Order dictated by:
Ms.Rachna Arora, Member
1. Sh.Paramjit Singh Osahan, has brought the instant complaint under section 11 & 12 of the Consumer Protection Act, 1986 on the allegations that he purchased health policy for himself from the Opposite Party bearing policy No.235301/48/2015/2130 for sum assured of Rs.4 lacs, valid for the period from 27.11.2014 to 26.11.2015 after paying the requisite premium to the Opposite Party and as such, the complainant availed the services of the Opposite Party and is consumer qua the Opposite Party as defined under the Consumer Protection Act. The complainant had been regularly getting the mediclaim policies from the Opposite Party since 2010 and at present the policy bearing cover note No. 114260 dated 25.11.2015 for sum assured of Rs.2,50,000/- valid for the period from 27.11.2015 to 26.11.2016 midnight is in force. The complainant had opted for the health insurance policies accepting the offer of the Opposite Party to meet any health claim in future, thereby providing mediclaim insurance to the complainant. The complainant felt some pain in his chest radiating to the left arm and shoulder in the month of August, 2015 and underwent certain tests and was advised to undergo coronary angiography having been diagnosed with coronary artery disease etc. Accordingly, the complainant got admitted in Fortis Escorts Hospital, Majitha Verka Byepass, Amritsar on 15.9.2015 and underwent coronary angiography on 15.9.2015 which showed single vessel disease and was advised for PTCA to LAD. In view of the same, the complainant underwent coronary angioplasty on 15.9.2015 and remained hospitalized till 17.9.2015 on which date he was discharged. The complainant having availed the services of the Opposite Party and duly covered for such emergency under the policy so obtained by him, immediately informed the Opposite Party for meeting out the necessary medical expenses as per the policy. The complainant incurred a total expenses of Rs.3,68,000/- upon the treatment. Although the complainant is insured and having a facility of cashless claim to the tune of Rs.2 lacs, but the complainant was shocked to know that only amount of Rs.1,25,000/- has been reimbursed illegally by withholding the other amount covered under the policy and rejected the remaining claim of the complainant. Vide instant complaint, the complainant has sought the following reliefs.
a) Opposite Party may be directed to make the payment of Rs.75,000/- i.e. the amount less paid out of total claim amount of Rs.2 lacs alongwith interest @ 18% per annum.
b) Compensation of Rs.50,000/- may also be awarded to the c for harassment, mental pain and agony suffered by him.
c) Costs of the complaint to the tune of Rs.22,000/- may also be awarded to the complainant.
d) Any other relief to which the complainant is found entitled to under law, equity be also granted in favour of the complainant.
Hence, this complaint.
2. Upon notice, Opposite Party appeared and contested the complaint by filing written statement taking preliminary objections therein inter alia that the complainant has not come to this Forum with clean hands and concealed the material facts from this Forum. The true facts are that after receiving the information from the complainant regarding the hospitalisation of the complainant who was admitted in Fortis Escort Hospital on 15.9.2015, the TPA of the Opposite Party immediately informed the said hospital and approved the cashless facility of the complainant to the tune of Rs.1,25,000/- and the complainant has used the said cashless facility, however, the complainant is covered under the policy in question for a sum insured of Rs.2 lacs per life. The claimant was admitted at Fortis Hospital for the treatment of Coronary Artery Disease, Single Vessal Disease and hypertension on 15.9.2015 and discharged on 17.9.2015. As per the submitted documents, it is evident that the claimant is suffering from hypertension for the past 15 years and prior to the inception of the policy, hence the sum insured for ailment has been restricted to the policy 4 years prior to hospitalisation i.e. 2010-2011 for Rs.1,25,000/- under clause 4.1 which reads that “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 upto 4 years of this policy being inforce continuously.” For the purpose of applying this condition, the date of inspection of this mediclaim policy taken from Opposite Party company shall be considered, provided the renewals have been continuous and without any break in period. This exclusion will also apply to any complications arising from pre existing ailments/ disease/ injuries. Such complications will be considered as a part of the pre existing health condition or disease. To illustrate if a person is suffering from hypertension or diabetes or both hypertension and diabetes at the time of taking the policy, then policy shall be subject to the exclusions fully mentioned in para No.2 of the preliminary objections of the written reply filed by the Opposite Party, hence the complainant is not entitled to get the relief claimed for. On merits, the Opposite Party took almost same and similar pleas as taken by the Opposite Party in preliminary objections. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.
3. In his bid to prove the case, complainant tendered into evidence affidavit Ex.C1 in support of the allegations made in the complaint and also produced copies of documents Ex.C2 to Ex.C28 and closed his evidence.
4. On the other hand, to rebut the evidence of the complainant, the Opposite Party tendered into evidence the affidavit of Sh.R.K.Sharma, Sr.Divisional Manager Ex.OP1 alongwith copies of documents Ex.OP2 to Ex.OP8 and closed the evidence on behalf of the Opposite Party.
5. We have heard the ld.counsel for the parties and have carefully gone through the evidence on record.
6. Ld.counsel for the complainant has reiterated the facts in the arguments as narrated in the complaint and argued that the complainant purchased health policy for himself from the Opposite Party bearing policy No.235301/48/2015/2130 for sum assured of Rs.4 lacs, valid for the period from 27.11.2014 to 26.11.2015 after paying the requisite premium to the Opposite Party and as such, the complainant availed the services of the Opposite Party and is consumer qua the Opposite Party as defined under the Consumer Protection Act. The complainant had been regularly getting the mediclaim policies from the Opposite Party since 2010 and at present the policy bearing cover note No. 114260 dated 25.11.2015 for sum assured of Rs.2,50,000/- valid for the period from 27.11.2015 to 26.11.2016 midnight is in force. The complainant had opted for the health insurance policies accepting the offer of the Opposite Party to meet any health claim in future, thereby providing mediclaim insurance to the complainant. The complainant felt some pain in his chest radiating to the left arm and shoulder in the month of August, 2015 and underwent certain tests and was advised to undergo coronary angiography having been diagnosed with coronary artery disease etc. Accordingly, the complainant got admitted in Fortis Escorts Hospital, Majitha Verka Byepass, Amritsar on 15.9.2015 and underwent coronary angiography on 15.9.2015 which showed single vessel disease and was advised for PTCA to LAD. In view of the same, the complainant underwent coronary angioplasty on 15.9.2015 and remained hospitalized till 17.9.2015 on which date he was discharged. The complainant having availed the services of the Opposite Party and duly covered for such emergency under the policy so obtained by him, immediately informed the Opposite Party for meeting out the necessary medical expenses as per the policy. The complainant incurred a total expenses of Rs.3,68,000/- upon the treatment. Although the complainant is insured and having a facility of cashless claim to the tune of Rs.2 lacs, but the complainant was shocked to know that only amount of Rs.1,25,000/- has been reimbursed illegally by withholding the other amount covered under the policy and rejected the remaining claim of the complainant.
7. On the other hand, ld.counsel for the Opposite Party has repelled the aforesaid contention of the ld.counsel for the complainant on the ground that after receiving the information from the complainant regarding the hospitalisation of the complainant who was admitted in Fortis Escort Hospital on 15.9.2015, the TPA of the Opposite Party immediately informed the said hospital and approved the cashless facility of the complainant to the tune of Rs.1,25,000/- and the complainant has used the said cashless facility, however, the complainant is covered under the policy in question for a sum insured of Rs.2 lacs per life. The claimant was admitted at Fortis Hospital for the treatment of Coronary Artery Disease, Single Vessal Disease and hypertension on 15.9.2015 and discharged on 17.9.2015. As per the submitted documents, it is evident that the claimant is suffering from hypertension for the past 15 years and prior to the inception of the policy, hence the sum insured for ailment has been restricted to the policy 4 years prior to hospitalisation i.e. 2010-2011 for Rs.1,25,000/- under clause 4.1 which reads that “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 upto 4 years of this policy being inforce continuously.” For the purpose of applying this condition, the date of inspection of this mediclaim policy taken from Opposite Party company shall be considered, provided the renewals have been continuous and without any break in period. This exclusion will also apply to any complications arising from pre existing ailments/ disease/ injuries. Such complications will be considered as a part of the pre existing health condition or disease. To illustrate if a person is suffering from hypertension or diabetes or both hypertension and diabetes at the time of taking the policy, then policy shall be subject to the exclusions fully mentioned in para No.2 of the preliminary objections of the written reply filed by the Opposite Party, hence the complainant is not entitled to get the relief claimed for.
8. It is not the denial of the case that the complainant purchased had been regularly getting the mediclaim policies from the Opposite Party since 2010 and at present the policy bearing cover note No. 114260 dated 25.11.2015 valid for the period from 27.11.2015 to 26.11.2016 midnight is in force. It is also not the denial of the case complainant felt some pain in his chest radiating to the left arm and shoulder in the month of August, 2015 and underwent certain tests and was advised to undergo coronary angiography having been diagnosed with coronary artery disease etc. Accordingly, the complainant got admitted in Fortis Escorts Hospital, Majitha Verka Byepass, Amritsar on 15.9.2015 and underwent coronary angiography on 15.9.2015 which showed single vessel disease and was advised for PTCA to LAD. In view of the same, the complainant underwent coronary angioplasty on 15.9.2015 and remained hospitalized till 17.9.2015 on which date he was discharged. The complainant having availed the services of the Opposite Party and duly covered for such emergency under the policy so obtained by him, immediately informed the Opposite Party for meeting out the necessary medical expenses as per the policy. The complainant incurred a total expenses of Rs.3,68,000/- upon the treatment. Although the complainant is insured and having a facility of cashless claim to the tune of Rs.2 lacs, The only ground for the repudiation of the remaining claim of the complainant is that the claimant is suffering from hypertension for the past 15 years and prior to the inception of the policy, hence the sum insured for ailment has been restricted to the policy 4 years prior to hospitalisation i.e. 2010-2011 for Rs.1,25,000/- under clause 4.1 which reads that “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 upto 4 years of this policy being inforce continuously.” For the purpose of applying this condition, the date of inspection of this mediclaim policy taken from Opposite Party company shall be considered, provided the renewals have been continuous and without any break in period. This exclusion will also apply to any complications arising from pre existing ailments/ disease/ injuries. Such complications will be considered as a part of the pre existing health condition or disease. To illustrate if a person is suffering from hypertension or diabetes or both hypertension and diabetes at the time of taking the policy, then policy shall be subject to the exclusions. As per the exclusion clause, the company shall not be liable to make any payment under this policy in respect of any expenses incurred by any insured person in connection with any pre existing health condition or disease. So, the Opposite Party repudiated the remaining claim vide letter and intimated the same to the complainant. The ground on which the claim of the complainant has been repudiated has been 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.”.
We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease.
- In such a situation the repudiation made by Opposite Party regarding genuine claim of the complainant appears to have been made without application of mind. It is usual with the insurance company to show all types of green pesters 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 seams 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.
- From the aforesaid discussion, it transpires that Opposite Party have wrongly repudiated the genuine claim of the complainant. Hence the Opposite Party is directed to make the payment of remaining insurance claim of the complainant to the tune of Rs. 75,000/-. The costs of the litigation are assessed at Rs.2,000/-. Compliance of this order be made within 30 days from the receipt of copy of the order; failing which, awarded amount shall carry interest @ 9% p.a from the date of filing of the complaint until full and final recovery. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
Dated:27.06.2017.
