BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 124 of 2019
Date of Institution : 11.3.2019
Date of Decision : 28.08.2019.
Ashok Kumar aged about 53 years son of Shri Rampal, resident of Gali Kanda Chungi Wali, M.C. Colony, Sirsa, Tehsil and District Sirsa.
……Complainant.
Versus.
1. HDFC Standard Life Insurance Co. Ltd., 1st Floor, Classic Auto Care Shop, Dabwali Road, Sangwan Chowk, Sirsa through Branch Manager.
2. HDFC Standard Life Insurance Co. Ltd. Mumbai Hub, 11th Floor, Lodha Excelus Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi Mumbai- 400011 through its authorized signatory.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA…………………………PRESIDENT
SH. ISSAM SINGH SAGWAL………… MEMBER
SMT. SUKHDEEP KAUR……………… MEMBER.
Present: Sh. Preet Amar, Advocate for the complainant.
Sh. A.S. Kalra, Advocate for opposite parties.
ORDER
The case of the complainant in brief is that on 25th June, 2017, the complainant had purchased a mediclaim policy namely HDFC Life Easy Health Plan bearing No.90527890 from the op no.1 and the policy was valid for a period of five years from the date of its purchase on payment of amount of annually premium. The complainant kept on making the payment of premium to op no.1 regularly without any break/ default. That in the month of July, 2018, the complainant fell seriously ill and remained admitted in Poonia Hospital, Sirsa from 17.7.2018 to 25.7.2018 and a total sum of Rs.1,75,000/- has been spent by him on his treatment. Thereafter, as his health could not be improved, he again remained admitted in the said hospital from 20.8.2018 to 25.8.2018 and spent a further sum of Rs.51600/-. On 14.9.2018, the complainant submitted his claim with op no.1 and submitted all the necessary documents including bills etc. and requested to indemnify his claim. The claim of complainant was acknowledged vide letter dated 17.9.2018 vide which some documents were demanded and accordingly he fulfilled all the necessary formalities and he was promised that his claim shall be indemnified at the earliest. It is further averred that since then the complainant has been making rounds to the office of op no.1 time and again but to no effect and such act and conduct on the part of ops clearly amounts to deficiency in service and unfair trade practice. That ultimately op no.1 flatly refused to admit the claim of complainant, hence the complainant got issued a legal notice upon the ops on 14.1.2019 but of no use. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement raising certain preliminary objections. It is submitted that complainant Ashok Kumar at the time of making the proposal for the said health policy had misrepresented about his health. He was suffering from, disease of “Diabetes Mellitus” for the last more than 10 years prior to issuance of the policy and suppression of this material fact at the time of filling and signing the proposal form based on which the said policy was issued amounts to suppression of true and material facts. This fact is very much evident from the email dated 20.11.2018 sent by son of complainant to the answering ops in response to the email sent by ops on 19.11.2018 for the requirement of duration of suffering of his father with diabetes mellitus, in which son of complainant had admitted that his father was suffering from diabetes mellitus for the last more than 10 years. This very fact clearly established that complainant Ashok Kumar has suppressed the factum of suffering from chronic pre-existing disease at the time of issuance of the policy. As such the health claim filed by complainant has been rightly repudiated vide letter dated 20.11.2018 and 21.11.2018. It is further submitted that complainant gave wrong information pertaining to his health. The proposal form clearly states that if it is found that the statement, answers or particulars stated in the proposal form and it’s questionnaire are incorrect or untrue in any respect, the insurance company shall incur no liability under the insurance. Thus, the complainant had fully understood the terms and conditions of the policy and further agreed that if any untrue statement be contained in the application, the policy contract shall be null and void and the moneys which have been paid in respect thereof shall stands forfeited to the company. With these averments, dismissal of complaint prayed for.
3. The parties then led their respective evidence.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. Learned counsel for complainant has contended that it has been proved on record that complainant had purchased medi claim policy namely HDFC Life Easy Health Plan from op no.1 on payment of amount of annually premium. In the month of July, 2018, the complainant fell ill and in order to get him treated, he got himself admitted in Poonia Hospital, Sirsa on 17.7.2018 and remained admitted there up to 25.7.2018 and again he remained admitted in the said hospital from 20.8.2018 and 25.8.2018 and in this way he spent Rs.1,75,000/- and Rs.51,600/- on his treatment which he paid to Poonia Hospital against bills. It has also been contended that due intimation was given to ops regarding illness and admission in the hospital and claim was lodged, but however, same was repudiated on illegal ground of pre-existing disease. The complainant was not suffering from any pre-existing disease. The ops have not placed on record any proposal form duly signed by complainant and have also not placed on record any opinion of the expert or record of the medical examination. Learned counsel for complainant has relied upon judgments in cases titled as Manish Goyal vs. Max Bupa Health Insurance Company Ltd., 2019 (2) CLT 205 (Hon’ble Chandigarh State Commission), Religare Health Insurance Company Ltd. vs. Subhash Chander, 2017 (3) CLT 140 (Hon’ble Punjab State Commission), Vipin Grover & anr. vs. NIAC II (2018) CPJ 374 (Hon’ble NC), Royal Sundaram Alliance Insurnace Co. Ltd. and anr. vs. Melanie Das, II (2018) CPJ 510 (Hon’ble NC) and Arun Kumar vs. NIAC, III (2017) CPJ 533 (Hon’ble NC).
6. On the other hand, learned counsel for ops has contended that complainant was suffering from pre-existing disease of Diabetes Mellitus and this fact has been concealed by complainant at the time of filling columns of proposal form and getting policy. The policy was obtained by misrepresentation and fraud. As per exclusion clause, complainant is not entitled to get reimbursement his medical claim qua his illness for the pre-existing disease. Even son of complainant has admitted this fact that his father was suffering from Diabetes Mellitus for the last 10 years vide his email. The ops have rightly repudiated the claim of the complainant.
7. We have considered the rival contentions of the parties and have gone through the case file as well as judgments relied upon by learned counsel for complainant.
8. The perusal of the record reveals that complainant in order to prove his case has furnished his affidavit Ex.CW1/A in which he has reiterated all the averments made in his complaint. He has also produced on record copy of legal notice, Ex.C1, postal receipts Ex.C2, Ex.C3, copy of letter Ex.C4, copy of first premium receipt Ex.C5, copies of receipt Ex.C6, Ex.C7, copies of bills Ex.C8, Ex.C9 and copy of deficiency letter Ex.C10. On the other hand, ops have furnished affidavit of Sh. Gurpreet Singh, Deputy Legal Manager Ex.R1 in which he has reiterated all the averments of the written statement. The ops have also placed on file copy of proposal form Ex.R2, Ex.R3, copy of discharge slip Ex.R4, copy of repudiation letter Ex.R5, Ex.R6, copy of mail Ex.R7 and authority letter Ex.R8.
9. Admittedly, the complainant had purchased a medi claim policy from the ops on 25.6.2017 for a period of five years on payment of annually premium. In the month of July, 2018, he fell ill and got himself admitted for treatment in Poonia Hospital and remained admitted there from 17.7.2018 to 25.7.2018 and spent Rs.1,75,000/- on his treatment. Thereafter, again in the month of August, 2018 he remained admitted in the Poonia Hospital from 20.8.2018 to 25.8.2018 and spent Rs.51,600/- on his treatment against bills Ex.C8 and Ex.C9. Due intimation was given to the ops and claim was lodged, but however, ops have repudiated the claim of complainant on the ground that complainant was suffering from pre-existing disease of Diabetes Mellitus and the ops have relied upon the mail of son of complainant namely Ravit Sharma as Ex.R7. As per law, it was legal obligation of the ops to prove the allegation of pre-existing disease of Diabetes Mellitus and that it has close proximity with the existing disease of complainant for which he got treatment from Poonia Hospital. The ops have tendered copy of proposal form Ex.R2 which reveals that it does not bear signatures of the complainant or the signatures of agent who filled this form on behalf of complainant in which he had concealed pre-existing disease of Diabetes Mellitus. The ops have not placed on record original proposal form, if any due to reason best known to them. The ops have not placed on record any affidavit of medical expert, who ever examined the complainant prior to his admission in the hospital to prove that complainant was suffering from disease of Diabetes Mellitus for the last ten years. The ops have even not placed on record the affidavit of any their expert of TPA, who examined claim documents of complainant and formed his opinion that he was already suffering from disease of Diabetes Mellitus for the last 10 years.
10. Admittedly, complainant is a man of 53 years of age and he was of 50 plus when he got this policy on 25.6.2017. As per instructions of the Insurance Regulatory and Development Authority of India (IRDAI), if a proposed insured is of more than 45 years old at the time of issuance of policy, his medical examination is necessary. But in the present case, ops have not placed on record any document from which it could be presumed that medical examination of complainant was ever got conducted by ops before accepting insurance proposal and issuance of the insurance policy to the complainant. So, if there is any lapse on the part of insurance company itself, it cannot blame complainant or any other person for their own wrong. Now at this stage, they cannot avoid their liability and we find force from the above said judgments relied upon by learned counsel for complainant. So, we are of the opinion that ops have repudiated the claim of complainant in a very ordinary and casual manner which is not justified and we hereby set aside the order of repudiation passed by insurance company. The repudiation of the genuine claim of the complainant clearly amounts to deficiency in service and unfair trade practice on the part of ops.
11. In view of our above discussion, we allow this complaint and direct the opposite parties to settle and pay the claim of the complainant as per terms and conditions of the policy within 45 days from the date of receipt of copy of this order. We further direct the ops to pay interest at the rate of 7% per annum on the claim amount from the date of lodging of claim till its realization. We also direct the ops to pay a sum of Rs.10,000/- as compensation for harassment and Rs.2000/- as litigation expenses to the complainant. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:28.08.2019. Member Member District Consumer Disputes
Redressal Forum, Sirsa.
