Order dictated by:
Ms.Rachna Arora, Member
- Mrs. Simmi Khurana complainant has brought the instant complaint under section 11 & 12 of the Consumer Protection Act on the allegations that complainant has been obtaining mediclaim policy from opposite party No.1 through opposite party No.2 since the year 2013. Lastly the husband of the complainant obtained policy from opposite party No.1 through opposite party No.2 for the period from 28.2.2015 to 28.2.2016 with sum insured Rs. 2 lacs under the plan opted for Health Companion vide policy No. 30081161201503. In the month of January 2016 husband of the complainant suffered from some health problem as he was having sugar problem . Accordingly the complainant took her husband to EMC Hospital Pvt.Ltd on 6.1.2016, where he was admitted . During his treatment in the said hospital, the complainant spent approximately Rs. 2 lacs on the treatment and other medical expenses of the treatment of her husband. However , the husband of the complainant expired on 18.1.2016. After the death of her husband, complainant being widow and beneficiary intimated the opposite party No.2 and also lodged claim with opposite party No.1 vide claim No. 177958. The complainant also sent e-mail dated 15.6.2016 with opposite party No.1 for disbursement of the sum insured of Rs. 2 lacs. But the opposite party No.1 repudiated the claim of the complainant vide letter dated 15.6.2016 on the ground that the husband of the complainant was having history of hypertension and diabetes mellitus since 20 years . The husband of the complainant had intimated the opposite parties No.1 & 2 that he was having sugar problem but still policy in question was issued to him. On the same policy and inspite of the fact that the husband of the complainant was having sugar problem, his earlier claims vide claim No. 68957 dated 14.2.2014 for Rs. 32,800/- and 2nd claim No. 132707 dated 5.6.2015 for Rs. 21,591/0 and 3rd claim No. 162472 dated 4.1.2016 for Rs. 34,390/- were settled. So the refusal of the opposite party No.1 in settling the current claim amounts to deficiency in service . Complainant has sought for the following reliefs vide instant complaint :-
- Opposite party No.1 be directed to disburse the sum insured of Rs. 2 lacs to the complainant alongwith interest @ 12% p.a. from the date of lodging till its actual realization;
- Compensation to the tune of Rs. 30000/- alongwith litigation expenses may also be awarded to the complainant.
Hence, this complaint.
2. Upon notice, opposite party No.1 appeared and filed written version in which it was submitted that Insurance policy bearing No. 30081161201200 valid for the period from 22.9.2012 to 27.2.2013 with sum insured Rs. 2,00,000/- was issued to the complainant. This policy was renewed by the complainant and policy bearing No. 30081161201301 valid from 28.2.2013 to 27.2.2014 was issued by opposite party No.1. This policy was once again renewed and policy bearing No. 30081161201302 valid from 28.2.2014 to 27.2.2015 was issued to the complainant. This policy was once again renewed and policy bearing No. 30081161201503 valid from 28.2.2015 to 28.2.2016 was issued to the complainant. The present complaint has been filed because of repudiation of claim No. 177958. In order to ascertain the facts of the case an investigator was appointed by opposite party No.1 . During the course of investigation it was revealed that the policy holder was suffering from HTM & DM since 20 years. Dr. Vineet Sehgal, Fortis Escorts Hospital , Amritsar vide medical consultation paper dated 7.3.2014 mentioned that the policy holder Mr. Avtar Singh had history of DM/HTN since 20 years . The complainant has concealed the material f acts from this Court and has not come to the court with clean hands, therefore, she is not entitled to any claim. Therefore, the claim was rightly repudiated on the ground of non-disclosure vide letter dated 25.1.2016. It was denied that husband of the complainant intimated opposite parties No.1 & 2 that he was having sugar problem . It was submitted that the policy holder had not disclosed regarding his disease of sugar. While denying and controverting other allegations, dismissal of complaint was prayed.
3. In his bid to prove the case Sh. Vikram Puri,Adv.counsel for the complainant tendered into evidence duly sworn affidavit of the complainant Ex.C-1 alongwith documents Ex.C-2 to Ex.C-14 and closed the evidence on behalf of the complainant.
4. To rebut the aforesaid evidence Sh.R.P.Singh,Adv.counsel for opposite party No.1 tendered into evidence affidavit of Sh.Sheetal Patwa Ex.OP1/1A alongwith documnents Ex.OP1/1 to Ex.OP1/10 and closed the evidence on behalf of opposite party No.1.
5. We have heard the ld.counsel for the parties and have carefully gone through the record on the file as well as written arguments filed on behalf of opposite party No.1.
6. Ld.counsel for the opposite party No.1 has vehemently contended that the claim of the complainant has rightly been repudiated on the ground that insured was suffering from HTM & DM since 20 years . But this fact has been concealed by the insured at the time of obtaining the insurance policy . Had this fact been disclosed by the complainant in the proposal form , the policy would not have been issued to the complainant . So as per the terms and conditions of the policy the complainant is not entitled to any claim as he was suffering from pre-existing disease at the time of obtaining of the Insurance policy. It is submitted that after receiving the claim , the investigator of the opposite party investigated the hospital record and produced on record medical consultation paper dated 7.3.2014 wherein it was mentioned that the policy holder Mr. Avtar Singh had history of DM/HTN since 20 years. In view of this , the claim of the complainant was rejected vide letter dated 25.1.2016, copy whereof account for Ex.C-6 on record . Ld.counsel for the opposite party has vehemently contended that there is no deficiency in service on the part of the opposite party and a prayer for dismissal of the complaint with cost was made.
7. But, however, from the appreciation of the facts and circumstances of the case, it emerges that undisputedly the policy in question commenced since the year 2012 . The policy in question was in operation w.e.f. 22.9.2012 to 27.2.2013 & thereafter from 28.2.2013 to 27.2.2014, then from 28.2.2014 to 27.2.2015 and then from 28.2.2015 to 27.2.2016. It is an admitted fact that husband of the complainant remained admitted in EMC Hospital Pvt.Ltd in the month of January, 2016. It is the case of the complainant that she incurred an expenditure of Rs. 2,00,000/- on the treatment of her husband. Copies of bills of EMC Hospital accounts for Ex. C-7 on record. Thereafter complainant lodged claim with the opposite party for payment of Rs. 2,00,000/- (incurred at EMC Hospital) by completing all the requisite formalities and he also provided all the relevant documents required for the settlement of the claim. The husband of the complainant was continuously insuring himself since the year 2012 and the opposite party is duty bound to reimburse the expenditure incurred on the treatment duly covered under the policy. The only ground on which the claim of the complainant has been repudiated , has been that the complainant was suffering from HTN & DM since 20 years i.e. prior to the issuance of the insurance policy. But as per the numerous case law on the point, hypertension & Diabetes Mellitus are not a material disease. In such a situation, it is preposterous to presume that said disease was pre-existing or that non disclosure thereof at the time of obtaining the insurance policy amount to concealment. We would like to record that Hypertension and Diabetes Mellitus are no longer the material diseases as millions of people in this country are afflicted with these ailments We draw support from Life Insurance Corporation of India Vs. Sushma Sharma from II (2008) CPJ 213 wherein Hon'ble State Commission has held as under:-
“So far as hypertension is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.
We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease.
8. Moreover, if after obtaining the aforesaid policy since the year 2012, the opposite party has earlier disbursed the claim No. 68957 dated 14.2.2014 for Rs. 32,800/-, claim No. 132707 dated 5.6.2015 for Rs. 21,591/- and claim No. 162472 dated 4.1.2016 for Rs. 34,390/-, how the opposite party can refuse the said claim on the ground of suffering from sugar since 20 years . The said act of the opposite party in refusing the genuine claim of the complainant amounts to deficiency in service on the part of the opposite party. In such a situation the repudiation made by Opposite Party regarding genuine claim of the complainant appears to have been made without application of mind. It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
9. Regarding quantum of claim amount, the complainant has produced on record copy of hospital bill Ex.C-7 to prove that the complainant has incurred an expenditure of Rs. 2,00,000/- on the treatment of her husband. As such the complainant is entitled to the sum insured of Rs. 2,00,000/-.
10. From the aforesaid discussion, it transpires that Opposite Party has wrongly repudiated the claim of the complainant . As such, opposite party No.1 is directed to reimburse the amount of Rs. 2,00,000/- (incurred at EMC Hosptal) as claimed by the complainant. The costs of the litigation are assessed at Rs.2,000/-. Compliance of this order be made within 30 days from the receipt of copy of the order; failing which, awarded amount shall carry interest @ 9% p.a from the date of filing of the complaint until full and final recovery. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Forum
Dated : 18.7.2017
