STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA
Date of Institution: 05.12.2017
Date of final hearing: 04.09.2023
Date of pronouncement: 17.11.2023
First Appeal No.1476 of 2017
IN THE MATTER OF:-
Religare Health Insurance Company Ltd. GYS Global, Plot No. A-3, A-4, A5, Sector-125, Noida and D-3, P3B, District Centre Saket, New Delhi through Ms. Ramnique Sachar, Corporate Manager-Legal, Authorized signatory, 3rd Floor, Vipul Tech Square, Tower C, Sector 43, Golf Course Road, Gurgaon, Haryana. ....Appellant
Versus
- Ranvir Mangla S/o Late Sh. Om Parkash, R/o H.No. 6, Civil Lines Enclave, Gurgaon.
- Shalu Mangla W/o Ranvir Mangla, R/o H.No. 6, Civil Lines Enclave, Gurgaon. …..Respondents
- Sandeep Kumar, Authorised agent, Religare Health Ins. Co. Ltd. G-311, First Floor, Sushant Lok-1, Gurgaon.
…..Porforma Respondent
CORAM: Naresh Katyal, Judicial Member
Argued by:- Sh. Sachin Ohri, counsel for the appellant.
Sh. Amit Singla, counsel for respondent No. 1 & 2.
Presence of respondent No.3 already dispensed with.
ORDER
NARESH KATYAL, JUDICIAL MEMBER:
Delay of 30 days in filing of present appeal stand condoned for the reasons stated in application for condonation of delay.
2. Challenge in this appeal No.1476 of 2017 has been invited by Religare Health Insurance Company Ltd. to the legality of order dated 06.10.2017 passed by District Consumer Disputes Redressal Forum-Gurgaon (In short “District Consumer Commission”) in complaint case No.328 of 2016, vide which complainant’s complaint has been allowed.
3. Complainants’ have alleged that: they took Religare Health Insurance Policy No. 10168795 (Plan-care with NCB Super) valid from 17.12.2015 to 16.12.2016. It related to health coverage for complainants’, as well as, their children and sum insured was Rs.5.00 lacs, towards hospitalization expenses, as well as, other benefits as detailed. Complainants’ paid premium of Rs.21,580/-. During subsistence of policy; on 20.12.2015, complainant No.1- Ranvir Mangla developed acute pain in his chest and back; he was taken to Pushpanjali Hospital-Gurgaon and referred to Medanta Hospital. He was suffering from heart attack; doctors started his treatment. He had undergone procedure of Coronary Angiography and PTCS + stent to (Promus Element) LAD on 20.12.2015. He spent Rs.5,000/-towards medicines and Rs.2,75,000/- (Total Rs.2,80,000/-) towards hospitalization and other expenses. He deposited documents for getting ‘cashless benefit’ in compliance of clause 5.2 (a) of terms and condition of policy, to Insurance Department of hospital; same were forwarded by hospital to OP No.1-appellant for compliance. On 21.12.2015, OPs No. 1 & 2 sent surveyor to Medanta Hospital, where he obtained signature of complainants on blank papers/documents. Thereafter, they (complainants) applied for reimbursement of expenses incurred by them, on treatment on 26.12.2015 as per clause 5.2 (b) of policy terms and conditions. Same was submitted in office of OP No.1/appellant on 28.12.2015, but OPs wrongly and illegally rejected their claim vide repudiation letter dated 05.01.2016.
4. It is pleaded that: there was no chronic disease or any pre-existing disease to complainant No.1-Ranvir Mangla. Reason given in repudiation letter is in any case of no significance, when the doctor who treated him (complainant No.1) has mentioned his medical history in discharge summary. Even in policy, it is no where mentioned that reason given in repudiation letter dated 05.01.2016 had any nexus with disease suffered by complainant. It is pleaded that at the time of filing of proposal form; complainants have never been asked about his smoking pattern; nor did OP No.2-agent of OP No.1 put any such question. From the proposal form filled by OP No.2-agent, it is clear that question regarding pre-existing disease was correctly answered by complainants. It is pleaded that: the only ‘modus operandi’ of OPs is to sell the policy by misrepresenting facts and thereafter, having made complainants’ and other innocent persons part with their valuable money, to create false excuse to repudiate claims, which is a clear case of cheating & fraud. In this manner; complainants have alleged that OPs have been deficient in their service towards them and have indulged in malpractices. Hence, through complaint, complainants’ have prayed for reimbursement Rs.2,80,000/ along with compensation of Rs.50,000/- on account of mental agony, harassment as well as litigation expenses with interest @ 18% p.a. from date of filing of complaint till its realization.
5. Upon notice, appellant/OP No.1 raised contest. In defence; it is pleaded that: complaint is not maintainable. All allegations made in complaint are false and frivolous. It is pleaded that principle of insurance is fundamental to utmost good faith and insurance is a contract between insured and insurer and both parties are bound by terms and conditions of policy, as well as, exclusion clause. Cashless facility request was denied as per policy terms and conditions and exclusion clause 4.3 (a) (xxiv) so reproduced below:-
(a) Any clam in respect of any insured person for, arising, out of directly or indirectly due to any of the following shall not be admissible unless expressly stated to the contrary elsewhere in policy terms and conditions:
(xxiv) Act of self-destruction or self-inflicted injury, attempted suicide while sane or insane illness or injury attributable to consumption, use, misuse or abuse of tobacco intoxicating drug, alcohol or hallucinogens.
6. It is pleaded that complainant is a chronic smoker, since 10 years, and his wife has admitted this fact. Medico-Legal Opinion reads: “Coronary artery disease is a direct linkage to smoking, which is both a cause and an aggravating factor for heart related problems. Hence, smoking as a habit or smoking sustained over a considerable period of time is a material fact to determine health-related risks of the insured under insurance cover”.
It is pleaded that insurer, under same policy, reimbursed claim for treatment of one of policy holders i.e. Yatharth Mangla, as there was no violation of terms and conditions of policy and exclusion clause. It is denied that reason given in repudiation letter dated 07.01.2016 had no nexus with suffered disease. Decision to repudiate claim has been taken, after considering all documents and facts of case and taking expert medical opinion over interrelation between smoking habit of complainant and his present heart ailment. Claim has been repudiated on sustained history of “act of self-destruction or consumption, use, misuse or abuse of tobacco by complainant since 10 years (7-8 cigarettes per day) as disclosed by complainants’ themselves in questionnaire filed and signed by them dated 21.12.2015”. It is denied that complainants spent Rs.2,80,000/- on treatment of complainant No. 1. It is denied that complainants were asked to sign blank papers. It is denied that on 26.12.2015, they applied for reimbursement of expenses in treatment of complainant No. 1 as per clause 5.2 (b) of policy terms and conditions and same was submitted in office of OP No.1/appellant on 28.12.2015. It is denied that on 05.01.2016; OPs have wrongly rejected the claim of complainants’. It is denied that OPs have not considered the ‘Discharge Summary’ of treating doctor. It is denied that reason given in repudiation letter dated 07.01.2016 had no nexus with disease suffered by complainant. It is denied that complainant’s claim has been denied on frivolous reasons and terms and conditions of policy were misrepresented to them. It is pleaded that question regarding pre-existing disease was correctly answered by complainants. There is no deficiency in service on its part.
7. OP No. 2 was proceeded against exparte on 28.07.2016.
8. Complainants, as well as, OP No. 1/insurer/appellant have led their respective evidence, oral as well as documentary.
9. On subjectively analyzing the same; learned District Consumer Commission-Gurgaon vide order dated 06.10.2017 has allowed the complaint, thereby directed appellant/OP No.1/insurer to pay Rs.2,80,000/- along with interest @9% p.a. from the date of filing of complaint till its realization and further to pay Rs.15,000/- as compensation for mental agony, harassment as well as for litigation expenses.
10. Feeling aggrieved; OP No.1/appellant/insurer has filed this appeal.
11. Learned counsel for appellant/insurer and respondents No. 1 & 2/complainants have been heard at length. With their assistance; record of learned District Consumer Commission has been perused.
12. Learned counsel for the appellant/insurer has urged that impugned order dated 06.10.2017 passed by learned District Consumer Commission-Gurgaon is erroneous, legally as well factually. Evidence, brought on record has not been appreciated in proper legal perspective. It is contended that Medico legal opinion concerning complainant No. 1 reflects that: Coronary Artirey Disease suffered by him has a direct link to his consistent smoking since last 10 years (with habit of 6-7 cigarettes a day) as per their admission in questionnaire signed by them on 21.12.2015. Based on this fact (Medico legal opinion); repudiation of complainants’ claim of reimbursement, by insurer/appellant through its letters viz: (i) dated 05.01.2016 (Ex.C-9 addressed to Shalu Mangla) and (ii) dated 07.01.2016 (Annexure D-addressed to Ranvir Mangla) were legally justified and same excludes insurer/appellant from its liability as per exclusion clause No. 4.3 (a) (xxiv) of terms and conditions of insurance policy. It is urged that above evidence was clinching in nature to non-suit complainants and same having not been properly appreciated; has caused manifest injustice to appellant/insurer.
13. Per contra, learned counsel for respondent No. 1 & 2/complainants has supported the impugned order dated 06.10.2017 passed by learned District Consumer Commission-Gurgaon by urging that it is outcome of proper appreciation of facts and evidence and same warrant no interference.
14. Undisputedly, appellant/insurer had issued insurance policy No. 10168795 which has currency period from 17.12.2015 to 16.12.2016. Undisputedly, complainants and their children have health coverage with insured sum of Rs.5.00 lacs towards hospitalization expenses and other benefits as per this policy. As per complainants’ claim; complainant No. 1 developed chest pain and back pain on 20.12.2015. He landed at Medanta Hospital for treatment on 20.12.2015 and was discharged on 22.12.2015. Rs.2,80,000/- has been allegedly incurred by complainants’ in relation to complainant No. 1’s treatment. Their claim for reimbursement of this amount has been repudiated vide letters dated 05.01.2016 (Ex.C-9) and dated 07.01.2016 (Annexure D). Appellant/insurer has tried to justify their act of repudiation, in their defence set up in their written version and through evidence led by it and their above stance has been negated.
15. Sole moot question before this Commission is: Whether appellant/insurer’s act of repudiation of complainants’ claim of reimbursement of Rs.2,80,000/- merits any credence or not? Discharge Summary-Ex.C8/Annexure-1 of Medanta Hospital reflects that complainant No. 1-Ranvir Mangla had landed there on 20.12.2015 at 05:23 and discharged on 22.12.2015 at 08:46. As per medical history mentioned in discharge summary; he complained mild retrosternal chest pain and discomfort radiating to back, associated with episode of vomiting. His ECG showed acute AWMI. He underwent Coronary Angiography on 20.12.2015 which revealed single vessel disease and his coronary stenting to LAD in same sitting. Procedure was uncomplicated and well tolerated. He was discharged on 22.12.2015 in stable condition.
16. Medical opinion Annexure-E and Annexure-F has been strenuously pressed by insurer/appellant. It is of Dr. C. H. Asrani-a doctor practicing at Mumbai. His conclusion viz-a-viz complainant No. 1’s case reads as follows:-
“Conclusion: Coronary Artery Disease has a direct linkage to smoking, which is both a cause and an aggravating factor for heart related problems. Hence, smoking as a habit or smoking sustained over a considerable period of time is a material fact to determine health-related risks of the insured under insurance cover.”
17. Based upon same insurer/appellant has invoked exclusion clause 4.3 of policy to repudiate the claim of complainants. Right here, it has to be borne in mind the legal portion, which is no more res-integra that: “in case, insurer invokes exclusion clause it has to lead express and positive evidence specific to justify/substantiate their act of exclusion from insurance policy”. While observing so, this Commission gain strength from the observations laid down by Hon’ble Apex in cases titled as “National Insurance Co. Ltd. Vs. Vedic Resorts and Hotels Pvt. Ltd.” (Civil Appeal No.4979 of 2019) decided on 17.05.2023, and “National Insurance Company Limited vs. Ishar Das Madan Lal” (2007) 4SCC 105 wherein it has been held that: “It is trite to say that wherever such an exclusionary clause is contained in a policy, it would be for the insurer to show that the case falls within the purview of such clause. In case of ambiguity, the contract of insurance has to be construed in favour of insured.”
18. While applying above cardinal principle so enunciated in above quoted judgments; this Commission is of firm opinion that exclusion by insurer/appellant from policy Ex.C2, in present case is unjustified. Reasons are obvious. Dr. C.H. Asrani’s medical opinion (Annexure-E and Annexure-F) has not been proved by insurer/appellant by leading evidence, admissible in law. There is no evidence in form of duly sworn affidavit of Dr. C.H. Asrani to support his opinion and neither he stepped into witness box. Dr. C.H. Asrani was not treating doctor of complainant No. 1. He had not ever examined complainant No. 1 at medical platform. Questionnaire Annexure-C bears signatures of both complainants with date 21.12.2015 will not throw their claim, over board. This is particularly when there is no evidence of any past history of complainant No. 1 developing coronary artery disease, prior to inception of insurance policy. Equally, there is no evidence that prior to inception of policy, proposal form got filled from complainants’ contain specific and alike questions regarding their medical history, akin to those, as were put across to them in questionnaire Annexure-C on 21.12.2015 at the time when complainant No. 1 was still hospitalized at Medanta Hosptial. Obviously, the hospitalization of complainant No. 1 might had a stress effect on him, leading to disturb his mental equilibrium to some extent, at that relevant time (21.12.2015). Even, medical investigations conducted upon complainant No. 1 at Medanta Hospital, does not reflect anything majestic, being abnormal (health-wise) and that is why it is mentioned in the discharge summary (Ex.C8/Annexure 1) under head: “Course in Hospital” that procedure performed on complainant was uncomplicated and well tolerated. It was a single vessel disease and his coronary stenting was done. No doubt, chronic smoking can possibly cause Coronary Artery problem but, nevertheless, it cannot be termed as sole reason. This observation of Commission is equally deciphered even from phraseology of medical opinion Annexure-E & Annexure-F.
19. This being so, this commission does not find any manifest error, legal or factual in the impugned order dated 06.10.2017 passed by District Consumer Commission-Gurgaon, which is the outcome of meticulous appreciation of all material facets of this case. Accordingly, order dated 06.10.2017 is affirmed and maintained. OP No.1/appellant/insurer have been rightly non-suited. Present appeal, being devoid of merits is hereby dismissed.
20. Statutory amount of Rs.25,000/- deposited by appellant at the time of filing of this appeal be refunded to it, after due identification and verification as per rules and on expiry of period meant for further appeal /revision, if any.
21. Application(s) pending, if any stand disposed of in terms of the aforesaid judgment.
22. A copy of this judgment be provided to all the parties free ofcost as mandated by the Consumer Protection Act, 1986/2019. The judgment be uploaded forthwith on the website of the Commission for the perusal of the parties.
23. File be consigned to record room.
Date of pronouncement: 17th November, 2023
Naresh Katyal
Judicial Member
Addl. Bench-II
