Delhi

StateCommission

CC/1264/2017

SH. GULSHAN RAI VERMA & ANR. - Complainant(s)

Versus

M/S RELIGARE HEALTH INSURANCE & ANR. - Opp.Party(s)

NIKHIL BAHRI

01 Sep 2017

ORDER

IN THE DELHI STATE CONSUMER DISPUTES REDRESSAL, COMMISSION : DELHI

(Constituted under Section 9 of the Consumer Protection Act, 1986)

Date of Arguments :  18.08.2017

Date of Decision :  01.09.2017

Complaint No. 1264/2017

 

IN THE MATTER OF:

 

1. Shri Gulshan Rai Verma,
2. Mrs. Annu Verma

 

Both resident of :

 

          C-6509, Pocket-6 & 7,

          Vasant Kunj,

          New Delhi-110070.                                                        ........Complainants

 

VERSUS

 

1. M/s. Religare Health Insurance,

D-3,  District Centre, Saket,

New Delhi-110017.

 

Also at:

 

Vipul Tech Square Tower-C,

3^rd Floor, Sector-43,

Golf Course Road,

Gurgaon-122009

 

2. M/s. SMC Insurance Broker Pvt. Ltd.,

11/6-B, Shanti Chamber,

Pusa Road, New Delhi-110005.                             …….…Opp. Parties

 

CORAM

 

SH. O. P. GUPTA, MEMBER (JUDICIAL)

SH. ANIL SRIVASTAVA, MEMBER

1.     Whether reporters of local newspaper be allowed to see the judgment?                                                               Yes/No

2.      To be referred to the reporter or not?                                                                                                        Yes/No

 

Present  :   Sh. Nikhil Bahri, Counsel for the Complainant.

PER   :   SHRI ANIL SRIVASTAVA, MEMBER

 

          Point for consideration in this complaint filed by Sh. Gulshan Rai Verma and his wife Smt. Annu Verma, resident of New Delhi, for short complainant no.1 and 2 respectively, is whether, the M/s. Religare Health Insurance, a Company registered under the provisions of the Companies Act, having its registered office at New Delhi, for short opposite party no.1, having insured the complainants through M/s. SMC Insurance Broker Pvt. Ltd. ( opposite party no.2) after accepting the premium and later cancelling the medical policy, causing hardship to the complainants, both mental and physical, have been deficient in rendering service to the complainants.

          On the request of the complainants the opposite party no.1 had issued a mediclaim policy to them on 22.08.2016 for a total sum insured for Rs.7,00,000/- through the opposite party no.2 although initially the sum insured was of an amount of Rs.10,00,000/-.  Premium was paid on 03.08.2016 on the sum insurance of Rs.10,00,000/-.

          The allegations of the complainant is that details regarding height and weight of  the insurers, the complainants as also their previous medical history were  incorrectly mentioned in the proposal form.  The incorrect details so indicated were brought to the notice of  the doctor conducting their medical check up as also to the Relationship Manager of the opposite party no.1 but no correction  was done in the proposal form.  The gravaman of the complainant is that the policy was issued in the sum insured of Rs.7,00,000/- on paying Rs.42,640/- an Rs.9,172/- as a composite premium, defeating the very purpose of the portability of the medical insurance which they had opted merely to have an enhanced sum insured but what they have been allowed was even lower in comparison to the previous policies.  The complainant expressed their unhappiness over this act of the opposite parties but somehow continued on the assurance of the OPs that this would be suitably compensated at the time of the renewal of the policy.

          The complainant no.1  had thereafter undergone a medical check up for his knee replacement in Max Hospital on 15.05.2017  and consequently an estimated expenses of an amount of Rs.4,31,3001/- was sent to the OP-1 and in response thereto the complainant was informed that their request for clearing the amount for the surgery has been rejected owing to the fact that pre existing ailments amounting to non disclosure of material facts were not indicated at the time of proposal. This led to filing of this complaint as, according to the complainant, the intimation regarding their pre-existing ailment was very well known to the doctor who examined both the complainants at the time the policy was purchased as also to the Relationship Manager of the OP.  The said policy was also cancelled, causing mental agony and financial hardship to the complainants.

          The complainants have accordingly prayed for a decree in their favour and against the respondents for a sum of Rs.30,00,000/- with interest at the rate of 18% on the said amount till the date of recovery.

          The matter was listed before us for admission hearing on 18.08.2017 when the ld. Counsel for the complainant appeared and advanced his arguments.  We have also perused the records of the case.

          Controversy in the case hinges on the point whether the OP was justified in cancelling the policy after accepting the premium, on the ground of concealment of material fact relating to pre-existing disease.  This leads to another question whether the complainant had furnished in the proposal form the details about the pre-existing disease suffered by him and, if so, whether the company is justified in cancelling the policy and, if not, whether the OP are found deficient in rendering of the service required of them in terms of the contract between the insured and insurer.

          This calls for the examination of the proposal form.  We do not find any details having been furnished with respect to pre-existing ailment of  the complainant. The only argument advanced by the complainant on the subject is that they were compelled to sign the proposal form without their having gone into the subject. We are not impressed with this argument.  The complainants are not illiterate.  We expect that the literate persons would sign a document only after knowing the meaning, content and implication of the information contained  in the form.  No document has been placed before us suggesting that the signature of the complainant have been obtained at their back and fraudulently.  To put it differently we may have to examine the proposal form the way it has been placed before us in the complaint and in that form no mention has been made about the pre-existing disease.

          The next question to examine is whether the OP is within their competence to cancel the policy where the details of pre-existing disease has  not been specifically and categorically indicated in which case the complainants would either not insure the insured or may claim premium at a higher rate.  It is a trite law that insurance is a contract based on .certain terms and conditions as agreed to between the parties to the contract. Once the contract is done both the parties to the contract are under an obligation to adhere to that.  The Hon’ble Apex Court in the matters of PC Chacho Anrs Vs. Chairman LIC – (2008)1 SCC 321 And in Satwant  Sandhu in New India Assurance Co. – (2009) 8 SCC 316 have ruled that

“if the insured has obtained the insurance policy by this representation / concealment of material fact, the insurance contract would be voidable at the instance of insurer and the insurance company would be justified in repudiating the claim ............or cancelling the policy”.

          Their Lordships in the matter of New India Assurance Co. Ltd. Vs Satpal Singh (2009) 4 JT 85 have ruled that

“concealment of pre-existing disease is a ground for the termination of the policy”. 

          The Hon’ble NCDRC in the matter of National Insurance Co. Ltd. Vs. Vinod Dun – I (2014) CPJ 341 (NC) has held that

“Insurance is a contract and the contract has to be construed like any other contract on the basis of its terms and conditions and outside aid for construction of insurance is impermissible”.

          Similarly in the matter of Col. T.S. Bakshi Vs. Star Health and Allied Insurance Co. Ltd. II (2014) CPJ 620 (NC), the NCDRC has held that

         “Insurance is a contract and while deciding dispute between insured and insurer, terms and conditions were to be construed strictly”.

          From the above, it is clear that both insured and insurer are governed by the terms and conditions as agreed to.

          In the given case the concealment of pre-existing disease in the proposal form is more than obvious an act in violation of the contract and if that be so, keeping in view the law laid down, the company is within its competence to cancel the policy and in doing so, we do  not find any infirmity in their action.

          We accordingly order dismissing the complaint in limini. Copy of the order may be forwarded to the parties to the case free of cost as contemplated under the Consumer Protection Rules 1987 and the Consumer Protection Regulations 2005.

          File be consigned to Record Room.

 

(ANIL SRIVASTAVA)                                           (O.P. GUPTA)                                  

 MEMBER                                                             MEMBER (JUDICIAL)