DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,
PATIALA.
Consumer Complaint No. 409 of 26.9.2016
Decided on: 2.8.2019
Satya Paul @ Sat Paul aged 65 years son of Subagh Rai, resident of House No.11-D, Ward No.2, Shiv Mandir Road, Rajpura Town, District Patiala (M.No.98143-24584).
…………...Complainant
Versus
1. Krishan Kikreja (Authorized Agent) r/o # 1663, Ward No.23, Near NTC, Rajpura Town, District Patiala (Licence No.2069952, agent No.0036986),HDFC Standard Life Insurance Co. Ltd.
2. HDFC Standard Life Insurance Company Ltd., Branch Office: HDFC, SL Chandigarh, Madhya Marg Branch, Second Floor, SCO 50-51,Sector 9-D,Near Fortis Hospital, Chandigarh.
…………Opposite Parties
Complaint under Section 12 of the
Consumer Protection Act, 1986.
QUORUM
Sh. M. P. Singh Pahwa President
Smt. Inderjeet Kaur Member
Sh. B. S.Dhaliwal Member
ARGUED BY
Sh.Dhiraj Puri , Advocate, counsel for complainant.
Complaint filed against OP No.1 not pressed.
Sh. Amit Kumar, Advocate, counsel for OP No.2.
ORDER
M. P. SINGH PAHWA,PRESIDENT
1. This is the complaint filed by Satya Paul @ Sat Paul (hereinafter referred to as the complainant) against Krishan Kukreja (Authorized agent) & HDFC Standard Life Insurance Company Ltd.(hereinafter referred to as the OPs).
2. Briefly, the case of the complainant is that OP No.1 approached him being authorized agent of OP No.2 and allured him to buy a policy ‘HDFC Life Health Insurance Plan’. He projected that under this plan, the life of the complainant and his wife shall be insured in the same premium during the period of policy if, complainant or his wife suffered any ailment. The ailment of both the insured persons shall be secured and there shall be no charges for the hospitalization to be paid by the insured and all the hospital expenses shall be paid by OP No.2 up to Rs.3lakh.
3. Believing this, complainant and his wife got filled proposal form on 4.2.2014.They paid Rs.16,226/- vide cheque.The blank proposal form was got signed from the complainant by OP No.1.The complainant and his wife were also taken to Samrita Nursing Home, Dalima Vihar Rajpura, wherein the empanelled doctor of OP No.2 Sarabjit Singh, MBBS, MD, conducted thorough check up of the complainant and his wife and reported that there is no ailment on the bodies of the complainant and his wife. Thereafter, OP No.2 issued policy No.90055165 with the option that any of the life insured in the family have the option to avail cashless service or claim the medical expenses as reimbursement in case of hospitalization.
4. It is further pleaded that unfortunately, complainant on 18.6.2015 suffered from some ailment. His family members took him to Fortis Hospital.The complainant was admitted there from 18.6.2015 to 24.6.2015.The doctors at Fortis Hospital examined the complainant and started treatment. The complainant was discharged with satisfactory condition. The total bill incurred upon the complainant in Fortis Hospital was Rs.1,90,815/-.The complainant lodged the claim with the OP alongwith complete set of documents of hospital treatment and bills for Rs.1,90,815/- for reimbursement. The OPs agreed to pass the genuine claim of the complainant vide letter dated 17.12.2014 but thereafter put off the matter on one or the other pretext. Untimely OP No.2 vide letter dated 22.6.2015 repudiated the genuine claim of the complainant on flimsy ground without any plausible cause on the ground of non disclosure of material facts. Clause No.25 does not provide any such terms and conditions and does not provide qualification through which the genuine claim of the complainant has been repudiated. The OPs have repudiated the claim without any reason/cause, which amounts to unfair trade practice and deficiency in service on their part. The complainant also suffered from mental agony pain etc.
5. It is also asserted that the complainant has never suffered from any such ailment nor hospitalized as mentioned by the doctors of Fortis Hospital. He never visited any doctor for such ailment. The doctors at Fortis Hospital have wrongly mentioned the facts on the basis of wrong diagnosis. The OPs have rejected the claim without any evidence .
6. The complainant has prayed for direction to the OPs to pay Rs.1,90,815 with interest, Rs.2,00,000/- as compensation and Rs.33000/- as litigation expenses. Hence this complaint.
7. Upon notice OP No.2 put in appearance through counsel .Notice to OP No.1 was not served. Ultimately counsel for the complainant suffered statement that he did not press claim against OP No.1.
8. OP no.2 contested the complaint by filing written reply. In reply the OP raised preliminary objections that the insured willfully and deliberately concealed the fact regarding his health condition at the time of purchase of the policy in the month of December,2014.The insured gave wrong answers to the questions of personal statement submitted at the time of submission of the policy for purchase of insurance product knowing well that these were incorrect.
9. Complainant has stated that he is in good health. He suffered ailment and his family took him Fortis Hospital on 18.6.2015. He obtained treatment on 18.6.2015 i.e. within 4-5 months from the purchase of the policy. Being the case of close proximity, claim was investigated by the OP. It was revealed that insured was not keeping good health prior to the purchase of the policy. He has not disclosed the fact regarding the medical history while taking the proposal. The insured was prejudice to the uberrima fides, which is the basis of all insurance contracts. The fact of ill health and consequent treatment was well within the knowledge of the insured. There was a willful suppression to obtain insurance policy. Had he disclosed the history of his pre existing disease, the insurance policy would not have been issued in favour of the insured. Therefore, on the strength of above facts, the competent authority of the OP repudiated the liability under the policy and conveyed to the complainant vide letter dated 22.6.2015.
10. Further preliminary objections are that the complaint is bad for non joinder and mis-joinder of parties and cause of action. The complainant has alleged that the doctor of Fortis Hospital has given wrong report regarding his pre-existing health condition and history of ailment but the complainant has not impleaded the concerned hospital as party to bring true facts before this Forum. The complainant is debarred to file the present complaint due to his own act and conduct. The complainant tried to defraud the OP and knowingly concealed the health conditions at the time of submission of the claim which clearly reveals the malafide intentions of the complainant to grab the public money. As such the policy was declared null and void under the provisions of Indian Contract Act,1872 as well as , as per the terms and conditions of the Insurance Contract. The complainant is estopped to file the instant complaint. There is no deficiency in service on the part of the OP. The insurance policy is a ‘De Novo’ contract. It is a contract of utmost good faith. The proposer is presumed to have means of knowledge, which are not assessable to the OP. Therefore, the proposer is bound to disclose everything affecting judgment of the insurer.
11. In the instance case, it being an early claim after taking policy, investigation of the case was conducted to verify genuineness of the claim. During investigation, it was revealed that the medical history was not revealed while taking the policy. The insured was not keeping good health at the time of obtaining the policy. He deliberately and intentionally gave wrong and false answers to the questions of the personal statement regarding health. Had he mentioned his true state of health while answering questions, the contract of insurance would have not been effected. The matter is to be decided by the Civil Court as full scale trial requiring the complete pleadings and evidence according to law. The summary trial under Consumer Protection Act,1986 is not proper remedy for the complainant. The complainant cannot invoke the provisions of the Consumer Protection Act.
12. On merits, the OP has controverted all the material facts and reiterated its stand as taken in the preliminary objections and detailed above.In the end the OP prayed for the dismissal of the complaint.
13. The parties were afforded opportunity to produce their evidence.
14. In support of his case, the complainant tendered into evidence his affidavit, Ex.CA, copy of premium receipt, Ex.C1, copy of proposal form, Ex.C2, copy of policy cover note, Ex.C3, copy of medical report, Ex.C4, copy of medical bills, Exs.C5,C6, copy of letter dated 17.12.2014, Ex.C7, copy of letter dated 22.6.2015, Ex.C8.
15. The OP tendered into evidence affidavit of Amit Khanna, Ex.OPA, copy of proposal form, Ex.OP1, copy of certificate, Ex.OP2, copy of illustration, Ex.OP3, copy of repudiation letter dated 22.6.2015, Ex.OP4.
16. We have heard the ld. counsel for the parties and also gone through the record of the case carefully.
17. The ld. counsel for the complainant has submitted that the material facts are not in dispute. It is not disputed that the complainant and his wife were insured by OP No.2 for the period from 22.12.2014.The complainant suffered from some ailment and took treatment w.e.f.18.6.2015 to 24.6.2015 and spent Rs.1,90,815/- . The complainant lodged the claim with the OP but the OP repudiated the claim vide letter dated 22.6.2015,Ex.C8. The ground to justify repudiation is mentioned that the complainant was suffering from diabetes and hypertension since two years and it was not disclosed to the company in the proposal form. The treatment taken was for high grade fever and not for diabetes or hypertension. Therefore, the repudiation on this ground was not sustainable. It amounts to deficiency in service and unfair trade practice.
18. It is further submitted by the ld. counsel for the complainant that even otherwise also the OP has not produced any evidence to prove that the complainant was suffering from hypertension and diabetes and he was taking treatment for this disease. In the absence of any evidence to prove this fact, the repudiation of claim is not justified. In support of these submissioin, the ld. counsel for the complainant has cited 2019(2)CLT 270 Neelam Chopra Versus LIC of India and others and II(2019)CPJ 59 Virpal Nagar versus HDFC Standard Life Insurance Company Ltd. .
19. On the other hand, the ld. counsel for the OP has submitted that the contract of insurance is based on good faith. The insured is required to disclose all the facts which are in his knowledge. Copy of the proposal form submitted by the complainant at the time of availing insurance is on the file as Ex.OP1.The complainant was required to answer certain questions regarding his health. Complainant was also asked if, he has suffered from High Blood pressure, diabetes and cancer. The categorical answer to these question was in negative. In support of the complaint, the complainant himself has produced on record copy of discharge summary, Ex.C4.The diagnosis is Type-2 Diabetes Mellitus. In the past history as got recorded by the complainant, he was known case of Type-2 diabetes and hypertension for 2-3 years. This history was recorded at Fortis Hospital only on the instance of the complainant. Complainant cannot impugne its correctness. Therefore, it is proved from the admission of the complainant that he was suffering from Type-2 diabetes and hypertension from 2-3 years. This information was given to the hospital on 18 June,2015.The policy was availed from the year 2014. Therefore, it is proved that the complainant was in the knowledge of pre-existing disease of Type-2 diabetes and hypertension. Despite this fact, complainant has suppressed this disease from the OP . Had the complainant disclosed this disease, the OP was having option to accept the proposal or to deny the same or accept the same under some special terms and conditions. In these circumstances, the OP No.2 was justified to repudiate the claim.
To support these submissions, the ld. counsel for the OP has cited 2018(1)C.P.R. 167 Allaudin Alias Ajauddin Versus Kotal Mahindra Old Life Insurance , 2008(1) ALL MR 408 P.C.Chacko and another versus Chairman, Life Insurance Corporation of India, 2017(3)CLT 511 Siddhant Khare Versus Branch manager, SBI Life Insurance Co. Ltd., 2018(3)ALL MR 19 Prashan Dattarya Patre Versus SBI Life Insurance Co.Ltd. 2018(2)C.P.J.204 Charanjit Singh Versus Life Insurance Corporation of India and 2013(3)C.P.J. 650 Rajesh Sharma Vs. Life Insurance Corporation of India.
20. We have given careful consideration to the rival submission and the case law.
21. The admitted facts are that the complainant and his wife got insurance regarding their health from the OP. The covered period was from 22.12.2014.The complainant suffered from some ailment and took treatment from Fortis Hospital from 18.6.2015 to 24.6.2015, which is within covered period and complainant spent sum of Rs.1,90,815/- for this treatment. The OP has repudiated the claim vide letter dated 12.6.2015,Ex.C8. The ground for repudiation as mentioned in this letter is that the complainant was suffering from diabetes and hypertension since two years and it was not disclosed to the company in the proposal form dated 9.12.2014.Therefore, the OP also declared the policy null and void as per clause 25 of the policy terms and conditions.
22. Therefore, the point for determination is that whether the OP was justified to repudiate the claim on the ground that the complainant was suffering from diabetes and hypertension.
23. In the case of Virpal Nagar Versus HDFC Standard Life Insurance Co. Ltd.(Supra) , the Hon’ble Delhi State Commission after taking note of various authorities of Hon’ble National Commission and Hon’ble Supreme Court has drawn 10 conclusions in paragraph 9 of the judgment regarding meaning and import of word disease, pre-existing disease in reference to medical insurance policy. Following is one of 10 conclusions:
(c) Malaise of hypertension , diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in or out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease”.
24. The discharge summary, Ex.C4 is also relevant to decide the controversy. The relevant part of discharge summary is as under:
PRESENT ILLNESS
Patient admitted with h/o high grade fever associated with rigors and chills alongwith puffiness over the face for the last 4-5 days. Initially he was taken to Dashmesh Hospital, Rajpura then brought to FHM for further evaluation and management. H/O drowsiness since 1 day.
PAST HIISTORY
K/C/O Type-2 Diabetes Mellitus x 2 years K/C/O Hypertension x 2-3 yrs.
25. A perusal of this discharge history also reveals that the complainant took treatment for suffering from ‘high grade fever’ and not for hypertension or diabetes. The OP has also not collected any evidence to prove that the complainant was taking any treatment for hypertension or diabetes. The only evidence relied upon by the OP is reference of hypertension and diabetes in the discharge summary.In these circumstances it can also be concluded that the OP has failed to establish that the complainant was suffering from diabetes and hypertension.
The net conclusion is that the repudiation of the claim is not sustainable and amounts to deficiency in service on the part of the OP No.2.
24. For the reasons recorded above, the complaint is partly accepted with Rs.10,000/-as costs to be paid to the complainant by OP No.2. The OP No.2 is further directed to pay the amount of Rs.1,90,815/- alongwith interest @9% per annum from the date of repudiation i.e. 22.6.2015 till its realization.
Order be complied by OP No.2 within a period of 45 days from the date of the receipt of the certified copies of this order. Certified copies of this order be sent to the parties free of cost under the Rules. Thereafter, file be indexed and consigned to the Record Room.
ANNOUNCED
DATED:2.8.2019
B.S.Dhaliwal Inderjeet Kaur M. P. Singh Pahwa
Member Member President
