Haryana

Karnal

CC/25/2022

Kamna Sharma - Complainant(s)

Versus

Reliance General Insurance Company Limited - Opp.Party(s)

Rishi Ram Sharma

02 Dec 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.25 of 2022

                                                        Date of instt 14.01.2022

                                                        Date of Decision: 02.12.2024

 

Kamna Sharma widow of Shri Anil Sharma and being nominee of Anil Sharma, resident of Flat no.005, Tower G-5, Sushant Royal, Sector 36, Ansal API Karnal. Aadhar no.6960 3832 8193. Mobile no.93506 92423.

 

                                                                        …….Complainant.

                                              Versus

 

1.  Religare General Insurance Company Limited Mehroli Road, Unit no.306, 111rd floor Palm Court Building, Gurugram (Haryana).
2. Reliance General Insurance Company Limited; Ground floor Unit no.4 and 5 Sector-14, Gurugram (Haryana).

 

…..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.     

              Ms. Neeru Agarwal…….Member

      Ms. Sarvjeet Kaur…..Member

 

Argued by:  Shri R.R. Sharma, counsel for the complainant.

                    Shri Ashok Vohra, counsel for the OPs.

                   

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that in the month of August 2019, the agent of the OPs came to the house of complainant and told her husband that the Reliance General Insurance has launched a Health Insurance Plan and he also told that the life of husband of complainant and his family members also got insured in that policy. On the allurement of agent of OPs, the husband of complainant namely Anil Sharma had taken the Reliance General Insurance Policy bearing no.200591928451000073, valid from 25.09.2019 to 24.09.2020. It was a dual policy and deceased Anil Sharma and his wife were covered under this policy. Prior to present insurance policy, the husband of complainant had taken a Swasthya Bima Policy from National Insurance Company Limited, vide policy no.420501/48/13/8500000163, valid from 20.08.2013 to 19.08.2014 and thereafter the husband of complainant remained insured with the OPs company till 19.08.2019. The husband of complainant paid the premium without any default upto August, 2019. On 09.12.2019, Anil Sharma fell ill and he was admitted in Amritdhara Hospital, Karnal and was diagnosed under the nature of disease fungal Phenomen/sepsis and he died on 13.12.2019 in the hospital and cause of death has been shown Cardiac Arrest Secondary to type-2 respiratory failure/septic shock on 13.12.2019 at 4.34 a.m. and the husband of complainant was suffering from cough with expectoration and moderate grade fever since last five days. The complainant had made payment of Rs.1,56,000/- to the hospital on cash basis upto 13.12.2019.

2.             It is further averred that the life of husband of complainant was fully insured and after his death, complainant approached the OPs and submitted all the relevant documents including the insurance policy, medical bills, tests etc. Thereafter, complainant received an e-mail dated 27.04.2020, by which the claim of the complainant has been rejected by the OPs on the ground that “Upon verification non-disclosure of Hypertension was found since 5-6 years on verified documents based on the above observation.”  Earlier the life of husband of complainant was insured with National Insurance Company and at the time of his death, he was insured with the OPs and during the period of previous insurance and present insurance, the husband of complainant never suffered any sort of illness and no claim was ever received by the deceased person in last six years as such the ground of rejection of claim of the complainant is totally unfounded and false one as such the OPs is liable to settle and allow the claim of the complainant.  Then complainant sent a legal notice dated 14.09.2021 but it also did not yield any result. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence, complainant filed the present complaint seeking direction to the OPs to pay a sum of Rs.1,56,000/- on account of medical claim alongwith interest @ 24% per annum from the date of it fell due till its realization, to pay Rs.1,00,000/- on account of mental pain, agony and sufferings and to pay Rs.33000/- as litigation expenses.

3.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the claim was duly processed and considered the same, but was not found payable due to the fact that husband of complainant Anil Sharma was Diagnosis for Fungal Neumonia Sepsis Septic Shock Type-2 Respirator Failure Post CPR Survivor AF with FVR as he was having complaints for cough with Expectoration Moderate Grade fever since 5 days. OPs have analyzed the documents submitted by the complainant  was rejected on the ground that upon verification of the documents, it is ascertained that the deceased had not disclose of Hypertension as the deceased patient was suffering since 5-6 years as it was found on verified documents namely Questionnaire submitted by son of the complainant. Based on the above observations and as per terms and conditions of policy under clause no.5.1.2 that the policy shall be void and all premium paid hereon shall be forfeited to the company in the event of mis-representation, mis-description or non of untrue or incorrect statement of any material particulars in the proposal form, personal statement, declaration and connected documents, or any material information having been withheld or any fraudulent means or device being used by the policy holder or any one acting on his/their behalf to obtain a benefit under this policy, the company may cancel this policy at its sole discretion and the premium paid shall be forfeited in its favour. In view of the above, the claim found non-payable and the policy has been cancelled. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint

4.             Parties then led their respective evidence.

5.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copies of premium receipts Ex.C1 to Ex.C5, copy of certificate of insurance Ex.C6, copy of premium certificate Ex.C7, copy of welcome letter Ex.C8, copy of CABNAAT test report Ex.C9, copy of death summary Ex.C10, copy of email dated 27.08.2021 Ex.C11, copy of email dated 21.02.2020 Ex.C12, copy of legal notice and its postal receipts and registered AD Ex.C13 to Ex.C16 and closed the evidence on 22.12.2022 by suffering separate statement.

6.             In additional evidence, learned counsel for the complainant has tendered medical bill alongwith detail report Ex.C17 and closed the additional evidence on 05.11.2024 by suffering separate statement.

7.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Suryadeep Singh Thakur Ex.OP1/A, copy of certificate of insurance Ex.O1, copy of policy schedule Ex.O2, copy of application form Ex.O3, copy of repudiation letter Ex.O4, copy of progress sheet Ex.O5 and closed the evidence on 25.10.2023 by suffering separate statement.

8.             We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

9.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that the husband of complainant Anil Sharma (since deceased) purchased an Insurance Policy from the OPs. In the said policy deceased Anil Sharma and his wife were covered. Prior to the present insurance policy, in the year 2013, the husband of complainant purchased a Swasthya Bima Policy from National Insurance Company Limited and thereafter ported the same in the OPs company and same is continue without any break. During the subsistence of the policy, husband of complainant had taken the treatment from Amritdhara Hospital, Karnal and spent an amount of Rs.1,56,000/-and died on 13.12.2019 due to Cardiac Arrest. Complainant lodged a claim with the OPs for reimbursement of the said amount and submitted all the required documents to settle the claim, but OPs repudiated the claim of complainant on the false and frivolous ground and lastly prayed for allowing the complaint.

10.           Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that claim of the complainant has been duly processed and observed that husband of complainant was suffering from Hypertension for the last 5-6 years. This fact had not been disclosed by the husband of complainant at the time of inception of the policy. Thus, the claim of the complainant has rightly been rejected and lastly prayed for dismissal of the complaint.

10.           We have duly considered the rival contentions of the parties.

11.           Admittedly, on 25.09.2019, Anil Sharma (since deceased) availed a Health Insurance Policy from the OPs. It is also admitted that during the subsistence of the insurance policy insured has taken treatment from Amritdhara Hospital, Karnal and spent an amount of Rs.1,56,000/- on the treatment. It is also admitted that insured died on 13.12.2019 due to Cardiac Arrest.

12.           The claim of the complainant has been rejected by the OPs, vide letter Ex.O4 dated 13.02.2020 on the ground that “since as per insured statement, patient  was suffering from Hypertension since 5-6 years for which he was taking medication from medical store but no documents for same provided by insured and also refused for affidavit. Hence, repudiated under NDC of HTN.”

13.           The claim of the complainant has been repudiated by the OPs on the abovementioned ground. OPs have alleged that life assured was suffering from “Hypertension” prior to purchase the insurance policy. The onus to prove its case was relied upon the OPs but OPs have miserably failed to prove the same by leading any cogent and convincing evidence. There is nothing on the file,  insured was taking medication from any medical store prior to purchasing the policy in question. The case of the OPs based upon the investigation report but OPs have neither examined the investigator who has conducted the investigation and came to the conclusion that insured was taking medication. Moreover, said investigation report is photocopy and have no weightage in the eyes of law.

14.           Husband of the complainant purchased insurance policy from National Insurance Company Limited, vide policy no.420501/48/13/8500000163, valid from 20.08.2013 to 19.08.2014 and he remained insured with the said insurance company till 19.08.2019. The said fact has not been denied by the OPs. The insured had got ported the policy from National Insurance Company Limited to OPs company without any break. The insured died on 13.12.2019.

 15.          Further, for the sake of arguments, if it be presumed that the deceased was suffering from Hypertension at the time of obtaining the insurance policy, in that case also the claim cannot be repudiated, because Hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension. In this regard, we are also fortified from the observations of the Hon’ble State Commission, New Delhi, titled as Life Insurance Corporation of India Versus Sudha Jain 2007 (2) CLT 423, in which Hon’ble State Commission has drawn conclusion in para 9 of the order and the relevant clause is 9 (iii), is reproduced as under:-

“9(iii) Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.” Taking into consideration the facts of the present case and law laid down by the Hon’ble Superior Fora in the above referred cases, we are of the view that OPs were not justified in repudiating the claim of the complainant and are thus liable to pay the amount which the complainant had incurred on his treatment”.

16.           As per insurance policy Ex.C6, the date of birth of insured is 10.06.1951 and policy in question purchased on 11.09.2016. Thus, at that time the age of complainant was more than 55 years. Hence, it was the duty of the OPs to get the medical examination of the deceased life assured as per the instructions issued by Insurance Regulatory & Development Authority of India (IRDAI). In this regard, we place reliance upon case titled as  National Insurance Company Ltd. Versus Harbirinder Singh appeal no.220 of 2016 decided on 30.09.2016, wherein Hon’ble State Commission U.T. Chandigarh has held that if the complainant and his wife both are older than 45 years of age but there is nothing on record to show that before insurance policy was issued to them, the appellants got them medically examined, which as per instructions issued by Insurance Regularly & Development Authority of India (IRDAI) is must in such like cases. Similarly, view was taken by Hon’ble Chandigarh State Commission in case of M/s Max Bupa Health Insurance Co.Ltd. Vs. Rakesh Walia, appeal no.191 of 2016 decided on 18.08.2016  and held that if contrary to the instructions issued by IRDAI, an insured above the age of 45 years, was not put to through medical examination, claim raised after issuance of insurance of policy cannot be rejected on account of non-disclosure of the fact of pre-existing disease when policy was obtained.

17.           Moreover, nowadays, it has become the routine practice of the insurance companies to reject the genuine claim on minor technicality. Thus, the denial of the claim of complainant is arbitrary and unjustified. In this regard, we place reliance on the judgment of Hon’ble Punjab and Haryana High Court titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.”

 

18.           Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OPs while repudiating the claim of the complainant amounts to deficiency in service and unfair trade pracice, which is otherwise proved genuine one. 

19.           The complainant has spent an amount of Rs.1,56,000/- on the treatment of her husband and in this regard complainant has submitted the medical bill Ex.C17, the said bill amount neither denied nor rebutted by the OPs. The sum assured under the policy is Rs.5,00,000/-.  Hence, the complainant is entitled for the paid amount alongwith interest, compensation for mental pain, agony harassment and litigation expenses etc.

20.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.1,56,000/- (Rs. one lakh fifty six thousand only) alongwith interest @ 9% per annum from the date of filing the complaint i.e. 14.01.2022 till its realization to the complainant. We further direct the OPs to pay Rs.25,000/- to the complainant on account of mental agony and harassment and Rs. 11,000/- towards the litigation expenses. This order shall be complied within 45 days from the date of receipt of copy of the order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated: 02.12.2024    

                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Neeru Agarwal)              (Sarvjeet Kaur)

                   Member                          Member