District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.659/2023.
Date of Institution:10.10.2023.
Date of Order: 25.10.2024.
Kailash Chand resident of Shop No. 59, Hani Gajak and Namkeen, Housing Board Colony, Sector-10, Faridabad.
…….Complainant……..
Versus
Reliance General Insurance Company Ltd. Airnat Tower, 2nd floor, NH-131A, Sub division-B, NIT-5, Opposite Banke Bihari Mandir, Railway Road, Faridabad.
…Opposite party……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma………..Member
Indira Bhadana………….Member.
PRESENT: Shri P.K.Tyagi, counsel for the Complainant.
Shri Rakesh Dabaas, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant had taken the mediclaim policy from his company for a period of 17.2.2022 to 16.2.2024 vide policy No. 201022228280000860 worth of Rs.6,00,000/- and the complainant had been paid the premium amount Rs.47,566/- pertaining to the above said policy to the opposite party without any delay. During the mediclaim policy the complainant was admitted in Sarvodaya Hospital and Research centre, Sector-8, Faridabad on dated 4.6.2023 and was discharged on 7.6.2023 and the hospital had raised the bill amount of Rs.79,017/- and at that time the complainant intimated to the representative of the opposite party through telephonically cell and the representative of the opposite party assured the complainant that his claim file No. 201230056156 would be definitely approved, but no fruitful result came out and the said amount had paid by the complainant from their own pocket and later on the complainant had sent all related documents regarding the treatment of the complainant for getting the imbursement of the mediclaim amount but no fruitful result came out. The complainant sent a legal notice dated 15.07.2023 through registered post but all in vain. During the mediclaim policy the complainant had admitted again on dated 15.07.2023 and discharged on dated 16.07.2023 at Sarvodya Hospital, sEcator-8, Faridabad and paid the bill amount of Rs.95,453/- from his own pocket and at that time the complainant intimated to the representative of the opposite party through telephonically call and the representative of the opposite party assured the complainant that his claim file No. 201230074294 would be definitely approved, but again no fruitful result came out and the said amount had paid by the complainant form his own pocket and later on the complainant had sent all related documents regarding the treatment for getting the imbursement of the mediclaim amount but no fruitful result came out. The complainant several times requested to the opposite party to make the respective medicalim amount of Rs.95,453/- and previous amount Rs.79,017/- but the opposite party linger on the matter on one pretext to the another. The complainant sent a legal notice dated 13.09.2023 through registered post but all in vain. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) make the mediclaim policy amount of Rs.95,453/- and previous amount Rs.79,017/- regarding the policy No. 201022228280000860 alongwith interest @ 18% p.a. to the complainant which had been beard complainant from his own pocket during the insurance policy.
b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 22,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that at the very threshold of the allegations contained in the complaint, it was established from the relied upon documents/information by the complainant pertaining treatment w.e.f. 15.07.2023 to 16.07.2023, he was a known case of hypertension since year 2021 & which was not disclosed at the time of policy inception 17.02.2022, which amply prove on record that the claim of the complainant falls within the Exclusion clause 6.1 (Disclosure of information norm) of the insurance policy so incorporated in the insurance policy. The complainant neither had any cause of action nor locus standi in lodging of the present complaint before this Hon’ble Commission, reason being, the complainant was having history of pre-existing disease as hypertension since year 2021. As a matter of record, the complainant had lodged reimbursement mediclaim vide under claim form dated 09.08.2023 by enclosing entire treatment papers by alleging indoor treatment w.e.f 15.07.,2023 to 16.07.2023 therein with Sarvodaya Hospital, Faridabad. During processing of the claim at the end of the insurance company, it was revealed that since, as per indoor record of treating hospital, the complainant was admitted with diagnosis Acute Malculus Cholecystitis for surgical management, upon claim verification, it was noted that patient was known case of hypertension since year 2021 & which was not disclosed at the time of policy inception 17.02.2022, which amply proved on record that the claim of the complainant falls within the Exclusion clause 6.1 of the insurance policy so incorporated in the insurance policy. As such, the opposite party had treated the subject claim as “repudiated” by closing the file in terms of “letter of intimation” dated 31.08.2023, which decision could not be termed unconscionable at all. Subsequently, insurance policy in question was also cancelled vide letter dated 1.09.2023. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party– M/s. Reliance General Insurance Co. Ltd. with the prayer to: a) make the mediclaim policy amount of Rs.95,453/- and previous amount Rs.79,017/- regarding the policy No. 201022228280000860 alongwith interest @ 18% p.a. to the complainant which had been beard complainant from his own pocket during the insurance policy. b) pay Rs.1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 22,000 /-as litigation expenses.
To establish his case, the complainant has led in his evidence EAx.CW1/A – affidavit of Kailash Chand, Ex.C-1 – Reliance Health Gain Policy Schedule, Ex.C-2 – receipt, Ex.C-2 – discharge summary, Ex.C-3 - clam repudiation letter dated 26.6.2023, Ex. C-4 – legal notice,, Ex.C-5 – postal receipt, Ex.C-6 – discharge summary, Ex.C-7 – repudiation letter,, Ex.C-8 – legal notice,, Ex.C-9 –postal receipt.
On the other hand counsel for the opposite party strongly agitated and opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Shri Suryadeep Singh, Thakur son of Manjeet Singh, aged 40 years, Area Manager (Legal Claims), M/s. Reliance General Insurance Company Limited, Regional Office, SCO-57-58-59, 4th floor, Opposite Hotel Taj, Sector-17A, Chandigarh, Ex.R-1 – Reliance Health Gain Policy Schedule, Ex.R-2 – proposal form, Ex.R-3 – terms and conditions, Ex.R-4 – repudiation letter, Ex.R-5 – RCU final report, Ex.R-6(colly) – discharge summary,, Ex.R-7 – Health claim form, Ex.R-8(colly) – insured/claimant questionnaire for insured, Ex.R-9 – reminder letter dated 01.09.2023.
6. In this case, the complaint was filed by the complainant with the prayer to make the mediclaim policy amount of Rs.95,453/- and previous amount Rs.79,017/- regarding the policy No. 201022228280000860 alongwith interest @ 18% p.a. to the complainant which had been beard complainant from his own pocket during the insurance policy. To prove his case, the complainant led in his evidence Ex.C-1 to C-9. On the other hand, opposite party led in their evidence Ex.R-1 to R-9.
7. The repudiation made by the opposite party on the ground that “the primary reasons for our inability to admit the liability of his claim as noted in the above mentioned documents and details are as follows: insured presented with diagnosis Acute Caculus Cholecystitis for surgical management. As per internal verification patient K/C/O HTN since 2021 which was not disclosed at the time of policy inception dated 17.12.2022. Hence, we regret to inform that claim had been repudiated as per clause section 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. The company reserves the right to add reasons of repudiation on other grounds jot listed above and available to the company at a later date.”
8. As per insurance policy vide Ex.C-1, when the insured is 48 years then the Insurance Company was at liberty to get the complainant medically examined prior to issuance of the policy in question. Insurance Company cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing the policy in question whether a person is fit to be insured or not. It was the duty of the opposite party to get the complainant immediately examined before issuing the policy as per IRDA guidelines.
9. After going through the evidence led by the complainant, the Commission is of the opinion that hypertension is not a disease today it is a life style. It is settled law from the Hon’ble Apex Court the hypertension now-a-days is not a disease is a part of life style. In the interest of justice, the complaint is allowed.
10. Opposite party is directed to process the claim of the complainant as per the T&C of the policy within 30 days of receipt of the copy of order and pay the claimed amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite party is also directed to pay Rs.3300/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on:25.10.2024 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad
