Punjab

StateCommission

A/798/2017

Future Generali India Insurance Company - Complainant(s)

Versus

Inderjit Singh - Opp.Party(s)

Rajesh K. Sharma

19 Apr 2018

ORDER

2^Nd ADDITIONAL BENCH

STATE  CONSUMER  DISPUTES  REDRESSAL COMMISSION, PUNJAB, CHANDIGARH.

 

First Appeal No.798 of 2017

 

                                                          Date of Institution: 27.11.2017

                                                          Order Reserved    : 10.04.2018

                                                         Date of Decision :   19.04.2018

 

1.      Future Generali Health Insurance Company, Divisional Office 3^rd        Floor, SCO No.5 and 6, Puda Complex, Court Road, Jalandhar,          Punjab through its Divisional Manager.

 

2.      Future Generali Health Insurance Company, Divisional Office    Eminent Mall, Suitehri Road, Hoshairpur through its Divisional        Manager.

 

          Both the appellants through authorized officer Sh.Tarun Kumar,          Assistant Manager (TP Claims), Future Generali India Insurance      Company Limited, 3^rd Floor, Kailash Building, Kasturba Gandhi Marg,          New Delhi.

 

                                                                       ……Appellants/OPs No.1&2

Versus

          Inderjit Singh son of Avtar Singh age 40 years resident of Mohalla      Tibba Sahib, H.No.698, Street No.4, Hoshiarpur.

                                                                 ……Respondent/Complainant

         

First Appeal against order dated 24.08.2017 passed by the District Consumer Disputes Redressal Forum, Hoshiarpur.

 

Quorum:-

          Shri Gurcharan Singh Saran, Presiding Judicial Member

          Shri Rajinder Kumar Goyal, Member

 

Present:-

          For the appellants        :         Sh. R.K. Sharma, Advocate

          For the respondent      :         Sh. P.S. Kanwar, Advocate

 

RAJINDER KUMAR GOYAL, MEMBER

ORDER

                   The appellants/opposite party No.1&2 (hereinafter referred to as Ops) have filed the present appeal against the order dated  24.08.2017 passed in Consumer Complaint No.18 of 2017 by District Consumer Disputes Redressal Forum,  Hoshiarpur (hereinafter referred to as ‘District Forum’), vide which the complaint filed by the complainant was partly accepted and Ops were directed to pay the amount spent on the treatment and medicines amounting to Rs.2,00,000/-. They were further directed to pay compensation to  the complainant to the tune of Rs.7000/- and litigation expenses of Rs.3000/-.

2.                Complaint was filed by the respondent/complainant (hereinafter referred as complainant) under Consumer Protection Act, 1986 (in short, "the Act") against the OPs on the averment that the complainant purchased a future Health Suraksha Family Floater Insurance Policy No.2016-HO16172-FHF for a sum assured of Rs.3,00,000/- covering complainant, his wife and his minor son for the period 11.04.2016 to 10.04.2017 and paid a premium of Rs.8365/-.  The complainant had also purchased the policy from the Ops for the previous year.  The complainant suddenly fell ill and was hospitalized in Mannat Super Specialty Hospital, Jalandhar from 07.11.2016 to 09.11.2016 and after that he was referred to Dayanand Medical College and Hospital Ludhiana where he remained admitted from 11.06.2016 to 26.11.2016 as Indoor patient for treatment of Jaundice. An intimation about hospitalization was sent to the Ops.  A sum of Rs.2,00,000/- was spent on the treatment and medicines during the above said period.  After discharge from DMC & Hospital Ludhiana the complainant lodged the claim with the Ops.  The Ops repudiated the same on flimsy grounds.  Alleging deficiency in service the complainant filed the complaint in the District Forum with the prayer to direct the Ops to pay a claim of Rs.2,00,000/- and to pay Rs.20,000/- as litigation expenses and Rs.15,000/- as charges for harassment of the complainant by the OP.  

3.       Upon notice, both the Ops appeared and filed their joint written reply whereby taking preliminary objections that the OP-Insurance Company has repudiated the claim vide letter dated 21.12.2016 i.e. much before to the filing of the present complaint.  As such, the present complaint is not maintainable in the eyes of law and deserved to be dismissed.  The complaint is bad for non-joinder of necessary parties; The complainant got treatment from Mannant Super Specialty Hospital Jalandhar and DMC Ludhiana, hence, the said hospitals are necessary parties and that intricate questions of law and facts are involved which require lengthy full scale trial recording of evidence of numerous witnesses, therefore, the matter be referred to the Civil Court.  On merits, it was admitted that the complainant purchased the insurance policy and remained admitted in Mannant Super Specialty Hospital and DMC Ludhiana.  As per treatment record of Mannat Super Specialty Hospital Jalandhar the complainant had undergone upper GI Endoscopy which revealed Duodenal Ulcers and Moderate Ascites in Polyis with features consistent with alcoholic liver whereas as per record of the DMC Ludhiana the complainant was hospitalized from 07.08.2007 to 12.09.2007 as a patient of cronic alcoholic Pancreatitis with Acute Exacerbation Grade E with Necrosis with Speticemia with Bilateral Pleural Effusion with Ascites Hepatitis with G6PD and form 11.11.2016 to 26.11.2016 with the complaint to Yelloish of eyes and urine since 8 days which also consistent with decompensated liver and from 23.01.2008 to 24.01.2008 for recurrent pancreatitis with common bile duct stenosis which are hospitalization for consistent with alcoholic Liver cirrhosis, hence the claim was repudiated as policy exclusion clause III.12 & III.2. A query letter dated 12.11.2016 was written by the OP insurance company to Dayanand Medical College & Hospital, Ludhiana for clarification of following points;

1. Cause of Cirrhosis & ulcer in this case?
2. All consultation papers for consultation and treatment taken for the condition till date.
3. Whether the injury/trauma/disease directly or indirectly caused under the influence of alcohol or intoxicating drugs.

          As reply from the Dayanand Medical College & Hospital Ludhiana was unsatisfactory, hence the claim was under verification, therefore, the cashless facility was denied. The remaining contents of the complaint were denied and lastly prayed that the complaint of the complainant is without merit and the same be dismissed.

4.                 In order to prove his case, the complainant himself tendered into evidence his duly sworn affidavit Ex.C1, insurance policy Ex.C2, repudiation letter Ex.C3, discharge summary Ex.C4, Adhaar Card Mark C5, copies of bills Mark C6 to Mark C60 and then closed the evidence. In rebuttal, counsel for the Ops tendered into evidence affidavit of Amit Yadav Ex.Ops-1 and some documents Mark Ops-2 to Mark Ops-5 and evidence of the Ops was closed by order.  

5.                After going through the allegations as alleged in the complaint, written version filed by Ops, evidence and documents brought on record the complaint filed by the complainant was partly accepted as referred above.

6.                Aggrieved with the order passed by the learned District Forum the appellants/Ops No.1&2 have filed the present appeal.

7.                We have heard the learned counsel for the parties and have perused the record carefully.

8.                Counsel for the appellants/Ops argued that the District Forum wrongly interpreted the documents and directed the appellants-Insurance Company to pay the claim of the complainant.  As per treatment record of Mannat Super Specialty Hospital, Jalandhar, the complainant had undergone Upper GI endoscopy which revealed Duodenal Ulcers and Moderate Ascites in Pelvis with other features consistent with Alcoholic liver, whereas as per the record of Dayanand Medical College & Hospital, Ludhiana the complainant/respondent was hospitalized from 07-08-2007 to 12-09-2007 as a patient of Chronic Alcoholic Pancreatitis with Acute Exacerbation Grade E with Necrosis with Septicemia with Bilateral Pleural Effusion with Ascites Hepatitis with G6PD.  As such, the complainant/respondent was suffering from pre-existing disease prior to the inception of policy.  It was clearly mentioned in the Hospital Treatment Record that respondent/complainant was hospitalized from 07-08-2007 to 120-09-2007 as a patient of Chronic Alcoholic Pancreatitis with Acute Exacerbation Grade E with Necrosis with Septicemia with Bilateral Pleural Effusion with Septicemia with Bilateral Pleural Effusion with Ascites Hepatitis with G6PD and and from 23.01.2008 to 24.01.2008 for Recurrent  Pancreatitis with Common Bile Duct Stenosis which are hospitalization for consistent with Alcoholic Liver Cirrhosis. Once it has been proved that the respondent/complainant had concealed material information with regard to his health at the time of proposal of the policy then the natural consequences should follow.  There has to be strict interpretation of the terms and conditions of the insurance policy.  The insurance contracts are based upon principle of ‘Uberrima fides’ i.e. of utmost good faith.  If any party fails to observe this utmost good faith principle, the contract may be avoided at the instance of other parts.  The District Consumer Forum has also failed to appreciate that the appellants-Insurance Company has rightly repudiated the claim of the respondent/complainant. As per the Exclusion III. 2 which is reproduced as below:-

          “Without derogation from the above point No.(1), any medical expenses incurred during the first two consecutive annual periods during which you have the benefit of the health Insurance Policy with us in connection with cataracts, bemgign prostatic hypertrophy, hernia of all types, hydrocele, all types of sinuses, fistulae, hemorrhoids, fissure in ano, dysfunctional uterine bleeding, fibromyoma endometrosis, hysterectomy, all internal or external tumors/cysts/nodules/polyps or any kind including breast lumps, surgery for prolapsed inter vertebral disc unless arising from accident, surgery of varicose veins and varicose ulcers”.

                   So any Medical Expenses incurred during the first two consecutive annual Periods were not payable for the treatment taken by the respondent/complainant. The present claim was lodged by the respondent/complainant during the first year of the coverage under the policy.  Counsel for the appellants prayed that appeal be accepted and dismiss the complaint.

9.                Counsel for the complainant argued that the hospitalization of the complainant in Mannat Super Specialty Hospital, Jalandhar from 07.01.2016 to 09.11.2016 and then in DMC & H Ludhiana from 11.11.2016 to 26.11.2016, where the complainant was treated for Liver disease is after the inception of the Insurance Policy.  There is no evidence on record that the complainant has taken the treatment for liver disease prior to the inception of the policy.  Therefore, there is a deficiency in service on the party of the opposite parties/appellants and prayed for dismissal of the appeal.

10.              From the above it is evident that the claim was repudiated by the Ops as per repudiation letter Ex.C-3 below wherein it was stated

          “On scrutiny of claim documents, it is observed that patient’s hospitalization is for the treatment of Chronic Liver Disease, Cirrhosis/Portal Hypertension/Ascites.  As per the policy terms and conditions, expenses incurred towards treatment of illness/disease/condition arising out of alcohol use/misuse or abuse of alcohol is not payable.  Hence claim stands repudiated under Exclusions III-12.

It is observed that the duration of current illness (Chronic Liver Disease, Cirrhosis/Portal Hypertension/Ascites) is prior to date of inception of health Insurance Policy (11^th April 2014). Since the current illness is preexisting and this is the first year of continuous mediclaim coverage, the claim stands repudiated as per policy Exclusions III-1.

It is observed that the Chronic Liver Disease, Cirrhosis/Portal Hypertension/Ascites is pre-existing & same was not disclosed in the proposal form at the time of policy inception, hence the claims stands repudiated”.                  

 

          From the above it was admitted that the date of the inception of the Health Insurance Policy is 11.04.2014 whereas the complainant remained admitted/hospitalized in the Mannat Super Specialty Hospital Jalandhar from 07.11.2016 to 09.11.2016 and further in DMC Hospital Ludhiana from 11.11.2016 to 26.11.2016 i.e. very well after the inception of the Insurance Policy.  Neither the Insurance Company/OP placed any document  to evident any pre-existing disease of the complainant before inception of the Policy in the District Forum nor the OP has presented any application for placing additional evidence on record  before  this Commission to prove any pre-existing disease before inception  of the policy. As such, simple documents on the record cannot be read in evidence.  We are further fortified by a judgment of the Hon’ble National Commission cited in 2015 (3) CPR 697 titled as “New India Assurance Co. Ltd. V. B.Y.Srikanta”, wherein the insurance company failed to show any iota of evidence to show that the complainant is having a pre-existing disease”. It was not agreed by the counsel for the appellant that the cost falls under any other exclusion clause.

11.              No other point was argued by the counsel for the parties.

12.              Sequel to the above, we are of the opinion that there is no merit in the appeal and the order of the District Forum is upheld.

13.              The appellant had deposited an amount of Rs.25,000/- with this Commission at the time of filing of the appeal.  This amount along with interest accrued thereon, if any, be remitted to the concerned District Forum, after the expiry of 45 days, from the dispatch of the certified copy of the order to the parties; subject to stay, if any, by the higher Fora/Court for release of the above amounts and the District Forum may pass the appropriate order in this regard.

14.              The appeal could not be decided within the statutory period due to heavy pendency of the Court cases.

 

 

                                                                (Gurcharan Singh Saran)

                                                                 PRESIDING JUDICIAL MEMBER

 

 

                                                                  

                                                                  (Rajinder Kumar Goyal)

                                                                                    MEMBER

April, 19     2018

PK/-