BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

Complaint No.208 of 14.05.2018

Date of Decision:09.02.2021

Rajesh Bhatia S/o Late Harbans Lal R/o ED-300, Dhann Mohalla, Old Railway Road, Jalandhar.

..........Complainant

Versus

1. ICICI Lombard General Insurance Company Limited, 2^nd Floor, Nirmal Complex, (Swagat Palace), Plot No.EH-198, G.T. Road, Jalandhar through its Branch Manager.
2. ICICI Lombard General Insurance Company Limited, ICICI Bank Towers Bandra – Kurla Complex, Mumbai – 400051 through its Chairman.
3. IL Health Care, PA Claims, ICICI Bank Tower, Plot No.12, Financial District, Nanakgamguda, Gachibowli, Hyderabad (A.P.) 500032 through its Incharge.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Sh. Kuljit Singh             (President)

Smt. Jyotsna                   (Member)

COUNSEL FOR THE PARTIES:

For complainant             :         Sh.Rakesh Sharma, Advocate

For Op No.1&2             :         Sh.R.K. Sharma, Advocate

For OP-3                        :         Ex parte

Order

Kuljit Singh (President)

1. The instant complaint has been filed by the complainant, wherein he alleged that complainantin the month of Sept. 2016 purchased Secure Mind Medi claim Insurance Policy certificate No.4065/FICL/121737690/00/000 for his life from the OP-1 and paid Rs.2877.58 Ps being the insurance premium for the period 20.09.2016 to 19.09.2020 and accordingly, the OP-2 issued insurance policy to complainant.  Unfortunately, the complainant become sick and went to Apollo Hospital Amritsar for his checkup on 09.04.2017 and concerned doctor advised the complainant for admission in hospital for proper diagnose. Doctor diagnosed a lever disease after performing the various investigation/tests in the hospital and accordingly for the treatment of diagnosed disease, complainant remained admitted in the hospital upto 18.04.2017. Complainant incurred an amount of Rs.77652/- during treatment at the time of admission in hospital.  Complainant visited the OP No.1 and filled up form for reimbursement of claim of Rs.77652/- and submitted the original bills with claim form.  Complainant received a letter dated 07.07.2017 issued by OP-3 wherein certain information was required for reimbursement of claim.  The complainant furnished the requisite information.  Complainant shocked when he received a letter dated 11.10.2017 where in OPs repudiated the claim of complainant.  In this way, there is deficiency in service, negligence and unfair trade practice on the part of OPs for non-reimbursement. Lastly prayer has been made that OPs be directed to pay Rs.3,00,000/- as compensation for mental tension, harassment.
2. Notice of the complaint was given to the OPs and accordingly, OPs No.1 & 2 appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that thecomplaint is not maintainable; claim is for reimbursement of the expenses on treatment from Apollo Hospital, Amritsar from 09.04.2017 to 18.04.2017. The complainant was admitted in Apollo Hospital Amritsar as a known case of Chronic Liver Disease due to recurrent and frequent Hepatitis leading to Chronic Liver disease (CLD). The treading doctor on the date of admission of complainant with Apolo Hospital Amritsar has given certificate date 09.04.2017 to the effect that complainant presented with jaundice and protrusion of abdomen from last two months and that the complainant is known case of Chronic Liver Disease with Ascites and there is past history of recurrent and frequent Hepatitis due to Chronic Liver Disease for last two years (Alcoholic Liver Disease). The treating doctor has also given certificate to this effect on 09.09.2017. The fact and history of liver disease of complainant is corroborated by U/s Scan whole abdomen dated 05.07.2016 by Kapoor Scanning Centre, Jalandhar and Ultra Sound study of abdomen report dated 21.01.2017 by Golden Diagnostics, Amritsar and Scan report dated 21.01.2017 of Golden Diagnostic Amritsar.  The questionnaire filled by treating doctor dated 29.09.2017 also shows that the complainant is known case of Alcoholic Liver Disease from last two years.  The discharge card of Apollo Hospital dated 18.04.2017 also reveals that complainant was admitted with the cirrhosis of Liver and final diagnosis of decompensated Liver Disease Cirrhosis from last two years which fall prior to and within 48 months from the date of policy inception on 20.09.2016 and is pre-existing disease, as such claim of the complainant was repudiated vide letter dated 11.10.2017 on the ground of pre-existing disease that any insured event arising on account of the or in connection with any pre-existing disease is not payable as per terms and conditions of insurance policy after due application of mind.  There is no deficiency on the part of OPs.  On merits, the OPs have reproduced all averments as submitted under preliminary objection.  Other averments of the complaint are denied and prayed for dismissal of complaint with costs.
3. Upon notice OP-3 has failed to appear and ultimately proceeded against ex parte vide order dated 20.06.2018.
4. In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavit complainant Ex.CW1/Aalongwith documents Ex.C-1 to Ex.C-11 and closed the evidence.
5. In order to rebut the evidence of the complainant, the counsel for OP No.1&2 tendered affidavit of Apurva Sharma Ex.O-A alongwith some documents Ex.O-1 to Ex.O-8 and then closed the evidence.
6. We have heard the argument from learned counsel for the respective parties and also gone through the case file very carefully.
7. During arguments the contentions of parties are similar to the pleadings, so no need to reiterate the same. The facts of the case, in brief, are that the complainant had taken an insurance policy bearing No.4065/FICL/121737690/00/000 from OPs with sum assured of Rs.1,00,000/- valid from 20.09.2016 to 19.09.2020. The become sick and went to Apollo Hospital Amritsar for his checkup on 09.04.2017 and concerned doctor advised the complainant for admission in hospital for proper diagnose. Doctor diagnosed a lever disease after performing the various investigation/tests in the hospital and accordingly for the treatment of diagnosed disease, complainant remained admitted in the hospital upto 18.04.2017. Complainant spent an amount of Rs.77,652/- as per Ex.C-2 and Ex.C-3 during treatment at the time of admission in hospital.  Complainant lodged reimbursement of claim of Rs.77652/- and which was repudiated by OPs vide letter dated 11.10.2017.
8. The OPs argued the matter, inter alia, on the ground that while submitting the proposal form for getting the policy, the insured had not correctly stated about his state of health as at that the complainant was admitted in Apollo Hospital Amritsar as a known case of Chronic Liver Disease due to recurrent and frequent Hepatitis leading to Chronic Liver disease (CLD). The treading doctor on the date of admission of complainant with Apollo Hospital Amritsar has given certificate date 09.04.2017 to the effect that complainant presented with jaundice and protrusion of abdomen from last two months and that the complainant is known case of Chronic Liver Disease with Ascites and there is past history of recurrent and frequent Hepatitis due to Chronic Liver Disease for last two years (Alcoholic Liver Disease).  The treating doctor has also given certificate to this effect on 09.09.2017. The fact and history of liver disease of complainant is corroborated by U/s Scan whole abdomen dated 05.07.2016 by Kapoor Scanning Centre, Jalandhar and Ultra Sound study of abdomen report dated 21.01.2017 by Golden Diagnostics, Amritsar and Scan report dated 21.01.2017 of Golden Diagnostic Amritsar.  The questionnaire filled by treating doctor dated 29.09.2017 also shows that the complainant is known case of Alcoholic Liver Disease from last two years.  He had concealed the material facts regarding his health and did not disclose them in his proposal form and made fake statements deliberately and, as such, the claim was rightly rejected. 
9. The learned counsel for OPs argued that Insurance Policy was obtained by making material concealment of pre-existing disease. As such, his claim is rightly rejected as per terms and conditions of the Insurance Policy. On it, the learned counsel for complainant argued that it is wrong that complainant was having any knowledge of any such disease. The complainant never concealed any fact regarding his health from the OPs. Moreover, OPs have not produced any evidence in support of their allegations that disease of complainant was preexisting at the time of filing major revival form. The OPs only made baseless allegations without any evidence.  Further, the learned counsel for the complainant vehemently argued that since the policy terms and conditions were not supplied to the complainants, as such these terms and conditions are not binding upon the complainant and the opposite party/insurance company cannot withhold the claim unless and until it is proved on the file that the terms and conditions were duly supplied to the complainant. There is no evidence on the file to the effect that the said terms and conditions were ever supplied or brought into the knowledge of the insured at the time of insurance.
10. So far as preexisting disease is concerned, there is judgment of the Hon’ble Himachal Pradesh State Consumer Disputes Redressal Commission, Shimla “ICICI Lombard General Insurance Company Ltd. Versus Jasbir Singh”, 2014 (1) CLT 220 followed the above observations. In that case, claim was repudiated on the ground that the insured suppressed pre-existing disease of hypertension at the time of filling the proposal form. Insured medically examined by the empanelled medical officer of the insurance company before issuing the insurance policy. It was held that hypertension is a life style disease and easily controllable with conservative medicines.”.
11. Counsel for OPs reliance on CA 3397/2020, Bajaj Allianz VsDalbir Kaur, SC 2776/2006, Life Insurance Corporation of India & Ors VsSmt.Asha Goel &Anr (2001 ACJ 806, AIR 2008 SC 424, CA No.3944 of 2019 @ SLP (C) No.5001/2019.  Further, we place reliance on 2010(1) C.P.J. 77 : 2010(2) CLT 121 : 2008(52) R.C.R.(Civil) 243 and relevant portion is reproduced as Consumer Protection Act, 1986 Section 15 Life Insurance - Suppression of Material Facts - Insurance claim repudiated - Forum held that all the questions were replied correctly by the insured, but correct information was not filled up by the agent - Medical Certificate produced on record cannot be treated as conclusive evidence, as facts given by doctor were contradictory in itself – LIC and it's agents played foul with the proposer and the proposals are not scrutinised properly - Where the entries are filled by agents, policy holders should not be blamed for concealing the information - Past history of policy holder cannot be made basis for repudiation of claim, in the absence of affidavit of the certifying doctor - Order of Forum upheld - Appeal of LIC dismissed.
12. In view of our above discussion and judgment (Supra), we partly allow the present complaint and order the OPs to reimburse the complainant Rs.77,652/- as spent by him on his treatment. Further direct the OPs to pay a sum of Rs.10,000/- as consolidated amount of compensation for causing mental and physical harassment to the complainant.  The OPs have no right to keep and misappropriate the public money.  It must go back to the public.  We, therefore, order that the OPs will deposit a sum of Rs.5,000/, the estimate rough amount, with the legal aid account of this Commission.

13.     Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room its due compliance.

ANNOUNCED IN THE OPEN COMMISSION:

9^th Day of February 2021

(Kuljit Singh)

President

(Jyotsna)

               Member