Haryana

Karnal

CC/191/2017

Dalbir Singh Mann - Complainant(s)

Versus

ICICI Prudential Life Insurance Company Ltd - Opp.Party(s)

Daljit Singh Mann

11 Jul 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                         Complaint No.191 of 2017

                                                         Date of instt. 02.06.2017

                                                         Date of decision:11.07.2018

 

Dalbir Singh Mann age 57 years son of Shri Kanwar Bhan resident of House no.2189, Sector-7, Urban Estate, Karnal.

                                                                                                                                                                        …….Complainant.

                                                Versus

 

1. ICICI Prudential Life Insurance Company Ltd. through its Branch Manager, Floor Shanti Colony, Mall Road, Karnal.

2. ICICI Prudential Life Insurance Company Ltd. unit no.1 & 2A, Raheja Tipco Plaza, Rani Sati Marg, Malad (East) Mumbai-400097.

 

                                                                     …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before   Shri Jagmal Singh……President.

                Shri Anil Sharma……Member

 

Present: Complainant in person.

                Shri Vikas Chauhan Advocate for opposite parties.

 

ORDER:                    

         

                   (JAGMAL SINGH, PRESIDENT)

 

                 This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant purchased a Health Insurance Policy from the OPs under the name and style of ICICI Prudential Health Saver. The complainant had deposited a premium amount of Rs.15,000/- which was to be paid by the complainant once in a year. After depositing the premium amount the OP issued a policy bearing no.12770031 dated 24.10.2009 to the complainant which is valid upto 22.10.2017. The official of the OP at the time of issuance of the policy assured that under this health policy the complainant individually is fully insured and would get the medical claim upto Rs.3 lakhs, upto the age of 75 years under this Health Insurance Policy. At the time of taking the policy complainant was healthy. On 05.01.2017 the complainant received chest pain and complainant remained admitted in Amritdhara Hospital Karnal from 5.1.2017 to 6.1.2017 and thereafter the complainant shifted to Medanta Global Health Pvt. Delhi where he remained admitted form 6.1.2017 to 8.1.2017 and has spent a sum of Rs.3,15,315/-. After discharging from the hospital, complainant approached the OPs and submitted all the relevant documents. Thereafter complainant visited the office of OPs several times and requested for reimbursement of the amount but OPs postponed the matter on one pretext or the other and lastly rejected the claim of the complainant vide letter dated 27.4.2017 on the false ground. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written statement stating therein that complainant submitted a health claim intimation on 16.1.2017 alongwith medical documents informing about his hospitalization from 5.1.2017 to 6.1.2017 in Amritdhara Hospital Karnal and thereafter the complainant shifted to Medanta Global Health Pvt. Ltd. Delhi where he remained admitted from 6.1.2017 to 8.1.2017 and submitted bills amounting to Rs.3,15,315/- towards medical expenses. The intimation of claim was received by the company on 16.1.2017 and after duly evaluating the claim, a letter rejecting the claim was sent to the complainant on 27.04.2017 i.e. within 6 months of claim intimation. The claim was rejected on the grounds that as per the policy documents, the company is not liable to pay for expenses incurred by the insured person where such expenses are in connection to a pre-existing condition. In the present two claims, for acute myocardial infraction and coronary artery disease, dysfunction, single vessel disease, hypertension they were both in connection to the complainant’s pre-existing condition of heart blockage due to which he underwent a Percutaneous Transluminal Coronary Angioplasty (“PTCA”) with stent to LCx and LAD. Hence there is direct nexus between the non-disclosure of the pre-existing condition and the subject claim. It is further stated that the assured has concealed the material facts which were necessary to be disclosed at the time of taking insurance, thereby rendering the contract of insurance void-ab-initio and inoperative, which is the reason for the claim being repudiated. It is further submitted that the assured had not disclosed his medical adversities at the time of availing the policy. It is duty of the assured at the time of availing the policy, to disclose the material information, which is essential for the purpose of underwriting, during issuance of an insurance policy. Hence there was no deficiency in service on the part of the OPs in repudiating the claim of the complainant. It is further stated that the policy documents were sent to the complainant including the policy terms and conditions and a forwarding letter stating the feelook provision alongwith copy of proposal form on 30.10.2009 and the same was duly received. The complainant had ample opportunities to go through the same and understand the terms and conditions of this subject policy. The OP had never received any freelook cancellation from the complainant which means the complainant had accepted the terms and conditions of the policy. It is further submitted that as per proposal form the complainant is a postgraduate and therefore, is educated enough to understand the policy terms and conditions. It is further submitted that the assured had concealed the material facts which were necessary to be disclosed at the time of taking insurance, thereby rendering the contract of the insurance vide abnitio and inoperative. The assured had not disclosed is medical adversities. It is further submitted that had the company prior knowledge of the aforementioned medical history of the complainant having undergone PTCA and stunt to LCx and LAD, the policy would not have been issued to the complainant by the company. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence his affidavit Ex.CA and documents Ex.C1 to Ex.C7 and closed the evidence on 25.10.2017.

4.             On the other hand, OPs tendered into evidence affidavit of Ms Tavishi Srivastava Ex.RW1/A and documents Ex.R1 to Ex.R5 and closed the evidence on 10.05.2018.

6.             We have heard the complainant and learned counsel for the OPs and perused the case file carefully and have also gone through the evidence led by the parties.

7.             From the pleadings of the parties, it is not disputed that complainant purchased the health insurance policy from the OPs, under the plan ‘ICICI PRU HEALTH SAVER, U56 and the OPs issued the policy no.12770031 dated 24.10.2009 to the complainant. The annual premium was Rs.15000/-. The complainant paid the premium amount regularly and the next due date for premium was 26.10.2017. It is not disputed that on 5.1.2017 the complainant has chest pain due to which the complainant remained admitted in Amritdhara Hospital, Karnal from 5.1.2017 to 6.1.2017 and thereafter shifted to Medanta Global Health Pvt. Ltd. Delhi, where he remained admitted from 6.1.2017 to 8.1.2017 and spent Rs.3,15,315/-. The complainant lodged the claim with the OPs and the same was repudiated by the OPs vide letter dated 27.4.2017 on the ground that the complainant had failed to disclose at the time of taking the policy that he had undergone Percutaneous Transluminal Coronary Angioplasty (“PTCA”) with stent to LCx and LAD in 2009, so the pre-existing disease.

8.             The complainant reiterated all the facts mentioned in the complaint.  The complainant argued that his claim has been wrongly repudiated by the OPs. He further argued that no doubt it is not mentioned in the complaint, but he disclosed about the disease to the agent who got signed on the blank form and the agent has not mentioned the same in the proposal form. The complainant submitted the authorities cited in IV (2006) CPJ 228 (NC) titled as New India Assurance Company Ltd. Versus Mary Jane Govias & Ors.and 2004(1) CPC (U.T. Chandigarh) titled as Daljit Singh Versus National Insurance Company Limited through its Senior Divisional Manager.

9.             On the other hand, learned counsel for OPs argued that the contention of complainant that the agent got signed on the blank proposal form is not tenable because the complainant is a post-graduate and it cannot be said that the complainant had signed on the blank proposal form. He further argued that the OPs had sent the policy document including terms and conditions to the complainant stating therein the freelook provisions alongwith copy of proposal form on 30.10.2009 and the same was duly received by the complainant. He further argued that the complainant have ample opportunities to go through the proposal form and understand the terms and conditions of the policy in question but the OPs never received any cancellation request from the complainant during the freelook period. This contention of the OP has force because as per the terms and conditions of the policy there was a freelook period but the complainant has neither pleaded that he had cancelled the policy during the freelook period nor producing any such evidence, therefore, it is clear that the complainant had agreed with the terms and conditions of the policy and he accepted the same. Moreover, the complainant is postgraduate, therefore, the above contention of the complainant that he has signed on the blank proposal form is not believable and has no force.

10.            The learned counsel for the OPs further argued that the present claims are regarding acute myocardial infraction and coronary artery disease, dysfunction, single vessel disease, hypertension, so they were in connection to the complainant’s pre-existing condition of heart blockage due to which he underwent a Percutaneous Transluminal Coronary Angioplasty (“PTCA”) with stent to LCx and LAD and the same has direct nexus between non-disclosure of pre-existing condition and the subject claim, therefore, the present claims of the complainant has been rightly repudiated. He further argued that the document Ex.R4, which was received by the OP from the complainant with the present claim, issued by Medanta Hospital clearly shows about this fact wherein it has been mentioned under the head Previous Intervention: Post PTCA+Stent to LCx & LAD (Aug 2009). It is pertinent to mention here that it is admitted case of the parties that the complainant had taken the policy on 24.10.2009 whereas the treatment of above disease was taken in August 2009. Now it is to be seen whether the complainant has disclosed about the same in the proposal form while taking the policy in question in October, 2009 and for that purpose the proposal form is necessary document which has been produced by the OPs as Ex.R1. On perusal of this document i.e. Ex.R1 it is found that clause 5.E.(x) is relevant which runs as under:-

5.E. Have you ever suffered or are suffering from any of the following:-

(x) Chest pain, palpitation, Rheumatic fever, heart, murmur, heart attack, shortness of breath or any other heart related disorder.

The complainant has answered this clause in the negative which means the complainant has not disclosed about the said treatment in the proposal form and concealed the same. Therefore, the argument of OP has force that the complainant has not disclosed the material facts regarding his pre-existing disease and suppressed the material facts while filling the proposal form at the time of taking the policy.

11.            On the query of this Forum about the applicability of the provisions of Section 45 of the Insurance Act, the learned counsel for OPs stated that as per latest finding of the Hon’ble National Commission the complainant cannot take the advantage of Section 45 of the Insurance Act and produced the authority cited in 2018(1) CLT 63 (NC) titled as Suita Goyal Versus Bajaj Allianz Life Insurance Co. Ltd. and others. The head note of which runs as under:-

        “Consumer Protection Act, 1986, Section 2(1)(g) & Insurance Act, Section 45- Insurance Claim-Proposal Form-Concealment of material facts-Insured suffering from diabetes and hypertension and also got treatment, but did not disclosed this material information in the proposal form-Health-it was, therefore, the bounden duty of the deceased to have disclosed these facts and for his failure to do so, he cannot take advantage of section 45 of Insurance Act, on the ground that the death took place after two years of obtaining the policy in question-Even after the lapse of two years of taking the policy. It was necessary to disclose information abo0ut the material facts before the insurance company-complaint dismissed.

In view of this authority of the Hon’ble National Commission the complainant was duty bound to disclose the information about the material facts including the pre-existing disease or treatment taken, if any, before the insurance company but the complainant has not do so and concealed the material facts regarding the treatment taken before the issuance of the policy in question.

12.            The learned counsel for OPs also argued that the facts regarding the disease for which the complainant had taken the treatment in the year 2009 were in the knowledge of the complainant and it was the complainant being insured who is the sole person who knows about the same and insurer have not the means to find out this material facts which was materially affect the risk but the complainant has not disclosed the material facts regarding the treatment as mentioned above. On this point the learned counsel for OPs  produced the authorities cited in 2017(4) CLT 318 (HR) titled as Life Insurance Corp. of India Versus Randhir Singh and 2015 (2) CLT page 396 (HR) titled as Rajpal Versus Birla Sun Life Insurance Company and another. Both these authorities are on the similar point and head note of the authorities cited in 2017 (4) CLT 318 (HR) runs as under:-

        “Consumer Protection Act 1986, Section 2(1)(g)-Insurance Claim-Held- the rule of non-disclosure of material facts vitiating a policy still holds the failed-the bargaining position of the parties in a contract of insurance is unequal-the insured knows all the facts, the insurer is unaware of anything which may be material to the risk-very often, it is the insured who is the sole person who has this knowledge-the insurer may not even have the means to find out facts which would materially affect the risk-the law, therefore, enjoins on the insure and absolute duty to disclose correctly all material facts which are within her personal knowledge or which he ought to have known had he made reasonable enquiries-a contract of insurance, therefore, can be repudiated for non-disclosure of material facts.”

                In view of above authorities the contention of the learned counsel for OP has force. The disease of the complainant and the treatment taken by the complainant was of such a nature that it was the complainant only who know about the same and the OP had no means to found out the same. The authorities produced by the complainant are not applicable to the facts of the present case whereas the authorities of the OPs are fully applicable to the facts of the case.

13.            The argument of complainant that he disclosed about the disease to the agent has no force because the agent has not been impleaded as party who is the only person who can tell about the same. Therefore, the complainant has failed to prove that he had disclosed about the disease to the agent.

14.            From the above facts and circumstances of the case, it is clear that the OPs have proved on the file that the complainant had underwent Post PTCA+Stent to LCx & LAD in August 2009 as this fact is clear from the document Ex.R4, issued by Medanta Global Health Pvt. Delhi hospital which was attached by the complainant with his claim papers and these material facts has been concealed and not disclosed by the complainant at the time of taking the policy. In view of the facts and circumstances of the case, we are of the considered view that the OPs have committed no mistake in repudiating the claim of the complainant. Hence we found no deficiency on the part of the OPs.

15.            Thus, as a sequel to above discussion, we do not find any merits in the complaint and the same is hereby dismissed. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:11.07.2018

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

 

                       (Anil Sharma)

                            Member