Order by:
Smt.Priti Malhotra, President
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that the complainant purchased group Medicare certificate of insurance of opposite party No.2 on persuasion of agent/co-partner of opposite party No.1 i.e. Muthoot Risk Insurance & Broking Services Pvt. Ltd, Railway Road, Moga. The said policy was issued in the name of Rakesh Kumar i.e. complainant bearing Master Policy No.0238502795 and certificate No.50617912. Unfortunately, the complainant suffered from right supraclinoid ICA dissecting aneurysm and was admitted in Postgraduate Institute of Medical Education and Research Chandigarh where ruptured right supraclinoid ICA dissecting aneurysm for which flow divertor procedure was performed on 19.06.2021. After completion of all the treatment and discharge from the hospital a total bill of Rs.3,39,140/- was raised by the hospital concerned. The original bills, admission card, discharge sheet, doctor prescription etc. and other documents which were required for the reimbursement of the Medi-claim of complainant were submitted with the opposite party by the Hospital in original while lodging the claim and thereafter on the demand of Opposite Parties again the same documents were submitted by the complainant along with certificate of not having similar Past Medical History with the opposite parties. Thereafter again on demand, the same was submitted by the complainant thrice from the local doctor as well as the doctor who treated the complainant. Further alleged that complainant incurred a sum of Rs.3,39,140/- on his treatment and even after completing all the formalities and even after supplying all the required documents by the complainant, the claim was rejected by the Opposite Parties for want of certificate of treating doctors for past history duration of hypertension. Due to the aforesaid illegal and unwarranted acts of the opposite parties, the complainant suffered huge mental tension and agony. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to pay an amount of Rs.3,39,140/- or the maximum amount covered by the policy on account of medical expenses out of total expenses of Rs.3,39,140/-.
b) To pay an amount of R.5,00,000/- as compensation for causing mental tension, harassment and agony to the complainant.
c) To pay an amount of Rs.50,000/- on account of counsel fee and other legal expenses and Rs.15,000/- for perusing the claim alongwith interest @ 12 % p.a. till the realization of the total amount from the date of filing of claim.
d) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Upon service of notice, none has appeared on behalf of Opposite Party No.1. Hence, Opposite Party No.1 was proceeded exparte.
3. Opposite Party no.2 filed written version taking preliminary objections therein inter alia that intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure under Consumer Protection Act and appropriate remedy, if any, lies only in the Civil Court. The complainant has concealed material facts and documents from this Commission as well as the replying opposite party therefore, the complainant is not entitled to any relief. The complainant has concealed the fact that the complainant lodged the claim and replying Opposite Party sent claim acknowledgement letter dated 18.10.2021. The replying Opposite Party sent various letters dated 22.10.2021, 01.11.2021, 11.11.2021, 19.11.2021, 25.11.2021, 01.12.2021 & 11.12.2021 demanding the various documents fully mentioned therein, but the complainant failed to supply the treating doctor’s certificate for past history duration of hypertension, when diagnosed for first time. As such, the replying Opposite Party rejected the claim of the complainant vide letter dated 27.12.2021 on the following grounds of clause I of section 5 of the policy, which reads as under:-
“we shall be under no obligation to make any payment under this policy (section 5 clause 5 i) unless we have received all premium payments in full in time and we have been provided with the documentation and information we or our TPA has requested to establish the circumstances of the claim, its quantum and our liability for it, and unless the insured person has complied with his obligation under the policy.”
The replying Opposite Party has also sent query response letters dated 17.12.2021, 16.12.2021, 30.11.2021, 24.11.2021 and 18.11.2021. The complainant has no locus standi or cause of action to file the present complaint against replying Opposite Party. The complaint is not maintainable in the present form and is liable to be dismissed. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
4. Complainant has filed the replication to the written reply of Opposite Party No.2 denying the objections raised by the Opposite Party No.2 in their written reply.
5. In order to prove his case, complainant tendered in evidence his affidavit Ex.CW1/A alongwith copies of documents Ex.C1 to Ex.C43.
6. To rebut the evidence of complainant, Opposite Party No.2 tendered in evidence copies of documents Ex.OPs2/1 to Ex.OPs2/16 and affidavit of Sh.Amit Chawal, AVP & Authorized Signatory, Tata AIG General Insurance Co. Ltd. Ex.OPs2/17.
7. We have heard the counsel for the parties and also gone through the documents placed on record.
8. The case of the complainant is that he purchased group Medicare insurance policy from the Opposite Party No.2, through Opposite Party No.1 for the period 07.04.2021 to 06.04.2022. During the policy coverage, the complainant suffered some health problem and got admitted in Postgraduate Institute of Medical Education and Research Chandigarh and was diagnosed as a case ruptured right supraclinoid ICA dissecting aneurysm, for which, flow divertor procedure was performed on 19.06.2021. The complainant spent Rs.3,39,140/- on his treatment. As per the version of ld. Counsel for the complainant, all the required documents were submitted with the Opposite Parties thrice, but despite that claim of the complainant got repudiated for want of certificate of treating doctors for past history duration of hypertension, which is illegal and wrong.
9. Ld. Counsel for the Opposite Party No.2 repelled the aforesaid contention of ld. Counsel for the complainant on the ground that the complainant lodged the claim with Opposite Party No.2 and thereafter Opposite Party No.2 sent various letters dated 22.10.2021, 01.11.2021, 11.11.2021, 19.11.2021, 25.11.2021, 01.12.2021 & 11.12.2021 demanding the various documents, but the complainant failed to supply the treating doctor’s certificate for past history duration of hypertension, when diagnosed for first time. As such, the replying Opposite Party rejected the claim of the complainant vide letter dated 27.12.2021 as per clause I of section 5 of the policy, which reads as under:-
“we shall be under no obligation to make any payment under this policy (section 5 clause 5 i) unless we have received all premium payments in full in time and we have been provided with the documentation and information we or our TPA has requested to establish the circumstances of the claim, its quantum and our liability for it, and unless the insured person has complied with his obligation under the policy.”
10. After due consideration of the admitted and proved facts on record, we have also considered the rival contentions of ld. Counsel for both the parties and have gone through the record. Perusal of the contention of ld. Counsel for the Opposite Party no.2 reveals that Opposite Party No.2 repudiated the claim of the complainant due to non submission of treating doctor’s certificate for past history duration of hypertension, when diagnosed for first time.
On the subject of hypertension, we are well guided by the judgement of Hon’ble State Consumer Dispute Redressal Commission, Punjab, Chandigarh in case titled as Life Insurance Corporation of India Vs. Sushma Sharma from II (2008) CPJ 213 wherein Hon'ble State Commission has held as under:-
“So far as hypertension is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material decease Nand Lal insured would not have survived for 10 years.”.
11. Thus, in guidance of the above, even if for the sake of arguments, it is presumed that the complainant was suffering from hypertension, even then the repudiation of the claim on that ground is baseless and not legal.
On merits also the repudiation of the claim is not genuine as the complainant has been treated for ‘ruptured right supraclinoid ICA dissecting aneurysm’ and there is no evidence being produced by the Opposite Party No.2 that there is direct nexus with the problem of hypertension. Further no medical literature corroborating the averment of the Opposite Party No.2 has been made part of the record revealing that the ailment suffered by the complainant during the coverage period was in any case was related with hypertension.
12. Also it is apt to mention that the Opposite Party No.2 not even bothered to consider the certificate issued by the treating doctor where he has categorically opined that ‘complainant was not having similar past history’ Ex.OP2/16. For the sake of convenience, the certificate of Doctor concerned of PGIMER is reproduced as under:-
“The Patient: Rakesh Kumar S/o Om Parkesh Kumar, Cr. No:202102143331, case of ruptured right supraclinoid ICA dissecting aneurysm for which flow divertor procedure was performed on 19.06.2021 to our knowledge patient does not have similar past history.
In view of the above, it is hereby concluded that the repudiation of genuine claim of the complainant is bad and by rejecting the genuine claim of the complainant , the Opposite Party rendered deficient services, thus is liable not only to pay the medical expenses incurred under the policy but also liable to pay compensatory cost besides litigation expenses.
13. Now come to the quantum of amount to be awarded to the complainant. Vide instant complaint, the complainant has claimed the amount of Rs.3,39,140/-, but perusal of the policy document Ex.C1 shows that complainant is insured under the policy in question for Rs.1,00,000/-. So, the claim of the complainant in toto cannot be granted.
14. From the above discussion, we partly allow the complaint of the complainant against Opposite Party No.2 and direct the Opposite Party No.2 to pay amount of sum insured i.e. Rs.1,00,000/- (Rupees One Lakh only) to the complainant. Opposite Party No.2 is further directed to pay an amount of Rs.10,000/-(Rupees Ten Thousand only) as compensation and Rs.7000/- (Seven Thousand only) litigation expenses to the complainant. Complaint against Opposite Party No.1 stands dismissed. The compliance of this order be made by the Opposite Party No.2 within 30 days from the date of receipt of copy of this order, failing which, it is further burdened with additional amount of Rs.10,000/-(Rupees Ten Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced on Open Commission
