DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION CAMP COURT AT LUDHIANA
RBT/Consumer Complaint No.236 of 2018
Date of institution: 09.04.2018
Date of Decision: 16.08.2022
Mohinderpal Singh son of Karnail Singh aged about 71 years, resident of 1046, Basant Avenue, Near Dugri Urban Estate, Now, resident of D-12, Flower Enclave, Near Dugri Urban Estate, Phase-3, Ludhiana-141013
….Complainant
Versus
- National Insurance Company Limited, Dhandari Kalan, Now AT-B-154, Kailash Nagar, Focal Point Road, Sherpur, Ludhiana through its Branch Manager
- Park Mediclaim TpA Private Limited, 702, Vikram Tower, Rajendra Place, New Delhi-110008, having Branch Office At Room No.11, Second Floor, Sona Complex, near Old Fire Brigade Office, GT Road, Millerganj, Ludhiana through its Manager/MD.
……..Opposite Parties
Complaint under Consumer Protection Act.
Quorum: Shri Ranjit Singh, President.
Mrs. Ranvir Kaur, Member
Present: Sh. Anand Sabharwal, Advocate, for complainant
Sh. D.R. Rampal, Advocate, for OP No.1
OP No.2 exparte
Order dictated by :- Shri Ranjit Singh, President
Order
The present order of ours will dispose of the above complaint filed under Consumer Protection Act, by the complainant against the Opposite Parties on the ground the complainant had purchased the mediclaim insurance policy for Rs.1716/- in the year 2010 from the OP1 for one year and family members of the complainant were also got insured in the said policy. The representative of the OP1 told the complainant that the policy covers the medical health and other related expenditure incurred for treatment of the insured and all the expenses and bills incurred on the treatment of the insured person are fully reimbursed by the OP1. The said policy was purchased through bank of India, and total premium of Rs.1716/- was paid. It is further alleged that in the year 2015, the wife of the complainant fell ill and was to be hospitalized in the DMC, Ludhianan and the complainant has spend Rs.54837/- on her treatment. In that period, the complainant continued his mediclaim policy. Thereafter, the complainant approached the OP1 and submitted the documents within time and requested for the reimbursement of the treatment amount and OP assured him that his claim will be shortly passed. The complainant sent many requests to the OP1 for passing the claim amount but at last the complainant received a letter dated 21.3.2016, wherein it was stated that the claim of the complainant is not maintainable and his claim is closed as No Claim. The aforesaid act of the opposite parties amounts to deficiency in service, unfair trade practice and it has caused mental as well as physical agony and also caused inconvenience to the complainant. Vide instant complaint, the complainant has sought the following reliefs:-
- To pay the claim amount of Rs.54837/- along with interest @ 18% from 17.06.2015 till realization.
- To pay Rs.1,00,000/- to the complainant as compensation
- To pay Rs.10,000/- as litigation expenses.
- Any other relief as per facts or circumstances of the case be also allowed if Hon’ble Forum thinks so necessary for the proper disposal of the complaint
2. Upon notice, the O.P. No.1 has filed written reply taking preliminary objections; that the complaint is not maintainable; that the complaint is false and frivolous one; that the complaint is bad for non joinder and misjoinder of the necessary parties; that the complainant has no locus standi to file the present complaint; that the complaint is also barred by time; that the parties are governed by terms and condition of the insurance policy. The said policy has not completed three years since its inception. On merits, it is stated that the claim of wife of the complainant was not covered under the said policy and competent doctors of OP2 minutely scrutinized the claim of the wife of the complainant and they recommended to treat the said claim as no claim vide recommendation dated 12.2.2016 to OP1 and OP1 also after going through the terms and conditions of the insurance policy and documents available on record scrutinized the claim and found that the claim is not maintainable and the same was repudiated as no claim by OP1. The such type of cases are being dealt with by Park Mediclaim TPA OP2 on behalf of National Insurance Company Limited. The papers concerning to treatment of Manjeet Kaur wife of complainant were also sent to the OP2 and OP2 vide letter dated 1.11.2017 demanded certain documents and thereafter reminders were sent to the complainant by OP2 and vide letter dated 27.1.2016 the OP2 has sent the file to OP1 for treatment the said file as NO claim. The complainant sent one letter dated 1.2.2016 and along with said letter one certificate bearing reference of DMC Hospital, unit DMC Heart institute dated 28.1.2016 was sent. Vide reply dated 21.12.2015 the complainant has also mentioned the starting dates of two policies dated 17.7.2013 and 03.07.2012. On receipt of required documents, the OP No.2 minutely scrutinized the claim of the wife of the complainant and found that patient is covered under bank of india, Nationnal Sawasthya Bima Policy for the period of 17.7.2013 to 16.07.2014, 03.07.2012 to 02.07.2013 and 13.5.2011 to 12.5.2012 which means there are break in insurance policies of 15 days and 52 days respectively in previous policies and break in insurance has not been condoned by competent authority. The date of inception cover is considered as 17.7.2013 and policy does not cover the expenses on the treatment of pre existing disease and complications. The patient is known case of diabetes since 20 years and hypertension since 9 years as per certificate of attending consultant dated 20.01.2016. Until 3 claim free years from the date of inception of cover are completed the claim is not admissible. The claim of the complainant was rightly repudiated by the OP. Thus, alleging no deficiency in service on its part has prayed for the dismissal of complaint in total.
- The OP No.2 has choosen to remain exparte.
- The complainant has tendered certain documents in the shape of evidence. On the other hand, the OP1 has tendered certain documents in the shape of evidence.
- We have heard learned counsel for the parties at considerable length and have also examined the record of the case.
- It is admitted fact that the complainant had purchased the Mediclaim insurance policy for Rs.1716/- from the OP1 for one year. After the end of policy year, the complainant renewed the said policy and has been paying the premium on time till date and moreover, the OP1 was pleased to increase the sum insured amount of which the due premium was also duly paid by the complainant. From the documents produced by the complainant, it shows that the in the year 2015, the wife of the complainant fell ill and was to be hospitalized in Dayanand Medical College and Hospital Ludhiana from 28.05.2015 to 03.06.2015. At that time, the complainant in continuance of his medi-claim policy with sum insured of Rs.2,00,000/-. The period of policy was 17.7.2014 to 16.7.2015 and total premium of Rs.4242/- was paid by the complainant. The OPs rejected the claim of the complainant stating that prior to the commencement of the policy, the wife of the complainant was having diabetes and hypertension.
- The OPs has repudiated the claim of the complainant on the Clause 4.1 of the Mediclaim Insurance Policy, the same has been reproduced for ready reference as under:
"EXCLUSIONS: The Company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any Insured Person in connection with or in respect of:
4.1 Pre-existing health condition or disease or ailment / injuries:
Any Ailment / disease / injuries / health condition which are pre-existing (treated / untreated , declared / not declared in the proposal form), when the cover incepts for the first time, are excluded for such insured person upto 4 years of this policy being in force continuously."
The Hon'ble National Commission while dealing with a similar set of facts, in Sunil Kumar Sharma Vs. TATA AIG Life Insurance Company and Ors. bearing case no. RP no. 3557/2013 decided on 01.03.2021 held as under:-
Moreover the claim had been repudiated only on the ground that the insured was suffering from diabetes for a long time. So far as life style diseases like diabetes and high blood pressure are concerned, Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., W.P.(C) No. 656 of 2007, decided on 17.09.2007 held as under:
"Insurance-Mediclaim-Reimbursement-Present Petition filed for appropriate directions to respondent to reimburse expenses incurred by him for his medical treatment, in accordance with policy of insurance-Held, there is no dispute that diabetes was a condition at time of submission of proposal, so was hyper tension-
Petitioner was advised to undergo ECG, which he did-Insurer accepted proposal and issued cover note-It is universally known that hypertension and diabetes can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications depending upon varied factors-That implies that there is probability of such ailments, equally they can arise in non-diabetics or those without hypertension-It would be apparent that giving a textual effect to Clause 4.1 of policy would in most such cases render mediclaim cover meaningless-Policy would be reduced to a contract with no content, in event of happening of contingency-Therefore Clause 4.1 of policy cannot be allowed to override insurer's primary liability-Main purpose rule would have to be pressed into service-Insurer renewed policy after petitioner underwent CABG procedure-
- Therefore refusal by insurer to process and reimburse petitioner's claim is arbitrary and unreasonable-As a state agency, it has to set standards of model behavior; its attitude here has displayed a contrary tendency-Therefore direction issued to respondent to process petitioner's claim, and ensure that he is reimbursed for procedure undergone by him according to claim lodged with it, within six weeks and petition allowed."
In RP No. 4461 of 2012, Neelam Chopra Vs. Life Insurance Corporation of India & Ors., decided on 08.10.2018, (NC), it was held that:
- From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases. The person insured may suffer consequences in terms of the reduced claims.
- Moreover, the non-disclosure of information in respect of this life style disease of diabetes, will not totally disentitle the complainant for indemnification of the claim in the light of the judgment of Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., (supra)."
- Relying on the aforesaid dicta of the Hon'ble National Commission, we can deduce that even though there were pre-exisiting diseases, it will not completely disentitle the respondent from indemnification of the claim from the Insurance Company for such common lifestyle diseases.
- The question to be decided is, whether the repudiation of the claims of the complainant on the above referred grounds is valid and legal or not?
The complaint was contested by the Ops denying all the allegations of deficiency in service leveled against them and admitting the issuance of the subject insurance policies to the complainant.
The learned counsel for the Ops repudiated the claim on the ground of pre existing disease of the complainant. The Hon’ble National Commission in this point has laid down the law in “Satish Chander Madan Versus Bajaj Allianz General Insurance Co. Ltd.”, I (2016) CPJ 613 (NC), has observed that 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 HTN as pre-existing disease is not justified. The same decision is observed by Hon’ble State Commission Punjab, Chandigarh in Order dated 26.04.2017 passed in First Appeal No.836 of 2016 titled “Reliance Health Insurance Company Ltd. Versus Subhash Chander Aggarwal” which is as under:
“Consumer Protection Act, 1986 Sections 2 (1) (g) and 15 Medical claim – Repudiation and cancellation of policy and refund on ground of concealment of pre - existing disease hypertension – Deficiency in service – Complaint before District Forum allowed – Challenged – Whether Hypertension is a disease which is required to be referred in proposal form – 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 – Therefore, ground that complainant suffering from hypertension not corroborated on basis of evidence on record – Further, as per terms and conditions of policy, OPs failed to prove on record that complainant before taking policy was suffering from any pre - existing disease which was concealed by him at time of taking policy – Originally mediclaim policy taken by complainant from Star Health and Allied Insurance Co. Ltd. – In year 2010 and he shifted to OPs in year 2013 on representation of representative of OPs – It was continuous policy – In year 2011 he had some problem of Hypertension, it was after 2010 when mediclaim policy was taken for first time by complainant from Star Health and Allied Insurance Co. Ltd. and then shifted to OPs – Therefore, it is not pre-existing disease – No material information was concealed by insured at time of taking policy – Claim was wrongly repudiated by OP on a frivolous ground for which they did not have any evidence – Hence, appeal dismissed with cost of Rs.10,000/- - (2016) CP 613 (NC), Relied on.”
13. Furthermore, in these days, Hypertension is considered as normal wear and tear. The Hon’ble Delhi State Consumer Disputes Redressal Commission, New Delhi in case Life Insurance Corporation of India Vs Sudha Jain 2007(2) CLT 423 has dawn conclusions in para 9 of the order and the relevant clause is 9(iii) which is reproduced as under:-
“Malaise of hypertension, diabetes occasional pain cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day to day basis by standard medication and cannot be used as concealment of pre existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.
14. Moreover, even non disclosing of insured being a patient of Hypertension/diabetes did not amount to suppression of material facts they being a lifestyle diseases, so as to entitle the insurer to repudiate the claim as held by our own High Court in case Veena Sharma Vs Life Insurance Corporation of India 1999 (1) R.C.R. (Civil) 646.
15. Disease that can be easily detected by subjecting the insured to basic tests like blood test, ECG, etc., the insured is not supposed to disclose such disease because of otherwise leading a normal and healthy life and cannot be branded as diseased person. Insurance Company cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing medi-claim policy whether a person is fit to be insured or not. It appears that Insurance Companies don’t discharge this obligation as half of the population is suffering from such malaises and they would be left with no or very little business. Thus any attempt on the part of the insurer to repudiate the claim for such non-disclosure is not permissible nor is ‘exclusion clause’ invoceable. Claim of any insured should not be and cannot be repudiated by taking a clue or remote reference to any so-called disease from the discharge summary of the insured by invoking the ‘exclusion clause’ or non-disclosure of pre-existing disease’ unless the insured had concealed his hospitalization or operation for the said disease undertaken in the reasonable near proximity as referred above. Day-to-day history or history of several years of some or the other physical problem one may face occasionally without having landed for hospitalization or operation for the disease cannot be used for repudiating the claim. For instance an insured had suffered from a particular disease for which he was hospitalized or operated upon 5, 10 to 20 years ago and since then had been living healthy and normal life cannot be accused of concealment of pre-existing disease while taking mediclaim policy as after being cured of the disease, he does not suffer from any ‘disease’ much less the ‘pre-existing disease’. For instance to say that insured has concealed the fact that he was having pain in the chest off and on for years but has never been diagnosed or operated upon for heart disease but suddenly lands up in the hospital for the said purpose and, therefore is disentitled for claim bares dubious design of the insurer to defeat the rightful claim of the insured on flimsy ground. Instances are not rare where people suffer a massive attack without having even been hospitalised or operated upon at any age say for 20 years or so. Non-disclosure of hospitalisation/or operation for disease that too in the reasonable proximity of the date of mediclaim policy is the only ground on which insured claim can be repudiated and on no other ground.
16. Even otherwise, with the fast growing business competition among the Insurance Companies, unhealthy practices develop to get maximum benefits and profits. It is not a case of a businessman, trader or an educated employed person but that of a common poor man. He puts his hard earned small savings in such schemes with a hope and aspiration that in case of accident or death, he or his family shall get some immediate financial assistance but in most of the cases, he is left cheated when his claim is rejected with just a stroke of pen that he concealed some material facts at the time of signing proposal form or the claim was not properly submitted before the Insurance Company or the claim is against the terms & conditions of the policy. That apart the agent of the company is required to explain all the details and conditions of the insurance policy sought by the customer. A common man is not supposed to know all the niceties and technicalities of law. Once accepting the premium and having entered into an agreement without verifying the facts, the Insurance Company cannot riggle out of the liability merely by saying that the contract was made by misrepresentation and concealment. The insurance policies should not be issued and repudiated in such a casual mechanical manner. The policy entails the liability on both sides. It is rather exploitation of the customer and more or less fraud on the public. Such practice should be strongly deprecated.
17. So, after considering all the facts, documents on file and the law laid down by Hon’ble higher authorities, it is held that the genuine claim of the complainant was wrongly, illegally and arbitrarily repudiated by the opposite parties
18. In view of the discussion made above, present complaint is allowed against opposite parties and directed to pay Rs.54,837/- to the complainant with interest @ 7% per annum from the date of repudiation of claim alongwith Rs.15,000/- for harassment and Rs.11,000/- as litigation expenses. This order is directed to be complied with within a period of thirty days from the date of receipt of copy of this order. Free certified copies of this order be sent to the parties, as per rules. The files be consigned to record room.
August 16, 2022
(Ranvir Kaur) (Ranjit Singh)
Member President
CC No.236 of 2018
Present: Sh. Anand Sabbarwal, Adv. for complainant
Sh. DR Rampal, Advocate, for OP1
OP2 exparte
Vide our separate detailed order of today, the complaint stands allowed. The file be sent back to the District Consumer Commission, Ludhiana, for consigning the same to the record room.
August,16 2022
(Ranjit Singh)
(Ranvir Kaur)
