PER:

Charanjit Singh, President

1        The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.

2        The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 12 and 13 against the opposite parties on the allegations that the complainant is a consumer and have sanctioned loan from the opposite party No. 1 and to receive the loan amount from opposite party No. 1 who imposed condition of Health and accidental insurance policy from the opposite party No. 2. At the time of disbursement of loan amount to the complainant, opposite party No. 1 deducted the amount of premium of health and accidental insurance of the complainant amounting to Rs.  67,948/- and directly paid to opposite party No. 2 and in that concern the opposite party No. 2 issued insurance policy No. PROHLR010106737 and LTPRAC020004463. The policies commenced from 30.12.2016 and expired on 29.12.2019 and 12.12.216 to 11.12.2019.  The opposite parties No. 1 and 2 deliberately received the premium for three years from the complainant for which they have no legal right to receive in the Health and accidental insurance policies and the opposite parties severally and jointly received the amount which is not legally chargeable from the complainant at the time of commencement of the policies to receive premium of three years instead of one year. In March, 2017 the complainant was fell down due to some accident and later on the internal back bone of the complainant was damaged and need for repairing by way of surgery was required and due to that reasons the complainant was admitted in Indian Spinal Injuries Centre, New Delhi, where the complainant was operated by the hospital of that centre and at that time the complainant requested the opposite party No. 2 for his cashless treatment but the genuine request of the complainant was not accepted by the opposite party No. 2 at that time. So the complainant paid all the necessary expenses which was approximately Rs. 4,26,398/- for his treatment to the said hospital on proper receipt and opposite parties assured at that time that after submission of the claim to the opposite parties and after receiving the approval from opposite party No. 3 the said claim shall be passed and with the assurance of opposite parties the complainant submitted his bills and documents to the opposite parties and after some time opposite parties have not reimbursed the claim of the complainant and issued a letter dated 28.9.2017 to the complainant after rejecting the claim of the complainant without reasonable cause and prayed that the opposite parties be directed to reimbursement of the medical bills of the complainant worth Rs. 4,26,398/- alongwith interest @18% p.a. from the date of submission of the claim till its realsiation and compensation of Rs. 30,000/- and litigation expenses to the tune of Rs. 22,000/- may kindly be awarded.

3        After formal admission of the complaint, notice was issued to Opposite Parties and opposite party No. 2 appeared through counsel and filed written version and contested the complaint by taking preliminary objections that  the complaint filed by the complainant is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead the commission. The complainant has suppressed material facts from this commission. Cigna TTK Health Insurance Company is a separate legal entity. It is well settled principle of law that person who fills up anything on a signed documents has status of ‘amanuensis’ only and cannot be treated as author of document. At the time of scribing (without admitting) the person who scribes(amanuensis) is treated as representative of person who has signed document and not the representative of the company, thus after signing the document the person cannot release from signed document and lead anything which is contrary to terms stated in written document. Policies under question i.e. Pro Health Protect and Lifestyle Protection was issued by the respondent company on the basis of the information provided by the Assured to the company. Since the information provided by the assured was established to be incorrect by the respondent company. It was well within its rights to reject the said claim of the complainant. Since the opposite party No. 2 has acted within the four corners of the statutory provisions, no case of deficiency in services can be said to have arisen, and as such, the present complaint is not maintainable before this commission. The complainant has tried to challenge the veracity of the decision of the opposite party company to reject the claim. The opposite party company has rejected the claim under the said policy by speaking order, which lists out the specific reasons for the decision. By no stretch of imagination the said decision can be brought under the umbrella of ‘Deficiency in Services’. The complainant should approach the Civil forms in order to challenge the veracity of the decision of the opposite party company to reject the claim. The present complaint is not maintainable. As per the terms of the policy contract, if the policy is not suitable, the policy holder may set his/her policy reviewed by returning the policy and policy documents within 15 days (Free Look Period) from the day the policy holder received the policy. The insurance company will return the premium paid to the policy holder after making certain deductions specified therein. In the present case, the policy along with the policy documents was dispatched to the policy holder and the same as duly received as admitted. The complainant after the receipt of the subject policy and policy documents did not approach the opposite party No. 2 and got his subject policy reviewed/ cancelled within free look period implying that the complainant duly accepted the subject policy and its documents with its terms and conditions. The policy holder never approached the opposite party No. 2 with any grievance pertaining to the subject policy and its terms and conditions. The complainant is bound by the policy contract and given up relinquish/ waived his right by not exercising the free look period. The complaint is devoid of any merit and is liable to be dismissed.  The opposite party No. 2 as per clause 4(1) and 6(2) of the IRDA(Protection of Policy Holder’s Interest) Regulations, 2002, sent the policies and policy documents to the policy holder giving him an opportunity to review / cancel the policy within free look period.  The repudiation of the claim under the subject policy was on the grounds of misstatement of information, suppression of material information and furnishing of false information in the proposal form. The insured i.e. Ravinder Sarpal, at the time of submitting the proposal from, did not disclose the correct information about his health and habits, as per the submitted documents/ investigation done by the company, it was found that the insured had history of Ankylosing Spondylitis and had also developed Kyhosis in the dorsal region of his spine which takes years to develop and the same were the direct cause of Anderson Lesion for which the complainant got operated which was not disclosed at the time of taking the policy. As per the policy terms and conditions the claim was rejected. These facts were also not disclosed at the time of taking the policy and the same came to the knowledge of the company only after the investigation was done. The said medical history was prior to the application for the policy which was not disclosed in the proposal form. From the stated circumstances, it is evident that the assured had given wrong information and suppressed material facts from the opposite party company in order to wrongfully obtain the subject policy from the opposite party company.   The complainant in his complaint has stated that the opposite party company collected three years premium together which is illegal. The opposite party received proposal forms for two policy bearing Nos. LTPRAC020004463 and PROHLR010106737. The details of the premiums paid towards the first year of policy year in both these polices are mentioned below:-

From the table above it is very clear that the complainant has paid the first year premiums towards the policies mentioned above. The allegation that the complainant collected three years premiums together is a wrong statement and is solely made to misguide the court and harass the opposite party. The complainant has submitted the claim under the policy stating  that the assured was operated for Anderson Lesion which is a spinal problem. As such, the opposite party has rightly rejected the claim preferred by the complainant. Insurance contracts are contracts based on “Utmost Good Faith”. As per the contract, the insurer is bound to honour the claim under the policy, provided that the assured at the time of applying for the policy, had disclosed all relevant information with regard to his health, habits, employment etc. which are the basis on which the insurer decides to cover the said person and at what rates. Since the proposer and assured did not perform their duty to disclose all material information, the contract of insurance between the opposite party and assured is a void contract. Insurance claim payouts are made from the pool of funds of many customers of the services of any insurance company. Hence, to honour an illegitimate claim, would mean doing injustice to other genuine policyholders. Hence, even entertaining the said case would be against the principles of natural justice and this would not be in the interest of customers of services of an insurance company. The assured has concealed 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 rejected. The proposer and assured had not disclosed her medical adversities at the time of availing the policy. It is the duty of the proposer/ 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. Therefore, the present claim is devoid of substance and deserves dismissal. The complaint is devoid of any material particulars and has been filed merely to harass and gain undue advantage and unjustified monies from the opposite party No. 2. Providing material information is the essential policy contract. The assured was under a bounden obligation, to disclose all material information to the opposite party No. 2 at the time of proposal.

11(1) The requirements of disclosure of “material information” regarding a proposal or policy apply, under these regulations, both to the insurer and insured.

11(3) The policyholder shall furnish all information that is sought from him by the insurer and also any other information which the insurer considers as having a bearing on the risk to enable the latter to assess properly the risk sought to be covered by a policy.

The opposite party company has been induced to issue the policy to the assured on the ground of suppression of material facts, which is otherwise necessary for the issuance of the policy. The complainant has not acted in good faith with respect to subject of this complaint and has approached the commission with unclean hands, whereas it is a settled legal preposition that “One who seeks equity must come with clean hands”. The complainant has failed to set up a nexus between the damages claimed in the present complaint and the damage suffered by him.  The compensation claimed is arbitrary, without basis and is an abuse of the process of law. The complainant had concealed and suppressed the material and relevant facts of the case. The assured fraudulently, dishonestly and by misrepresentation obtained the policy on the basis of which the complainant is seeking claim. The policy is an outcome of fraud and misrepresentation, therefore, the claim of the complainant is liable to be dismissed.  On merits, it was pleaded that the opposite party No. 2 had received an application forms requesting for the issuance of policy on the health insurance policy. Based on the information provided in the said application/ proposal forms, the company issued policy bearing No. PROHLR010106737 (ProHealth- Protect SB02) and LTPRAC020004463(Life Style Protection-Accident Care) The detail of the same are mentioned hereunder

The assured had not approached the opposite party during the Free Look Period with any grievance regarding the policies or terms and conditions, meaning thereby that the assured agreed to the terms and conditions. In the proposal form the company received from the assured the following replies:-

Right from proposal, it was always made abundantly clear to the proposer/ assured, that truthful answers to the questions in proposal form are of immense importance for accepting the insurance proposal of the assured, and the obligation of disclosing true fact continues even after the Proposal Form and on the acceptance of risk by the opposite party company.  It is clearly stated in proposal form, that in the event a reply to a question in the proposal form turns out to be false or misleading, the contract of insurance is liable to be declared null and void and also that a claim under the policy is liable to be rejected in such event. The opposite party No. 2 submits that the repudiation of the claim under the subject policy was on the grounds of misstatement of information, suppression of material information and furnishing of false information in the Proposal Form. The insured Ravinder Sarpal, at the time submitting the proposal form, did not disclose the correct information about his health and habits, as per the submitted documents/ investigation done by the company it was found that the insured had history of Ankylosing Spondylitis and had also developed Kyhosis in the dorsal region of his spine which takes years to develop and the same were the direct cause of Anderson Lesion for which the complainant got operated which was not disclosed at the time of taking policy. The medical terminology is mentioned hereunder:-

Ankylosing Spondylitis (AS) is a type of arthritis in which there is long term information of the joints of the spine. Typically the joints where the spine joins the pelvis are also affected. Occasionally other joints such as the shoulders or hips are involved. Eye and bowel problems may also occur. Back pain in a characteristic symptom of AS, and it often comes and goes stiffness of the affected joints generally worsens over time. 

The opposite party No.  2 has denied the other contents of the complaint and prayed for dismissal of the same.

4        Notice was issued to the opposite parties No. 1 and 3 and it was duly served but it opted not to come forward to contest the complaint and consequently, the opposite parties No. 1 and 3 was proceeded against ex-parte. 

5        To prove his case, Ld. counsel for the complainant has tendered in evidence affidavit of complainant Ex. C-1, copy of letter dated 28.9.2017 Ex. C-2 copy of discharge summary dated 6.7.2017 Ex. C-3, copy of bill dated 17.10.2017 Ex. C-4, copy of bill dated 6.7.2017 Ex. C-5, copy of policy schedule Ex. C-6, copy of policy schedule Ex. C-7 and closed the evidence. On the other hands,  Ld. counsel for the opposite party No. 2 has tendered in evidence, affidavit of Akhil Kumari Assistant Vice President Ex. OP2/A, copy of proposal form Ex. OP2/1, copy of the policy contract Ex OP2/2, copy of claim form Part A Ex. OP2/3, copy of OPD Card Ex. OP2/4, copy of claim denial letter dated 28.9.2017 Ex. OP2/5, affidavit of Dr. C.H. Asrani Ex. OP2/6 and closed the evidence.

6        We have heard the Ld. Counsel for the parties and have carefully gone through the record.

7        From the combined and harmonious reading of pleading and documents placed on record is going to prove that the complainant has availed the loan facility from the opposite party No. 1 who imposed the condition of health and accidental insurance of the complainant and directed the complainant to take the health and accidental insurance policy from the opposite party No. 2 and opposite party No. 2 collected the amount to the tune of Rs. 67948/- which was paid by the opposite party No. 1 for taking health and accidental insurance policy. Thereafter, the opposite party No. 2 issued insurance policies No.           PROHLR010106737 and LTPRAC020004463. The said policies commenced from 30.12.2016 to 29.12.2019 and 12.12.2016 to 11.12.2019.

8        In the month of March 2017, the complainant fell down due to some accident and later on the internal back bone of the complainant was damaged and there was need for repairing by way of surgery. For the above mentioned surgery, the complainant was admitted in Indian Spinal Injuries Centre, New Delhi where the complainant was operated and paid Rs.4,26,398/- for his treatment to the said hospital. Thereafter, the complainant submitted his claim with opposite party No. 2 but his claim was repudiated by the opposite party No.2 vide letter dated 28.9.2017 on the ground that hospitalization documents suppressed/ concealed/ misrepresent material facts about the ailment as per documentary evidence availed. Hence, the claim is not admissible under the policy condition. As per the opposite party No. 2 the repudiation of claim under the said policy was on the ground of misstatement of information, suppression of material information and furnishing of false information in the proposal form. As per opposite party No. 2 the insured i.e. Ravinder Sarpal at the time of submitting the proposal form did not disclose the correct information. In the investigation which was done by the company, it was found that the insured had history of Ankylosing Spondylitis and had also developed Kyhosis in the dorsal region of his spinal which takes years to develop and the same were the direct cause of Anderson Lesion for which the complainant got operated, which was not disclosed at the time of taking of policy.  But to prove this fact that the complainant had the history of above said disease, the opposite party No. 2 has not placed on record even a single document which shows that the complainant was having knowledge of this disease and he is taking any kind of treatment for this disease. The opposite party No. 2 has not placed on record, record of any hospital which proves that the complainant was taking the treatment for the said disease prior to the commencement of the policy. The discharge summary of the complainant i.e. Ex. C-3 of the Indian Spinal injuries centre  diagnosis: Ankylosing spondylitis with Andersson lesion D11-D-12 with paraparesis with normal bowel bladder. In the column of HOPI: Patient was apparently asymptomatic 10 days back when he  had an alleged history of fall. Following fall he started complaints of pain in left low back which was sudden in onset, sharp in nature, moderate to severe in intensity, non radiating pain, aggravated by lying down and followed by changing of posture and partially relieved by rest and medication and also associated of difficulty in walking. Now he came to India Spinal injuries centre for further management. No history of bladder and bowel involvement. And in this discharge summary in the column of past history it is written that History of hypertension from 10 days (on medication). So this discharge summary clearly proves that the complainant was not suffering from any previous disease. The said Ankylosing Spondylitis with Andersson lesion is due to fall only.

9        That complainant i.e. Ravinder Sarpal is aged about 59 years and it was bounden duty of the opposite party No. 2 to conduct the medical examination before issuance of policy. The complainant is above 45 years of age and what prevented the opposite party to conduct the detailed medical examination before the inception of policy.   Reliance in this connection has been placed upon Bajaj Allianz Life Insu.Co.Ltd. & Ors Vs. Raj Kumar III(2014) CPJ 221 (NC) wherein it was held that usually the authorized doctor of the Insurance Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. Thus the repudiation of the claim on the ground of pre existing disease was held to be invalid.

10      To support its version, the opposite party No. 2 has placed on record affidavit of Dr. C.H. Asrani DNB, MBBS as Ex. OP2/6. It is pertinent to mention here that said Dr. C.H. Asrani Ex. OP2/6. It is pertinent to mention here that said Doctor C.H.Asrani is not an ortho spine specialist. His qualification is DNB MBBS which pertains to medicine whereas he has given expert opinion regarding disease of  Ankylosing Spondylitis with Andersson lesion and he himself admitted in the para No. 4 that the medical management would be same but this being a grievous injury, hospital would have insisted on FIR/MLR under IPC 202/ Cr.Pc 39. We are of the considered view that the opposite party No. 2 has failed to prove that the complainant was suffering from any preexisting disease. Prior to inception of insurance policy and also failed to prove that the complainant was suffering from Ankylosing Spondylitis with Andersson lesion. The opposite party No. 2 has not placed on record even a single document which shows that complainant was under treatment with some hospital for the said disease.

11      Furthermore, It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of DharmendraGoel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.UshaYadav& Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.        The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

The opposite party No. 2 has rejected the genuine claim of the complainant on false ground amounts to deficiency in service and unfair trade practice.

12      In light of the above discussion, the complaint succeeds and the same is hereby allowed with costs in favour of the complainant. The opposite Party No. 2 is directed to make the insurance claim to the complainant. The complainant has been harassed by the opposite party No. 2 unnecessarily for a long time, therefore, the complainant is also entitled to Rs.15,000/- (Rs. Fifteen Thousand only) as compensation on account of harassment and mental agony and Rs 10,000/- ( Rs. Ten Thousand only) as litigation expenses. Opposite Party  No. 2 is directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation. The present complaint against the opposite parties No. 1 and 3 is dismissed. Copy of order will be supplied by District Consumer Disputes Redressal Commission, Amritsar to the parties as per rules. File be sent back to the District consumer Disputes Redressal Commission, Amritsar.

 Announced in Open Commission

14.7.2022