| Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA CC.No.431 of 27-07-2016 Decided on 24-10-2017 Sukhvir Singh aged about 41 years S/o Karnail Singh S/o Gurdev Singh R/o Kothe Natha Singh Wale (Mehma Swai), Tehsil Goniana Mandl, District Bathinda. ........Complainant Versus 1.HDFC Standard Life Insurance Co. Ltd., 12th and 13th Floors, Lodha Excelus, Apollo Mill Compound, N.M Joshi Marg, Mahalaxmi, Mumbai, Maharashtra, through its Manager. 2. HDFC Standard Life Insurance Co. Ltd., E-Meditek (TPA) Services Ltd., Plot No.577, Udyog Vihar, Phase-V, Gurgaon, through its Manager. 3.HDFC Standard Life Insurance Co. Ltd., Ground Floor, Plot No.3038-A, Dalip Singh Walia Complex, Guru Kanshi Marg, National Highway No.15, Bathinda, through its Branch Manager. .......Opposite parties Complaint under Section 12 of the Consumer Protection Act, 1986 QUORUM Sh.M.P Singh Pahwa, President. Sh.Jarnail Singh, Member. Present:- For the complainant: Sh.Vikas Gupta, Advocate. For opposite parties: Sh.Vinod Garg, Advocate. ORDER M.P Singh Pahwa, President The complainant Sukhvir Singh (here-in-after referred to as complainant) has filed complaint U/s 12 of Consumer Protection Act, 1986 against opposite parties HDFC Standard Life Insurance Co. Ltd. and Others (here-in-after referred to as opposite parties). Briefly, the case of the complainant is that in month of September 2014, he purchased one health insurance policy i.e. HDFC Life Health Assurance Plan Family Policy for his family consisting of himself, his wife Chranjit Kaur, son Harkamal Singh and daughter Jaspreet Kaur. Opposite parties issued policy bearing No.90044662. The sum assured of the policy was Rs.3 lakhs per member. The complainant paid premium of Rs.15,663/- for the policy. It is case of the complainant that unfortunately, in the first week of December, 2014, he suffered from Laproscopic and Adhesiolysis disease. He visited Max Super Specialty Hospital, Bathinda and consulted Dr.Vikas Jindal, Laproscopic and General Surgeon. On his advise, X-ray of the complainant was conducted on 10.12.2014 wherein 'few small fluid levels' were seen in abdomen. The complainant paid an amount of Rs.450/- for X-ray examination. As per advise of doctor also, the complainant got conducted various tests such as RBC count and CPR. On advise of doctor, the complainant was admitted and treated in MAX Super Specialty Hospital, Bathinda. He was suffering from recurrent SAIO for which he had undergone laproscopy and adhesiolysis surgery on 13.12.2014. The surgery was done by Dr.Vikas Jindal. The complainant paid Rs.53,933/- for his treatment to Max Hospital, Bathinda. He was discharged on 15.12.2014. He submitted his claim alongwith medical bills to opposite party No.3 for reimbursement as per the insurance policy. Opposite party No.3 asked the complainant to submit the claim alongwith documents to the head office situated at Gurgaon. Accordingly, he sent all the documents alongwith claim to opposite party No.2 at Gurgaon through On-Dot courier vide receipt dated 4.3.2015. It is alleged that the claim of the complainant was not accepted/rejected by opposite parties till date. He had filed the complaint bearing CC No.113 of 9.4.2015, which was accepted by this Forum against opposite parties with the directions that they will decide the claim of the complainant within one month after receiving X-ray films from him. He submitted X-ray films to opposite party No.3 on 8.2.2016. Opposite parties did not decide the claim of the complainant within one month. On 7.4.2016, the complainant filed the complaint U/s 27 of 'Act'. Opposite parties had appeared in the complaint and filed reply. Alongwith copy of reply, letter dated 10.3.2016 issued to the complainant by opposite party No.1 was produced whereby the claim was repudiated on the ground that from the records submitted in connection with hospitalization claim, it had been established that the complainant was suffering from Sub Acute Intestinal Obstruction since four months prior to surgery and it was not disclosed to the company in the proposal form dated 12.9.2014. It is also case of the complainant that he was not suffering from alleged disease prior to obtaining the medi-claim policy from opposite parties. There is no such record showing that he was suffering from decease prior to obtaining the medi-claim policy from opposite parties. His claim has wrongly been repudiated and made in hurry under pressure of complaint U/s 27. On this backdrop of facts, the complainant has alleged deficiency in service on the part of opposite parties. He has also pleaded that this deficiency caused him immense prejudice, harm, embarrassment, botheration and mental agony. He has claimed Rs.1 lakh as compensation for mental tension and agony etc. in addition to payment of Rs.53,933/- incurred by him for medical expenses and Rs.11,000/- as cost of litigation. Hence, this complaint. Upon notice, opposite parties appeared through their counsel and contested the complaint by filing the written version. In the joint written version, opposite parties have raised the legal objections that the intricate questions of law and facts are involved in the complaint, which require voluminous documents and evidence for determination. It is not possible in the summary procedure under 'Act' and appropriate remedy, if any, lies only in the civil court. The complainant has concealed the material facts and documents from this Forum and opposite parties. He has concealed the fact that he was suffering from Sub Acute Intestinal Obstruction (SAIO) since 4 months prior to surgery and it was not disclosed to opposite parties in the proposal form dated 12.9.2014. The policy was issued on the basis of proposal form dated 12.9.2014. Had this information been provided to opposite parties at the time of applying for policy, they would not have issued the policy on existing terms and conditions. Since vital and material information was not provided to opposite parties at the time of applying for policy, the claim was repudiated vide letter dated 10.3.2016. The policy was declared null and void as per Clause 25 of the policy and premium paid had been forfeited. Other legal objections are that the complainant is not 'consumer' of opposite parties. The complaint is not maintainable in its present form and it is liable to be dismissed. On merits, regarding purchase of policy, it is stated to be matter of record. It is further mentioned that the policy was issued strictly subject to terms and conditions thereof. The complainant has made material concealment about his health at the time of applying for insurance policy. It is admitted that the policy bearing No.90044662 was issued to the complainant wherein sum assured was Rs.3,00,000/- and premium was Rs.15,663/-. It is also admitted that the complainant submitted the claim, but it is denied that the claim was submitted with complete documents. It is further admitted that he filed complaint earlier on same cause-of-action. Opposite parties called upon the complainant to submit complete documents vide letter dated 27.1.2015 and 3.2.2015, but he failed to submit the documents and filed the earlier complaint. It is admitted that the complainant had filed complaint No.CC/113 of 9.4.2015, which was decided by this Forum, but it is denied that opposite parties did not decide the claim of the complainant within one month. It is admitted that the complainant filed complaint U/s 27 on 7.4.2016 and opposite parties appeared and filed their reply wherein they intimated the complainant that the claim has been repudiated vide letter dated 10.3.2016. All other averments of the complainant are denied. Opposite parties have reiterated their stand as taken in the legal objections and detailed above. In the end, they have prayed for dismissal of complaint. Parties were asked to produce the evidence. In support of his claim, the complainant has tendered into evidence his affidavit dated 2.11.2016, (Ex.C1); photocopy of first premium receipt, (Ex.C2); photocopy of prescription slip, (Ex.C3); photocopy of e-mail, (Ex.C4); photocopy of discharge summary, (Ex.C5); photocopies of bills, (Ex.C6, Ex.C10 to Ex.C12 and Ex.C15); photocopies of deposit receipts, (Ex.C7 to Ex.C9); photocopies of investigation reports, (Ex.C13 and Ex.C14); photocopy of claim intimation form, (Ex.C16); photocopy of policy documents, (Ex.C17); photocopies of letters, (Ex.C18 and Ex.C19) and closed the evidence. To rebut the claim of the complainant, opposite parties tendered into evidence affidavit of Amit Khanna dated 15.3.2017, (Ex.OP1/1); photo copies of letters, (Ex.OP1/2, Ex.OP1/3, Ex.OP1/6, Ex.OP1/7 and Ex.OP1/11); photo copy of discharge summary, (Ex.OP1/4); photo copy of claim form, (Ex.OP1/5); photo copy of insurance policy, (Ex.OP1/8); photo copy of investigation report, (Ex.OP1/9); photo copy of treatment record, (Ex.OP1/10) and submitted written arguments. We have heard learned counsel for parties and gone through the file as well as written arguments submitted by learned counsel for opposite parties. Learned counsel for complainant has reiterated his stand as taken in the complaint and detailed above. It is further submitted by learned counsel for complainant that the material facts are not in dispute. It is not disputed that the complainant purchased health insurance policy of opposite parties on payment of Rs.15,663/- as premium for sum of assured of Rs.3 lakhs. It is not disputed that the complainant took treatment from Max Super Specialty Hospital, Bathinda by spending Rs.53,933/-. It is admitted that he submitted the claim, which has been repudiated by opposite parties. Firstly, opposite parties caused unnecessary delay in settlement of claim, which forced the complainant to knock the door of this Forum. Thereafter on the directions of this Forum, passed in earlier complaint, opposite parties have repudiated the claim of the complainant vide letter dated 10.3.2016, (Ex.C18). The repudiation is on the ground that the complainant was suffering from Sub Acute Intestinal Obstruction since 4 months prior to surgery and it was not disclosed to the company in the proposal form dated 12.9.2014. Opposite parties were to prove that the complainant was suffering from this disease since 4 months prior to surgery and that they were justified to repudiate this claim on this ground, but they failed on both counts. There is no evidence on record to prove that the complainant was suffering from this disease since 4 months. Of-course, opposite parties have placed on record investigation report, (Ex.OP1/9). This report is not proved on record. Moreover there is no concrete evidence collected by the investigator for confirming this conclusion. Only evidence collected by the investigator and produced on record is one prescription slip dated 10.12.2014. Of-course, in this prescription slip, it is mentioned 'History of SAIO 4 months', but this evidence is not conclusive proof. There is no other evidence to prove that the complainant has ever taken treatment for this disease and that he was in the knowledge of this disease. It is further submitted by learned counsel for complainant that opposite parties have also placed on record copy of policy documents as Ex.OP1/8. There is nothing to show that for this alleged disease, the complainant was not entitled to reimbursement. It is also submitted by learned counsel for complainant that opposite parties have also taken contradictory stand. Admittedly, the complainant filed earlier complaint on 9.4.2015. Opposite parties have placed on record copy of letter dated 8.4.2015, (Ex.C19) whereby it is stated that due to non-disclosure about aforesaid information, company declared the policy No.90044662 null and void as per Clause 25 of the policy terms and conditions and premium paid stands forfeited. This fact was not revealed in the earlier complaint, which was certainly filed after 8.4.2015. Therefore, it is to be concluded that opposite parties are making lame excuses to repudiate the claim and harass the complainant. The deficiency in service and unfair trade practice on the part of opposite parties stands established. Therefore, the complaint be accepted in terms of reliefs as claimed for. On the other hand, learned counsel for opposite parties has submitted that the contract of insurance is based on uberrima fides i.e. good faith. The insured is expected to disclose all the material facts, which are relevant for opposite parties to decide that whether they are able to issue insurance policy or not. The complainant has concealed the fact that he was suffering from Sub Acute Intestinal Obstruction since four months prior to policy. This fact was not disclosed in the proposal form dated 12.9.2014. Had this information been provided to opposite parties at the time of filling-up proposal form, they would not have issued the policy on existing terms and conditions. The vital and material information was not provided to opposite parties. As such, they were justified to repudiate the claim. The policy was declared null and void as per Clause 25 and premium paid was forfeited. We have given careful consideration to these rival submissions. Admitted facts are that the complainant purchased health insurance policy from opposite parties. During the cover period, he took the treatment in the month December 2014 by spending Rs.53,933/-. The claim submitted by him was not previously decided and later on, the claim has been repudiated. He has produced on record copy of letter dated 10.3.2016, (Ex.C18) vide which the claim has been repudiated. The ground to justify the repudiation by opposite parties is that the complainant was suffering from Sub Acute Intestinal Obstruction since four months prior to surgery and it was not disclosed to the company in the proposal form dated 12.9.2014. The onus to prove this fact is upon opposite parties. Opposite parties have not brought on record copy of proposal form to prove that the complainant was asked for this information and he has concealed this fact. The complainant has brought on record copy of letter dated 8.4.2015, (Ex.C19) wherein part of information relating to personal medical details is extracted. As per this document, the complainant was asked to give following information, which he replied in negative:- “Personal Medical Details: Please answer the below mentioned questions by checking Yes (Y) or No (N) only Yes No A | Is any of the life to be insured currently suffers or have ever suffered from high blood pressure, diabetes, cancer, chest pain, heart disorder? | | N | B | Is any of the life to be insured currently suffers or have ever suffered from any other chronic medical ailment? | | N | C | In the last 5 years, have you or any of the proposed insured been hospitalized, undergone a surgery or taken treatment for a continuous period exceeding 7 days? | | N” |
A perusal of above performa reveals that the complainant was asked about high blood pressure, diabetes, cancer, chest pain and heart disorder and there is nothing to show that this information is incorrect. The complainant was also asked regarding any other chronic medical ailment, which he answered in negative. It was also not case of opposite parties that the complainant was suffering from any chronic medical ailment. The last question regarding health was regarding hospitalization, surgery or treatment for continuous period exceeding 7 days. Opposite parties have also not produced/collected any evidence to prove that the complainant remained hospitalized and he had undergone surgery or taken treatment for continuous period exceeding 7 days. In these circumstances, the averment of opposite parties that the complainant has concealed the fact regarding his health, is not proved. When the claim is repudiated on the ground that the complainant was suffering from SAIO, opposite parties were also to prove this fact by affirmative evidence. Only evidence produced by opposite parties is one prescription slip dated 10.12.2014 wherein doctor has mentioned 'H/o SAIO 4 months back'. This document is not signed by the complainant. This document is also not proved as per law. This fact was also not disclosed in the written version to enable the complainant to rebut this evidence. Therefore, from this prescription slip also, it cannot be conclusively proved that the complainant was suffering from any disease since 4 months as alleged by opposite parties. Other facts on the record reveal that opposite parties have also been taking contradictory plea. It is not disputed that earlier complaint No.113 of 9.4.2015 was filed by the complainant, which was decided in his favour by directing opposite parties to decide the claim of the complainant within one months after receiving X-ray films. From this fact, it can be safely inferred that opposite parties have not revealed that the claim has already been repudiated on 8.4.2015 i.e. a day before filing of earlier complaint. The version of opposite parties is that the claim has been repudiated vide letter dated 10.3.2016. Copy of letter is produced as Ex.OP1/2. Of-course, this letter is on the basis of order passed by this Forum in earlier complaint, but in this letter, it is revealed that the claim has already been repudiated on 8.4.2015. Had this fact been revealed in the earlier complaint filed on 9.4.2015, the complainant would not have filed the subsequent complaint and this controversy would have been settled in earlier complaint, In this way, it can be inferred that opposite parties were also not sure about the action taken against the claim submitted by the complainant and it resulted not only delay in settlement, but in unnecessary litigation also. Therefore, deficiency in service on the part of opposite parties stands proved. Now, question is regarding relief claimed by the complainant. Of-course, he has pleaded that he has spent a sum of Rs.53,933/- for his treatment. He has not brought on record policy containing entire terms and conditions. Opposite parties have brought on record copy of policy, (Ex.OP1/8). The benefits and their limits are also mentioned in the policy. The complainant is entitled to the benefits as per policy only. Therefore, opposite parties can be directed to pay the claim as per terms and conditions of policy. For the reasons recorded above, the complaint is partly accepted with Rs.10,000/- as cost and compensation against opposite parties. Opposite parties are directed to pay the amount payable to the complainant as per terms and conditions of policy. The compliance of this order be made within 30 days from the date of receipt of copy of this order. The complaint could not be decided within the statutory period due to heavy pendency of cases. Copy of order be sent to the parties concerned free of cost and file be consigned to the record. Announced:- 24-10-2017 (M.P Singh Pahwa) President (Jarnail Singh) Member
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