Haryana

Ambala

CC/266/2021

Anil Chopra - Complainant(s)

Versus

Reliance General Insurance Co ltd - Opp.Party(s)

Ashutosh Aggarwal

16 Aug 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	266 of 2021
Date of Institution	:	27.08.2021
Date of decision	:	16.08.2024

Anil Chopra s/o Late Sh.Lajpat Rai, age 69 Yrs, r/o H.No.5309, Anaj Mandi, Ambala Cantt.

  ……. Complainant.

Versus

1. Reliance General Insurance Co. Ltd. through its Manager,

1^st Address- Registered Office: H-Block, 1 Floor, Dhirubhai Ambani Knowledge City, Navi Mumbai-400710

2nd Address- Corporate Office: Reliance Centre, South Wing, 4th Floor, Off. Western Express Highway, Santacruz (East), Mumbai-400 055.

3rd Address- Team R Care Health, Krishe Sapphire, Krishe Block, III Floor, South Wing, Survey No.88, Hi Tech City Main Road, Madhapur, Hyderabad- 5000081

2. Bank of India, Rai Market, Ambala Cantt, Ambala through its Manager

                                                                                   ….…. Opposite Parties.

Before:        Smt. Neena Sandhu, President.

                     Smt. Ruby Sharma, Member,

          Shri Vinod Kumar Sharma, Member.           

 

Present:      Shri Ashutosh Aggarwal, Advocate, counsel for the complainant.

                    Shri Mohinder Bindal, Advocate, counsel for the OP No.1.

                    Shri Bhanu Pratap Singh, Advocate, counsel for OP No.2.            

Order:        Smt. Neena Sandhu, President.

                   Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

1. To pay claim amount of Rs.43,278/- alongwith interest @18% p.a. from the date of repudiation of claim, till realization
2. To payRs.50,000/-, on account of professional misconduct.
3. To pay Rs.50,000/- on account of mental and physical harassment, pain and embracement.
4. To pay Rs.50,000/-, on account of deficiency in providing service.
5. To pay Rs.50,000/-, on account of unfair trade practice.
6. To pay Rs.31,000/- as cost of litigation.OR

Grant any other relief which this Hon’ble Commission may deems fit.

 

2.             Brief facts of the case are that the complainant is a regular customer of the OP No.2 for the last approx. 20 years and having Account No.671027100001474 in the name of his firm Glass Agencies.  OP No.2 is a Corporate Agent of the OP No.1. Corporate entities represent an insurance company and sell its policies. Usually they are engaged in a particular business and sell insurance policies to their existing customers based on the situation.  OP No.2 for the last many years had been remained corporate agent of various insurance companies as the understanding of terms and conditions and collaboration of insurance company/ies with OP No.2 also keeps on changing. As such, on the instigation of the OP No.2, the complainant was secured with the currency of health insurance from National Insurance Company for the last many years and it was used to be renewed from time to time as when required by the OP No.2. OP No.1 in connivance with the OP No.2 sold the present Reliance General Health Insurance Policy i.e. RGI-BOI Swasthya Bima of 4 Lakhs (Health Policy No.200491928451000130) to the complainant valid from 17-09-2019 to 16-09-2020 against a premium amount of Rs.10999/- which was received by the officer of the O.P. No.1 while sitting in the office of the O.P. No.2. Premium amount of Rs.10999/- against the said policy was paid by the complainant to the O.P. No.2 through Paytm which was debited from the account maintained by the complainant and his wife in Oriental Bank of Commerce situated at Ambala Cantt (Now Punjab National Bank) on 07-09-2020 (Annexure C-4). After few days, a photocopy of Cover Note of Master Policy bearing No.920291828450000328 (Health Policy No.200491928451000130) was issued by the O.P. No.1 in the name of the complainant and his wife namely Smt.Suman Chopra and the nominee as son namely Sh.Nitin Chopra wherein the complete details were mentioned alongwith the date of enrollment as 17-09-2015 and the previous policy details of three years (Annexure C-5). But surprisingly even after many days, the OPs intentionally didn't issue any original insurance policy to the complainant and even no terms and conditions of the insurance policy were ever served to the complainant reasons best known to the OPs. Before taking the health policy, it was categorically asserted to the OP No.1 & 2 that the complainant was satisfied with the services of the existing health policy of National Insurance Co. but the  OP  No.2 moulded the version of the complainant and stated that the services rendered by the  OP  No.1 were better than any other health insurance since the  OP  No.2 had developed collaboration with the  OP  No.1 and hence on instigation of the  OP  No.1, the complainant took the currency of the said health policy from the  OP  No.1. It was also asserted to the OPs that presently the complainant is not suffering from any chronic or heart disease and the  OP  No.1 should take all the previous detailed medical/health records from National Insurance Co. since being the complainant is now a senior citizen, so medical/ health checkup is always done on regular basis as prescribed medically and all the records thus are also updated /maintained timely with National Insurance Co.  OP  No.1 gave his NOD to the version of the complainant and also suggested the complainant that he should not make any worry to this effect since the  OP  No.1 is having prestigious reputation socially being from Reliance Group and the complainant is fully covered under clause 3.1 (iii) of the policy. The clause 3.1. Pre-Existing Diseases (Code-Excl 01) is reproduced as under (Annexure C-6):

(i) Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 36 months of continuous coverage after the date of inception of the first policy with Insurer.

(ii) In case of enhancement of Sum Insured the exclusion shall apply afresh to the extent of Sum Insured increase.

(iii) If the Insured Person is continuously covered without any Break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage.

(iv) Coverage under the policy after the expiry of 36 months for any Pre-existing disease is subject to the same being declared at the time of application and accepted by the Insurer

On 19-04-2020 because of some problem, the complainant was admitted to Rotary Cancer and General Hospital and was diagnosed as cervical problem and subsequently was discharged on 21-04-2020. All the treatment records and medical bills alongwith duly filled mediclaim form were submitted to the OP No.1 for medical claim for the amount of Rs.43,278/- and the information was given to  OP  No.2 while visiting the bank. The medical claim no.201200054137 was thus generated by the O.P No.1. One gentleman who claimed to be some doctor appointed by the OP No.1 approached the complainant in the month of December 2021 for investigation of the said medical claim. The said gentleman categorically stated that the OP No.1 has no medical record of the complainant and asked the complainant to provide the previous and present medical record. It was asserted that all the previous medical record and history of the complainant is already lying with the National Insurance Co. as the complainant was having currency of health policy from National Insurance Co, for the last many years and moreover the complainant was not suffering from any chronic disease or cardiac disease ever, hence the OP No.l should take all those necessary medical documents from National Insurance Co. But the said gentleman showed his inability and demanded health record documents from the complainant only. The complainant being prudent law abiding citizen without hiding anything, made available his previous health records viz., old Health Record from Deparrtment of Cardiology, IVY Hospital Mohali and present health record from Rotary Ambala Cancer and General Hospital Ambala (Annexure C-7 to C-20). For many months, the complainant was not given any information about the status of the mediclaim. Suddenly, the OPs in connivance with each other rejected the claim of the complainant without any cogent reason. The complainant showed his resentment by way of e-mail dated 09-12 2020 and asked the reason for inadmissibility of the mediclaim' (Annexure C-21). On 14-12-2020, the  OP  No.l sent e-mail by citing reason for rejection as 'Member reimbursement cannot be considered as per received documents patient Mr.Anil Chopra admitted in Rotary Cancer and General hospital from DOA 19/04/2020 to DOD 21/04/2020 with complaints of cervical problem and is treated conservatively. Upon claim verification it is found that patient is known case of Hypertension and CAD since 2013 and on regular medication and same was not disclosed by Insured in Proposal copy at the time of policy inception 17/09/2020. As per Policy T&C- clause 5.2- Duty of Disclosure: The policy shall be null and void and no benefit shall be payable in the event of untrue and incorrect statements, misrepresentation, mis-description or non-disclosure of any material particulars in the proposal form, personal statements, declaration and connected documents. In this case member has not disclosed his past Medical history at the time of policy inception. Hence we regret to inform you that the claim is repudiated & policy for cancellation. (Annexure C-22). OP  No.1 in connivance with  OP  No.2 intentionally and illegally rejected the genuine mediclaim of the complainant since Report of Stress Echocardiography Dated 21-04-2020 is Negative for Inducible Ischemia as is reported by the expert Dr.Brig Rahul Trehan (Retd), M.D., DNB (Cardiology), Rotary Ambala Cancer and General Hospital, Opposite Dusshehra Ground, Ram Hagh Road, Ambala Cantt. (Annexure C-13 & C-14).

                   In the eyes of the medical world/study the meaning of INDUCIBLE ISCHEMIA is the presence of new wall motion abnormalities at peak exercise that were not present al rest whereas in the present case, Inducible Ischemia is found negative. The medical documents clearly mention that even at the age of 61 years, when the approached IVY Hospital Mohali on 22-04-2012 for medical advice and the diagnosis given by the Ivy Hospital was - Dyslipedemia,? CAD (Cortonary Artery Disease), Insignificant CAD. After a long investigation, it was found that the complainant was having Insignificant Plaque (Annexure C-15 to C-20). The meaning of Dyslipidemia refers to unhealthy levels of one or more kinds of lipid (fat) in your blood. Your blood contains three main types of lipid (Annexure C-23); high-density lipoprotein (HDL); low-density lipoprotein (LDL) triglycerides. The meaning of Coronary Artery Disease (CAD) is the buildup of plaque in the arteries that supply oxygen-rich blood to the heart. Plaque causes a narrowing or blockage that could result in a heart attack. Symptoms include chest pain or discomfort and shortness of breath. Treatments include lifestyle changes and medications that target risk factors and/or possibly surgery (Annexure C-24). The meaning of Plaque is - semi-hardened accumulation of substances from fluids that bathe an area. Whereas in the present case, the complainant was finally diagnosed as Insignificant Plaque (Annexure C-25). All these documents were also given to the gentleman appointed by the  OP  No.1 in Dec 2020 who came for investigation of the claim raised by the complainant. Thus, the OPs illegally repudiated the legal entitled medical claim of the complainant. Hence, the present complaint.

3.           Upon notice, OP No.1, appeared and filed written version wherein it raised preliminary objections to the effect that the present complaint is not maintainable in the present form;  this complaint contains complicated questions of facts and law and can be decided by civil court only; there is no cause of action in favour of the complainant to file this complaint etc. On merits, it has been stated that as a matter of fact, the complainant by concealing and suppressing true and material facts about his pre-existing ailment (hypertension, DM and CAD since 2013), procured the insurance policy illegally from the OP No.1 on the basis of misrepresentation and false information about the status of his ailments and diseases submitted in the proposal form. As a matter of fact, on getting intimation about the alleged treatment undergone by the complainant and request for the reimbursement of treatment expenses, the claim of the complainant was immediately entertained in due course and necessary steps were initiated to process his claim. The representative of OP No.1 contacted the complainant personally and obtained the required papers from him about his old ailments as mentioned in his treatment record being necessary for the processing of his claim. On the basis of such documents and further clarification/verification from the relevant record of the IVY hospital and Fortis Hospital where the complainant had been under treatment and medication for CAD and hypertension, it was revealed that the complainant has been referred as a known case of hypertension and CAD since 2013 and on medication which information he concealed. As per treatment record submitted by the complainant for the re-imbursement of medical expenses against his admission and treatment in Rotary Cancer & General Hospital, Ambala Cantt. from 19.04.2020 to 21.04.2020, the complainant has been a known case of hypertension, DM and CAD since 2013. It is thus established that the complainant has been suffering from hypertension, DM and CAD for the past 6 years which is prior to the inception of medical insurance policy from OP No.1 for the period from 17.09.2019 to 16.09.2020. The insurance policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. Under the insurance contract utmost good faith must be observed by the contracting parties and good faith forbids either party from non-disclosure of the facts which the party knows. The insured has a duty to disclose each and every information and material fact about pre-existing ailment and about his health at the time of availing the policy. Since the complainant has intentionally and deliberately concealed and suppressed the material facts about his pre-existing ailment to take illegal benefits of policy from OP No.1, hence the claim was rightly and legally held not maintainable and payable as per exclusion clause 5.2 which says: Duty of Disclosure: "The policy shall be null and void and no benefit shall be payable in the event of untrue or incorrect statements, misrepresentation, miss-description or non disclosure of ant material particulars in the proposal form, personal statement, declaration and connected documents. The entire set of documents was considered in detail by the competent authority and after scrutinizing and elaborating the whole facts, situation, records and the evidence, it was found and established that the insured concealed his existing ailments while getting the insurance policy. The complainant in order to put undue pressure filed this false complaint by exploiting the process of law. Rest of the averments of the complainant were denied by the OP No.1 and prayed for dismissal of the present complaint with costs.
4.           Upon notice, OP No.2, appeared and filed written version wherein it raised preliminary objections to the effect that the complaint is not maintainable in the present form; the complaint is bad for mis-joinder of necessary parties; the complainant has not come to this Commission with clean hands and suppressed the material facts etc. On merits, it has been stated that that there is no fault or deficiency in service on the part of OP No.2. OP No.2 was to work as per instructions of their consumers for doing banking business and it is not working for the insurance company or its agents. OP No.2 being third party is not related qua the claim repudiated by OP No.1. OP No.2 is engaged in purely banking business and not selling insurance policies. Rest of the averments of the complainant were denied by the OP No.2 and prayed for dismissal of the present complaint with special costs.
5.           Learned counsel for the complainant tendered affidavit of complainant as Annexure CW/1A alongwith documents as Annexure C-1 to C-25 and closed the evidence on behalf of complainant. On the other hand, learned counsel for the OP No.1 tendered affidavit of Suryadeep Thakur, Area Manager (Legal Claim)-cum-authorized signatory, Reliance General Insurance Co. Ltd., Chandigarh as Annexure OP-1/A alongwith documents as Annexure OP-1/1 to OP-1/7 and closed the evidence on behalf of OP No.1. Learned counsel for the OP No.2 tendered affidavit of Nidhi Gupta, Manager of OP No.2-Bank of India, Rai Market Ambala Cantt. as Annexure OP-W2/A and closed the evidence on behalf of OP No.2.
6.           We have heard the learned counsel for the parties and have also carefully gone through the case file.
7.           Learned counsel for the complainant submitted that neither any wrong information was provided by the insured with regard to his health at the time of filling up of the proposal form nor he was suffering from any pre-existing disease, yet, the genuine claim filed by the complainant has been repudiated by the OPs, which act amounts to deficiency in providing service, negligence and adoption of unfair trade practice on their part. 
8.           On the contrary, the learned counsel for the OP No.1 submitted that since there has been concealment of material facts with regard to the disease referred to above, suffered by the insured, at the time of obtaining the insurance policy in question, as such, the claim filed by the complainant was rightly rejected by OP No.1, strictly as per terms and conditions of the insurance policy.
9.           Learned counsel for the OP No.2 submitted that there is no fault or deficiency in service on the part of OP No.2. He further submitted that OP No.2 was to work as per instructions of their consumers for doing banking business and it is not working for the insurance company or its agents. He further submitted that OP No.2 being third party is not related qua the claim repudiated by OP No.1. He further submitted that OP No.2 is engaged in purely banking business and not selling insurance policies.
10.           Admittedly, the claim of the complainant was repudiated by the insurance company vide letter dated 10.12.2020, Annexure OP-1/1, on the ground that there has been concealment of fact with regard to his pre-existing disease i.e. Known case of Hypertension and CAD since 2013.  However, the moot question, which falls for adjudication in this case is, as to whether  OP No.1 has been able to prove its case that the treatment taken by the insured during subsistence of the policy in question, had any direct nexus with the said alleged pre-existing diseases or not? It may be stated here that it is the own case of OP No.1 that the insured was suffering from pre-existing disease i.e. Known case of Hypertension and CAD since 2013. Whereas, on the other hand, it is also mentioned by OP No.1 in the repudiation letter aforesaid that the complainant was admitted in Rotary Cancer and General Hospital from 19.04.2020 to 21.04.2020 and took treatment of cervical. It is the case of the complainant that he has spent an amount of Rs.43,278/- for treatment of cervical in Rotary Cancer and General Hospital  for which he had  submitted his claim with OP No.1, but it refused to pay the said amount. As per OP No.1 complainant was suffered from Hypertension and CAD since 2013, but did not disclose the said fact, at the time of taking the policy in question. If it is assumed that the insured took treatment for Hypertension and CAD in the year 2013 even then it has no direct nexus with the treatment taken by the insured i.e. for CERVICAL, for which the claim in question has been raised by the complainant. A similar question as to whether, the claim is payable, in case there is no direct nexus with the treatment taken by the insured, with the pre-existing disease he is suffering from and was not disclosed, fell for determination before the Honourable Supreme Court in Sulbha Prakash Motegaonkar & Ors. Vs. LIC of India [Civil Appeal No.8245 of 2015] decided on 5.10.2015, wherein,  although it was proved that the insured therein had concealed regarding his pre-existing disease but he died on account of some other reason, even then the Honourable Supreme Court of India, allowed the consumer complaint while holding that the disease from which the insured died had no nexus with the pre-existing disease. Relevant part of the said order is reproduced hereunder:-

“…..We are of the opinion that the National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim by the respondent. The death of the insured due to ischaemic heart disease and myocardial infarction had nothing to do with his lumbar spondilitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified…….”

11.            In Life Insurance Corporation of  India Vs. Jyotsna Rawal, Revision Petition No. 864 of 2018 decided on 08.05.2018, the Honourable National Commission  held as under :

8.       In this context, I would like to rely upon the decision of Hon'ble Supreme Court in Civil Appeal No.8254 of 2015 in the case of Sulbha Prakash Motegaonkar & Ors. Vs. Life Insurance Corporation of India, decided on 05-10-2015. This was the case where the deceased died due to Ischemic Heart disease and myocardial infarction. There was a concealment of lumbar spondylitis with PID with sciatica and, therefore, the insurance company repudiated the claim. Hon'ble Supreme Court held that it was not the case of insurance company that the deceased was suffering from life threatening disease which could or did cause death of the insured. The Court observed as below:

"We are of the opinion that the National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim by the respondent. The death of the insured due to ischemic heart disease and myocardial infarction had nothing to do with his lumbar spondylitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified.

12.           In Bajaj Allianz General Insurance Co. Ltd. Vs. Usha P Joshi and Ors., First Appeal No. 48 of 2012 decided on 01.12.2019, the Honourable National Commission  observed as under:

“13.   The Appellant has failed to show that diabetes, hypertension and angina had any nexus with ‘SYNCOPE’ for which the respondent was treated and the claim put up.”

18.    The appellant, however, has failed to bring to my notice any proved fact in support of the contention that there was suppression of any material information or concealment of a pre-existing disease which had the nexus with the disease for which the respondent/complainant was treated in USA and for which she had put up her claim.  It is noteworthy that the present claim is under ‘travel secure policy’ to redeem the insured for the expenses for the treatment of an ailments abroad. The appellant has failed to prove that the ailment with which the respondent/complainant had taken treatment while in USA had any nexus with her earlier condition of diabetes or two/three fainting episodes or hypertension etc. and that she had deliberately concealed her condition of “SYNCOPE” for which she was treated in USA.

13.           Recently, the Honourable National Commission in Life Insurance Corporation Of India Versus Dr. Nilam Hetalkumar Patel & 4 Ors., Revision Petition No. 1096 Of 2019 Decided On 20 September 2023 under almost the  similar situation has held as under:-

“………..10. State Commission also relied upon judgment in P.Venkat Naidu Vs. Life Insurance Corporation of India IV ( 2011) CPJ 6 ( SC), which was upheld by the Supreme Court. Other case law relied upon by the State Commission was case of LIC Vs. Jyotsna Rawal, RP No. 864 of 2008 decided by the National Commission, relying on the judgment of Honourable Supreme Court in Sulbha Prakash Matogaonkar and Ors. ( supra) and case of Neelam Chopra Vs. LIC and Ors in RP No. 4461 of 2012. After taking note of various judgments of this Commission and Honourable Supreme Court, the State Commission concluded that “ …….It is very clear that the husband of original complainant no.1 was suf ering from major depression and he died due to heart attack. Thus, it cannot be said that there is any nexus between the ailment and the cause of death. Hence, the repudiation of the claim made by the LIC on the ground of non disclosure of material facts is not justified.” State Commission also duly considered various case laws cited by LIC in support of their contention that there was non-disclosure of material facts and even if there is no nexus with the disease and the cause of death of deceased, then also the LIC was entitled to repudiate the claim of the Complainant and observed as follows: “All the above cited cases are decided by the Honourable National Commission in the year 2014-2015 in which it was held that if there is non disclosure of material facts then nexus between the disease and the cause of death is not material. This pronouncement is now no longer a good law as the contrary view has been taken by the Honourable Supreme Court of India in the case of Sulbha Prakash case (supra), which was followed by the Honourable National Commission in the latest judgment which was delivered in December 2018 in the case of Reliance Nippon Life Insurance Co. Ltd. Vs. Yellapu Venkata.”

 

11. Accordingly, State Commission held that “……… if there is no nexus between the disease and the cause of death then the repudiation of the claim has been made by the Insurance company is not legal and valid. In the instant case, the deceased insured before taking the policies was suffering from major depression but he died due to cardiovascular arrest and therefore, the repudiation of the claim made by the LIC was not legal and valid” and upheld the order of the District Forum and dismissed seven appeals and also allowed the two Consumer Complaints.

 

12. We have carefully gone through the facts and circumstances of the case, orders of the State Commission, other relevant records, case laws relied upon by the parties / State Commission and rival contentions of the parties and are of the view that State Commission has correctly placed reliance on the judgment of Honourable Supreme Court in Sulbha Prakash Motogaonkar ( supra ) that as there is no nexus between the disease, information about which was not disclosed and the cause of death, hence the repudiation of the claim by OP Insurance Company is not correct….”

14.           Considering that there was no nexus between the material fact /information relating to pre-existing ailment alleged to have been suppressed and  Keeping in view the decision of Hon’ble Supreme Court in Sulbha Prakash Matogaonkar (supra) and other judgments of the Hon’ble National Commission  cited above, we are of the view that repudiation of the claim by OPs No.1 and 2 is not correct and the complainant is thus held entitled to get the amount of Rs.43,278/-, incurred by the complainant on his treatment, as is evident from Annexure OP1/6. Complainant is also entitled to get compensation for the mental agony and physical harassment suffered by him alongwith litigation expenses.
15.           Complaint against OP No.2 is liable to be dismissed as no deficiency in service has been proved on its part.
16.           In view of the aforesaid discussion, we hereby dismiss the present complaint against OP No.2 and allow the same against OP No.1 and direct it, in the following manner:-
    1. To pay the claim amount of Rs.43,278/- (as per the bill, Annexure OP-1/6) to the complainant alongwith interest @6% p.a. w.e.f 10.12.2020, i.e the date of repudiation of the claim, onwards. 
    2.  To pay Rs.5,000/-, as compensation for the mental agony and physical harassment suffered by the complainants.
    3. To pay Rs.3,000/- as litigation expenses.

               The OP No.1 is further directed to comply with the aforesaid directions within the period of 45 days, from the date of receipt of the certified copy of the order, failing which the OP No.1 shall pay interest @ 8% per annum on the awarded amount, from the date of default, till realization. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced:- 16.08.2024.

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President