BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 48 of 2018
Date of Institution : 01.02.2018
Date of Decision : 07.08.2019
Nisha Bansal wife of Shri Bharat Bansal, resident of C/o Shyam Sunder Bansal & Sons Hisar Road, Sirsa, District Sirsa (Haryana).
……Complainant.
Versus.
- ICICI Lombard Healthcare, ICICI Bank Tower, Plot No.12, Financial District, Nankarm Guda, Gahibodwli, Hyderabad- 500 032, through its Manager/ Authorized signatory.
- ICICI Lombard General Insurance Co. Ltd., Parshu Ram Chowk, Ambala Cantt.
- ICICI Lombard Healthcare, Office No.78, 5th Floor, Metro Police Mall, Opp. Vidyuat Sadan, Near Sun City, Delhi Road, Hisar, through its Manager.
- Hemant Jain, Agent, ICICI Lombard Healthcare, resident of Dr. Inderjeet Street, Opp. Hathi Park, Sirsa, Tehsil and District Sirsa.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA………………. ……PRESIDENT.
SH. ISSAM SINGH SAGWAL……..MEMBER
MRS. SUKHDEEP KAUR……………..MEMBER.
Argued by: Sh. JBL Garg, Advocate for the complainant.
Sh. H.S. Raghav, Advocate for opposite parties No.1 to 3.
Opposite party no.4 exparte.
ORDER
The case of the complainant, in brief, is that complainant had purchased health insurance policy from ops no. 1 to 3 through op no.4 agent for the period 3.12.2014 to 2.12.2016 and lastly she had purchased the said health policy bearing No.4128/HSM/97012846/01/000 for the period 27.12.2016 to 26.12.2018 and paid a sum of Rs.30,000/- as insurance premium. It is further averred that complainant developed heavy bleeding P/V and for that she had been taken to Medanta The Medicity, Gurugram, where she remained admitted as an indoor patient w.e.f. 18.4.2017 to 22.4.2017 and underwent surgical operation her uterus. A sum of Rs.four lacs was incurred by the complainant on her said treatment. It is further averred that doctors of aforesaid hospital have taken the sample of Adrenal vein, report of which is still awaited. That the complainant lodged her claim for the above amount with the ops and supplied all the required and relevant documents, medical tests reports and bills etc. and thereby extended her full cooperation in settlement of her claim. However, to the dismay of the complainant, her claim has been rejected by the ops vide letter dated 17.7.2017 which was received by the complainant on 25.11.2017 on the ground that she has not declared or disclosed the material facts and has acted in breach of the terms and conditions as provided in the proposal form and the policy. During the process of the authorization request No.110100310690 for admission at Medanta The Medcity, Global Health Pvt. Ltd. on 11.4.2017, they came to know that as per the Pre-operative evaluation from the insured Nisha Bansal, she is known case of hyper tension but the same was not disclosed during the policy incepetion i.e. on 3.12.2014. It is further averred that ground/ excuse taken for the repudiation of the claim of complainant is out of scope of terms and conditions of the insurance policy and the same has also no relevance with the disease of the complainant upon which she incurred the aforesaid amount. Therefore, the aforesaid repudiation letter is liable to be ignored and set aside. It is further averred that it may be possible that she may undergo another surgical operation, for which she reserves her right to lodge additional claim with the ops. That the health policy is effective up to 26.12.2018 and she apprehends that the ops in order to wriggle out from their liability to indemnify the complainant may adopt some illegal procedure and process and thereby to cancel the policy and if the ops indulge in such illegal and unlawful activity, then the same would amount to unfair trade practice, for which she reserves her right to prosecute the ops before the competent court of law. It is further averred that complainant approached the ops and requested them to admit her claim and to make payment of the claim amount but the ops did not pay any heed to the same. Ultimately, the complainant got served a legal notice upon the ops on 6.12.2017, but to no effect. Hence, this complaint.
2. On notice, opposite parties no 1 to 3 appeared and filed written statement taking certain preliminary objections. It is submitted that complaint is not maintainable and is liable to be dismissed as there is no deficiency in service on the part of ops in terminating the claim and same was intimated to her vide termination letter dated 17.7.2017 on the ground that the insured Nisha Bnsal is known case of hyper tension, but the same was not disclosed during the policy inception i.e. on 3.12.2014 and due to this hyper tension disease, the insured is consuming amlodepin 5mg tablet on regular basis, which contains many type of side effects. It is further submitted that contents of the termination letter may be considered part and parcel of this written statement. It is further submitted that the claim in question is pre mature in nature as the medical report is still pending, due to this reason many important facts are left behind for rightly disposal of the present complaint. The complainant never supplied the required documents and concealed the true and material facts and regarding this, the insurance company issued letter to provide all relevant documents. The complainant concealed the facts at the time of purchase of health policy, hence the policy in question was terminated due to breach of terms and conditions of the policy and same was intimated to the claimant vide termination letter dated 17.7.2017. Remaining contents of complaint are denied and prayer for dismissal of complaint made.
3. Opposite party no.4 failed to appear despite service and was proceeded against exparte.
4. The parties then led their respective evidence.
5. We have heard learned counsel for the parties and have perused the case file carefully.
6. Learned counsel for complainant has contended that it is proved on record that complainant had purchased health insurance policy from ops no.1 to 3 for the period 3.12.2014 to 2.12.2016 and then she had purchased the said health policy bearing No.4128/HSM/97012846/01/000 for the period 27.12.2016 to 26.12.2018. During the period of this policy, complainant developed heavy bleeding P/V and she was taken to Medanta The Medicity Hospital, Gurugram where she remained admitted as an indoor patient from 18.4.2017 to 22.4.2017 and underwent surgical operation of uterus and a sum of Rs.four lacs was spent by her on her treatment. The claim was lodged with the ops but same was rejected on the ground that at the time of filing proposal form, complainant has not declared or disclosed her pre-existing disease of hyper tension. The ops have wrongly repudiated the claim of complainant. Hyper tension is not a disease as per law laid down by the Hon’ble Supreme Court. Moreover, before issuance of the policy, the insurance company always prefer to get proposed insured medically examined from their panel doctors and thereafter they accept the proposal and issue the insurance policy. The ops have not placed on record any affidavit of officials of the ops nor they have furnished affidavit of any doctor/ expert who have examined the medical record of the complainant and concluded that complainant was suffering from pre-existing disease of hyper tension. It has also been contended that the ops even have not placed on record affidavit of the alleged attending doctor who declared that complainant was having a pre existing disease of hyper tension. The alleged disease of hyper tension has no relation with the present disease of heavy bleeding P/V for which she underwent surgery and the order of repudiation is liable to be set aside. He has relied upon judgments of the Hon’ble National Commission in case titled as Birla Sun Life Insurance Co. Ltd. and others vs. Gudela Siva, 2019 (1) CLT 90, LIC of India vs. Reena Nanda, RP No.1782 of 2018 decided on 20.7.2018 and decision of our own State Commission, Haryana in case titled as Rajinder Singh vs. The New India Assurance Co. Ltd. and others, 2018 (3) CLT 187.
7. On the other hand, learned counsel for ops has strongly contended that complainant was suffering from hyper tension since long and by concealing this fact, she submitted her proposal to the insurance company and succeeded in getting the insurance policy by making misrepresentation qua her pre-existing disease. As per terms and conditions of the insurance policy, it falls within the exclusion clause and the policy issued by the insurance company is void abinitio. The insurance company is not bound to honor the claim of the complainant. It has also been contended that claim of complainant was rightly repudiated and moreover, the policy of the complainant was also terminated and due notice was given to the complainant. As per discharge summary as well as medical record of Medanta Hospital, it is apparently clear that complainant was suffering from the disease of hyper tension from the last so many years and she was taking Amlodepin 5mg tablet, as a result of which she developed certain other diseases. The complaint of complainant is not maintainable and same is liable to be dismissed.
8. We have considered the rival contentions of learned counsel for the parties and have gone through the record as well as judgments relied upon by learned counsel for complainant.
9. The perusal of the record reveals that complainant in order to prove her complaint has furnished her affidavit Ex.C1 in which she has deposed and reiterated all the averments made in the complaint. She has specifically deposed qua the issuance of the insurance policies from time to time and further deposed qua her disease of heavy bleeding Primary Aldoiteronism for which she went to Medanta Hospital, Gurugram where she was admitted and remained there from 18.4.2017 to 22.4.2017 and she underwent surgery and spent money from own pocket. She has also tendered copy of letter dated 25.7.2017 Ex.C2, copy of termination notice dated 17.7.2017 Ex.C3, copy of prescription slip Ex.C4, copy of policy certificate Ex.C5, copy of premium certificate Ex.C6, copy of health care card Ex.C7, copy of policy certificate Ex.C8, copy of tax certificate Ex.C9, copy of health care card Ex.C10, copies of medical record, bills, receipts Ex.C11 to Ex.C15, copy of discharge summary Ex.C16, copies of medical record and bills etc. Ex.C17 to Ex.C26, copy of legal notice Ex.C27 and postal receipts Ex.C28.
10. On the other hand, ops have tendered document Ex.R1 i.e. copy of prescription slip of Bansal Hospital, Sirsa dated 19.1.2017 and closed their evidence.
11. Undisputedly, the complainant had purchased health insurance policy from ops no.1 to 3 through op no.4 for the period 3.12.2014 to 2.12.2016 and then she purchased the said health policy bearing No.4128/HSM/97012846/01/000 for the period 27.12.2016 to 26.12.2018. It is admitted fact on record that she was suffering from heavy bleeding and Primary Aldoiteronism as a result of which she remained admitted in Medanta Hospital, Gurugram from 18.4.2017 to 22.4.2017 and spent more than two lacs rupees on her treatment. The claim was lodged by complainant with the ops and same was repudiated on the ground that she was having a pre existing disease of hyper tension from the last so many years and this fact has been concealed by the complainant while furnishing her declaration at the time of getting policy.
12. Though, during the course of arguments, learned counsel for ops has strongly insisted that since the complainant had concealed this fact while furnishing the declaration qua her pre existing disease of hyper tension, as a result of which the claim was repudiated and policy was terminated but perusal of the evidence of ops reveals that ops have only tendered document Ex.R1 and closed their evidence. The ops have not furnished affidavit of any of their officials in order to prove their plea that complainant was having a pre existing disease of hyper tension nor the ops have furnished affidavit of any medical expert of their TPA who inspected the medical record of the complainant and formed their opinion that complainant was having a pre existing disease in order to repudiate the claim of the complainant. Further, the ops have also not furnished affidavit of any attending doctor who ever treated the complainant qua her alleged pre existing disease of hyper tension.
13. As per record of the Medanta Hospital, she had undergone a surgery for removal of adrenal as she was facing problem of high bleeding and PV when she approached the Medanta Hospital for treatment. The medical record of the Medanta Hospital reveals that the doctor has not given any opinion that this disease which she was suffering developed due to any alleged disease of hyper tension. So, it appears that there is no close proximity of the disease of hyper tension with the disease of adrenal in uterus.
14. Though, the ops have alleged that they have terminated the policy but however record reveals that they have only served a show cause notice to the complainant in order to explain her position why she has concealed this fact of pre existing disease and also policy should not be terminated but the ops have not placed on record any order of termination and moreover had the policy been terminated, then natural justice demands that ops should have refunded the premium of the proportionate amount taking into consideration the validity period of the policy. So it appears from the evidence of the ops that they have no legs to stand and they have not led any cogent and convincing evidence in order to prove their defence plea. They have arbitrarily and illegally repudiated the claim of the complainant.
15. In view of 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 after considering the medical bills of the hospital as well as medicines within a period of 45 days from the date of receipt of copy of this order, failing which the complainant will be entitled to interest @7% per annum on the claim/ payable amount from the date of order till actual payment. We further 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. Member Member President,
Dated:07.08.2019. District Consumer Disputes
Redressal Forum, Sirsa.
