Chandigarh

StateCommission

A/16/2019

Apollo Munich Health Insurance Company Ltd. - Complainant(s)

Versus

Mrs. Ragini - Opp.Party(s)

Sachin Ohri, Adv.

11 Mar 2019

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

 

 

Appeal No.	:	16 of 2019
Date of Institution	:	25.01.2019
Date of Decision	:	11.03.2019

 

Apollo Munich Health Insurance Co. Ltd., Manager, Chandigarh, Branch office: 4^th Floor, SCO No.50-51, Sector 34-A, Chandigarh, Manager/Authorised Signatory, 10^th Floor, Building No.10, Tower-B, DLF City, Phase-II, DLF Cyber City, Gurgaon through Deepti Rustagi, Vice President – Legal & Compliance, Apollo Munich Health Insurance, iLabs Centre, 2^nd & 3^rd Floor, Plot No.404-405, Udyog Vihar, Phase-III, Chandigarh.

 …….Appellant.

 

Versus

 

Mrs. Ragini wife of Mr. Tarlochan Singh, aged about 54 years, resident of House No.269, Phase 3-A, Mohali 160059 (Punjab).

 

...Respondent.

 

Appeal under Section 15 of the Consumer Protection  Act, 1986 against  order dated 15.10.2018 passed by District   Consumer Disputes Redressal Forum-II, U.T. Chandigarh  in Consumer Complaint No.865 of 2017.

 

BEFORE: JUSTICE JASBIR SINGH (RETD.), PRESIDENT.

                MRS. PADMA PANDEY, MEMBER.

                MR. RAJESH K. ARYA, MEMBER.

 

Argued by:

 

Sh. Sachin Ohri, Advocate for the appellant.

 

PER  RAJESH  K.  ARYA, MEMBER

                   The appellant/opposite party has filed this appeal against order dated 15.10.2018 passed by District Consumer Disputes Redressal Forum-II, U.T., Chandigarh (in short ‘the Forum’ only), vide which, complaint bearing No.865 of 2017 filed by the respondent/complainant was allowed in the following manner:-

“12]      From the above discussion, it is held that the Opposite Parties have wrongly & illegally rejected the claim of the complainant as well as wrongly cancelled the policy in question, which clearly amounts to gross deficiency in service and unfair trade practice on their part.  Therefore, the present complaint is allowed against the Opposite Parties with following directions:-

a.      To reimburse  the claim amount of Rs.67,413/- to the complainant;

b.      To restore the policy in question in the name of subscriber/insured with upto date benefits;

c.      To pay an amount of Rs.15,000/- as compensation for causing harassment & mental agony to the complainant on account of deficiency in service coupled with unfair trade practice on the part of OPs;

d.      To pay an amount of Rs.7000/- towards litigation expenses.

         This order be complied with by the OPs within a period of 30 days from the date of receipt of its certified copy, failing which the Opposite Parties shall also be liable to pay additional cost of Rs.20,000/- apart from the above relief.”

2.              Before the Forum, it was case of the complainant that the complainant and her husband took a Health Insurance Medical Coverage from the Opposite Parties on 18.3.2013. It was stated that the agent of the Opposite Parties got signed blank proposal & other forms from the complainant and her husband for providing medical coverage. It was further stated that the complainant and her husband had to get medical tests done from empanelled hospital/lab of the Opposite Parties i.e. Universal Diagnostic Centre, Sector 19-D, Chandigarh and only thereafter, the Opposite Parties issued ‘Optima Restore Insurance Policy’ in favour of the complainant and her husband valid from 23.3.2013 to 22.3.2014.  It was further stated that the said policy was got renewed by the complainant from time to time. It was further stated that in September 2016, the complainant suffered from Dengu fever for which a claim was reported to the opposite parties for treatment and a sum of Rs.48,754/- was paid by the opposite parties and at that time, no ailment of pre-existing disease was found at the Ivy Hospital, Mohali. It was further stated that on 11.5.2017, the complainant got admitted in Laser Eye Clinic, Sector 22-A, Chandigarh for getting treatment for Cataract Right Eye for which a reimbursement claim of Rs.67,413/- was lodged with the Opposite Parties, but the same was illegally rejected by them vide letter dated 20.7.2017 (Annexure C-10) on flimsy ground claiming that as per medical history, the complainant was a known case of diabetics for the last 10 years.  It was further stated that the Opposite Parties not only rejected the genuine claim of the complainant but also terminated the policy of insurance, in question, despite having it renewed for one year from March, 2017 to March, 2018. Hence, complaint was filed before the Forum.

3.             The opposite parties, in their reply, while admitting the factual matrix of the case, stated that the claim of the complainant was received on 2.6.2017 for a total sum of Rs.67,413/- which included consultation, medicine, biometry and cataract surgery. It was further stated that during the investigation of medical claim of complainant, it was revealed that the complainant was a known case of diabetic mellitus and hypertension for the last more than 10 years and had been taking treatment in various Hospitals including Post Graduate Institute of Medical Education and Research, Chandigarh.  It was further stated that this fact was also mentioned in a prescription slip issued by Dr. D. Sachdeva, which in fact the policyholder did not disclose in the application/proposal form filled for obtaining insurance policy inspite of specific questions asked relating to medical and life style information of insured/proposer.  It was further stated that since the insured member i.e. Ragini was a known case of diabetic mellitus & hypertension and since this fact was not disclosed by the complainant in the proposal form dated 18.3.2013, which was material to be disclosed in the said form, therefore, the opposite parties rightly repudiated the claim and cancelled the policy as per terms & conditions of the policy. It was further stated that neither there was any deficiency, in rendering service, on the part of the opposite parties nor they indulged into any unfair trade practice. The remaining averments, were denied, being wrong.

4.             The complainant filed rejoinder, wherein she reiterated all the averments, contained in the complaint and controverted those, contained in written version of the opposite parties.

5.            The parties led evidence. The Forum, on analysis of pleadings of the parties, documents on record, and the arguments addressed, allowed the complaint as referred to above.

6.             The appellant has assailed the impugned order passed by the Forum on the ground that the policy was issued as per disclosures made by the policy holder in the proposal form believing the information given in the proposal form as true. It was further submitted that the Forum misinterpreted the medical examination and formed its own opinion that since the complainant and her husband had undergone medical examination before issuance of the policy, in question, so no question arises about suppression of fact to be left open to decide. It was further submitted that the medical examination of members to be insured is done on the basis of the disclosures made by the policy holder to the insurance company. It was further submitted that on the basis of disclosures, insurance company gets the members medically examined otherwise only routine tests are conducted before issuing the policy. It was further submitted that it is not possible to conduct N number of tests of the human body and cost of the same would be very high and even more than the premium of the policy. To support his argument, the Counsel placed reliance on the judgment of Hon’ble National Consumer Disputes Redressal Commission, New Delhi in Bajaj Allianz Life Insurance Co. Ltd. & Anr. Vs. Raj Mittal, 2015 (4) CLT 379. It was further stated that the finding of the Forum is totally against the guidelines of the IRDA. By raising the aforesaid argument, it was prayed that appeal be allowed and the impugned order passed by the Forum be set aside.

7.             After going through the evidence on record and submissions of the Counsel for the appellant, we are of the opinion that the appeal is liable to be dismissed, at the preliminary stage, for the reasons to be recorded hereinafter. Undoubtedly, the policy, in question, was issued by the opposite parties after satisfying qua the health of the complainant and her husband and that too after medically examining both of them. Not only this, they (opposite parties) kept on renewing the said policy from time to time, which reveals that both of them were not suffering from any disease and were hale and hearty. Had the complainant and her husband not been medically examined before issuing of the policy in question, which was renewed from time to time, the matter would have been different. The ground on which the claim was repudiated was totally without any basis particularly when there is nothing on record to show that the complainant is suffering from Diabetes & Hypertension since 10 years. We agree with the finding given by the Forum that the rejection of the claim, in question, on the ground of pre-existing disease i.e. Diabetes Mellitus since 10 years, had no substantial basis as the opposite parties had with malafide intention sidelined the information supplied by the treating doctor that the complainant is a known Diabetic and Hypertensive since four years. Thus, the opposite parties miserably failed to prove on record that the complainant was suffering from Diabetes and Hypertension since 10 years and was under treatment. Accordingly, as rightly held by the Forum, repudiation of genuine claim of the complainant on aforesaid ground of pre-existing disease and non-disclosure of the same at the time of inception of policy and subsequent thereto was totally illegal and not tenable. The Forum in Paras 10 and 11 of its order rightly held as under:-

“10]      It is also observed that the complainant has first availed the insurance policy in question in the year 2013 and since then, is getting the same renewed on yearly basis and the Opposite Parties are also enriching themselves by getting the premiums while renewing the policy in question. Further, it is not denied that they had also paid one medi-claim during the subsistence of the coverage period in the year 2016.  Strange enough to think that at one point of time, the OPs are disbursing the claim to the complainant treating the policy to be valid and at the same time they are rejecting the claim for subsequent period under the same renewed policy. This contradictory stand of the Opposite Parties is not acceptable.  Thus, it is held that the complainant is entitled for reimbursement of her claim to the tune of Rs.67,413/- incurred on the treatment during the coverage period.

11]      Further, it is pertinent to mention that the complainant has rightly challenged the wrong cancellation of the policy done by the OPs. We are of the view that the cancellation of the policy done by the OPs is totally illegal and arbitrary and also the OPs cannot be allowed to forfeit the right of the complainant/policyholder to get the policy renewed for further period.”

8.             The judgment relied upon by the appellant (opposite parties) in the case of Bajaj Allianz Life Insurance Co. Ltd. & Anr. (supra), is of no help to the appellant (opposite parties) being distinguishable on facts. In that case, the claim was repudiated by Insurance Company on the ground of misrepresentation and concealment of material facts of earlier diagnosis of Chronic Renal Failure (CRF), Hypothyroidism and the problem of Prostate. The Forum allowed the complaint. The appeal filed was also dismissed by the State Commission, Punjab. Hence, revision was filed by the Insurance Company before the Hon’ble National Commission. The contention of the complainant that concealment would not matter firstly, because the insured was medically examined before issue of the insurance policy and secondly, because the cause of death had no relation whatsoever with the ailments for which the deceased was diagnosed by hospital in the year 2005 was rejected by the Hon’ble National Commission. It was held by the Hon’ble National Commission that the medical examination before issuance of policy is not a thorough medical examination which may detect each and every ailment. Repudiation of claim was held proper by the Hon’ble National Commission.

9.             In the instant case, first of all, there is no such plea taken by the complainant as was taken before the Hon’ble National Commission in the cited case. Furthermore, tests to detect Diabetes & Hypertension are very common and simple tests, which every Insurance Company is expected to conduct before issuing any policy. The argument raised by the appellant (opposite parties) that it is not possible to conduct N number of tests of the human body and cost of the same would be very high and even more than the premium of the policy, has no legs to stand. Such an irresponsible argument on the part of the appellant (opposite parties) shows their business minded attitude and becoming only premium collecting agencies by pocketing hard earned money of poor consumers, who approach them with a hope that they will be indemnified in case of any ailment, for which purpose, the policy was proposed for. It is generally seen that the Insurance Companies at the time of issuing medi-claim policies made high claims qua benefits covered under the said policies and receive hefty premiums from poor consumers but when they receive any medical claim, their tendency is usually to repudiate the same by taking baseless and flimsy grounds. In our considered opinion, the aforesaid argument raised by the Counsel for the appellant does not hold water. We, therefore, affirm the view held by the Forum that the opposite parties illegally rejected the claim of the complainant on false and flimsy grounds and as such, they are liable to reimburse the claim amount to the complainant. The Forum rightly directed the opposite parties to pay the claim amount of Rs.67,413/- to the complainant and also to restore the policy, in question, in the name of the subscriber/insured with up-to date benefits. It also rightly awarded an amount of Rs.15,000/- and Rs.7,000/- towards compensation for causing harassment & mental agony to the complainant and litigation expenses.

10.           Hence, we are of the opinion that the order passed by the Forum, being based on the correct appreciation of evidence and law, on the point, does not suffer from any illegality or perversity.

11.           No other point was raised by the Counsel for the appellant.

12.           For the reasons recorded above, this appeal being devoid of any merit, is dismissed in limine, with no order as to costs. The impugned order passed by the District Forum is upheld. Consequently, in view of dismissal of appeal, the application for condonation of delay in filing the instant appeal stands dismissed having been rendered infructuous.

13.           Certified copies of the order be sent to the parties free of charge.

14.           File be consigned to the Record Room after completion.

Pronounced

11.03.2019.

[JUSTICE JASBIR SINGH (RETD.)]

PRESIDENT

 

 

(PADMA PANDEY)

        MEMBER

 

 

(RAJESH  K. ARYA)

MEMBER

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