Chandigarh

DF-I

CC/132/2019

Dr Mahesh Ch Rai Prajapati - Complainant(s)

Versus

Life Insurance Corporation - Opp.Party(s)

S.S. Pathania

15 Dec 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/132/2019
Date of Institution	:	01/03/2019
Date of Decision	:	15.12.2022

 

Dr. Mahesh Ch Rai Prajapati aged 48 years son of Sh. Lalsa Prajapati, resident of House No.3923, Sector 22-D, Chandigarh (UT).

… Complainant

V E R S U S

1.   Life Insurance Corporation, Division office, Jeevan parkash Building, Sector 17-B, Chandigarh (UT) – 160017 through its Sr. Divisional Manager.

2.   M/s Genins India Insurance TPA Limited 6-A, Friends colony, Janpath, Lal Kothi, jaipur 302015.

3.   Sh. Subhash Chander Maurya, agent Code 03802163, Branch Code: 163, Resident of House NO. 6-B, Sainik Apartment, near M C Park Lohgarh, Zirakpur, District SAS Nagar Mohali 140603.

.  … Opposite Party

 

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR SURESH KUMAR SARDANA	MEMBER MEMBER

                        

ARGUED BY		Sh. Sumit Guleria vice counsel for Sh. S.S. Pathania, Counsel for the complainant.
		Sh. Piyush Sharma, Counsel for OP No.1
		Sh. Sudhir Gupta, Counsel for OP No.2 (OP No.2 already exparte)
		Opposite Party No.3 exparte.

Per Suresh Kumar Sardana, Member

1. Succinctly put, the complainant had taken LIC’s Jeevan Arogya Policy vide policy Annexure C-1 covering the complainant and his family i.e. wife and son for insurance cover of Rs.2.00 lakh. The annual premium of the policy was Rs.13,010/- which the complainant was paying regularly. On 17.3.2018 to 31.3.2018 the complainant was admitted in Forties Hospital with the complaint of chest heaviness, whereas various tests were conducted and he was diagnosed and treated for CAD ACS (Extensive AWAMI), Cardiogenic Shock with acute LVF with severe LV systolic dysfunction  SVD; post PCTA+stent to LAD Sepsis and Diabetes Millitus Type-2.  The copy of discharge summary is attached as Annexure C-6.  The hospital raised bill of Rs.13,79,814.23 vide Annexure C-7. The complainant approached Opposite Party No.3 for reimbursement of the insured sum of Rs.2.00 lakh  as per policy and submitted all the requisite documents alongwith claim form Annexure C-8. A claim reimbursement letter dated 13.4.2018 was received by the complainant asking for supply of certain non-existing and documents already supplied. The complainant vide letter dated 1.5.2018 intimated the OPs that he was not aware  about the diabetes and he was not taking any treatment or medicine for the same and it was only when the complainant was admitted in forties hospital investigation showed diabetes and treatment was started. It was further intimated that the documents requisitioned has already been supplied alongwith claim form. Despite that the Opposite Parties vide various communications time and again sought same documents and information from the complainant, which were duly replied.  Ultimately the complainant through RTI information supplied vide  Annexure C-20 came to know that the claim of the policy is pending with Opposite Party No.1 in the absence of original treatment record. The complainant served legal notice dated 15.1.2019 upon the Opposite Parties which was replied by Opposite Party No.1. It is alleged that the OPs are not passing the genuine claim of the complainant on flimsy grounds of firstly demanding those documents which are not existing and then on pretext of non-readability of the record.       Alleging the aforesaid acts of the Opposite Parties deficiency in service this complaint has been filed. 
2. In its written statement Opposite Party No.1 while admitting the factual matrix of the case stated that the complaint being premature in nature is not maintainable as the Opposite Party No.1 has not passed the final order on the claim filed by the complainant due to non-cooperation of the complainant himself. It is averred that the complainant lodged his claim with the Opposite Party No.1 and  Opposite Party No.1 promptly sent the same to Opposite Party No.2. The Opposite Party No.2 found that it is a known case of Diabetes Mellitus-II, which was apparent from the claim form as well as from the discharge summary of Fortis Hospital and Treatment Card of GMSH-16, Chandigarh.  Consequently Opposite Party No.2 vide letter dated 13.4.2018 asked the complainant to file complete documents as mentioned in the claim form but nothing was provided by the complainant despite numerous reminders resultantly no final decision  could be taken upon the claim of the complainant.  It is alleged that the complainant is a known case of DM-II and  was already on treatment, which is apparent from treatment card of GMSH-16 and his sugar was uncontrolled. Therefore the various documents regarding the treatment history of diabetes Mellitus-II was asked from the complainant. Thus, there is no deficiency on the part   of the answering Opposite Party. Denying all other allegations leveled in the complaint it is prayed that the complaint be dismissed.
3. Rejoinder was filed and averments made in the consumer complaint were reiterated.
4. Contesting parties led evidence by way of affidavits and documents.
5. We have heard the learned counsel for the contesting parties and gone through the record of the case.
6. The main grievance of the complainant is that  inspite of paying regular premium of Jeevan Arogya Policy of the Opposite Parties,  his genuine claim was not processed by the Opposite Parties on the ground of non-submission of all the documents. Whereas the defence of Opposite Parties is that the complainant was a known case of diabetes and was already taking treatment of the same, therefore, treatment record of previous ailment was called for which was not supplied by the complainant  the policy holder.
7.  We have gone through the record carefully. A Bare perusal of Annexure C-9 the check list shows that the relevant documents of the treatment taken by the complainant were duly submitted by him to the Opposite Parties. However the OPs stated that the complainant was a known case of diabetes, hence, the Opposite Party asked for original record of treatment taken for the same. Whereas as per complainant he duly intimated the OPs that he came to know about the diabetes when he was admitted in the Fortis Hospital and the treatment was accordingly started. Thus the complainant have not concealed regarding the disease. Even otherwise it was the duty of the Opposite Parties that prior to issuance of policy it must have checked the complainant medically and later on when the complainant filed claim, the same was not decided on the ground that the complainant was having pre-existing disease of diabetes, which is not tenable. If there was any iota of doubt to the OPs that the complainant was concealing pre-existing disease of diabetes and its treatment taken  then the  OPs should have come with some concrete past medical record of the complainant which shows that the complainant was suffering from diabetes prior to issuance of the policy in question. Hence, onus lies on the Insurance Company to prove that the insured was suffering from diabetes prior to filing the proposal form. Thus, the Opposite Parties wrongly kept on holding the claim of the complainant on the ground of previous treatment taken for the diabetes.  Even otherwise it has been held in catena of judgments by various Hon’ble courts that diabetes and high blood pressure are life style disease and the claim of insured cannot be repudiated/rejected on that ground only.  The Hon’ble National commission in Neelam Chopra vs Life Insurance Corporation Of  India  decided  on 8 October, 2018   held as under:-

“11.      “From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases.  The person insured may suffer consequences in terms of the reduced claims.”

 

14. Moreover, the non-disclosure of information in respect of this life style disease of diabetes, will not totally disentitle the complainant for indemnification of the claim in the light of the judgement of Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., (supra)."

 

8.  From the above it is clear that the claim of the insured cannot be withheld or repudiated merely on the ground of life style disease like diabetes and hypertension. Moreover in the instant case as stated above the Opposite Parties failed to prove that the complainant was suffering from diabetes or hypertension prior to issuance of policy. Hence, the Opposite Parties wrongly kept pending the claim of the complainant for want of documents  though the relevant documents were already supplied by the complainant, which is apparent from the check list. Hence, it is proved on record that there is deficiency  in service and unfair trade practice on the part of the OPs by not processing the claim of the complainant which caused immense harassment to him and as such the Opposite Parties  are liable to pay the claim of the complainant on the basis of documents already submitted as it is held above that lifestyle disease and hypertension cannot be a ground to reject or withhold the claim of the insured.       
9. In view of the above discussion, the present consumer complaint succeeds and the same is accordingly allowed. OPs are directed as under:-

1. to pay the insured amount of Rs.2.00 lakh to the complainant with interest @ 9% p.a. from the date of submission of claim till realization  .
2. to pay Rs. 10000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹7,000/- to the complainant as costs of litigation.

10.      This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above
11.      Certified copies of this order be sent to the parties free of charge. The file be consigned

			Sd/-
			[Pawanjit Singh]
			President
			Sd/- [Surjeet Kaur] Member Sd/-
			[Suresh Kumar Sardana]
mp			Member