BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.182 of 2019
Date of Instt. 23.05.2019
Date of Decision: 18.05.2023
Sh. Harjeet Singh of 67 years old S/o Lt. S. Amar Singh, R/o 161-L, Model Town, Near Daya Nand Model School, Jalandhar-144003. 98143 20006 (M)
..........Complainants
Versus
M/s Religare Health Insurance Co. Ltd., through its Managing Director/Chairman, Regd. Office: 5th Floor, 19 Chawla House, Nehru Place, New Delhi-110 019, Branch Office; 2nd Floor, SCO-44, PUDA Complex, Opposite District Administration Complex Jalandhar-144001.
….….. Opposite Party
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. A. K. Walia, Adv. Counsel for Complainant.
Sh. R. K. Sharma, Adv. Counsel for OP.
Order
Dr. Harveen Bhardwaj (President)
1. This complaint has been filed by the complainants, wherein alleged that the OP is engaged in the business of providing insurance coverage with regards to the person and property to general public for consideration throughout India and more particularly at Jalandhar. The complainant on getting convinced on the false promises of the OP through its agents/representatives, the firstly purchased one Religare Health Insurance policy bearing No.11558537 for the period 30-08- 2017 to 29-08-2018 on the payment of premium of Rs.37,902/- and again before the expiry of the earlier policy got it extended for the period 30-08- 2018 to 29-08-2019 by paying the premium of Rs.37,902/- on 24-08-2018, for himself and for his spouse Smt. Manjeet Kaur for Sum Insured Rs.5,00,000/-. The complainant at the time for getting the above mentioned Insurance Policy disclosed each and every thing including the health of the complainant and about the health of his spouse to the agent/representative of the OP and after considering the condition of health of the complainant and of the spouse of the complainant the opposite party issued the above mentioned policy and renewed the same for the second time. The OP allotted Client ID as 57033185 and send letters for the same without terms & conditions of the policy both times to the complainant. The complainant never received any terms and conditions of the above mentioned Policy at any time till now. Unfortunately, the complainant fell down at home and on 18-11-2018 admitted in the Johal Multispeciality Hospital, Hoshiarpur Road, Rama Mandi, Jalandhar - 144 005 and at the Hospital the concerned doctor noted down the Chief Complaints: patient presented with a/h/o fall at home last night pain over right thigh and pelvic region unable to move right thigh k/c/o htn dm dcmp and discharged on 25-11-2018 after treatment of fracture of Right Thigh and the complainant has paid the total amount of Rs.1,17,592/- to the said Hospital for the treatment besides expenses for medicine. The OP during the treatment of the complainant at Johal Multispeciality Hospital, Hoshiarpur Road, Rama Mandi, Jalandhar 144 005 vide its letter dated 20-11-2018 illegally against the terms and conditions of the policy refused cashless hospitalization. The complainant at last on 03-12-2018 lodged the claim for Rs.1,37,316/- with the opposite party at Jalandhar at its Branch Office with all the original documents. As per the terms as conveyed to the complainant by the OP, the complainant is entitled for Hospitalization Expenses, Treatment for breakage of bones, post hospitalization Medical Expenses, Domiciliary Hospitalization. The OP illegally, arbitrarily, without considering the documents, against the terms and conditions of the policy as received by the complainant, without application of mind etc, repudiated the claims of the complainant vide its letter dated 31-12-2018. The complainant was not treated at Johal Multispeciality Hospital, Hoshiarpur Road, Rama Mandi, Jalandhar - 144 005 during 18-11-2018 to 25-11-2018 for DCMP (Dilated Cardiomyopathy). The complainant was treated at Johal Multispeciality Hospital, Hoshiarpur Road, Rama Mandi, Jalandhar during 18-11-2018 to 25-11-2018 only for fracture in Right Thigh and advised for post operative conservative treatment and not for any other ailment/disease. Due to the above said facts complainant suffered mental tension, mental agony, financial loss, harassment, inconvenience etc. and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay Rs.3,00,000/- to the complainant as compensation for causing mental tension and harassment to the complainant.
2. Notice of the complaint was given to the OP, who filed joint written reply and contested the complaint by taking preliminary objections that at the very outset, it is respectfully submitted that the Complainant had purchased a health insurance Policy bearing No.11558537 (Product- Care Freedom) covering the Complainant and his spouse with effect from 30-08-2017 till 29-08-2018 which was further renewed till 29-08-2019 for a Sum Insured of Rs. 5,00,000/- subject to Policy Terms and Conditions. It is further averred that there is no deficiency of service or unfair trade practice on the part of the OP to invoke the jurisdiction of the Commission. Hence the complaint is liable to be dismissed at the outset for want of cause of action. The insurance is a contract between two parties and both the parties are under the obligation to obey/fulfill all terms and conditions of the policy in the strict sense of the words written therein. As terms and conditions of the policy are sacrosanct, the claim arrived is also processed within the precincts of the policy only. It is further averred that the complainant through his hospital approached the OP Company with a Cashless Claim Request with respect to hospitalization of the Complainant for the treatment of Right Femur at Johal Multi Specialty Hospital, Jalandhar. On receipt of the Cashless request, the OP company sought additional documents to get more clarity of the matter vide Query Letters dated 19.11.2018 received, it came to light that the complainant herein is a K/C/O dilated Cardiomyopathy (DCM). Therefore, the OP company denied the cashless request the same was intimated vide denial letter dated 20.11.2018. It is further averred that therein after the Complainant approached the OP Company with a Reimbursement Claim on 03.12.2018 pertaining to the hospitalization of the Complainant at Johal Multi Specialty Hospital, Jalandhar from 18-11- 2018 to 25-11-2018 wherein he underwent surgery for Rt Femur Fracture. On receipt of the Reimbursement Claim the OP Company to get more clarity of the matter triggered a claim investigation. Basis of the documents received in Query Reply and through investigation, it came to light that the Complainant herein has a history of Dilated Cardiomyopathy (DCMP) and the same was never disclosed to the Opposite Party Company at the time of Policy Inception. The Claim was thereby rejected vide Rejection Letter dated 31-12-2018.
That the contract of Insurance is contract of Uberrimae Fides, and by not declaring correct and accurate information at the time of proposing for the referred Policy, the Insured is guilty of breach of breach of principle of utmost good faith. As per Clause 7.1 of the Policy Terms and Conditions, the Insured was under obligation to disclose all material facts at the time of taking the Policy. For the sake of convenience Clause 7.1 of the Policy Terms and Conditions is reproduced herein below for your reference:-
Clause 7.1- ‘Disclosure To Information Norm’
‘If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particulars or any material information having been withheld or if a claim is fraudulently made or any fraudulent means or devices are used by the policy-holder or the insured person or anyone acting on his/their behalf, the company shall have no liability to make payment of any claims and the premium paid shall be forfeited to the company.’
As per the Consultation Paper dated 5.10.2016 and 02.12.2016 (i.e. prior to Policy Inception) prepared by Shri Ram Cardiac Centre Joshi Hospital, Jalandhar, the Complainant is specified to have been diagnosed with ‘Dilated Cardiomyopathy (DCMP)’. That in addition to the same As per the Discharge Summary dated 01-10-2016 (i.e. prior to Policy Inception) as prepared by BBC Heart Care, Pruthi Hospital, Jalandhar, the Insured had Acute LVF. It is further averred that the Insured had disclosed his history of Hypertension and Diabetes Mellitus in his proposal form. Along with these, the Complainant had the opportunity to disclose his history of Dilated Cardiomyopathy (DCMP) at the time of filling the Proposal Form. However, no such disclosure was made by the Complainant. It is pertinent to mention here that the Complainant has willfully left the question pertaining to Cardiovascular/Heart disease blank. On merits, the factum with regard to purchase a health insurance policy covering the complainant and his spouse w.e.f. 30.08.2017 to 29.08.2018 and the same was further renewed till 29.08.2019 for a sum insured of Rs.5,00,000/- subject to terms and conditions, is admitted and it is also admitted that the complainant had disclosed the history of Dilated Cardiomyopathy (DCMP) to the at the time of availing the policy, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.
6. It has been admitted and proved that the complainant purchased one Health Insurance policy bearing No.11558537 covering the complainant and his spouse w.e.f. 30.08.2017 till 29.08.2018, which was further renewed till 29.08.2019 for a sum insured of Rs.5,00,000/-. The complainant has proved on record the copies of the policies Ex.C-1 and Ex.C-2. The complainant has alleged that on 18.11.2018, he fell down at home and was admitted in the Johal Multispeciality Hospital, Jalandhar. He has proved on record the admission record of the complainant Ex.C-3, which shows that he presented with A/H/O fall at home last night pain over right thigh and pelvic region unable to move right thigh K/C/O HTN DM DCMP. He has proved on record the discharge summary Ex.C-4, which shows that he was discharged on 25.11.2018, meaning thereby he remained admitted in the hospital from 18.11.2018 to 25.11.2018 with A/H/O Fall At Home and he underwent surgery on 19.11.2018 and after due treatment and medication, he was discharged. It is admitted that the insurance policy was a cashless policy, but the OP denied the cashless request vide letter dated 20.11.2018.
7. The OP has proved on record the copy of cashless request form Ex.R-2 and query letter Ex.R-3, denial of claim has been proved as Ex.R-4/C-5. It is also admitted that thereafter the complainant lodged the claim for Rs.1,37,316/- with the OP and the claim form has been proved as Ex.C-3. The claim was rejected vide rejection letter dated 31.12.2018 vide Ex.C-7.
8. The contention of the OP is that the complainant has concealed the material facts from the OP and he has not disclosed about his pre-existing disease. His claim was rejected under clause 7.1 of the terms and conditions of the insurance policy. The Clause 7.1 of the policy reads as under:-
Clause 7.1- ‘Disclosure To Information Norm’
‘If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particulars or any material information having been withheld or if a claim is fraudulently made or any fraudulent means or devices are used by the policy-holder or the insured person or anyone acting on his/their behalf, the company shall have no liability to make payment of any claims and the premium paid shall be forfeited to the company.’
9. Perusal of the Ex.C-5 shows that the cashless request was denied under non-disclosure as patient is K/C/O Dilated Cardiomyopathy (DCM) prior to policy inception and a non-disclosure of material fact/pre-existing ailments at time of proposal. Perusal of Ex.C-7/R-6 shows that the claim was declined and denied on the same ground.
10. The OP has alleged that the medical record of the complainant was collected and it came to the light that the complainant is a case of Dilated Cardiomyopathy (DCMP). The OP has produced on record the consultation paper dated 05.10.2016 and 02.12.2016 prepared by Shri Ram Cardiac Centre Joshi Hospital, Jalandhar Ex.R-7 and Ex.R-8. The proposal form has also been proved by the OPs. Perusal of Ex.R-7 and Ex.R-8, the discharge summary show that the complainant was diagnosed with TDM/HTN/DCMP/LVEF-20-25% and Ex.R-8 shows that he was diagnosed with Acute LVF (underlying Severe systolic dysfunction). This discharge summary shows that he remained admitted in the BBC Heart Care Hospital from 29.09.2016 till 01.10.2016. The OP has alleged that the contract of insurance is contract of Uberrimae Fides and by not declaring correct and accurate information at the time of proposing for the referred policy, the insured is guilty of breach of principle of utmost of good faith. Therefore, they have alleged that the claim was rightly repudiated. The OP has relied upon the proposal form Ex.R-9, in which the complainant has allegedly not disclosed about his pre-existing disease. The OP has also relied upon the law laid down by the Hon’ble Supreme Court, in a case titled as “Satwant Kaur Sandhu Vs. New India Assurance Co. Ltd.” 2009 (4) RCR (Civil) 692, in which the question for consideration was whether the fact that at the time of taking out the mediclaim police, the policy holder was suffering from chronic diabetes and Renal failure or not and on account on non-disclosure of the fact, whether the insurance company was justified in law in repudiating the claim of the appellant? The Hon’ble Supreme Court in the above said case has held that the insurance company was justified in rejecting the claim as it was a fraudulent claim. The complainant was suffering from chronic and Renal failure and diabetic Nephropathy from 1st June, 1990 i.e. within 3 weeks of taking the policy and thereafter he died, but in the present case the facts are different and these facts are not applicable to be present case.
11. The OP has relied upon the law referred by the Hon'ble National Commission, in a case titled as ‘LIC Vs. Neelam Sharma’, in which the Hon'ble National Commission has held that the material facts, which were related with the disease diagnosed later on and concealment of this fact was held to be material for the purpose of obtaining the policy, but in the present case, the facts are different as the complainant was diagnosed as per the record produced by the OPs with Dilated Cardiomyopathy (DCMP), but he took the treatment from Johal Hospital, regarding which he applied for the present claim, for fall at home last night, pain over right thigh. Both the DCMP and Pain due to fall are different problems. Perusal of the proposal form Ex.R-9 shows that the complainant has neither admitted nor denied about the cardio vascular heart disease. He has disclosed about the hypertension/high blood pressure and he has also disclosed about the diabetes mellitus type at the time of inception of the policy and in the column of additional information, it was specifically mentioned that the insured was diabetes for the last 10 years and having hypertension for the last 8 years. There is no concealment of the fact that he was suffering from BP and diabetes. The OP has not got him medically examined to know about the medical health or heart health to know the effects of diabetes and BP. At the time of renewing the policy or doing the policy initially, it is the duty of the insurance company to get the person medically checked up, so that they can come to the conclusion as to whether he is eligible for the insurance or not. The insurance companies cannot be allowed to take the premium and when the complainant suffers problem and seeks reimbursement, then they refuse on the ground that he has concealed the previous medical problem. It has been held by the Hon’ble Punjab & Haryana High Court, in Civil Revision No.2318 of 2008, decided on 22.04.2008, titled as “New India Assurance Company Limited Vs. Smt. Usha Yadav & Others”, 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’. So, there was no reason for the OPs not to ask or get him medically examined to know about the heart health. More so, there is not a connection of heart disease with the problems suffered by the complainant for which he was admitted in hospital. It has been held by the Hon’ble Punjab & Haryana High Court, in a case titled as ‘Aviva Life Insurance Company India Limited Vs. Sarita Tripathi and ors’ that ‘act of repudiation cannot itself be construed as act of annulment of policy itself - Cause of death was neither directly nor indirectly related to any health issues, ailment, sickness or disease and was altogether an in- dependent, unrelated risk i.e. motor vehicular accident Fact of suppression of coronary - angiography would have material information in case cause of death was directly or in- directly linked to health However, since - cause of death has no proximity to health, in- formation would only be relevant information Insurance policies intend to provide respite to family upon occurrence of unfortunate event, interpretation to be adopted should advance object of law - Legislative intent of information to be ‘material’ cannot be completely ignored and to deprive insured of all benefits treating all information to be material) Hence, award upheld’.
In the present case also, the disease i.e. the fracture suffered by the complainant due to fall has no proximity to heart health, therefore this was not a material information or material facts to be disclosed. Thus the complainant is entitled for the relief.
12. In view of the above detailed discussion, the complaint of the complainants is party allowed and OP is directed to pay hospital expenses and medicine expenses etc. as per bills submitted in the Court by the complainant. Further, OP is directed to pay a compensation of Rs.15,000/- for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
13. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Dr. Harveen Bhardwaj
18.05.2023 Member President
