Sh.Anoop Sharma, Presiding Member
1. Smt.Ritu Nayyar has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that the complainant is having her saving bank account in Punjab National Bank, Putlighar Branch, Amritsar bearing account No.0026000139927050 being agent/ broker of PNB-Oriental Royal Mediclaim Policy Schedule. The concerned official of said bank branch persuaded the complainant to obtain health insurance policy and as per their persuasions, the complainant obtained health insurance policy for herself as well as for her husband namely Surinder Mohan Nayyar vide policy No. 233300/48/2015/5720 covering the risk period w.e.f. 20.2.2015 to 19.2.2016 for sum assured of Rs.1,00,000/- by paying a premium of Rs.1749/- and as such, the present controversy relates to Oriental Insurance Company Limited. In the evening of 17.12.2015 the husband of the complainant fell down from stairs in his house and he became unconscious and as such, he was immediately taken to Nanda Hospital, Amritsar in an unconscious condition and put on ventilator supports. After monitoring the husband of the complainant for about one and half hour, the concerned doctor referred him K.D.Hospital, Amritsar and accordingly as per the advice of the concerned doctor of Nanda Hospital, Amritsar he got admitted in K.D.Hospital, Amritsar on the same day and it was stated by the concerned doctor that the husband of the complainant was hospitalized for sudden high BP and respiratory distress. The husband of the complainant remained admitted in K.D.Hospital, Amritsar w.e.f. 17.12.2015 to 2.1.2016 and the complainant had incurred Rs.1,63,683/- on the medical treatment of her husband. The intimation was given to the Opposite Parties about the ill health and medical treatment of husband of the complainant and the claim for his hospitalization and medical treatment was referred to Opposite Parties for cashless treatment as the said policy issued by the Opposite Parties is on cashless terms, but however, the said request of the complainant for cashless treatment was denied by the Opposite Parties on false and frivolous ground. The impugned claim was lodged for reimbursement of medical expenses with the Opposite Parties and all the requisite documents and original medical bills etc were supplied to the Opposite Parties, but the Opposite Parties have failed to process the claim of the complainant and rather repudiated the claim of the complainant vide repudiation letter dated 29.12.2015 on the false and flimsy ground. Vide instant complaint, the complainant has sought the following reliefs.
a) Opposite Parties may be directed to pay a sum insured of Rs.1 lac alongwith interest @ 12% per annum and compensation of Rs.20,000/- on account of mental agony and harassment besides costs of litigation to the tune of Rs.11,000/-.
Hence, this complaint.
2. Upon notice, Opposite Party No.1 appeared and contested the complaint by filing written statement taking preliminary objections therein inter alia that the complainant has violated the basic terms and conditions of the policy in question and hence the present complaint is not maintainable. In the light of terms and conditions of the policy in question, it was found that the claim was not payable as per denial/ exclusion clasue 4.1 and 4.2 which read as under:-
4.1 “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 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), in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person upto 3 years of this policy being in force continuously. For the purpose of applying this condition, the date of inception of the first indemnity based health policy taken shall be considered, provided the renewals have been continuous and without any break in period, subject to portability condition. This exclusion will also apply to any complications arising from pre-existing ailments/ diseases/ injuries.”
4.2(xvii) During the period of insurance cover, the expenses on treatment of Hypertension for specific period of two years are not payable if contracted and/ or manifested during the currency of the policy.”
The policy has incepted on 20.2.2015 which makes it clear that the policy in question was running in first year. The ailment/ disease was found pre-existing. Moreover, the present ailment is not payable in the first two years. Accordingly, the claim was considered as inadmissible by competent authority of Opposite Parties, therefore, the Opposite Parties repudiated the claim on merits in accordance with law. Further, on scrutiny of claim documents it was found that patient Surinder Mohan as admitted in K.D.Hospital, Amritsar with the diagnosis as a case of intra parenchyamal haemorrhages with hypertension. As per the available documents it was found that the patient is a known case of HTN. Moreover, the findings in discharge summary shows that the patient was admitted with complaint of sudden high blood pressure, then loss of conscious with respiratory distress. Hence Opposite Party No.2 vide letter dated 2.3.2016 has recommended that the claim in question was not payable vide exclusion clause 4.1 and 4.2 (xvii) of the insurance policy in question. Accordingly, the Opposite Parties repudiated the claim of the complainant and intimated the same to the complainant clearly stating that the claim was not payable. On merits, the Opposite Parties took up the same and similar pleas as taken by them in the preliminary objections. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.
3. None appeared on behalf of Opposite Party No.2 despite due service, hence Opposite Party No.2 is proceeded against exparte vide order dated 21.4.2016 of this Forum.
4. In his bid to prove the case, complainant tendered into evidence affidavit Ex.CW1/A in support of the allegations made in the complaint and also produced copies of documents Ex.C1 to Ex.C41 and closed his evidence.
5. On the other hand, to rebut the evidence of the complainant, Opposite Party No.1 tendered into evidence the affidavit of Ravi Gupta, Deputy Manager Ex.OP1/1 alongwith documents Ex.Op1/2 to Ex.Op1/5 and closed the evidence on behalf of the Opposite Parties.
6. We have heard the ld.counsel for the parties and have carefully gone through the evidence on record.
7. On the basis of evidence on record, ld.counsel for the Opposite Party has vehemently contended that the husband of the complainant was suffering from hypertension for two yeas from the date of his admission regarding medical treatment in dispute. But however, the complainant did not disclose the factum of suffering of hypertension to the Opposite Party at the time of obtaining of the policy and the complainant as such, is guilty of suppression of factum of previous disease to Opposite Party. The admission of the husband of the complainant from 17.2.2015 to 2.1.2016 for medical treatment in K.D.Hospital, Amritsar is not disputed and the complainant spent Rs.1,63,683/- on his medical treatment. But however, her insurance claim has been rightly repudiated under section 4.1 and 4.2 of the terms and conditions of the policy, copy of cover note accounts for Ex.OP1/4. On the basis of aforesaid contention, ld.counsel for the Opposite Parties have vehemently contended that claim of the complainant has rightly been repudiated under the terms and conditions of the policy in dispute. Moreover, the complainant is guilty of suppression of factum of previous disease suffered by him at the time of obtaining the policy and a such, the claim of the complainant has rightly been rejected and the complaint being false and frivolous is liable to be dismissed and the same may be dismissed accordingly.
8. However from the appreciation of the facts and circumstances of the case it becomes evident that the complainant obtained insurance policy in dispute cover risk period 20.2.2015 to 19.2.2016 from Opposite Party on payment of premium, copy of insurance cover accounts for Ex.C2. It is also not disputed that the husband of the complainant remained admitted in K.D.Hospital, Amritsar for his treatment w.e.f. 17.12.2015 to 2.1.2016. It is further in evidence that the complainant incurred an expenses of Rs.1,63,683/-, copies of treatment pertaining to K.D.Hospital, Amritsar accounts for Ex.C7 to Ex.C37. It is also an admitted fact that the claim was repudiated vide letter Ex.OP1/3. The ground on which the claim of the complainant has been repudiated has been that the complainant was suffering from hypertension for two years prior to the issue of the insurance cover in dispute. It was upon the Opposite Party to get medically check up the proposer before issuing any policy and if the proposar was having any pre existing disease the Opposite Parties have not to issue the policy to him. Even otherwise, hypertension 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 pastures 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 has wrongly repudiated the genuine claim of the complainant. Undisputedly, the complainant obtained health insurance policy for herself as well as for her husband namely Surinder Mohan Nayyar vide policy No. 233300/48/2015/5720 covering the risk period w.e.f. 20.2.2015 to 19.2.2016 for sum assured of Rs.1,00,000/-, but however, the complainant spent Rs.1,63,683/- on the treatment of her husband as referred above, hence Opposite Parties are directed to make the payment of insurance claim of the complainant to the tune of Rs. 1,00,000/-. The Opposite Parties are also directed to pay Rs.8,000/- as compensation on account of mental tension and harassment besides Rs.4,000/- as costs of litigation. 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
