Punjab

Ludhiana

CC/20/53

Vikrant Chand Sharma - Complainant(s)

Versus

ICICI Lombard Gen.Insurance Co.Ltd - Opp.Party(s)

Nitin Gulati Adv.

03 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:53 dated 07.02.2020.                                                 Date of decision: 03.10.2023.

Vikrant Chand Sharma S/o. Sh. Parkash Chand Sharma, R/o. House No.1054/22, Street No.2, Bal Singh Nagar, Basti Jodhewal, Ludhiana, Punjab.                                                                                   ..…Complainant

                                                Versus

1. ICICI Lombard General Insurance Company Ltd., having its registered office at 144, Veer Savarkar Marg, Near Sidhi Vinayak Temple, Prabhadevi, Mumbai-400025 through its Manager/Authorized Signatory.
2. ICICI Lombard, TF 1-5, 3^rd Floor, 88, Kunal Tower, The Mall Road, Ludhiana through its Manager/Authorized Signatory.

…..Opposite parties 

Complaint Under section 2, 12, 14 of the Consumer Protection Act, 1986.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Nitin Gulati, Advocate.

For OPs                          :         Sh. Rajeev Abhi, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant availed ICICI Lombard Health Insurance policy No.4015i/banc/166426265/00/000 for a term of 5 years commencing from 06.03.2019 to 05.03.2024 for annual sum assured of Rs.5,00,000/- and also a policy No.4015i/banc/167458813/00/000 for a term of 5 years commencing from 22.03.2019 to 21.03.2024 for annual sum assured of Rs.5,00,000/-. The complainant paid total premium of Rs.20,650/- for both policies. The complainant stated that in the month of April, 2019 he felt chest pain and discomfort  and he went to Kulwant Heart and Vascular Centre and informed the opposite parties regarding his admission upon which the opposite parties informed that their panel doctor shall visit the hospital but nobody visited the hospital. The complainant was discharged from the said hospital on 16.04.2019 due to persistence of chest heaviness and he went to Hero DMC Heart Institute and was admitted on 16.04.2019 where he was diagnosed to have CAD with acute coronary syndrome, triple vessel disease, LVEF 42%, Mild LV Systolic Dysfunction, 20% calcified plaque at LCB extending into LECA. On 18.04.2019, the complainant underwent byepass heart surgery by Dr. Sarju Ralhan, Chief Cardiac Surgeon, DMC Hospital, Ludhiana. Intimation was given to the opposite parties by the wife of the complainant with request to provide cashless treatment but the same was denied by the opposite parties rather they assured for reimbursement of medical treatment up to Rs.5,00,000/- in current policy year. The complainant claimed to have paid the entire hospital bills from his own pocket. After his discharge, the complainant approached the opposite parties but they never make the payment of medical expenses or surgery and other hospital charges to the complainant. The complainant further stated that on 19.06.2019, the opposite parties issued letter of rejection of the claim due to “non disclosure of HTN, DM since 20 years”. The complainant stated that he was not a patient of hypertension and diabetes mellitus in past nor the same was detected in the tests conducted by the opposite parties from their hospital of their own choice. Even the complainant showed his medical reports to the opposite parties and even issued a letter by Dr. Sarju Ralhan, Chief Cardiac Surgeon, DMC Hospital, Ludhiana mentioning that the complainant had no history of diabetes mellitus and hypertension as per hospital record. Moreover, the opposite parties wrote a letter dated 29.10.2019 bearing ref. No.291019621499 and cancelled the policy of the complainant, which is totally illegal and same amounts to deficiency in service and unfair trade practice on the part of the opposite parties due to which the complainant has suffered mental tension, harassment, agony etc. In the end, the complainant prayed for issuing direction to the opposite parties to reimburse the claim amount of Rs.4,00,000/- and to withdraw the cancellation of the policy No.4015i/banc/166426265/00/000 dated 29.10.2019 and also to pay compensation of Rs.80,000/- and litigation expenses of Rs.11,000/-.

2.                Upon notice, the opposite parties appeared and filed joint written statement and by taking preliminary objections, assailed the complaint on the ground of maintainability of the complaint; concealment of material facts; the complainant is estopped by his own act and conduct; the complainant has no locus standi to file the present complaint. According to the opposite parties, on receipt of the claim, it was duly registered and entertained. The complainant obtained the insurance policy bearing No.4015/BANC/166426265/00/000 valid from 06.03.2019 to 05.03.2024 with annual sum assured of Rs.5,00,000/- with plan GCHI_BANC_5L_SI_1A-5_YT. The opposite parties stated that the insurance policy is contract in itself and the parties are bound by the terms and conditions of the policy and nothing can be added or subtracted out of it. The policy also contained condition i.e. part III of Schedule clause I of the policy in contestability and duty of disclosure, which is reproduced as under:-

“The policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, mis-description or non-disclosure in any material particulars in the proposal form, personal statement, declaration and connected documents or any material information having been withheld or devised being used by you or anyone acting on your behalf to obtain any benefit under this policy.”

The complainant lodged claim for reimbursement of medical expenses incurred on his treatment with Kulwant Heart and Vascular Centre from with date of admission from 11.04.2019 to 16.04.2019 with diagnosis of cardiac arrest and with DMC Hospital Unit Hero DMC Heart Institute from 16.04.2019 to 20.04.2019, upon receipt of which, the complainant was called upon to supply material information required for processing of the claim vide additional information request form dated 24.05.2019, which is reproduced as under:-

Sr. No.	Query	Remarks
1.	EFT deficiency	Kindly submit photocopy of cancelled cheque/attested photocopy of bank passbook of proposer Vikrant Chand Sharma for the same account number as provided in part C of claim form for further processing of claim.
2.	Final hospital bills not received.	Kindly submit original final hospital bill with detailed cost-wise break up along with supported documents.
3.	Discharge summary not received.	Kindly provide the original detailed discharge summary mentioning the date of admission, date of discharge, diagnosis, presenting complaints, past history, clinical findings, course in the hospital, treatment given during the period of hospitalization and the period of hospitalization and advise at discharge.
4.	Investigation reports not received	Kindly furnish the investigation reports for all the investigations mentioned in final bill for further processing of claim.
5.	Payment receipts not received.	Kindly furnish the original payment receipts towards settlement of final hospital bill with revenue stamp affixed on it and duly stamped and signed by the hospital authorities for further process of the claim.

 

According to the opposite parties, the complainant failed to submit all the additional information and documents required for processing the claim, which was valuable and material information for processing of the claim. Further, the opposite parties had investigated the claim and as per investigation i.e. questionnaires for doctor submitted by Dr. Kulwant Singh, MD, Medicine, consultant Cardiologist dated 01.06.2019, the said doctor has given the reply to the questionnaires clearly stating that the complainant was suffering from HYP (Hypertension) for the last 20 years and had the history of smoking and alcohol since 20 years. The relevant questionnaires answered by Dr. Kulwant Singh, the treating cardiologist of the complainant at questionnaires 6 and 7 are reproduced as under:-

6. Please specify since when is the patient suffering from Dyslipidemia, Hypertension or Diabetes? What treatment has patient taken for the same till date?

Suffering from HYP for last twenty years (20 years). No. history of DM

7. Kindly specify about social habits like smoking drinking or other drugs addition in the patient.

History of smoking and alcohol since 20 years.

As per the indoor patient admission record of Kulwant Heart and Vascular Centre, Ludhiana where the complainant Vikrant Chand Sharma was admitted on 11.4.2019 and discharged on 16.4.2019, the complainant had the history of depression disorder and limnology and history of P.Koch's for 25 years back. It is further stated in the indoor patient admission record of the complainant with Kulwant Heart and Vascular Centre, Ludhiana under the head Hypertension x since 20 years,

Smoking x since 20 years (one bundle one day).

Family history - h/o cardiac arrest father.

Alcohol x since 20 years.

                   As per the record of DMC Hospital the complainant has the history of smoking for the last 20 years.

                   As per the Insurance Company/TPA Clam Verification Form, in answer to the questionaries' submitted by the complainant and his daughter Ms Neha in their hand and under their signatures, have clearly stated that the complainant was suffering B.P., sugar for the last 20 years and was under treatment from Dr. Parveen Khurana, Sunder Nagar, Ludhiana and the record of the said doctor is not available. It is further stated that the complainant had the history of smoking for the last 10 years and was taking one bundle per day. It is further stated by the complainant and his daughter that the complainant was suffering from:

• Hypertension x 20 years under treatment of Dr. Parveen Khurana,
•  Diabetes x 20 years under treatment of Dr. Parveen Khurana.
•  Heart disease x April, 2019.

                   After the receipt of the aforesaid documents and after the receipt of documents placed in the claim file and after due application of mind by the officials of the opposite party in terms of the insurance policy the claim of the complainant was repudiated as no claim vide repudiation letter dated 19.6.2019 on the ground that "Claim is rejected under non-disclosure of HTN, DM since 20 yrs, as per part III of schedule, clause I of policy T&C., Incontestability and Duty of Disclosure: The Policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, mis-description or on non- disclosure in any material particular in the proposal form, personal statement, declaration and connected documents, or any material information having been withheld, or devices being used by You or any one acting on Your behalf to obtain any benefit under this Policy." The claim of the complainant has rightly been repudiated as no claim and the grounds of repudiation are legal, valid and enforceable and are in accordance with the terms and conditions of the policy.

                   The complainant had requested for cancellation of policy. The policy in question as such cancelled on 23 10 2019 and the proportionate premium of Rs 17,500/- out of total premium of Rs 20.650/- has been transferred in the loan account No xxxxx9883 towards the refund of premium as per terms and conditions of the policy. After the cancellation of the policy, the complainant is no more a consumer of the opposite parties.

                   On merits, the opposite parties reiterated the crux of averments made in the preliminary objections. The opposite parties stated that the claim was lodged in policy No.4050/BANC/16626265/00/000 which stands repudiated as no claim vide letter dated 19.06.2019. On the request of the complainant, the said policy was cancelled w.e.f. 23.10.2019 and proportionate premium of Rs.17,500/- was returned. The opposite parties have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

3.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents i.e. Ex. C1 is the copy of risk assumption letter, Ex. C2 is the copy of policy certificate, Ex. C3 is the copy of policy certificate, Ex. C4 is the copy of insurance card, Ex. C5 is the copy of additional information request form, Ex. C6 is the copy of rejection letter dated 19.06.2019, Ex. C7 is the copy of policy cancellation letter dated 29.10.2019, Ex. C8 is the copy of inpatient final bill, Ex. C9 to Ex. C11 are the copies of hospital record of DMC Hospital, Ex. C12 is the copy of carotid Doppler report, Ex. C13 is the copy of discharge summary, Ex. C14 is the copy of treatment advised, Ex. C15 is the copy of certificate of Dr. Sarju Ralhan and closed the evidence.

4.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RA of Sh. Nishant Gera, Manager Legal of the opposite parties along with documents Ex. R1 is the copy of questionnaire for doctor, Ex. R2, Ex. R5 to Ex. R10 Ex. R12 to Ex. R16  is the treatment record Kulwant Heart and Vascular Centre, Ex. R3 and Ex. R4 are the copies of high risk consent of Kulwant Heart and Vascular Centre, Ex. R11 is the copy of consent Form-C of AIMC Bassi Heart Centre, Ex. R17 is the cop of coronary angiography report of AIMC Bassi Heart Centre, Ex. R18, Ex. R19 are he copies of patient notes of Hero DMC Heart Institute, Ex. R20 is the copy of questionnaire for insured, Ex. R21 is the copy of Aadhar card of the complainant, Ex. R22 is the copy of passport of the complainant, Ex. R23 is the copy of driving licence of the complainant, Ex. R24 is the copy of authorization request, again Ex. R24 is the copy of proposal form, Ex. R25 and Ex. R26 are the copies of investigation reports,  Ex. R27, Ex. R33 is the copy of risk assumption letter and policy documents, Ex. R28 is the copy of enrollment form, Ex. R29 is the copy of declaration form, Ex. R30 is the copy of authorization request, Ex. R31 is the copy of claim form, Ex. R32 is the copy of rejection letter dated 19.06.2019, Ex. R34 is the copy of key information sheet of the policy and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.

6.                Admittedly, vide Ex. C1= Ex. R33, the complainant purchased online ICICI Lombard Group Health Policy from the opposite parties for himself w.e.f. 06.03.2019 to 05.03.2024. Firstly, the complainant remained admitted at Kulwant Heart and Vascular Centre from 11.04.2019 to 16.04.2019 where he was diagnosed of cardiac arrest. Secondly, the complainant was admitted at Hero DMC Heart Institute, Ludhiana on 16.04.2019 where he was diagnosed to have CAD with acute coronary syndrome, triple vessel disease, LVEF 42%, Mild LV Systolic Dysfunction, 20% calcified plaque at LCB extending into LECA. The complainant underwent byepass heart surgery on 18.04.2019 by Dr. Sarju Ralhan, Chief Cardiac Surgeon, DMC Hospital, Ludhiana. The complainant stated to have incurred Rs.4,00,000/- on his treatment. He submitted hospitalization claim form on 13.05.2019 (Ex. R31). During the investigation, the opposite parties obtained documents and questionnaire for doctor (Ex. R1) where the treating Dr. Kulwant Singh, M.D. Medicine Consultant Cardiologist stated that the patient was suffering from HYP for last 20 years as well as history of smoking and alcohol since 20 years. The opposite parties also obtained questionnaire from the complainant in which the complainant himself stated that he had been suffering from BP and sugar since 20 years and he is on medication for these ailments from Dr. Parveen Khanna, Sunder Nagar, Ludhiana. So by invoking part III of schedule 1 of the policy terms and condition, Incontestability and Duty of Disclosure, the opposite parties rejected the claim of the complainant vide rejection letter dated 19.06.2019 (Ex. R32) on account of non-disclosure of HTN, DM since 20 years by. The operative part of Ex. R32 reads as under:-

“We have perused the documents submitted by you and regret to inform that your claim cannot be settled for the following reasons.

Sr. No.	Reason	Description
1.	Standard exclusion	Claim is rejected under non disclosure of HTN, DM since 20 yrs., as per part III of schedule 1 of the policy T&C., Incontestability and Duty of Disclosure :“The policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, mis-description or non-disclosure in any material particulars in the proposal form, personal statement, declaration and connected documents or any material information having been withheld or devised being used by you or anyone acting on your behalf to obtain any benefit under this policy.”

 

We continue to remain committed to you as a valued customer and assure you the best ser ices at all times.

Should you like any further clarification, please feel free to write to us at the below mentioned address, or e-mail us according to your preference, quoting the above claim no, and we shall be pleased to assist.

In case you have any query, kindly contact us within a period of 8 weeks. In case no response is received from your end within 8 weeks, the claim would be considered as accepted Rejection from our end.”

Further vide letter dated 29.10.2019 Ex. C7, the policy of the complainant was cancelled on 23.10.2019 and an amount of Rs.17,500/- was transferred in the account of the complainant towards the refund of premium as per terms and conditions of the policy.

7.                Now the question arise whether the rejection/cancellation of the policy on the ground mentioned therein is valid or not? The rejection of the claim of the complainant was effected by the opposite parties by invoking policy has been proposed to be cancelled by the opposite parties part III of schedule 1 of the policy terms and condition, Incontestability and Duty of Disclosure that the complainant had not disclosed about the pre-existing disease of HYP and DM for last 20 years. In the proposal form Ex. R28 is the copy of enrolment form in which under the column of personal details of the life to be assured, the complainant the answered all the questions in negative. The claim of the complainant is sought to be rejected on the ground that he was a patient of HYP and DM since 20 years. It is a matter of common knowledge that as a normal practice the form is filled by the insurance agent. In addition to this, despite being of age of 42 years at the time of issuance of the policy, the complainant was not got medically examined and moreover, the insurance company may have additional questions for the insured or may ask him to undergo medical tests to complete full medical assessment. No evidence has been lead by the opposite parties as to whether any additional questions were put to the complainant or not nor any evidence has been adduced that the complainant was subjected to some medical tests at the time of issuance of the policy in the Month of March 2019.

8.                In the present case, the complainant was admitted in Hero DMC Heart Institute, Ludhiana on 16.04.2019 with final diagnosis for CAD with acute coronary syndrome, triple vessel disease, LVEF 42%, Mild LV Systolic Dysfunction, 20% calcified plaque at LCB extending into LECA as per discharge summary Ex. C13. As per discharge summary, under the column of presenting history, the patient presented with complaints of chest heaviness few hours prior to admission. Coronary angiography done outside which revealed triple vessel disease. Patient admitted here for CABG. The complainant undergone total Arterial complete revascularization with bilateral IMA, OPCABG X 2, LIMA to LAD, IMA RIMA Composite Graft, RIMA to OM1

 She is being discharged in improved condition. Therefore, any treatment taken by the complainant prior to taking the policy about which no questions were asked in the proposal form, it cannot be said that the opposite parties are justified in rejecting the claim or cancelling the policy on the ground of suppressing his  pre-existing disease of HYP and DM for 20 years. Further, the opposite parties have not produced any evidence of medical record with regard to diagnosis and treatment of the said pre-existing disease of the complainant. Even the report or the affidavit of the investigator was not brought on record to substantiate its claim. It is well settled that on account of non-disclosure of such general diseases, the genuine claim cannot be rejected. In this regard, reference can be made to Religare Health Insurance Company Ltd. Vs Subhash Chander Aggarwal in 2017(3) CLT 140 whereby it has been held by Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh that hypertension is a common disease and can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack. Further reference can be made to Tarlok Chand Khanna Vs United India Insurance Co. Ltd. 2012(1) C.P.J. 84 whereby it has been held by Hon’ble National Consumer Disputes Redressal Commission, New Delhi  that the onus to prove that the insured was suffering from pre-existing disease was on the insurer and if the insurer has not produced the expert opinion, the reasons for repudiation of the claim were held to be unjustified. A reference can be further made to Lakhwinder Singh and another Vs United India Insurance Company etc.  decided in Appeal No.29 of 2009 whereby it has been held by Hon’ble State Consumer Disputes Redressal Commission, U.T, Chandigarh that the maladies like diabetes, hypertension being normal wear and tear of the life cannot be treated as pre-existing diseases.

9.                Further in a case titled as Manmohan Nanda Vs United India Assurance Co. Ltd. and others 2022(I) CPJ 20 (SC) wherein the Hon’ble Supreme Court of India has observed as under:-

“(6)   The appellant’s argument that there is no hard and fast rule that every person with DM-II will necessarily have a cardiac disease merely because it is a risk factor holds water. A person who does not suffer from DM-II can also suffer from a cardiac ailment. He had disclosed his DM-II status for which he was under treatment. The ECG report and other tests also indicated normal parameters. Further, statins were a preventive prescription to prevent development of cardiac issues as DM-II is a risk factor, not because he had a cardiac ailment or hyperlipidaemia. Further, the examining physician was informed of the same before the policy was taken. Accordingly, there was no suppression of any material fact by the appellant to the insurer.

(7)     It was for the insurer to gauge related complications based on the information provided. The insurance company did not think that the medical and health condition of the appellant was such which did not warrant issuance of a medical policy. The insurance company therefore did not decline the proposal of the assured as a prudent insurer.”   

Therefore, in our considered view, the rejection of the claim on the basis of   non-disclosure of pre-existing diseases could not have   been made a ground to   reject the claim and cancel the policy on this ground cannot be sustained  in the eyes of law.  The insurance companies are required to be more liberal in their approach without being too technical. In the given set of above said facts and circumstances, it would be just and appropriate if the rejection letter Ex. Ex. C6 = Ex. R32 as well as cancelation letter Ex. C7 issued by the opposite parties is set aside and the opposite parties are directed to settle and reimburse claim lodged by the complainant in respect of his treatment at Kulwant Heart and Vascular Centre, Ludhiana from 11.04.2019 to 16.04.2019 and further his treatment at DMC Hero Heart Centre, Ludhiana from 16.04.2019 to 24.04.2019 along with composite costs of Rs.10,000/-.

10.              As a result of above discussion, the complaint is partly allowed with an order that the rejection letter Ex. Ex. C6 = Ex. R32 as well as cancelation letter Ex. C7 issued by the opposite parties is set aside and the opposite parties are directed to settle and reimburse claim lodged by the complainant in respect of his treatment at Kulwant Heart and Vascular Centre, Ludhiana from 11.04.2019 to 16.04.2019 and further his treatment at DMC Hero Heart Centre, Ludhiana from 16.04.2019 to 24.04.2019  as per terms and conditions of the policy within period of 30 days from the date of receipt of copy of the order failing which the opposite parties shall pay interest @8% per annum on the settled amount to the complainant from the date of order till its actual payment. The opposite parties shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Payment of costs shall be made within a period of 30 days from the date of the receipt of the copy of this order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.     

11.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)                        (Sanjeev Batra)

Member                                       President        

 

Announced in Open Commission.

Dated:03.10.2023.

Gobind Ram.