ORDER

SMT.NANDINI.H.KUMBHAR, MEMBER

1. The Complaint is filed by the complainant under section 35 of the C.P.Act, 2019 against the OPs alleging deficiency of service directing the  OPs to a sum of Rs.2,59,165/- towards insurance claim No.31796273 and Rs.80,145/- towards insurance claim No.32617497, Rs.5,00,000/- towards compensation for mental agony, loss  and also direct the OPs to re-instate the insurance policy No.PHOHLN881923399 and PROTOP881923399 and such other reliefs.

2. The brief facts of the case is as follows:

       This is the case of the complainant that  the complainant approached the OPs for issuance of insurance policy in favour of complainant’s parents each for a sum of Rs.5,00,000/- and the OPs have suggested the complainant the “Pro Health Plus Plan” to cover the needs of the complainants aged parents at an annual premium of Rs.75,814/-.  The complainant submits that the OPs have also compelled the complainant to pay additional amount and take “Super Top-up Plus Plan” for an additional sum of Rs.11,371/- and being lured and enticed by the OP the complainant agreed to purchase both the insurance plans and took insurance policy by paying total sum of Rs.87,186.54/- bearing No.PRoHLN881923399 and PROTOP881923399  and the policy valid from 17.09.2020 to 16.09.2021.  The complainant submits that the complainant paid premium regularly and renewed the policies year on year and at the time of inception of policy the complainant had disclosed the pre-existing condition of Diabetes Mellitus which the parents had and also vide email communication during month of 02.09,2021 the complainant had further disclosed the condition of Hypertension of his father which was detected only in 2021. The complainant submits that there after the complainant had made insurance claim during August-September-2021 for treatment of “Transluminal coronary Angioplasty with stenting (PTCA with stenting)” for his parents and later the complainant made insurance claim having claim No.31796273 for treatment taken at Jupiter Lifeline Hospital Ltd. for this father  for provisional diagnosis of “Left Ventricular failure” during the month of February-2023, but the OP have repudiated the claim of the complainant by stating non-disclosure of pre-existing diseases of Hypertension during inception of policy. The complainant submits that the complainant made another insurance claim having claim No.32617497 for treatment taken for his father at Jupiter Lifeline Hospitals Ltd. for provisional diagnosis of Diabetes Mellitus due to underlying condition with Hypoglocaemia without coma in March 2023, but the OPs have repudiated the claim  stating non-disclosure of pre-existing diseases at the time of inception of policy. The complainants submits that due to repudiation of claims, the complainant has paid medical expenses from his own packet and the complainant also received email communication from the OP  have wrongly terminated the entire insurance policy which stood in the name of the complainants aged parents for reasons best known to them.  Due to the act of the OPs, the complainant got issued legal notice on 23.08.2023, calling upon the OPs to reimburse the insurance claim and also reinstate the policy, but the OP have neither taken any steps nor bothered to reply to the legal notice issued.   Aggrieved by the act of OP, the complainant filed the present complaint seeking  relief as prayed in the complaint.

3.  Notice to the OPs duly served, OPs represented by counsel filed written version and affidavit along with relevant documents in support of their defense.

4. Complainant filed chief examination affidavit by re-iterating the complaint allegations and also filed relevant documents in support of their plea.

5.  Heard arguments and matter is reserved for orders.

6. The points that arise for our consideration are;

1. Whether the Complainant prove that there is deficiency of service on the part of the OP as alleged in the complaint and thereby prove that he is  entitled for the relief sought?
2. What order?

8. The findings on the above points are as under:

Point No.1           :       Partly in Affirmative

Point No.2           :       As per final order.

REASONS

9. POINT NO.1:-  It is the case of the complainant that as per the assurance of the OP-1, the complainant obtained a insurance policy to his aged father and mother, each for a sum of Rs.5,50,000/- at an annual premium of Rs.75,814/-. Thereafter, compelled by the OP, the complainant paid additional amount of Rs.11,371/- for super Top-Up plans for health insurance policy. Totally the complainant had paid a sum of Rs.87,186.54 for the period from 17.09.2020  to 16.09.2021 by renewing the policy  year on year. At the time of inception the complainant also disclosed the pre-condition of Diabetes to the OP-1 via email on September 2021, as the copy  produced by the complainant is marked as Annexure-C. Further, the complainant submits that, the complainant made an insurance claim of No.31796273 during August-September-2021 for treatment of Transluminal Coronary Angioplasty  with stenting to  his parents and the said treatment was taken at Jupiter Lifeline Hospitals during month of February-2023, but the OP had repudiated the claim under clause-VIII-1. Further, occasion also when the complainant made another insurance claim No.3261497 for treatment at Jupiter Lifeline Hospital for his father for the provisional diagnosis  of Diabetes  Mellitus, the OPs have repudiated the insurance claim via email dt.28.04.2023 by stating that the pre-existing condition was not disclosed at the time of inception of policy. The complainant made several requests for reimbursement of insurance claim amount, when all these  efforts went in vain, the complaint preferred and sought for refund of insurance claim amount as prayed in the complaint.

10. The OP-1 represented by counsel filed  written version also filed chief examination affidavit by denying the claim of the complainant under the insurance contract clause. The OP admits having issued health policy on 17.09.2020 for a period of one year, which was subsequently  renewed and valid till 16.09.2023 for a coverage sum of Rs.5,50,000/- each to his father and mother. The claim of the complainant’s father was rejected for non-disclosure of information of the policy condition as he was known case of Hypertension since 2015. As per policy condition-V.1 pre-existing diseases  are not covered  for a period of 48 months and they have  no liability to settle the claim. In view of the above, they pray for dismissal of complaint on these grounds.

11. The complainant filed chief examination affidavit reproducing the complaint allegations as against the OPs and also produced relevant documents in support of their contention. The contention taken by the OP, that the complainant  has not disclosed his pre-existing disease at the time of obtaining the policy as the complainant’s father was a known case  of HTN since December-2018 and Diabetes Mellitus  since 1997 and denied the claim of the complainant. Under the insurance contract clause-VIII-1. When the OP has  undertaken to indemnify the claim and losses of the complainant, it is bounden duty of the OP to honour the claim of the complainant. In support of this case, the averments of the complainant  has produced all the relevant documents. The copy of email communication dt.02.09.2021 between the complainant and Op, where the complainant has disclosed the condition of Hypertension, which was detected only in 2021 marked as Annexure-A and also produced insurance policy copy marked as Annexure-C1, in which it clearly mentioned the pre-existence disease at the time of availing of policy. But the averments of the complaint and reason assigned by the OP that, for non-disclosure of pre-existing disease cannot be considered for simple reason that the complainant’s father suffering from Diabetes Mellitus since 1997, for which the OP has denied liability to reimburse the claim of the complainant as it is not come under the general clause of the policy appears to be not valid and in order to escape from the liability to pay the legitimate claim of the complainant, the OP has  technically rejected the valid claim of the complainant.

12. On this ground the commission relied upon the judgment rendered by the Hon’ble NCDRC, New Delhi and Hon’ble Supreme Court of India, clearly stated in many cases, that the medi-claim   policy is a contract of good faith, it is bounden duty of the  OP to honour the claim of the complainant. The repudiation of claim due to suppression of pre-existing illness  cannot be justified, Hypertension and Diabetes are not a disease, it is life style of the people in the society, it is a common disease and it does not amounts to suppression of material illness which  cannot be considered as a violation of policy terms and conditions. Further, the Hon’ble Supreme Court of India pointed out in the case between Satwant Kaur Sandhu V/S New India Assurance Co. Ltd., the Hon’ble Supreme court held that Mediclaim is a non-life insurance policy meant to assure the policy holder in respect of certain expenses  of hospitalization and it is a contract of insurance falling under the category of contract uberrima fedai (utmost  good faith) on the party of the assured. When the policy was issued to the complainant and renewed from 17.09.2020 till 16.09.2021  and after receiving the premium for the said policy, the OP has accepted  to indemnify and issued the policy. When OP has entered into an insurance contract with the complainant, the OP has bound to settle the insurance claim under the said policy. But the OP have miserably failed to settled the claim of the complainant. The act and omission of the OP company appears to be negligent and careless attitude in  rejection of the claim of complainant. The OP have not executed their right in a valid and proper manner.

13. In view of the above discussion and ratio laid down by the Appellate Authority, the commission held that the ground for rejection of complainant’s claim does not amounts to suppression of material facts. Upon which, the claim of the complainant cannot be rejected on flimsy ground, which is not justified under law. The act and omission of the OPs attracts deficiency in service on the part of the OP. Hence, OPs are jointly held liable to pay the legitimate claim of the complainant along with other reliefs.  Accordingly, we answer the Point No.1 in partly affirmative.

14. POINT NO.2:- In the result, for the forgoing reasons,  we passed the following:

                                      ORDER

1. The complaint is hereby allowed in part.
2. The OP-1 &2 are jointly and severally directed to pay a sum of Rs.2,59,165/- and a sum of Rs.80,145/- along with interest at 6% p.a. from the date of repudiation till entire payment is made to the complainant.
3. The OP-1 &2 are jointly and severally directed to pay compensation of Rs.25,000/- for deficiency in service, Rs.10,000/- towards pain and suffering along with Rs.10,000/- towards cost of the proceedings.
4. The OPs shall comply this order within 45 days from the date of this order, failing which the OPs shall liable to pay interest at 6% p.a. on all the above said amounts.
5. Furnish free copy of this order to both the parties.

(Dictated to the Stenographer, got it transcribed, typed by him and corrected by me, then pronounced in the Open Commission on 29^th June 2024)

(RAMACHANDRA M.S.)

PRESIDENT

     (NANDINI H KUMBHAR)                   (SHRINIDHI.H.N)            

              MEMBER                                                 MEMBER                     

Witness examined on behalf of the complainant by way of affidavit:

Sri Narssimhan Kannan-Who being the complainant.

Documents produced by the complainant:

Witness examined on behalf of the OP-1 by way of affidavit:-

Sri Ashish Kaur Saluja

Witness examined on behalf of the OP-1 by way of affidavit:- Nil

Documents produced by the OP-1:

Documents produced by the OP-2: Nil

(RAMACHANDRA M.S.)

PRESIDENT

     (NANDINI H KUMBHAR)                 (SHRINIDHI.H.N)            

         MEMBER                                    MEMBER                                       

SKA*