Chandigarh

DF-I

CC/198/2023

NISHANT THAKKAR - Complainant(s)

Versus

RELIANCE GENERAL INSURANCE CO. PVT LTD. - Opp.Party(s)

ARJUN KUNDRA

01 Apr 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/198/2023
Date of Institution	:	17/04/2023
Date of Decision	:	01/04/2024

Nishant Thakkar S/O Surinder Kumar R/O #1362 Sector 44-B, Chandigarh-160047.

… Complainant

V E R S U S

1. Reliance General Insurance Company PVT. LTD. Through Manager Legal, 2nd Floor, SCO 145/146/147/148, Sector 9-C, Madhya Marg, Chandigarh -160009.

2. Reliance General Insurance Company PVT. LTD. Through its Authorized Signatory or Manager Legal or Managing Director, SCO 123-124, Third Floor, Sector 17-B, Chandigarh-160017.

3. Reliance General Insurance Company PVT. LTD. Through Managing Director, Correspondence Unit, 2^nd & 3^rd Floor, Winway Building, 11/12, Block No-4, Old No-67, South Tukoganj, Near Madhumilan Square, Indore, Madhya Pradesh, India - 45200.

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                               

ARGUED BY	:	Sh. Vishal Sharma, Advocate, Proxy for Sh. Arjun Kundra, Advocate for complainant
	:	Sh. Arun Kumar (through VC) and Varun Bhardwaj, Advocate for OPs

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Nishant Thakkar, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations, as projected in the consumer complaint, that the complainant had obtained Reliance Healthgain Insurance Policy (hereinafter referred to as “subject policy”) from the OPs which was valid w.e.f. 21.4.2021 to 20.4.2022 (Annexure C-1) with sum insured of ₹3.00 lacs. On 11.11.2021, complainant was admitted at the Fortis Hospital, Mohali (hereinafter referred to as “Treating Hospital”) for the treatment of “Left ACL Tear complete with MM Ramp Tear Unstable” and was discharged on 12.11.2021 as per discharge summary (Annexure C-2).  At the time of discharge, Treating Hospital had raised bills (Annexure C-3) to the tune of ₹1,39,932/- which was paid by the complainant and thereafter he had lodged claim (Annexure C-4) with the OPs.  However, the genuine claim raised by the complainant was repudiated by the OPs vide letter dated 7.2.2022 (Annexure C-5) on the flimsy ground of non-disclosure of Right ACL tear repair of the complainant since 2018 and as the said fact was not disclosed at the time of inception of the subject policy, the same amounts to violation of the terms and conditions of the subject policy. The complainant at the time of issuance of the subject policy had disclosed each and every precise information to the OPs and even the factum of right ACL tear repair in the year 2018 was also best known to the OPs.  Moreover, the said tear repair was not at all linked to the treatment of left ACL tear repair for which the present claim had been lodged by the complainant. In this manner, the aforesaid act of the OPs amounts to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action, concealment of facts and also that the complainant has not disclosed material facts qua his previous treatment taken by him prior to the inception of the subject policy.  On merits, admitted that the subject policy was issued to the complainant and he had lodged claim with the OPs.  It is further alleged that as the complainant had undergone right knee surgery for which he remained hospitalized at Landmark Hospital, Chandigarh w.e.f. 30.6.2018 to 2.7.2018 and the said fact was not disclosed by him at the time of inception of the subject policy, the claim of the complainant was rightly repudiated.  Copies of previous medical record and repudiation letter are Ex.OP-3 and OP-4.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. Despite grant of sufficient opportunity, rejoinder was not filed by the complainant to rebut the stand of the OPs.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had obtained the subject policy (Annexure C-1) from the OPs which was valid w.e.f. 21.4.2021 to 20.4.2022 and during the currency of the same, complainant had undertaken treatment of “Left ACL Tear complete with MM Ramp Tear Unstable”  from the Treating Hospital, as is also evident from the discharge summary (Annexure C-2) and had paid an amount of ₹1,39,932/- to it, as is also evident from the inpatient summary bill (Annexure C-3) and the claim of the complainant was repudiated by the OPs on the ground of non-disclosure of material facts qua the earlier treatment taken by him in the year 2018, i.e. before inception of the subject policy, for his right ACL tear repair, the case is reduced to a narrow compass as it is to be determined if the OPs/ insurers are unjustified in rejecting/repudiating the claim and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs have rightly rejected/repudiated the claim on the ground of non-disclosure of material facts and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, medical record, having been relied upon by the parties, and claim rejection/repudiation letter and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Annexure C-1 is copy of subject policy which clearly indicates that the same was valid w.e.f. 21.4.2021 to 20.4.2022  and clause 6.1 of the same indicates that the policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, mis-description or non-disclosure of any material fact by the Policyholder. Clause 6.1 of the subject policy is reproduced below for ready reference :-

        “6. General Terms and Conditions

6.1 Disclosure of Information

The Policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, mis description or non-disclosure of any material fact by the Policyholder.

(Explanation: "Material facts" for the purpose of this policy shall mean all relevant information sought by the company in the proposal form and other connected documents to enable it to take informed decision in the context of underwriting the risk.”

4. Discharge summary (Annexure C-2) issued by the Treating Hospital clearly indicates that earlier surgery of right knee of the complainant was done 1½ back whereas presently he was treated for Left ACL reconstruction.  Relevant portion of discharge summary is reproduced below for ready reference :-

“Course in the hospital

30 Years old male patient was admitted with the above mentioned complaints. All the relevant investigations were done. After consent, clearance and PAC, patient was taken up for LEFT ACL RECONSTRUCTION (Hybrid PL) + MM RAMP REPAIR DONE ON 11/11/2021. Operative findings :- Patient laid in supine position. Spinal + Block Painting and draping done. Left leg PL harvest (7.5 mm graft). Wash done. Closure done with 2-0 vicryl, 2-0 ethilon. Dressing done. LEFT Knee scopy :- Complete ACL tear + medial meniscus RAMP tear unstable. Medial meniscus RAMP repair with 1 x fast fix 360. Femur 20 mm CL endobutton. Graft 8mm Hybrid (1 x PL + 1 x FT). Tibia 10 x30 mm. PEEK Bioscew with 1 X FT. Wash done. Closure done with 2-0 vicryl 2-0 ethilon. Dressing done. Immobiliser applied. Post operatively patient was shifted to Ward & managed with IVF, I/V Antibiotics, analgesics, antacids & other supportive treatment. Gradually condition of patient remained improved and Patient is now being discharged on the following discharge advice.”

 

5. Annexure C-5 is letter dated 7.2.2022 vide which the claim of the complainant was repudiated and the relevant portion of the same is reproduced below for ready reference :-

“Member reimbursement cannot be considered as per received documents patient NISHANT THAKKAR was admitted with left ACL Tear complete with MM Ramp Tear Unstable at Fortis Hospital with DOA 11/Nov/2021 to DOD 12/Nov/2021. Upon verification Non-disclosure of Right ACL, Tear Repair was found on verified documents since 2018 which was not disclosed at the time of inception of policy. Based on above observations as per policy terms and conditions Clause 6.1 The Policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, mis-description or non-disclosure of any material fact by the Policyholder. Hence we regret to inform you that this claim stands non payable and policy has been cancelled.

The above claim reported by you is not admissible as per the terms and conditions of the policy. Hence we are unable to reimburse/admit any amount under the captioned claim. We have retained the photocopy of the claim documents for future reference.”

 

6. OPs have also relied upon the discharge summary (Ex.OP-3) of the previous treatment taken from the Landmark Hospital, which clearly indicates that, at that time, right ACL was found torn by the said Hospital and the treatment for the same was given in the said hospital. Relevant portion of the aforesaid discharge summary is reproduced below for ready reference :-

“Any Procedure Performed:

Patient underwent Arthroscopic ACL Reconstruction under Tourniquet under S/A on 30/06/2018.

Hamatrines graft used

Implant -CONMED USA

ALD Button 1

Bio Screws - TCP: 10X30mm”

 

7. Learned counsel for the complainant contended with vehemence that as it stands proved on record that earlier the complainant had taken treatment for right ACL tear repair whereas the present treatment was taken by him for left ACL reconstruction, which has no nexus with the previous surgery performed by the then Hospital as the complainant had suffered injury to his left ACL for which the surgery was performed by the Treating Hospital and the complainant had raised claim, OPs have wrongly repudiated the claim of complainant on flimsy ground of non-disclosure of previous ailment and instant consumer complaint deserves to be allowed.
8. On the other hand, learned counsel for OPs/insurers contended with vehemence that as the complainant was supposed to disclose the treatment taken by him in the year 2018 i.e. prior to the inception of the subject policy, which was not disclosed by him, the claim was rightly repudiated and the consumer complaint deserves to be dismissed.
9. However, there is no force in the contention of the learned counsel for the OPs as it stands proved on record that earlier the surgery for right ACL (Anterior Cruciate Ligament), connecting the thigh bone (femur) to the shin bone (tibia), which may be caused or torn during sports, was taken from the Landmark Hospital whereas during the currency of the subject policy, complainant had undergone treatment for the Left ACL reconstruction and both the treatments i.e. surgeries performed upon the complainant are altogether different and have no nexus with each other.  Hence, it is safe to hold that the defence of the OPs that the complainant, at the time of inception of the subject policy, had not disclosed about the earlier surgery/treatment to the OPs and the same amounts to material concealment of fact, is without merit. 
10. The Hon’ble National Commission in the case titled as Neelam Chopra Vs. Life Insurance Corporation of India & Ors., IV (2018) CPJ 321 (NC), while dealing with the question of suppression/non-disclosure of material facts, has held as under :-

     12. In the present case, clearly the cause of death is cardio respiratory arrest and this disease was not existing when the proposal form was filled. Clearly, there is no suppression of material information in respect of this disease, which is the main cause of death. The other disease of LL Hansen, which was prevailing for five weeks on the date of admission on 1.8.2003 was also not existing when the proposal was filed by the DLA. The fact of DLA having been treated in the year 2002 for LL Hansen is not supported from any direct evidence though PGI Chandigarh in its certificate has mentioned that disease was treated in 2002. Moreover, this disease does not have any correlation with the cause of death in the present case. Hon’ble Supreme Court in Sulbha Prakash Motegaonkar and Ors. v. Life Insurance Corporation of India, Civil Appeal No.8245 of 2015, decided on 5.10.2015 (SC) has held the following:

        “We have heard learned Counsel for the parties.

                It is not the case of the Insurance Company that the ailment that the deceased was suffering from was a life threatening disease which could or did cause the death of the insured. In fact, the clear case is that the deceased died due to ischaemic heart disease and also because of myocardial infarction. The concealment of lumbar spondylitis with PID with sciatica persuaded the respondent not to grant the insurance claim.

                We are of the opinion that 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 this 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.”

11. In view of the foregoing discussion and the ratio of law laid down above, it is clear that the OPs/ insurers have not been able to connect the previous diseases/ailments with the present diseases/ailments. Hence, it is unsafe to hold that OPs/insurers were justified in repudiating the claim of the complainant qua the subject policy and the present consumer complaint deserves to succeed. 
12. Now coming to the quantum of amount, since the complainant has proved the inpatient summary bill (Annexure C-3) totaling to ₹1,39,932/- towards the expenses spent on his hospitalisation/treatment, it is safe to hold that OPs/insurers are liable to pay the said amount to the complainant alongwith interest and compensation etc.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹1,39,932/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 7.2.2022 onwards.
2. to pay ₹15,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

01/04/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member
	Sd/- [Suresh Kumar Sardana] Member