Before the District Consumer Dispute Redressal Commission [Central District] - VIII, 5th Floor Maharana Pratap ISBT Building, Kashmere Gate, Delhi
Complaint Case No.-97/2021
Anil Goyal s/o Late Sh. Ram Rattan Goyal
r/o H. No. 123, Rameshwar Nagar, North-Ex
Model Town, Model Town-III, Delhi-110009 …Complainant
Versus
Manipal Cigna Health Insurance Company Ltd.
Through its Managing Director/ Chairman,
Office at: 32-B, IIIrd Floor, Rajinder Nagar,
Pusa Road, Near Pillar No. 122 of Metro Station
Karol Bagh, New Delhi-110005 ...Opposite Party
Date of filing: 04.10.2021
Date of Order: 06.10.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
ORDER
Inder Jeet Singh , President
1.1. (Introduction to case of parties) - The complainant/Insured filed the complaint against his Insurer/OP for allegations of deficiency of services because of want of reimbursement of hospitalization & medical bills of his wife, firstly - by declining him cashless facility of hospitalisation & medical bills and subsequently- by declining such bills of Rs..1,43,522/- despite it were covered under Medi-claim family health Insurance Policy. It was declined on the false pretext of concealment in proposal form of disease of hypertension for the last two years to his wife. Whereas, the complainant protests and denies this plea of OP that she was not suffering from hypertension and she was got examined medically by OP before issue of policy, since complainant had made declaration that she is diabetic. When complainant clearly made this declaration, there was no reasons for suppression of hypertension, since she was not suffering from this hypertension.
The complainant seeks reimbursement of medical bills of Rs.1,43,522/- algonwith interest of Rs.8,611/-, compensation of Rs. 2,00,000/- on account of harassment , mental agony and sufferings, apart from litigation costs of Rs. 55,000/- and other appropriate relief under the circumstances.
1.2. The OP opposed the complainant by denying allegations of deficiency of services and it also justifies repudiation of claim. The pre-authorised was rightly declined and then claim was also declined as per terms of policy, since it revealed in investigation that the complainant had suppressed material facts of his wife suffering from hypertension for the last two years, which was never disclosed in the proposal form. Since, the complainant had suppressed and failed to disclose this disease, the policy was obtained by misrepresentation and against the principles of utmost good faith, therefore, it cannot be construed deficiency of services. Thus, the complaint is without cause of action, complainant is not entitled for any claim/relief being claimed.
2.1. (Case of complainant) – The complainant has been subscriber to medi-claim Family Health Insurance Policy from National Insurance Company first time from 18.05.2017 onwards to secure himself, his wife Mrs. Seema Goel, their daughter Vanshika and son Deepak Goel for a sum assured of Rs. 3,00,000/- and it was got renewed in the year 2018 and then in the year 2019 without any break. Thence the complainant was convinced and allured by the representative of present OP/Insurer by visiting his residence to buy OP's medi-claim family health insurance policy and consequent to such assurances, the complainant bought medi-claim family health insurance policy no. PROSLA 0000 10268 w.e.f. 31.05.2019 to 30.05.2020 under "ProHealth Select-A Plan" for sum assured Rs. 3,00,000/-, the complainant was getting renewed the said policy regularly onwards. However, he was initially issued insurance policy first time getting the policy but on renewals no further policy was issued but receipt/certificate against premium paid. Moreover, the complainant’s wife Smt. Seema was suffering from diabetes-II and she was also got examined medically by the OP before issuing the policy.
2.2. On 08.01.2021, complainant’s wife Smt. Seema Goel fell sick on account of high grade fever and cough, she took treatment from Dr. Sharad Mathur, Ishwar Clinic but she did not recover, therefore, on 14.01.2021 she was taken to emergency of Jaipur Golden Hospital, Sector-3, Rohini, Delhi because of high fever and cough; she was admitted in the hospital because of such sickness but discharged on 20.01.2021
2.3. On 14.01.2021 on the eve of admission of Smt. Seema Goel in the hospital, the complainant applied for cashless facility, it was declined by OP with advice to apply for reimbursement of medical claim after submitting all original medical bills and record. Therefore, the complainant had to pay amount of Rs. 1,38,292/- of hospitalization expenses and a sum of Rs. 5,230/- on medicines, tests etc. and he had spent total amount of Rs. 1,43,522/-. The complainant after collecting all original documents (viz. medical bills, reports, discharge summary, x-ray etc.) and deposited them in the office of OP for settlement of claim. But on 07.05.2021, he received information on his mobile phone through OP's agent Prashant that insurance company has rejected the claim on the ground of pre-existing illness/ B.P. of wife of complainant. Whereas she was not suffering from B.P. (hypertension, HTN) and had it been so, the complainant would have declared in the declaration by adding it with declared pre-existing disease of diabetic.
2.4. The OP had rejected the claim without any valid reason but to avoid the insurance liability which has caused mental agony and harassment. Dr. Sharad Mathur of Ishwar Clinic had issued certificate dated 29.03.2021 and Jaipur Golden Hospital had also issued separate certificate dated 14.06.2021 that Smt. Seema Goel was not given any treatment for HTN during hospitalization.
2.5. The complainant also issued legal notice dated 31.08.2021 to the OP to reimburse valid medical claim to the complainant but no result. That is why the complaint for relief claimed.
2.6. The complainant is accompanied with documentary record of first insurance policy, premium certificates, bills of prescription & pharmacy, receipts, record of emergency department of Jaipur Golden Hospital, bills, screen shot of message dated 07.05.2021 of rejection of claim, discharge summary dated 20.01.2021, certificate dated 29.03.2021 by Dr. Sahrad Mathur, Ishwar Clinic, certificate dated 14.06.2021 by Jaipur Golden Hospital and copy of legal notice dated 31.08.2021 with track report of its services upon the OP.
3.1 (Case of OPs)- There is composite reply by the OP on some of the facts are not disputed and other are denied. Since there are complicated questions of acts involved, it cannot be decided in summary trial but by detail evidence in civil court.
The OP does not deny the facts mentioned in para 2.1 about issue of first insurance policy to the complainant (except he was allured by OP) and the complainant had earlier took insurance policy from the National Insurance Co. Ltd. The OP also does not deny of complainant's taking policy from OP and about decline of pre-authorisation request as stated in para 2.3 above. However, the complainant was issued new policy on each renewal and lastly policy issued was bearing no. PROSLA 0000 10268 w.e.f. 31.05.2021 to 30.05.2022
3.2. However, the OP denies the allegations narrated in para 2.2 above. The complaint is opposed by the OP that there is no cause of action in favour of the complainant and against the OP. There is concealment of material facts by the complainant as well as violation of conditions of the policy, which does not entitle the complainant for any relief being claimed.
3.3. The OP also opposed the complainant by denying allegations of deficiency of services and also confirming that repudiation of claim was in terms of policy. The OP had carefully examined the documents made available and it was discovered in investigation that complainant’s wife was a known case of hypertension for the last two years, which was not disclosed by the complainant at the time of purchasing the insurance policy, it amounts to breach of clause VIII.1, consequently the claim was rejected vide letter dated 20.04.2021. Had the complainant disclosed his wife’s history of hypertension, the OP would not have accepted the risk of person of the age of Smt. Seema Goel suffering from two chronic conditions or otherwise the complainant would have been asked to continue his policy with the previous insurer. The parties are bound by the terms and conditions of the policy in its literal and strict covenants, without any add or deletion or modification of terms and conditions. The complaint is liable to be dismissed. [The reply embraces certain case law, it will be referred at the stage of arguments phase].
3.4 The reply is accompanied with copy of proposal form, policy with terms and conditions, claim form, copy of investigation, copy of medical record by Jaipur Golden Hospital and claim rejection letter dated 20.4.2021.
4. (Replication of complainant) – The complainant in his replication reaffirms his case and he denies the allegation of written statement by emphasizing that complainant’s wife was not suffering from hypertension at the time of taking the policy, she was diabetic and it was declared in the proposal form and had she been suffering from HTN, it would have also been mentioned in the declaration. The rejection of claim was without any substance, the treating doctor and the treating hospital have also issued certificate to this effect that she was not treated for HTN. The present Commission is competent to adjudicate the complaint.
5.1. (Evidence)- The complainant Sh.Anil Goyal led evidence by filing his detailed affidavit with the support of documentary record of bills, discharge summary, certificates issued by treating doctor of Ishwar Clinic and Jaipur Golden Hospital, other medical/clinical record and reports, and copy of legal notice.
5.2. OP led its evidence by filing detailed affidavit of Shri Jaswinder Singh Sekhawat, Senior Manager Legal on the lines of reply to complaint.
6.1 (Final hearing)- Both the parties have filed their written arguments. At the stage of oral submissions, Sh. Sanjay Goyal, Advocate for complainant and Shri Yuvraj Sharma, Advocate for Shri Pankan Seth, Advocate for OP presented the submissions. The OP fortifies its contentions by deriving reasons in its support from the following cases:-
(a) Export Credit Guarantee Corpn. Of India vs M/s Garg Sons International 2013(1) Scale 410, that while construing the terms of the contract of Insurance, the words used therein must be given paramount importance and it is not open for the court to add, delete or substitute any words.
(b) General Assurance Society Ltd. vs. Chandumull Jain & Anr. (1966) 3 SCR 500 in interpreting documents relating to a contract of insurance, the duty of the court is to interpret the words in which the contract is expressed by the parties.
(c) Oriental Insurance Co. Ltd. vs. Sony Cherian (II 1999 CPJ 13 SC) that the insurance policy between the insurer and the insured represents a contract between the parties, since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy the terms of agreement have to be strictly construed to determine the extent of liability of the insurer.
(d) The material facts could have been in the personal knowledge of insured, who is bound to disclose those material facts to the insurer while taking the policy, reliance is placed on Oriental Insurance Co. Ltd. vs. Mahendra Construction 2019 (7) Scale 187, Reliance Life Insurance Co. Ltd. & anr. Vs Rekhaben Nareshbai Rathod SLP (c) no. 14312/2015 dod 24.04.2019 and Life Insurance Corporation of India vs Manish Gupta SLP (C) no. 5001/2019 decided on 15.04.2019.
(e) LIC vs Sunita 2021(13) Scale 125, it held that it is well settled legal position that in a contract of insurance there is requirement of good faith on the part of assured (further reliance is placed on Vikram Greentech Eye Ltd. vs New India Assurance Co. Ltd. 2009 5 SCC 599
(f) The insured cannot claim anything more than what is covered under the insurance policy (reliance is placed on General Assurance Society Ltd. vs. Chandmull Jain (1966) 3 SCR 500, Oriental Insurance Co. Ltd. vs. Sony Cheriyan AIR 1999 SC 3252 and United India Insurance Co. Ltd. vs Harchand Rai Chandan Lal (2004) 8 SCC 644).
7.1 (Findings)- The submissions of both the side are considered, analyzed and assessed including evidence of parties, the documentary record and case law. The rival contentions of parties are not being reproduced here, since parties’ cases have already been narrated in detail.
7.2. It is manifest from plain reading of case of parties, that the relationship of the complainant and of the OP are of the Insured and of the Insurer, the medi-claim policies issued from time to time inclusive of latest policy by OP, its tenure and premium paid are not in dispute. The complainant had made declaration that his wife is diabetic-II is also not disputed. Complainant's wife was got examined medically by OP prior to issuance of policy is also not disputed by OP. It is also not disputed that the complainant's wife was hospitalised and she was given medical treatment as indoor patient in the Jaipur Golden Ram Hospital and the complainant had paid the all medical bills from his own pocket, since cashless facilities were not extended.
7.3 The OP took the plea in its reply that matter needs settlement through the Civil Court as it involves complicated question of facts and law, which is opposed by the complainant.
However, the OP has not elucidated anywhere as to what complex question either of fact or of law is involved, which cannot be determined by the Consumer Commission. The case is based on simple facts as well as documentary record, which can be determined easily by this Commission, therefore, the request of OP is declined that it is to be determined by the Civil Court.
7.4. However, the basic issue involved is 'whether or not the complainant's wife had pre-existing disease of hypertension for the last two year or was it concealed from the OP? Whether or not the complainant is entitled for reimbursement of medical bills claim under the insurance policy and other reliefs? For adjudicating them in summary way, the evidence of the parties is to be considered, whether there was pre-existing of disease from the point of obtaining policy and for want of its declaration, what legal consequences would flow.
7.5 In order to appreciate the rival plea of parties, it is relevant to refer law laid down in "Jagdish Vs LIC of India [FA no.1055/2003 dod 17.12.2007, decided by Hon'ble State Commission]", in which circumstances and parameters for determination of pre-existing disease were laid down in detail, its paragraph 10 is reproduced -
"Para 10 -Our conclusions on the meaning and import of words disease, pre-existing
disease for the purpose of medi-claim insurance policy, as under:
(i) Disease means a serious derangement of health or chronic deep-seated disease
frequently one that is ultimately fatal for which an insured must have been hospitalized or operated upon in the near proximity of obtaining the medi-claim policy,
(ii) Such a disease should not only be existing at the time of taking the policy but also
should have existed in the near proximity. If the insured had been hospitalized or operated upon for the said disease in the near past, say, six months or a year he is supposed to disclose the said fact to rule out the failure of his claim on the ground of concealment of information as to pre-existing disease,
(iii) 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 and 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,
(iv) If insured had been even otherwise living normal and healthy life and attending to
his duties and daily chores like any other person and is not declared as a diseased person as referred above he cannot be held guilty for concealment of any disease, the medical terminology of which is even not known to an educated person unless he is hospitalized and operated upon for a particular disease in the near proximity of date of insurance policy say few days or months,
(v) Disease that can be easily detected by subjecting the insured to basic tests like
blood test, ECG etc. the insured is not supposed to disclose such disease because of otherwise leading a normal and healthy life and cannot be branded as diseased person,
(vi) Insurance company cannot take advantage of its acts of omission and commission as it is under obligation to ensure before issuing medi-claim policy whether a person is fit to be insured or not. It appears that insurance Companies do not discharge this obligation as half of population is suffering from such malaises and they would be left with no or very little business.
Thus any attempt on the part of the insurer to repudiate the claim for such non-disclosure is not permissible, nor is exclusion clause invoke-able,
(vii) Claim of any insured should not be and cannot be repudiated by taking a clue or
remote reference to any so-called disease from the discharge summary of the insured by invoking the exclusion clause or non-disclosure of pre-existing disease unless the insured had concealed his hospitalization or operation for the said disease undertaken in the reasonable near proximity as referred above,
(viii) Day to day history or history of several years of some or the other physical problem
one may face occasionally without having landed for hospitalization or operation for the disease cannot be used for repudiating the claim. For instance an insured had suffered from a particular disease for which he was hospitalised or operated upon 5, 10 to 20 years ago and since then had been living healthy and normal life cannot be accused of concealment of pre-existing disease while taking medi-claim policy as after being cured of the disease, he does not suffer from any disease much less the pre-existing disease,
(ix) For instance, to say that insured has concealed the fact that he was having pain in
the chest off and on for years but has never been diagnosed or operated upon for heart disease but suddenly lands up in the hospital for the said purpose and therefore is disentitled for claim bares dubious design of the insurer to defeat the rightful claim of the insured on flimsy ground. Instances are not rare where people suffer a massive attack without having even been hospitalised or operated upon at any age say for 20 years or so,
(x) Non-disclosure of hospitalization/or operation for disease that too in the
reasonable proximity of the date of medi-claim policy is the only ground on which insured claim can be repudiated and on no other ground.
7.6 Since there is issue of pre-existing disease of hypertension and its concealment in the proposal form is raised by OP, they are inter-related, thus both of them are taken together. By considering facts, features, evidence of parties along-with the settled law, the following conclusions are drawn:-
(a) There is no dispute of latest renewed insurance cover/medi-claim policy is w.e.f. 31.05.2021 to 30.05.2022 as well as initially first policy was issued by OP w.e.f. 31.05.2019 to 30.05.2020. OP has also filed proposal form dated 06.05.2019 and terms & conditions policy. The policy holder is complainant and beneficiaries are also his spouse and two dependent children.
(b) The terms and conditions filed by OP are in the paper-book of OPs, however, it has not been proved by the OP that these terms and conditions were provided to the complainant, since complainant asserted that initially he was issued policy but subsequently premium receipt on renewal but no policy. To say, the complainant has proved that he was not provided with the terms and conditions of policy.
Moreover, in Manmohan Nanda Vs United- India Assurance Co. [Civil Appeal no. 8386/2013) decided on 6.12.2021 by Hon'ble Supreme Court of India has also dealt the regulations 'the IRDA (Protection of Policyholder' Interests) Regulations 2002' and it was held (in paragraph 34 thereof) "that just as insured has a duty to disclose all material facts, the insurer must also inform the insured about the terms and conditions of policy that is going to be issued to him and must strictly confirm to the statement in the proposal form or prospectus or those made through its agents. Thus, principle of utmost good faith imposes meaningful reciprocal duties owned by the insured to the insurer and vice-versa".
(c) The complainant's wife Seema Goel was given admission for treatment at Jaipur Golden Hospital and she remained there as an indoor patient. As per discharge summary, she was finally diagnosed and treated for acute febrile illness with bilateral pneumonia with type-II diabetes mellitus with hypertension.
Further, in the discharge summary dated 20.1.2021 there is mentioning of chief complaint of high grade fever with chills for 7-8 days, cough with slight expectoration & difficulty in breathing. Her BP was 140/70mmHg. The past medical history of diabetes and hypertension is also mentioned.
(d) Prior to Seema's treatment at Jaipur Golden Hospital, she had under-gone treatment under Dr. Sharad Mathur, MBBS (LKQ) Ishwar Clinic, who issued certificate that on 6.1.2021 she was suffering high grade fever, cough & expectoration, breathlessness and chills, she was diagnosed c/o of enteric fever & ? Pneumonia, she had mild-hypertension probably due to high grade fever, pneumonia, anxiety. Later Jaipur Golden Hospital also issued certificate dated 14.06.2021 (subsequent to discharge summary dated 20.1.2021) that Seema was diagnosed of hypertension since 6.1.2021 at Ishwar Clinic but Seema was not given any treatment for HTN during her hospitalization, only dietary restrictions was taken, there was no major past history of hypertension.
(e) It is settled law, by case of Jagdish Vs LIC of India [FA no.1055/2003], when the complainant has been leading normal life, or when she had high grade fever, breathlessness, pneumonia and anxiety, due to which she had mild hypertension, then it cannot be treated as pre-existing disease of HTN.
At the time of filling in the proposal form, the disease should have been either in continuation or in proximate of time immediately before the proposal form, but it was not so in this case nor it means pre-existing disease. Had the complainant's wife been under continuous ailment or treatment for such ailment, then it would have to be evaluated from that prospective.
(f) The complainant's wife Seema was also examined medically prior to issuing insurance policy, since she had made declaration of her suffering from diabetes. The OP does not deny this fact specifically in its reply to para 3 of the complaint nor the evidence of complaint to this effect has been disproved by the OP. Therefore, once insured was examined medically prior to enter into insurance contract, premium has been accepted and then policy was issued, then subsequently OP is estopped from this kind of objections.
(g) The OP has filed investigator's report that it was discovered that complainant's wife was suffering from HTN for the last two years, but it just refers a sheet filled in and signed by patient, however, there is no independent proof or record or medical record that Seema was suffering from HTN for the last two years or she was under specific medication for HTN. Simultaneously the certificate issued by Ishwar Clinc and also by Jaipur Golden Hospital has sanction of medical record in favour of patient/wife of complainant. Thus, the record proved by complainant proves that she was not patient of HTN at the time of her taking policy.
(h) In view of settled law and facts discussed hereinabove, the case of complainant's wife is to be construed a case of non-existence of previous disease of hypertension, consequently the question of concealment/suppression of disease does not arise, therefore, the plea of OP that principle of utmost good faith has been broken by the complainant or there is misrepresentation of complainant to obtain policy, does not apply.
(i) The proposal form has been proved by the OP and Seema was also examined medically before issuing policy, which does not show HTN, it does not amount to concealment of disease from the point of obtaining policy as it is not pre-existing disease. Thus, it is held that there was not occasion for complainant to conceal fact or information of HTN for want of its existence of this condition of wife of complainant prior to the policy.
(j) The OP declined the claim on ground of "non-disclosure of HTN and also permanent exclusions’. Since, it stand established that it is not a case concealment of ailment or of existence of disease HTN, therefore, there was no reason to decline reimbursement of medical bills claim.
7.7. Further, by taking into account the facts, features, material and record proved, the following conclusions are also drawn:-
(i) The complainant has proved medical papers of the treatment rendered, reports, discharge summary, certificates by treating doctor & hospital and other medical bills in sequence, which proves that the complainant's wife was admitted in Jaipur Golden Hospital for six days from 14.06.2021 to 20.06.2021, the medical expenses of Rs.1,32,292/- are pertaining to her hospitalization & her treatment and Rs.5230/- towards medicines & tests. The complainant has proved valid medical claim covered against risks under the policy having validity period from 31.05.2021 to 30.05.2022.
(ii) Since, the circumstances are establishing case of medical treatment and expenses, which are covered within the medical policy as well as during the tenure of policy but OP failed to pay valid claim amount of Rs.1,43,522/-. It is deficiency of services, when valid medical claim is not reimbursed via a vis there was mentioning of HTN in discharge summary.
(iii) The complainant made his all efforts for getting reimbursement of the claim, firstly he could not succeed in cashless facilities, then his entire claim was declined. Consequently, he had faced trauma for getting the claim reimbursed.
7.6. Therefore, complainant is held entitled for reimbursement of medical claim bills of Rs.1,43,522/-.
7.7. The complainant has also sought damages of Rs.2,00,000/- towards harassment and agony, therefore, considering totality of circumstances of case of both sides especially concluded in aforementioned paragraph, damages of Rs 5,000/- is allowed in favour of complainant and against OP. The cost of litigation is also determined as Rs.5,000/-in his favour and against the OP.
8. Accordingly, the complaint is allowed in favour of complainant and against the OP to pay/reimburse medical bills amount of Rs.1,43,522/- besides to pay damages of Rs.5,000/-, costs of Rs.5,000/- to complainant.
OP are also directed to pay the amount within 30 days from the date of receipt of this order. In case amount is not paid within 30 days from the date of receipt of order, then interest rate of interest 6% pa on amount of Rs.1,43,522/- will be payable from the date of complaint till realisation of amount..
9. Announced on this 06th October 2023 [अश्विन 14, साका 1945].
10. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
[Vyas Muni Rai] [Shahina] [Inder Jeet Singh]
Member Member (Female) President
