DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, JALANDHAR
Complaint No.299 of 2017 Date of Instt. 23.08.2017 Date of Decision: 09.03.2021
Chander Parkash son of Sh. Amar Nath Shoor, resident of 192, Adarsh Nagar, Jalandhar.
….. Complainant
Versus
1. M/s Appollo Munich Health Insurance, ILABS Centre, 2nd and 3rd Floor, Room No. 404-405, Udyog Vihar, Phase III, Gurgaon, Haryana, through its Chairman.
2. Customer Care Head, M/s Appollo Munich Health Insurance, ILABS Centre, 2nd and 3rd Floor, Room No. 404-405, Udyog Vihar, Phase III, Gurgaon, Haryana.
3. Claim Support Head, M/s Appllo Munich Health Insurance, ILABS Centre, 2nd and 3rd Floor, Room No. 404-405, Udyog Vihar, Phase III, Gurgaon, Haryana.
4. Chairman /Chief Head, M/s Appollo Munich Health Insurance, ILABS Centre, 2nd and 3rd Floor, Room No. 404-405, Udyog Vihar, Phase III, Gurgaon, Haryana.
5. Appollo Munich Health Insurance, Satnam Complex, Near BMC Chowk, Jalandhar through its Branch Manager/Authorized Representative.
6. Appollo Munich Health Insurance, 1st Floor, SCF-19, Sector 14, Gurgaon, Haryana through its Authorized Representative.
7. Appllo Munich Health Insurance, Appollo Hospital Complex, Jubilee Hills, Hyderabad 500 033, Telangana through its Chairman.
…Opposite parties
Complaint under the Provisions of Consumer Protection Act.
QUORUM:
SH. KULJIT SINGH, PRESIDENT
MRS. JYOTSNA, MEMBER
ARGUED BY :
For Complainant : Sh.Gulshan Arora, Advocate
For OPs No.1 to 7 : Sh.A.K. Gandhi, Advocate
ORDER:-
KULJIT SINGH, PRESIDENT
The present complaint has been filed by complainant against the OPs on the averments that he purchased a Health Insurance Policy bearing no. 110300/11001/10003399781 from OP no.4 in the year 2012. At the time of getting insurance policy, he was directed to get his thorough medical checkup by the doctor on the panel of insurance company, which he got conducted. After satisfaction of the medical condition of the complainant, he got insurance policy, which was granted to him after issuance of medical certificate from the panel of doctors, who certified that complainant was not suffering from any disease. The complainant has been regularly paying the annual premium without any default since 2012. He felt ill and remained admitted in Shingara Singh Hospital Jalandhar from 10.11.2016 to 12.11.2016 and thereafter he remained admitted in Global Hospital from 12.11.2016 to 21.11.2016. Thereafter, he remained admitted in Fortis Hospital Gurgaon from 05.01.2017 to 07.01.2017. Thereafter, he lodged claim for reimbursement of medical expenses incurred by him at Shingara Hospital Jalandhar vide claim ID 495682 for Rs.33,681.00 and expenses incurred at Global Hospital against claim ID 494949 for Rs.2,35,229.00 and expenses incurred to the tune of Rs. 44,387/- at Fortis Hospital, Gurgaon. After filing of the claim, OP no.3 sent email message dated 16.12.2016 to the complainant and email dated 19.12.2016 informing that the claim lodged by the complainant was registered and it was under process and would be settled within 7 days from the date of issuance of acknowledgment. A query was raised on 21.12.2016 asking the complainant to submit some additional documents along with the original documents, which were already submitted with the OPs at the time of lodging the claim. He was asked to deposit the additional documents, which were already submitted by him. On 25.01.2017 OP no.3 sent email to complainant intimating that claims against ID No. 495682 and 494949 have been repudiated without any reason on the ground that complainant is the history of diabetic and hypertension and this fact was concealed by him. The complainant is not a case of Diabetic and Hypertension and he submitted his blood test report dated 05.11.2016 along with medical certificate of Dr. Navdeep Gupta who certified that complainant did not have hypertension nor he is diabetic. Before grant of insurance policy, he was thoroughly medically checked up and he was declared medically fit. After four years, when the complainant suffered problem and lodged his claim, the OPs illegally repudiated the same. The complainant sent email dated 07.02.2017 with attachment of Blood Test Report, which clearly shows that Thyroid Test is normal and certificate from Dr. Navdeep Gupta of Karna Hospital, Jalandhar stating therein that the complainant had no Hypertension or Thyroid and also attached certificate from Jatinder Pal Singh of Shingara Singh Hospital, Jalandhar. Due to act and conduct of OPs, he has filed the present complaint and prayed that OPs be directed to disburse the amount of Rs.3,13,297.00 to the complainant being the expenses incurred by him for his treatment and also to pay Rs.10 lakh as damages for undue harassment, inconvenience, mental tension and loss of time.
Upon notice, OPs appeared and filed their joint written reply and contested the complaint of the complainant by raising preliminary objections that complaint is false. The complainant is not consumer of OPs. On merits, it was averred that policy was purchased by the complainant with his free will and the terms and conditions of the policy was duly explain to the complainant. It was duty of the complainant to disclose all the material facts to OPs in the proposal form. Due to non-disclosure of material facts by the complainant to OPs, the insurance contract become void and premium paid by the complainant stand forfeited. The complainant felt ill and remained admitted in Shingara Singh Hospital Jalandhar from 10.11.2016 to 12.11.2016 and thereafter remained admitted in Global Hospital from 12.11.2016 to 21.11.2016 and complainant further admitted in Fortis Hospital from 05.01.2017 to 07.01.2017. The complainant has failed to supplied the documents and also failed to answer the query raised by OPs, vide letter dated 22.12.2016 despite several reminders dated 05.01.2017, 13.01.2017, 30.12.2016, 06.01.2017, 20.01.2017 and 02.02.2017 were sent to the complainant. As per investigation and medical record, it has duly proved the fact that complainant was suffering from diabetes and hypertension since 7 years. Rest of the averments of the complaint was denied by OPs and they prayed for dismissal of the complaint.
The complainant has tendered in evidence his affidavit Ex.C-A along with copies of the documents Ex.C-1 to Ex.C-21. On the other hand, OPs have tendered in evidence affidavit of Deepti Rustogi Senior Vice President- Legal & Compliance as Ex.OP-A along with copies of the documents Ex.OP-1 to Ex.OP-11.
We have perused the written arguments filed by both the parties on the record as well as record of the case very minutely.
5. The complainant has tendered in evidence his affidavit Ex.C-A on the record. He testified his averments in his affidavit. Ex.C-1 is copy of letter dated 29.09.2017. Ex.C-2 is copy of query letter. Ex.C-3 is copy of rejection letter dated 28.03.2017. Ex.C-4 is copy of rejection letter dated 14.04.2017. Ex.C-5 is copy of claim acknowledgment letter dated 16.12.2016. Ex.C-7 is copy of query letter. Ex.C-8 is copy of rejection letter. Ex.C-9 to Ex.C-10 are copies of prescription slip of the doctor. Similarly, we have also examined other copies of documents Ex.C-11 to Ex.C-21 placed on the record.
6. To refute this evidence of the complainant, OPs tendered in evidence affidavit of Deepti Rustagi Senior Vice President as Ex.OP-A on the record. Ex.OP-1 is copy of proposal form. Ex.OP-3 is copy of claim form. Ex.OP-4 is copy of card issued in the name of the Patient Chander Parkash. Ex.OP-5 is copy of discharge summary of the patient. Ex.OP-6 is copy of reimbursement claim verification report dated 24.02.2017. Similarly, we have examined other documents placed on record.
7. It is an established fact that the complainant felt ill and remained admitted in the Shingara Singh Hospital Jalandhar from 10.11.2016 to 12.11.2016 and thereafter he remained admitted in Global Hospital from 12.11.2016 to 21.11.2016. Thereafter, he remained admitted in Fortis Hospital Gurgaon from 05.01.2017 to 07.01.2017. He lodged claim for reimbursement of medical expenses incurred by him at Shingara Singh Hospital Jalandhar vide Claim ID 495682 for Rs.33,681/- with OPs. On the other hand, OPs repudiated the claim of the complainant on the ground that complainant had past history of Diabetic Mellitus and Hypertension for the last seven years.
8. The main controversy involved in the present case is that complainant has concealed the fact of pre-existing disease from OPs or not? We are of the opinion that the diseases of diabetic mellitus and hypertension are not diseases, which means tension or tonus that is greater than normal, a condition in which the patient has a higher blood pressure than that judged to be normal, cannot be treated as a disease. Hypertension is not a permanent diseases and it sometimes increased and sometimes it reduces and that non-mentioning of such type of disease in the declaration form would not amount to misstatement in the real sense. We observed that Diabetic Mellitus and Hypertension are not a chronic diseases, both are increase or decrease at any time.
9. The learned counsel for complainant relied upon various judgments in support of his case, the case titled as United India Insurance Company versus Anil Kaushal reported in 2013(2) CLT 442 of Hon’ble State Commission, Punjab Chandigarh wherein it has been held “that repudiation of insurance claim on the ground that insured concealed the pre-existing issue while making declarations in proposal form. Held. No evidence produced on record to establish that insured have prior knowledge of disease.” The case titled as Manish Goyal versus Max Bupa Health Insurance Company Limited reported in 2018(2) CLT 205 of Hon’ble State Commission Punjab Chandigarh wherein it has been held that “insurance claim rejected on the ground that insured not disclosed the pre-existing disease and doctor recorded the past history of illness. No medical examination got conducted by the insurance company.” The case titled as Religare Health Insurance Company Ltd versus Subhash Chander Aggarwal reported in 2017(3) CLT 140 that “repudiation and cancelation of policy and refund on ground of concealment of pre-existing disease hypertension. Deficiency in service. District Forum allowed the complaint. Hypertension is a common disease and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack and repudiation on account of pre-existing disease was not justified.” The case titled as United India Insurance Co. Ltd. & Another versus S.K. Gandhi reported in 2015(2) CLT 71 of Hon’ble National Commission, New Delhi that “repudiation on the ground that complainant had history of acute hypertension and CAD which are main factors for heart ailment but the aforesaid ailment was not disclosed by him to the insurance company at the time of taking the policy. The onus was upon the insurance company to prove that he had made a misrepresentation while obtaining the insurance policy.” The case titled as Life Insurance Corporation of India versus Rampati reported in 1997(2) CPJ 137 of Haryana State Commission, Chandigarh that “concealment of disease –Insurance claim was repudiated on the ground of concealment of previous disease by the insured. Secondly, diabetes is not such a serious ailment to be disclosed by the insured. Order of District Forum accepting the insurance claim is well reasoned. Appeal stands dismissed.”
10. On the other hand, learned counsel for OPs relied upon judgments Diwan Surender Lal vs. Oriental Insurance Co. Ltd of Hon’ble National Commission reported in 2008(4) CPR 438 that assured must disclose to the insurer all material facts. Breach of this duty by assured entitles the insurer to avoid the contact of insurance. General Assurance Society Ltd Vs. Chandumull Jain and Another reported in 1996(3) SCR 500 that policy document being a contract and it has to be read strictly. The contract is expressed by the parties. Senior Divisional Manager LIC vs. Satwant Kaur Sandhu in Revision Petition 3138 of 2006 SC that if proposal had knowledge of “material fact” he is obliged to disclose it particularly while answering questions in the proposal form.
11. From perusal of citations and considering the facts of the present case, we find that, it was duty of OPs to medically check up the insured at the time of filling up the proposal form and from perusal of proposal form it is clear that insured/complainant is medically fit. Hypertension and Diabetic Mellitus are rise after taking the policy. Both diseases are not chronic diseases, these are increase or decrease at any time. Both diseases are reduces with the help of medication. There is also no material to show that there was any earlier treatment in respect of any Hypertension or Diabetic Melltus, which were concealed by the complainant while making the proposal for insurance cover. The defence which has been taken by the insurance companies/OPs was having no legs to stand. We are of the view that the burden was on the OPs to prove that the insured had concealed the material fact of his pre-existing disease at the time of taking the policy. The OPs have failed to produce on record any document to show that insured/complainant was suffering from above said diseases. The National Consumer Disputes Redressal Commission (NCDRC) said even if the insured person was suffering from a diseases (Hypertension & Diabetic Mellitus) and did not know about it nor was taking any treatment for the same, the claim cannot be denied by an insurance
