Chandigarh

DF-I

CC/448/2023

HARJOT KAUR DHANOA, AGED 49 YEARS, D/O SH. HARINDER SINGH DHANOA, RESIDENT OF 643, PSB SOCIETY, SECTOR 49-A, CHANDIGARH-160047. - Complainant(s)

Versus

ICICI LOMBARD GENERAL INSURANCE COMPANY LIMITED - Opp.Party(s)

04 Sep 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/448/2023
Date of Institution	:	15/09/2023
Date of Decision	:	04/09/2024

 

Harjot Kaur Dhanoa, aged 49 years d/o Sh. Harinder Singh Dhanoa, resident of 643, PSB Society, Sector 49-A, Chandigarh 160047.

… Complainant

V E R S U S

1. ICICI Lombard General Insurance Company Limited, through its Authorised Signatory/Manager, Plot No.149, Fourth The Statement Industrial Area, Chandigarh 160002.
2. ICICI Lombard General Insurance Company Limited, through its Authorised Signatory/Manager, Registered office at ICICI Lombard House, 414, P Balu Marg, Off Veer Savarkar Road, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Satpal Dhamija, Advocate for complainant
	:	Sh. Ankur Gupta, Advocate for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Smt.Harjot Kaur Dhanoa, complainant against the aforesaid 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 in order to secure the uncertain future, complainant took a medical/ health insurance policy from the OPs namely “iH-Individual (Complete Health Insurance)” which was valid w.e.f. 19.9.2018 to 18.9.2019, by paying premium of ₹9,547/- with sum insured of ₹10.00 lacs.  The said policy was got duly renewed by the complainant, from time to time, uptil the renewal of the subject policy valid w.e.f. 19.9.2022 to 18.9.2023. Copies of all the policies are Ex. C-1 (Colly.). On 13.6.2023, complainant felt restriction in movement of her arm and severe pain and visited Fortis Hospital (hereinafter referred to as “treating hospital”) for check up where various tests were carried out.  On receipt of reports from the Department of Radiology Lab and Department of Nuclear Medicine & Moleculer Imaging, the treating doctors diagnosed the complainant as “carcinoma left breast with fibroadenoma right breast pT2NxMO”. Accordingly, chemotherapy was advised by the treating doctor and the treatment is still going on.  Copy of medical record is Ex.C-2 (Colly.).  Thereafter the complainant lodged claim with the OPs for reimbursement of the amount incurred on her treatment till the lodging of the claim.  However, OPs/insurer vide letter (Ex.C-3) intimated the complainant that the policy is being cancelled for the reason that the complainant was suffering from hypertension in the year 2016, as mentioned in the OPD papers issued by Bhatia Heart and Diabetes Centre, which fact was not disclosed by the complainant at the time of inception of the policy on 19.9.2018 and accordingly due to non disclosure of hypertension by the complainant, OPs had repudiated/rejected the claim of the complainant vide letter dated 28.7.2023 (Ex.C-4).  Even when hypertension has no nexus with the present disease, from which the complainant has been suffering, OPs have wrongly repudiated the claim and cancelled the subject policy.  Moreover, Ex.C-5 nowhere mentions that medicine for hypertension was prescribed for the complainant regarding which OPs have made reference in the claim repudiation/rejection letter and policy cancellation letter.  Even vide certificate (Ex.C-6) Bhatia Heart & Diabetes Centre had given reference of medicine AZILSARTAN (ZILARBI) for the last four years and there was no question that the complainant had  to disclose about hypertension at the time of inception of the policy as she was not suffering from the same at that time.   In this manner, the aforesaid act of the OPs amounts to deficiency in service and unfair trade practice. 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 and concealment of material facts.  On merits, it is not disputed that the complainant had obtained the subject policy from the OPs by obtaining the first policy on 19.9.2018, but, denied that there is any deficiency in service or unfair trade practice on their part.  It is further alleged that, in fact, complainant had not disclosed about the pre-existing disease i.e. hypertension from which she was suffering before the inception of the first policy and due to non disclosure and misrepresentation on the part of the complainant, OPs had repudiated the claim of the complainant and had decided to cancel the subject policy. 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. Despite grant of sufficient opportunity, rejoinder was not filed by the complainant to rebut the stand of the OPs.

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 written arguments.
   1. At the time of arguments, the learned counsel for the complainant has stated that the complainant has already filed a separate complaint with respect to the mediclaim against the OPs qua the medical bills regarding which the facts have already been stated in the present case and the same is pending before the Learned District Commission-II, UT, Chandigarh, the complainant confines her claim only qua the revival of the subject policy and does not claim any relief qua the amount which she has spent for his medical treatment.
   2. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had obtained the first health insurance policy from the OPs on 19.9.2018 which was valid till 18.9.2019 and got the same renewed annually, by paying premium to the OPs, upto the issuance of the subject policy which was valid w.e.f. 19.9.2022 to 18.9.2023 without any break, as is also evident from Annexure C-1 Colly., and on 13.6.2023 due to her health issue when the complainant first time approached the treating hospital i.e. Fortis Hospital for treatment she was diagnosed with breast malignancy and had taken treatment through chemotherapy on different dates and when she lodged the claim with the OPs, same was repudiated/rejected by the OPs vide letter (Ex.C-4) and had OPs had also served notice (Ex.C-3) for cancelation of the subject policy, both dated 27.8.2023,  on the ground of non disclosure of hypertension at the time of inception of the policy, the case is reduced to a narrow compass as it is to be determined if OPs are unjustified in cancelling the subject policy and she is entitled to the relief prayed for revival of the policy, as is the case of the complainant, or if OPs have rightly cancelled the subject policy and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of the OPs.
   3. 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, medical record, cancellation letter and the same are required to be scanned carefully for determining the real controversy between the parties.
   4. As per the case of complainant, she was diagnosed from hypertension in the year 2019 only by the Bhatia Heart & Diabetes Centre and was not having this problem at the time of inception of the subject policy whereas it is the defence of the OPs that the complainant had been suffering from the said disease i.e. hypertension prior to the inception of the policy.  However, perusal of the certificate dated 21.6.2023 (Ex.C-7) issued by foresaid  Bhatia Heart & Diabetes Centre clearly indicates that, at that time, doctor had opined that the patient has been suffering from hypertension since last about four years i.e. June 2019 meaning thereby during the currency of the subject policy as the date of inception of the subject policy is 19.9.2018 and this certificate (Ex.C-7) demolishes the defence of the OPs that the complainant was suffering from hypertension prior to the inception of the policy. 
   5. Moreover, law on this point is well settled that common lifestyle diseases like diabetes and hypertension cannot be treated as pre-existing diseases and cannot be a ground of repudiation of claim by Insurance companies. In this regard reliance can be placed on the order passed 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.) in which it was held 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.”

6. 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:-

“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."

7. Not only this, when after repudiation/rejection of the claim vide letter (Ex.C-4) and notice for cancellation of the policy vide letter (Ex.C-3), OPs had sent letter (Ex.C-8) for renewal of the policy to the complainant requesting her to get the subject policy renewed and in pursuance to the same complainant had sent cheque dated 14.9.2023 (Ex.C-9) to the OPs,  makes it clear that the OPs themselves were not clear in their mind if the subject policy has rightly been cancelled by them vide letters (Ex.C-4 & Ex.C-3 respectively) and on the other hand, they have been requesting the complainant to pay premium for the renewal of the subject policy.
8. Moreover, even as per the terms and conditions of the subject policy, hypertension was not covered under the definition of pre-existing disease as the OPs have failed to prove on record that the complainant had been suffering from hypertension 48 months prior to the inception of the policy, especially when it has already been discussed above that the complainant had been diagnosed with hypertension for the first time in the year 2019 only.
9. In view of the foregoing, when it has come on record that the complainant was diagnosed with “carcinoma left breast with fibroadenoma right breast pT2NxMO”, which otherwise has no nexus with hypertension, it is unsafe to hold that the OPs were justified in cancelling the subject policy and the present consumer complaint deserves to succeed.

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 revive/reinstate the subject policy on payment of due premium by the complainant, but, without levying any additional charges.
2. to pay ₹10,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs, jointly and severally, within a period of 45 days from the date of receipt of certified copy thereof, failing which the amount mentioned at Sr.No.(ii) above shall carry interest @ 9% per annum (simple) from the date of expiry of said period of 45 days, till realisation, over and above payment of ligation expenses.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

04/09/2024	Sd/- [Pawanjit Singh] President
	Sd/-
	[Surjeet Kaur] Member
	Sd/-
	[Suresh Kumar Sardana] Member