease like diabetes and hypertension, cannot be treated as pre existing diseases and cannot be a ground of repudiation of claim by Insurance companies - Respondents failed to show any evidence that any medical tests or examination was done, before issuing said policy in question - Respondents are directed to pay a sum of Rs.3,20,126 (Cost of Medical Expenses) to Appellant along with interest @ 6% p.a.”

10. Similarly, the Hon’ble National Commission in the case titled Sunil Kumar Sharma v. Tata AIG Life Insurance Company and Ors., Revision Petition No.3557 of 2013 decided on 1.3.2021, while dealing with the issue of pre-existing disease, has held as under:-

“10.   We further deem it appropriate to refer to Revision Petition No.3557 of 2013 titled as Sunil Kumar Sharma vs. TATA AIG Life Insurance Company and Ors., decided on 01.03.2021, wherein the Hon’ble National Commission has dealt the issue of pre existing disease and held as follows:

“14.   Moreover the claim had been repudiated only on the ground that the insured was suffering from diabetes for a long time. So far as life style diseases like diabetes and high blood pressure are concerned, Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., W.P.(C) No.656 of 2007, decided on 17.09.2007 held as under:

"Insurance – Mediclaim -Reimbursement-Present Petition filed for appropriate directions to respondent to reimburse
expenses incurred by him for his medical treatment, in accordance with policy of insurance - Held, there is no dispute that diabetes was a condition at time of submission of proposal, so was hyper tension - Petitioner was advised to undergo ECG, which he did - Insurer accepted proposal and issued cover note. It is universally known that hypertension and diabetes can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications depending upon varied factors. That implies that there is probability of such ailments, equally they can arise in non-diabetics or those without hypertension. It would be apparent that giving a textual effect to Clause 4.1 of policy would in most such cases render mediclaim cover meaningless. Policy would be reduced to a contract with no content, in event of happening of contingency. Therefore Clause 4.1 of policy cannot be allowed to override insurer's primary liability. Main purpose rule would have to be pressed into service. Insurer renewed policy after petitioner underwent CABG procedure. Therefore refusal by insurer to process and reimburse petitioner's claim is arbitrary and unreasonable. As a state agency, it has to set standards of model behaviour; its attitude here has displayed a contrary tendency. Therefore direction issued to respondent to process petitioner's claim, and ensure that he is reimbursed for procedure undergone by him according to claim lodged with it, within six weeks and petition allowed."

15. In RP No.4461 of 2012, Neelam Chopra v. Life Insurance Corporation of India & Ors., decided on 08.10.2018, (NC), it
was held that:

"11. From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases. The person insured may suffer consequences in terms of the reduced claims.

14. Moreover, the non-disclosure of information in respect of this life style disease of diabetes, will not totally disentitle the complainant for indemnification of the claim in the light of the judgment of Hon'ble High Court of Delhi in Hari Om Agarwal v. Oriental Insurance Co. Ltd., (supra)."

16. Based on the above discussion, I am of the opinion that the Insurance Company had not been able to prove beyond doubt that the Complainant was suffering from diabetes before filing of the proposal form. It is also to be noted that the Insurance Company had given Insurance to a person of 66 years of age without any preliminary medical examination which could have definitely revealed whether the proposer was suffering from diabetes or not. It is commonly known that a person of 66 years of age has a high probability of suffering from common lifestyle diseases like diabetes and hypertension. If the company is ready to take the risk at this age of the proposer, without any preliminary medical examination, then the company should be ready to honour the claim also because the chances of death of such persons are more during the currency of the Policy.”

11. In view of ratio of law laid down in the aforesaid orders, it is safe to hold that act of OPs in repudiating the genuine claim of the complainant certainly amounts to deficiency in service on their part and the present consumer complaint deserves to succeed.
12. In order to determine the quantum of compensation, complainant has placed on record the claim form (Ex.C-2) for the sum of ₹68,491/- which was paid by him from his own pocket to the said Cheema Hospital for the treatment of his father, which has not been disputed by the OPs.  Hence, OPs are liable to reimburse the said to the complainant amount alongwith interest and compensation for the harassment suffered by him.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹68,491/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 8.1.2022 till realization of the same.
2. to pay an amount of ₹15,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 01/05/2023 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Surjeet Kaur] Member