DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BATHINDA.

CC.No.217 of 20-05-2013

Decided on 27-09-2013

Ajay Kumar aged about 56 years S/o Hem Raj R/o backside of 75-B, near New Grain Market, Ajay Shuttering Store, Bathinda.

........Complainant

Versus

1.Tata AIA Life Insurance Company Ltd., (erstwhile Tata AIG Life Insurance Company Ltd.), Campus/Branch Office: Zila Parishad Building, near Pukhraj Cinema, Bathinda, through its Branch Manager/Branch Head/Incharge.

2.Tata AIA Life Insurance Company Ltd. (erstwhile Tata AIG Life Insurance Company Ltd.), registered & corporate office address: 14^th floor, Tower-A, Penisula Business Park, Sanapati Bapat Marg, Lower Parel, Mumbai-400 013, through its M.D/Chairman/Director/Authorized Signatory.

.......Opposite parties

Complaint under Section 12 of the Consumer Protection Act, 1986.

QUORUM

Smt.Vikramjit Kaur Soni, President.

Sh.Amarjeet Paul, Member.

Smt.Sukhwinder Kaur, Member.

Present:-

For the Complainant: Sh.M.L Bansal, counsel for the complainant.

For Opposite parties: Sh.Sukhmander Singh, counsel for opposite parties.

ORDER

VIKRAMJIT KAUR SONI, PRESIDENT:-

1. The instant complaint is filed under section 12 of the Consumer Protection Act, 1986 as amended upto date (Here-in-after referred to as an 'Act') by the complainant. The brief facts of the complaint are that on the allurement of the opposite parties, the complainant has purchased one ULIP policy for sum assured of Rs.5 lacs and paid Rs.30,000/- as premium for basic coverage. The policy was for 10 years and during this period the complainant and his spouse namely Smt.Renu Goyal insured for Rs.5 lacs each and the complainant is at liberty to get the refund of the premium after three years at anytime. The opposite parties have also given the health rider for the complainant and his spouse, the complainant has paid Rs.5510/- more as top up premium and in that case both the insured i.e. complainant and his wife would get Rs.2000/- each as daily hospital benefit and Rs.40,000/- each as surgical benefit in case of any health disorder to them and the opposite parties shall indemnify the insured for the total expenses incurred thereon by the insured. In this way, the complainant has paid the total amount of Rs.35,510/- (Rs.30,000/- for the basic coverage and Rs.5510/- as top up premium). In the month of February, 2013, Smt.Renu Goyal wife of the complainant was not feeling well and there was some health disorder, they approached Dr.Seema Wadhwa of Fortis Hospital, Mohali, with a complaint of bleeding P/V for check-up and further management. On checking, the attending doctor of Fortis Hospital, Mohali had advised for 'Hysteroscopy & Polypectomy Operation' and the complainant got admitted his wife in the aforesaid hospital on 5.2.2013 and on the same day after conducting the various tests, doctors done the aforesaid operation of his wife. Fortis Hospital, Mohali, charged Rs.75,000/- including room rent, admission fee, room charges, operation/surgical fee, doctor visiting charges, nursing charges, blood sugar charges etc. and apart from this, the complainant has spent the amount for the purchase of the medicines and on account of tests etc., in total he has spent Rs.1 lac on the treatment of his wife. The complainant submitted the abovesaid bills and receipts with the opposite party No.1 for the reimbursement of the same and has completed all the requisite formalities, the opposite party No.1 after getting all the formalities completed from the complainant, assured him that the abovesaid amount of Rs.1 lac incurred by him on the abovesaid treatment shall be paid to him within few days and all the bills/receipts and claim forms are in the possession of the opposite party No.1. The opposite parties vide letter dated 15.4.2013 has repudiated the lawful claim of the complainant on the pretext that he has gave wrong answer to them, about the questions asked from him at the time of submitting the proposal form and they further conveyed by the opposite parties vide aforesaid letter that they are rescinding the benefit on the life of Smt.Renu Goyal wife of the complainant under the abovesaid policy and the policy will be continued on the life of Ajay Kumar. The complainant further contended that there was no pre-existing disease. The complainant has purchased the policy in question in the month of March, 2010, whereas his wife suffered from health disorder in the month of February, 2013 i.e. after about 3 years that cannot be said the pre-existing disease. The opposite parties denied the lawful claim of the complainant. Hence the complainant has filed the present complaint to seek the directions to the opposite parties to make the payment of Rs.1 lac; to resume the benefit of the policy to Smt.Renu Goyal wife of the complainant alongwith interest, cost and compensation and to give any other additional, alternative and consequential relief for which he may be found entitled to.

2. Notice was sent to the opposite parties. The opposite parties after appearing before this Forum have filed their joint written statement and pleaded that the complainant 'life assured' i.e. Sh.Ajay Kumar has submitted a joint proposal/application dated 15.3.2010 for the purchase of Tata AIG Invest Assured Health Plus policy for the coverage of his and his wife life i.e. Smt. Renu Goyal to them. The proposal was accepted on the standard rates based on the information provided by the LA and consequently a policy bearing No.U153059979 was issued for the period of 10 years. The annual premium for the said policy was Rs.30,000/- and there was an option to take a health rider for an additional annual premium of Rs.5510/-, wherein a daily hospitalization benefit of Rs.2000/- alongwith the surgical benefit to the tune of Rs.40,000/- was offered and the said premium was to be paid in addition to Rs.30,000/-. The opposite parties further pleaded that before acceptance of the proposal form/application by them, the contents of the proposal form/application, illustrations and addendum form were read and understood by LA, after receiving the proposal form, the proposal was processed by the opposite parties and thereafter the abovesaid policy was issued to the LA. As per the guidelines of the IRDA the authority regulating the affairs of the opposite parties, the life insured gave detailed description about the features of the said plan including the premium amount to be paid, all the charges that would be levied on the same and was also apprised with its terms and conditions before signing of the said application. In the proposal form/application signed by the complainant question No.3 of Step 11 has been replied in negative. During the claim evaluation it was found that the covered member under the policy Smt.Renu Goyal was under the treatment for Diabetes Mellitus prior to submission of the application for the insurance. The vital information of the pre-existing disease was not disclosed in the reply to the specific questions in the application dated 15.3.2010 for the abovesaid policy. After carefully scrutinize the documents submitted by the complainant for the claim, the opposite parties have came to the conclusion that the replies to the aforesaid questions in the application forms were incorrect. If this information has been given by the complainant in the proposal form correctly, the opposite parties would not have issued the abovesaid policy to the complainant or his wife or in the alternative the premium would have been on the higher side. Smt.Renu Goyal has suffered from Diabetes Mellitus for the last 10 years and was on the regular medication, this fact was not disclosed at the time of applying for the insurance policy in the application dated 15.3.2010. Moreover Smt.Renu Goyal was operated for Ectopic in the year 2000 & 2004. The following abbreviation have been used in the medical record:-

K/C/O=Known Case of,

DM=Diabetes Mellitus,

RX=Regular Medication,

SX=Surgery

As this vital information was not disclosed to the opposite parties, they have rightly repudiated the claim of the complainant vide letter dated 15.4.2013. The complainant/life insured had concealed the material information regarding the health of his spouse in the proposal forms submitted by him, therefore he is not entitled to any claim from the opposite parties. To support their version, the opposite parties have relied upon Revision Petition No.2130 of 2007 titled as Life Insurance Corporation of India Vs. Smt.Surekha Shankar Jadhav & Others, decided on 31.7.2012. The opposite parties further pleaded that there is a complex question of law which can be decided by the Civil Court only and further pleaded that the complainant has suppressed the material facts. The opposite parties have referred the various authorities in this regard.

3. The parties have led their evidence in support of their respective pleadings.

4. Arguments heard. The record alongwith written submissions submitted by the parties perused.

5. Admittedly, the complainant has purchased one ULIP policy for sum assured of Rs.5 lacs for 10 years with the health rider and paid Rs.35,510/- i.e. Rs.30,000/- for basic coverage and Rs.5510/- as additional annual premium. Under this policy, the complainant and his wife was covered for any health problem and would get Rs.2000/- each as daily hospitalization benefit alongwith the surgical benefit to the tune of Rs.40,000/- each in case of any health disorder.

6. In the month of February, 2013, Smt.Renu Goyal wife of the complainant was not feeling well and was checked by the attending doctor of the Fortis Hospital, Mohali, she was advised for 'Hysteroscopy & Polypectomy Operation' and accordingly, the complainant admitted his wife in the aforesaid hospital on 5.2.2013 and on the same day after conducting the various tests, doctors done the aforesaid operation of his wife. Fortis Hospital, Mohali, charged Rs.75,000/- including room rent, admission fee, room charges, operation/surgical fee, doctor visiting charges, nursing charges, blood sugar charges etc. and apart from this, the complainant has spent the amount for the purchase of the medicines and on account of tests etc., in this way he has spent Rs.1 lac in total on the treatment of his wife. The complainant has submitted all the documents i.e. bills and receipts with the opposite party No.1 for the reimbursement of the same and has completed all the requisite formalities, the opposite party No.1 after getting all the formalities completed from the complainant, assured him that the abovesaid amount of Rs.1 lac incurred by him on the abovesaid treatment shall be paid to him within few days and all the bills/receipts and claim forms are in the possession of the opposite party No.1. The opposite parties vide letter dated 15.4.2013 have repudiated the lawful claim of the complainant on the pretext that he has gave wrong answer to them about the questions asked from him at the time of submitting the proposal form and they further conveyed him vide their aforesaid letter that they are rescinding the benefit on the life of Smt.Renu Goyal wife of the complainant under the abovesaid policy and the policy will be continued on the life of Ajay Kumar, the complainant. The complainant has purchased the policy in question in the month of March, 2010, whereas his wife suffered from health disorder in the month of February, 2013 i.e. after about 3 years that cannot be said to be pre-existing disease.

7. The claim of the complainant has been rejected vide letter dated 15.4.2013 on the ground that in the proposal form/application signed by the complainant question No.3 of Step 11 has been replied in negative. The following questions were replied in negative:-

During the claim evaluation it was found that the covered member under the policy Smt.Renu Goyal was under the treatment for Diabetes Mellitus prior to submission of the application for the insurance. In their reply the opposite parties have specifically submitted that the complainant has concealed the vital information of pre-existing disease and replied the specific questions in negative. If this information has been given by the complainant in the proposal form, the opposite parties would not have issued the abovesaid policy to the complainant or his wife or in the alternative the premium would have been on the higher side. The case summary of the Fortis Hospital shows that Smt.Renu Goyal has been suffering from Diabetes Mellitus for the last 10 years and was on the regular medication, this fact was not disclosed at the time of applying for the insurance policy in the application dated 15.3.2010. Smt.Renu Goyal was operated for Ectopic in the year 2000 & 2004 and the abbreviation those have been used in the medical record are K/C/O=Known Case of; DM=Diabetes Mellitus; RX=Regular Medication and SX=Surgery. Thus the ground of the repudiation of the claim of the complainant was vital information has not been disclosed by the complainant's wife in the proposal form. Vide letter dated 15.4.2013, Ex.C12, the claim of the complainant was repudiated and the reference of question Nos.3 and 4 of Step 11 has been given in this letter. A perusal of application form, Ex.OP1/2, shows Step 11 Health Details of Proposal Assured and Family Members. In reply to the question No.3 that 'Do You have or have you ever had any of the following; (C)Diabetes, thyroid disorder or any other hormone disorder', the wife of the complainant has given the answer of the same 'No' and in reply to the question No.6 that 'at any stage during the past 5 years, have you (a) Attended any hospital, clinic or doctor office for diagnostic tests such as X-ray, mammogram, PAP, smear, ultrasound, blood test, CT scan, biopsy for any lump, cyst, tumor, chronic, lesions or growths of any kind, ECG, urine other investigations other than for routine employment checkups purpose', the wife of the complainant has given answer 'No'. The treatment record of the Fortis hospital, Ex.OP1/4, shows that the complainant was suffering from Multiple Fibroids and further perusal of Ex.OP1/4, Out Patient Gynecology (First Assessment report), page No.2 recorded the history of the patient 'H. DM (10 years)', operated for Ectopic in the year 2000'. Similar P/V episode earlier also in year 2004 was based on Endom Polypectomy; Hysteroscopy & Polypectomy↓GA. Relying upon the history, the claim of the complainant was rejected by the opposite parties vide their letter dated 15.4.2013, Ex.OP1/5, in this question No.6 was regarding the past 5 years. At the cost of repetition, in reply to the relevant question No.6 of Step 11 that 'at any stage during the past 5 years, have you (a) Attended any hospital, clinic or doctor office for diagnostic tests such as X-ray, mammogram, PAP, smear, ultrasound, blood test, CT scan, biopsy for any lump, cyst, tumor, chronic, lesions or growths of any kind, ECG, urine other investigations other than for routine employment checkups purpose', the wife of the complainant has answered 'No', meaning thereby there is no concealment on the part of the wife of the complainant as all these information was regarding previous 5 years and for the policy in dispute the proposal form was filled in the year 2010 and the policy was also issued in the year 2010 and the wife of the complainant took treatment on 5.2.2013, thus there is nexus with the present disease, thus the history is regarding the Ectopic pregnancy is relating to year 2000 and 2004 that has no nexus with the surgery conducted on dated 1.12.2013. Moreover the question No.6 was regarding the last 5 years not regarding the last 6 or 10 years. The question was specifically about last 5 years only.

Regarding the other question of Diabetes, before issuance of the medical policy, the empaneled doctors conducted the tests and after that they issue the policy in question. The proposal form is fully scrutinized before issuing the policy. In the case in hand there is no record on the part of the opposite parties to support their version that the complainant was suffering from Diabetes at the time of surgery dated 1.12.2013. Moreover the opposite parties are merely relying upon the history recorded at Fortis hospital. There is no independent credible documentary evidence/expert medical opinion in support of their case. No affidavit of any of the empaneled doctor of the company is produced on file by the opposite parties to prove that before issuing the policy she was medically examinated and various tests were conducted. Furthermore it is the duty of the opposite parties to get conducted the entire medical check-up before issuing of the policy. If the opposite parties cannot get all these tests conducted that also amounts to deficiency in service on their part and they cannot repudiate the claim of the complainant on these grounds when he lodge the claim. Moreover Ectopic surgery was conducted in the year 2000 and 2004 which has no nexus with the surgery of 1.12.2013. Moreover Ectopic surgery is not considered to be a pre-existing disease. All the queries were relating to any disease regarding the last 5 years.

8. Thus in view of what has been discussed above there is deficiency in service on the part of the opposite parties in repudiating the claim of the complainant. The wife of the complainant remained admitted in the Fortis hospital on 5.2.2013 and operated on the same day and charged Rs.75,000/-including room rent, admission fee, room charges, operation/surgical fee, doctor visiting charges, nursing charges, blood sugar charges etc. and the complainant has to spend more amount to purchase the medicines and on account of tests etc., in this way he has spent Rs.1 lac in total on the treatment of his wife, whereas as per the record placed on file, the wife of the complainant remained admitted in the hospital for one day only. In Ex.C8 it has been specifically mentioned 'one day admission only' and in Ex.C8 it has also been mentioned 'procedure:-Rs.30,000/-(PKG)+Biopsy=2 T approx. Rs.35,000/-; one day admission-Rs.20,000/- to Rs.45,000/-(as per DBL plan) P+ID proof/cash/credit/debit'. As per the policy, the wife of the complainant was insured for daily hospitalization benefit of Rs.2000/- alongwith the surgical benefit to the tune of Rs.40,000/- and the said premium was paid in addition to Rs.30,000/-. In the case in hand the wife of the complainant remained admitted in the hospital for one day only, hence she is entitled for Rs.2000/- as hospitalization benefit + Rs.40,000/- as surgical benefit. The bills has been placed on file by the complainant show that he has spent Rs.400/- vide Ex.C13; Rs.450/- vide Ex.C14; Rs.80/- vide Ex.C15; Rs.2590/- vide Ex.C16; Rs.30,000/- vide Ex.C17; Rs.1080/- vide Ex.C18; Rs.166.60/- vide Ex.C19; Rs.350/- vide Ex.C20 and Rs.400/- vide Ex.C21, in total he has spent the amount of Rs.35,516.60/- vide the abovesaid bills.

9. With utmost regard and humility to the authorities relied upon by the learned counsel of the opposite parties, have distinguishable facts and circumstances.

10. Therefore in view of what has been discussed above the complainant is entitled to Rs.2000/- as hospitalization benefit + Rs.40,000/- on account of surgery including medical bills as per the terms and conditions of the policy. Thus we are of the considered opinion that the opposite parties have not paid the claim of the complainant, hence there is deficiency in service on their part. Thus this complaint is accepted with Rs.5000/- as cost and compensation against the opposite parties and the opposite parties are directed to pay Rs.42,000/- to the complainant and the opposite parties are further direct to resume the benefit of the policy to Smt.Renu Goyal, wife of the complainant.

11. The compliance of this order be done within 45 days from the date of receipt of the copy of this order.

12. In case of non-compliance the interest @ 9% per annum will yield on the amount of Rs.42,000/- till realization.

13. A copy of this order be sent to the parties concerned free of cost and file be consigned to the record room.

Pronounced in open Forum

27-09-2013

(Vikramjit Kaur Soni)

President

(Amarjeet Paul)

Member

(Sukhwinder Kaur)

Member