Sh.Anoop Sharma, Presiding Member.

1.       The complainant has  brought the instant complaint under section  12 & 13 of the Consumer Protection Act, 1986 on the allegations that she has taken health insurance from Opposite Party for herself and his husband since long and latest being vide policy No. 30193689201502 covering risk period from 14.3.2015 to 13.3.2016. Mohinder Pal Singh husband of the complainant unfortunately fell ill and got admitted in Fortis Escort Hospital, Amritsar and was to be under medical treatment for the period 18.11.2015 till 22.11.2015 and the claim for his hospitalization and medical treatment was referred to Opposite Party and the claim bill of Rs.80188/- was filed with Opposite Party which was neither repudiated nor settled by Opposite Party inspite of the fact many telephonic reminders are being made to the Opposite Party. It is pertinent to mention over here  that no policy condition is communicated to the complainant and the Opposite Party had issued the said policy on cashless basis for the medical treatment, but the complainant had to pay the amount from out of pocket. The aforesaid act of the Opposite Party in not paying the genuine claim of the complainant is an act of deficiency in service, Unfair Trade Practice, malpractice and is not sustainable in the eyes of law. Vide instant complaint, the complainant has sought the following reliefs.

a)       Opposite Party may kindly be directed to pay the claim of Rs.80188/- alongwith interest @ 12% per annum thereon from the date of payment till realization.

b)      Opposite Party may also be directed to pay the compensation of Rs.50,000/- to the complainant.

c)       Opposite Party be directed to pay the adequate cost of the present litigation. 

d)      Any other relief to which the complainant is found under the law, equity and justice be also allowed.  

Hence, this complaint.

2.       Upon notice, Opposite Party appeared and contested the complaint by filing  written statement taking preliminary objections therein inter alia that the complainant did not disclose any medical history in the policy proposal form, therefore, assuming that the proposer is a healthy person and risks involved in insuring him are within the acceptable limits, the Opposite Party issued health insurance policy opted by the complainant. The health insurance policy called family first silver 5 lacs+ 4 lacs and bearing No. 30193689201300 was issued by Opposite Party to the complainant which was valid from 14.3.2013 to 13.3.2014 with sum insured was Rs.14 lacs. The said policy was renewed from time to time and detail of which is given in para No.7 of the preliminary objections of the written reply filed by the Opposite Party.  It is further submitted that entire policy booklet which included the welcome letter, insurance certificate, premium receipt, policy terms and conditions, proposal form filled by the complainant, etc was provided to the complainant when the policy was issued.  On 19.11.2015 a pre authorisation request form for cashless treatment of the insured person was submitted to the Opposite Party. On receipt of the discharge summary it was revealed that the insured person was diagnosed with Chronic alcoholism/ Type II DM/ UGI-Bleed, AVM duodenum, APC/ Clipping done.  And previous authorisation also stands cancelled  because as the available documents, the patient is known chronic alcoholic with complaints of ALD  with upper GI bleed. The present condition is a complication of alcohol abuse and hence, not covered under exclusion 4(e)(i). Addictive conditions and disorders-treatment related to addictive conditions and disorders, or from any kind of substance abuse or misuse. Hence, the complainant is guilty of material non disclosure as she was duty bound to disclose all medical conditions so as to give the underwriter a fair chance for proper  risk evaluation and underwriting of the policy. The complainant has suppressed the material information  regarding the medical condition of her  husband and therefore, the claim is not tenable.  On merits, the Opposite Party had taken almost same and similar pleas as taken up by them in the preliminary submissions.  Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.

3.       In her bid  to prove the case, complainant tendered into evidence  affidavit Ex.C-1 in support of the allegations made in the complaint and also produced copies of documents Ex.C2   to Ex.C4  and closed his evidence.

4.       On the other hand, to rebut the evidence of the complainants, the Opposite Party tendered into evidence the affidavit of Sh.Akanksha Kapoor, Manager Ex.OP11 alongwith copies of documents Ex. Op1 to Ex.OP10 and closed the evidence on behalf of the Opposite Party.

5.       We have heard the ld.counsel for the parties and have carefully gone through the evidence on record.

6.       From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant  has taken health insurance from Opposite Party for herself and his husband since long and latest being vide policy No. 30193689201502 covering risk period from 14.3.2015 to 13.3.2016. Mohinder Pal Singh husband of the complainant unfortunately fell ill and got admitted in Fortis Escort Hospital, Amritsar and was to be under medical treatment for the period 18.11.2015 till 22.11.2015 and the claim for his hospitalization and medical treatment was referred to Opposite Party and the claim bill of Rs.80188/- was filed with Opposite Party which was neither repudiated nor settled by Opposite Party inspite of the fact many telephonic reminders are being made to the Opposite Party. It is pertinent to mention over here  that no policy condition is communicated to the complainant and the Opposite Party had issued the said policy on cashless basis for the medical treatment, but the complainant had to pay the amount from out of pocket. The aforesaid act of the Opposite Party in not paying the genuine claim of the complainant is an act of deficiency in service, Unfair Trade Practice, malpractice and is not sustainable in the eyes of law. Ld.counsel for the   complainants  submitted that all this amounts to deficiency of service on the part of the Opposite Party.

7.       Whereas the case of the Opposite Party is that the complainant did not disclose any medical history in the policy proposal form, therefore, assuming that the proposer is a healthy person and risks involved in insuring him are within the acceptable limits, the Opposite Party issued health insurance policy opted by the complainant. The health insurance policy called family first silver 5 lacs+ 4 lacs and bearing No. 30193689201300 was issued by Opposite Party to the complainant which was valid from 14.3.2013 to 13.3.2014 with sum insured was Rs.14 lacs. The said policy was renewed from time to time and detail of which is given in para No.7 of the preliminary objections of the written reply filed by the Opposite Party.  It is further submitted that entire policy booklet which included the welcome letter, insurance certificate, premium receipt, policy terms and conditions, proposal form filled by the complainant, etc was provided to the complainant when the policy was issued.  On 19.11.2015 a pre authorisation request form for cashless treatment of the insured person was submitted to the Opposite Party. On receipt of the discharge summary it was revealed that the insured person was diagnosed with Chronic alcoholism/ Type II DM/ UGI-Bleed, AVM duodenum, APC/ Clipping done.  And previous authorisation also stands cancelled  because as the available documents, the patient is known chronic alcoholic with complaints of ALD  with upper GI bleed. The present condition is a complication of alcohol abuse and hence, not covered under exclusion 4(e)(i). Addictive conditions and disorders-treatment related to addictive conditions and disorders, or from any kind of substance abuse or misuse. Hence, the complainant is guilty of material non disclosure as she was duty bound to disclose all medical conditions so as to give the underwriter a fair chance for proper  risk evaluation and underwriting of the policy. The complainant has suppressed the material information  regarding the medical condition of her  husband and therefore, the claim is not tenable.  Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the Opposite Party.

8.       From the entire above discussion, we have come to the conclusion that the  complainant  has taken health insurance from Opposite Party for herself and his husband since long and latest being vide policy No. 30193689201502 covering risk period from 14.3.2015 to 13.3.2016. Mohinder Pal Singh husband of the complainant unfortunately fell ill and got admitted in Fortis Escort Hospital, Amritsar and was to be under medical treatment for the period 18.11.2015 till 22.11.2015 and the claim for his hospitalization and medical treatment was referred to Opposite Party and the claim bill of Rs.80188/- was filed with Opposite Party but the same was  repudiated by the Opposite Party on the ground that on receipt of the discharge summary it was revealed that the insured person was diagnosed with Chronic alcoholism/ Type II DM/ UGI-Bleed, AVM duodenum, APC/ Clipping done.  And previous authorisation also stands cancelled  because as the available documents, the patient is known chronic alcoholic with complaints of ALD  with upper GI bleed. The present condition is a complication of alcohol abuse and hence, not covered under exclusion 4(e)(i). Addictive conditions and disorders-treatment related to addictive conditions and disorders, or from any kind of substance abuse or misuse. Hence, the complainant is guilty of material non disclosure as she was duty bound to disclose all medical conditions so as to give the underwriter a fair chance for proper  risk evaluation and underwriting of the policy. The complainant has suppressed the material information  regarding the medical condition of her  husband and therefore, the claim is not tenable. On the other hand, though  Opposite Party has produced on record the discharge summary of life insured regarding his admission in the hospital, but the Opposite Partu has not filed any affidavit of any doctor who has medically treated the insured for the disease prior to taking of the policy. It has been held by the Hon'ble National Commission in case New India Assurance Co.Ltd & Anr Vs. Murari Lal Bhusri 2011(III) CPJ 198 (NC) that where the Insurance company failed to produce any evidence to show that respondent was aware of any pre-existing disease at the time when insurance policy was taken, opposite party was not justified in repudiating the claim of the complainant on the ground of pre-existing disease. It has been held by the Hon'ble Supreme Court of India in case P.Vankat Naidu Vs. Life Insurance Corporation of India & Anr 2011(3) CPC 350 that where no cogent evidence was produced by the respondent to prove that insured/deceased had concealed any fact about his illness or hospitalization, it was held that no material fact was suppressed by the deceased in this respect. It has been held by the Hon'ble State Commission of Punjab in case  Life Insurance Corporation of India Vs. Miss Veenu Babbar and another 2000(1) CLT 619 that repudiation on the basis of history recorded in the hospital records is illegal and arbitrary and the same could not be treated as substantive material to base any decision. Same view has been taken by the Hon'ble National Commission in case Life Insurance Corporation of India & Ors. Vs. Kunari Devi IV(2008) CPJ 89 (NC) that where no document has been produced in support of allegation of suppression of disease at the time of taking policy or revival of policy, history recorded in hospital's bed ticket, not to be treated as evidence as doctor, recording history not examined, suppression of disease not proved, insurer was held liable under the policy. It has further been held by the Hon'ble National Commission in case Sahara India Life Insurance Co. Ltd. & Anr Vs. Hansaben Deeepak Kumar Pandya IV(2012) CPJ 13(NC) that where the opposite party insurance company has failed to produce on record any evidence to show that deceased insured ever consulted doctor for taking treatment of heart disease, the repudiation of the claim on the ground of suppression of material fact is totally illegal. It has been  held by Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in case titled as Ashwani Gupta & Ors. Vs. United India Insurance Company Limited 2009(1) CPC page 561 that where the claim of the complainant has been repudiated on the ground that the assured had pre-existing disease of diabetes mellitus which was not disclosed- apparently, burden to prove lies  upon the insurer- If assured was suffering from pre-existing disease why insurer  had not checked it at the time when proposal form was accepted by its  staff-Respondent has failed to fulfill this requirement before repudiating the claim and the appellant was held entitled  to claim alongwith interest.

9.       In view of the above discussion, we are of the opinion that the Opposite Party  has wrongly repudiated the claim of the complainant. Consequently, we allow the complaint with costs and the Opposite Party  is directed to pay the claim amount of Rs.80,188/- to the complainant, within one month from the date of receipt of copy of this order failing which the complainant shall be entitled to interest @ 6% per annum on this amount from the date of filing of the complaint till the payment is made to the complainant. Opposite Party is also directed to pay litigation expenses to the complainant  to the tune of Rs. 2000/-.  Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Announced in open Forum.