Order by:

Sh.Amrinder Singh Sidhu, President

          Complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 on the allegations that complainant took a Health Insurance Policy No.30846144201800 dated 17.12.2018 for the period 15.12.2018 to 14.12.2020 from the Opposite Party. The complainant deposited gross premium for the above said policy amounting to Rs. 66613/- and the sum assured for the above said policy was Rs. 20.00 lacs and period of the policy was two years. On 19.03.2019 the complainant felt some uneasiness in his stomach and chest and accordingly he went to Dr. Sanjeev Mittal of Mittal Hospital and Heart Centre, Dussera Ground Moga. Originally Dr. Sanjeev Mittal treated the complainant with medicines. Thereafter said Dr. Sanjeev Mittal referred the complainant to Delhi Heart Institute and Multi Specialty Hospital Moga. On 20.03.2019 complainant went to Delhi Heart Institute and Multi Specialty Hospital Moga and approximately at 10.00 clock the complainant was admitted in the said Hospital and checkup/angiography of the complainant was done there and accordingly the said Delhi Heart Institute and Multi Specialty Hospital Moga advised heart Surgery to the complainant. On the same day i.e. 20.03.2019, complainant went to Dayanand Medical College and Hospital, Civil Line, Ludhiana and he was admitted there in emergency. Accordingly heart surgery of the complainant was done at Dayanand Medical College and Hospital Ludhiana and in total complainant has to spend approximately Rs. 3,50,000/- for his treatment and intimation was given to the agent of the Opposite Party, who were visiting the said DMC Hospital, Ludhiana regularly. After heart surgery, the complainant requested the Opposite Party to make payment of hospital charges, but the Opposite Party declined the claim of the complainant on the ground that complainant has concealed his disease of diabetic mellitus since two to three years of his treatment, as such opposite party is not liable to make any payment to the complainant with regard to said health policy. Thus, the Opposite Party has repudiated claim of the complainant on 07.06.2019. The repudiation of the claim of the complainant is liable to be set aside on the following grounds:-

i)       That complainant never suffered and is also not suffering from diabetic mellitus. The observation of Dr. Sanjeev Mittal, Moga, Delhi Heart Institute and Multi Specialty Hospital, Moga and also observation of DMC Hospital Ludhiana to the effect that complainant is suffering from diabetic mellitus and hypertension factually incorrect and is wrong because complainant never suffered from above said disease. The observations of above said hospitals to the effect that complainant is suffering from diabetic mellitus, hypertension etc. apparently seems to be misdiagnosed. Because the complainant was never diabetic or hypersensitive and he also never took any medicines for the said alleged diseases. Even now the complainant is not suffering from said disease.

ii)      That complainant is ready to undergo any medical test or treatment to fortify the said version and to falsify the said observation of above said hospitals - that at the alleged relevant time and even now the complainant never had the above said diseases.

          The Opposite Party has made a concocted story of diabetes and hypertension. Hence this claim. Vide instant complaint, complainant has sought the following reliefs:-

a)       Opposite Party may be directed to make the payment to the complainant of his medical claim under Health Insurance Policy.

b)      And any other relief which this Commission may deem fit and proper be also granted to complainant in the interest of justice and equity.

2.       Opposite Party appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complainant opted for the policy bearing "Health Companion Variant 3" bearing No.30846144201800 from the period 15.12.20218 to 14.12.2020 and the gross premium is Rs 66,613/-. Further in the aforesaid policy, the insured person includes the complainant, wife, son and daughter. The complainant had submitted cashless request bearing No. 232653 for proposed hospitalization at Dayanand Hospital. The cashless request had been declined as the medical documents clearly suggested that the ailment was pre-existing, hence the complainant was asked to file claim for reimbursement. In the month of June 2019, the complainant submitted the claim request with respect to the treatment for Hypertension at Dayanand Medical Hospital, Ludhiana from 20.03.2019 to 25.03.2019. The reimbursement claimed amount for the aforesaid treatment was Rs.3,09,868/-. After receiving the aforesaid request of the complainant along with relevant documents, the opposite party generated the claim bearing no. 417694. At the time of reviewing the documents as filed by the complainant, the opposite parties found that the complainant failed to disclose the pre-existing medical illness/ conditions at the time of applying the health insurance policy with the opposite party. The following are the details with respect to non disclosure of pre-existing medical illness/ conditions on the part of complainant:-

          “history of Diabetes Mellitus since 2-3 years on treatment”

          Further alleges that the specified diabetes mellitus is a specific waiting period exclusion under the terms and conditions of the policy. From the aforesaid observations, the opposite party also serves a letter dated 21.03.2019 to the complainant with a request to submit the following documents:-

“…Kindly provide treating DR certificate for history duration of diabetes with all the past treatment past records with the first consultation paper.

                    “... Kindly provide the photograph of the patient...”

          Further alleges that the clause 5.3 and 10.21 of the terms and conditions of the policy provides for specific waiting period and disclosure to information. Since the mediclaim insurance policy is a contract of insurance falling in the category of contract uberrimae fidei, i.e. utmost good faith on the part of the assured and further both the parties in the policy are bound by the terms and conditions of the policy, therefore, the opposite parties cancel the policy of the complainant and disallowed the reimbursement claim. Further alleges that at the outset, the opposite party denies all the averments, allegations and claims made in the present complaint as the same are false, frivolous, vexatious, except those, which are specifically adverted to and admitted herein. By filing the present complaint, the complainant is wasting the precious time of the Commission on account of fact that the opposite parties with respect to the fact that there is concealment of pre-existing medical illness/conditions at the time of applying the health insurance policy by the complainant. The statements/details in the proposal form and medical tests are executed for the benefit of the insured and to prevent any future loss to the applicant. On the other hand, the complainant did not disclose the pre-existing medical illness/ conditions and has filed the complaint which is liable to be dismissed. The present complaint is not maintainable on the sole ground that the complainant is blaming hospital with respect to the incorrect diagnosis mentioned in the discharge summary. The malafide intention of the complainant is substantiated by the fact that if there is incorrect observation by the hospital, the complainant has not filed any complaint before any forum till date. The complainant be put to strict proof in this regard. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint is made.

3.       Complainant has filed replication to the written reply of opposite party stating that in fact the policy issued by the opposite party to the complainant was for cashless payment. Complainant was admitted in DMC Ludhiana and his son Amritpal Singh submitted the said application for cashless payment of hospitalization charges of the complainant. By leveling false allegations of "Previous Ailment" opposite party wants to escape their liability to make payment of Hospitalization charges qua the complainant. Before the policy was issued, opposite party duly got medical checkup of the complainant and now it does not lie in their mouth which now they are concealing as there was no such disease found at that time. In fact complainant made request in April 2019 and not in June 2019. Complainant remained hospitalized upto 31.03.2019 and complainant was discharged from Hospital on 01.04.2019. In fact on 25.03.2019 the complainant was operated upon in DMC Ludhiana. The complainant claimed reimbursement of Rs. 3,03,868/-. But his claim was wrongly and illegally rejected by the opposite party. The opposite party did not peruse and review the documents carefully, independently, consciously and sincerely. Complainant never had any disease of Diabetes Mellitus for the last 2/3 years. All other objections taking by the opposite party in the written reply have been denied.

4.       In order to prove his case, complainant has tendered in evidence his affidavit Ex.C1/A along with copies of documents Ex.C1 to Ex.C38 and his additional affidavit Ex.C39.

5.       To rebut the evidence of complainant, opposite party tendered in evidence affidavit of Sh.Bhuwan Bhashker, Senior Manager Legal Ex.OP1, another affidavit Sh.Bhuwan Bhashker Ex.OP2 along with copies of documents Ex.OP2 to Ex.OP8.

6.       During the course of arguments both the parties ld. counsel for the complainant as well as ld. counsel for the opposite party have mainly reiterated the same facts as narrated in the complaint as well as written reply respectively. Ld. counsel for the complainant has contended that complainant took a Health Insurance Policy from the Opposite Party. During the policy period, he admitted in Dayanand Medical College and Hospital, Ludhiana, where heart surgery of the complainant was done and he has spent approximately Rs.3,50,000/- on his treatment. After discharge from the hospital, he lodged the claim with Opposite Party, but the Opposite Party has repudiated claim of the complainant on the ground that complainant has concealed his disease of diabetic mellitus. However, at the time of proposal the life assured complainant was not suffering any disease, but the opposite parties intentionally and knowingly  repudiated the lawful and genuine claim of the complainant. Ld. counsel for the opposite party has repelled the contentions of ld. counsel for the complainant on the ground that they received the claim request from the complainant and on scrutiny of claim documents, the opposite party found that the complainant failed to disclose about his pre-existing medical illness/conditions i.e. “history of Diabetes Mellitus since 2-3 years on treatment.” From the aforesaid observations, the opposite party also served a letter dated 21.03.2019 to the complainant with a request to submit the following documents:-

i)       Kindly provide treating DR certificate for history duration of diabetes with all the past treatment past records with the first consultation paper.

ii)      Kindly provide the photograph of the patient...”

          Further the clause 5.3 and 10.21 of the terms and conditions of the policy provides for specific waiting period and disclosure to information. Both the parties in the policy are bound by the terms and condition of the policy, therefore, the opposite parties cancel the policy of the complainant.

7.       We have perused the rival contentions of ld. counsel for both the parties and have gone through the record. The main point for adjudication vehemently contended before us by Opposite Parties is that at the time of reviewing the documents as filed by the complainant, the opposite parties found that the complainant failed to disclose the pre-existing medical illness/ conditions at the time of applying the health insurance policy with the opposite party. The complainant failed to disclose pre-existing medical illness/ conditions of i.e. history of Diabetes Mellitus since 2-3 years”. Based on these findings, the medical team of Opposite Parties is of the opinion that the insured patient has history of Diabetes Mellitus since 2-3 years prior to inception of the Insurance policy, hence the above diagnoses is a pre existing disease. But we do not agree with the aforesaid contention of the ld.counsel for the Opposite Parties. We are of this view that Opposite Parties have failed to discharge the onus solemnly laid upon it to prove this fact that life assured was suffering from above pre-existing disease before taking the policy and he deliberately and fraudulently concealed this material fact from Opposite Parties. We, thus, conclude that there is no substantive evidence on the record to prove this fact that life assured was suffering from any disease before he took the insurance policy and he willfully suppressed this fact fraudulently from the Opposite Parties. Moreover, if the life assured was suffering from any diseases prior to issuance of the policy, in question, the same must not have escaped the notice of the empanelled doctors of the Insurance Company. However, no such investigation record has been produced by the opposite parties. In case Bajaj Allianz Life Insurance Co. Ltd. & Ors. Vs. Raj Kumar III (2014) CPJ 221 (NC), it was held by the Hon’ble National Commission that “usually, the authorized doctor of the Insurance Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. It was held that the Insurance Company wrongly repudiated the claim of the complainant.”

8.       Furthermore,  as per the Customer Identity card,  attached with the policy document,   at the time of obtaining the policy, the life assured has duly mentioned his date of birth as 16.12.1971 (meaning thereby which is  more than 45 years, so it was the bounden duty of the Opposite Parties-Insurance Company to get the life assured medically examined before issuing the policy in his name who was above 45 years of age. In support of his contention Ld.counsel for the complainant placed reliance upon I.R.D.A.I Rules and Instructions with regard to thorough medical examination if the insured is more than 45 years which is reproduced as under:-

“As per instructions issued by the Insurance Regulatory and Development Authority of India (IRDAI), it was bounded duty of the insurer to put insured to thorough medical examination in case Mediclaim insured was more than 45 years and if insurance company failed to do so then insurance company has no right to decline the insurance claim on account of non disclosure of the facts of pre existing disease when the policy was taken. The above observations is supported by law cited in SBI General Insurance Company Limited Vs. Balwinder Singh Jolly” 2016(4) CLT 372 of the Hon’ble State Commission, Chandigarh.” 

However, the Opposite Parties-Insurance Company has not placed on record any evidence that before issuing the policy they ever got medically examined the insured. So the abovesaid law squarely covers the case of the complainant that it was the duty of the insurer to get medically examined while issuing the policy and once the policy was issued the insurer cannot take the plea of pre-existing disease of the insured.

10.     It also needs to be mentioned that Section 19 of the General Insurance Business (Nationalization) Act, 1972 states that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community. The denial of medical expenses reimbursement is utterly arbitrary on the ground that disease in question was pre-existing disease. It is mere an excuse to escape liability and is not bona fide intention of the insurance company. Fairness and non-arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State and public behavior. Any policy in the realm of insurance company should be informed, fair and non-arbitrary. When the insurance policy has exclusions/conditions to repudiate the claim or limit the liability, the same must be specifically brought to the notice of the insured and are required to be got signed to show that such exclusions and conditions have been brought to his/her notice.  Recently, our own Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in  First Appeal No. 50 of 2019 titled as Bajaj Alliance General Vs. Arjan Singh decided on 04.03.2021 also held so.

11.     Moreover, the ground on which the claim of the complainant has been repudiated that the complainant was suffering from hypertension and diabetes  prior to the issue of the insurance cover in dispute. But hypertension and diabetes is not a material disease, therefore, non disclosure thereof is not a concealment. We draw support from 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 deceased Nand Lal insured would not have survived for 10 years.”.

12.     In such a situation the repudiation made by Opposite Parties-Insurance Company regarding genuine claim of the complainant have been made without application of mind. It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

“It seems 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.  The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

13.     In view of the above discussion, we hold that the Opposite Party-Insurance Company have  wrongly and illegally rejected the claim of the complainant.

14.     Now come to the quantum of compensation.  The complainant has claimed the amount of Rs.3,50,000/- allegedly spent on his medical treatment, but perusal of the record i.e. In Patient Final Bill shows that he spent Rs.2,84,069/-, hence we hold that the complainant is entitled to the reimbursement of this amount.   

15.     In view of the aforesaid facts and circumstances of the case,  we partly allow the complaint of the Complainant and direct Opposite Parties-Insurance Company to pay Rs.2,84,069/- (Rupees Two lakh eighty four thousands sixty nine only) to the complainant.   The compliance of this order be made by the Opposite Parties within 60 days from the date of receipt of copy of this order, failing which the complainant shall be at liberty to get the order enforced through the indulgence of this District Consumer Commission.  Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced in Open Commission.