Delhi

East Delhi

CC/17/2012

SANGEETA - Complainant(s)

Versus

RELIANCE LIFE INS - Opp.Party(s)

17 Apr 2012

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVIENIENT SHOPPING CENTRE, SAINI ENCLAVE: DELHI-92

 

 

CC No.17/ 2012:

 

 

 

In the matter of:

 

 

Smt. Sangeeta Sadh

W/o. Late Sh. Sapan Kumar

R/o.X - 4199, Gali No. 18/3, Shanti Mohalla,

Gandhi Nagar, Delhi – 110 03

Complainant

 

Vs.

 

Reliance General Insurance Co. Ltd.

(Through its Concerned Officer)

2^ndFloor, Aditya Tower,

Plot No.5, Laxmi Nagar,

Vikas Marg, Delhi – 110 092

 Opposite Party

 

 

Date of Admission  : 10/02/2012

                                                                                                    Date of Order           :24/04/2015

 

ORDER

 

 

 

Ms. Poonam Malhotra, Member :

 

 

 

 

The brief conspectus of facts of the present complaint are that on 08/12/2008 the husband of the complainant had taken a Health Insurance Policy bearing No.282510358109 for a period of two years i.e., from 08/12/2008 to 07/12/2010 for Rs.3,00,000/-.  It is submitted that at the time of taking the policy the health of the husband of the complainant was good and he was not suffering from any pre-existing disease.  It is alleged that on 05/02/2009 the husband of the complainant was admitted to Max Balaji Hospital, Delhi for treatment and intimation about it was given to the respondent on the same day.  He stayed in the hospital upto 18/02/2009 and incurred expenses of Rs.2,82,815/- on treatment and drugs.  Thereafter, on 19/02/2009 he was transferred and admitted to Sir Ganga Ram Hospital, Delhi where also heavy expenditure is alleged to have been incurred on his treatment. The husband of the complainant expired on 27/02/2009 and thereafter on 12/06/2009 the complainant submitted the claim under the said policy in respect of the treatment of his husband but the same has not been decided by the respondent.  Legal Notice sent to the respondent on 21/02/2011 was of no consequence.  It is further submitted that a complaint filed in this Forum on 11/06/2011was dismissed on 29/06/2011 on the ground of no cause of action and the complainant was directed to move the Insurance Company again pressing for the claim to be decided by it within three months and in case it fails to decide the claim within three months the complainant may approach the Forum for relief. Again a legal notice was served upon the respondent but of no consequence.  The complainant has prayed for reimbursement of his claim of Rs.2,82,815/- alongwith interest.  He has also prayed for compensation including the litigation charges.

 

In response to the notice issued to the respondent it filed its written version.  While admitting the fact of issuance of the policy in question insuring the deceased for the period 08/12/2008 to 07/12/2010 it is submitted by the respondent that the claim of the complainant was repudiated under “Exclusion Clause 10”as the treatment for alcoholism and related disorder are not payable under the policy in question and the repudiation was intimated to the complainant vide letters dated 18/02/2009 and 16/12/2009.  It has denied allegations of deficiency in service and unfair trade practice on its part.  It is further contended that this Forum has no jurisdiction to entertain the present complaint as it involves adjudication of complicated questions of fact that require leading of elaborate evidence by parties.  Rest of the allegations have been denied.    

 

Evidence by way of affidavit filed by the complainant and the respondent in support of their respective cases. 

Heard and perused the record.

On an indepth perusal of the case, it is not denied that on the date of admission into the hospital Sh. Sapan Sadh, the husband of the complainant, was insured and was covered for the medical treatment vide Health Insurance Policy bearing No.282510358109 for a period of two years i.e., from 08/12/2008 to 07/12/2010 for Rs.3,00,000/-.  A simple question which needs to be answered in this complaint is as to whether at the time of the buying of this policy the husband of the complainant was suffering from the disease, for which he was later on treated first in Max Balaji Hospital and then in Sir Ganga Ram Hospital, where he finally succumbed to his illness, and whether it will amount to concealment of facts which could disentitle her from claiming the benefit under the policy.  On perusal of the Medical History Report of Max Balaji Hospital and the Death Summary issued by the Sir Ganga Ram Hospital filed on record by the complainant it is clear that the husband of the complainant was admitted to Max Balaji Hospital on 05/02/2009 with recurrent pain in the right upper abdomen for three days associated with nausea and vomiting and was thereafter was treated at Sir Ganga Ram Hospital from 19/02/2009 to 27/02/2009.  The Death Summary issued by the Sir Ganga Ram Hospital reflected the period of affliction as two weeks.  Further, it is contended by the Ld. Cl. for the complainant that ordinarily it is not possible for a human being to know what type of metabolic activities are going on inside the body.  This is a matter of common knowledge and experience that ailments are noticed all of a sudden without any prior symptoms.  In certain cases though the disease molts into a chronic condition with the passage of time but the symptoms of such affliction appear only when it has reached a very serious and inveterate condition.  In the case in hand, the respondent has repudiated the claim of the complainant as being hit by Exclusion Clause 10 of the Terms & Conditions of the policy. It is pertinent to mention here that the onus to prove that the husband of the complainant was a chronic ethanolic and he was in the knowledge that he was suffering from a disease associated to his habit of consuming alcohol as on the date of taking the policy (i.e., 08/12/2008) is on the respondent.  Neither any cogent documentary evidence/any credible medical record has been filed on record by the respondent to rebut the allegation of the complainant that at the time of taking the policy the health of her husband was good and he was not suffering from any pre-existing disease associated to his habit of consuming alcohol so as to disentitle her to a claim under the policy.    It is pertinent to mention here that it is the insurance companies get the persons approaching them for health insurance examined medically prior to the issuance of the health insurance policy to them for any medical condition to rule out the existence of any medical condition that would fall within the expression “Pre-existing Disease” as used in the Contract of Insurance.  In the case in hand, the fact of issuance of the policy to the husband of the complainant also gives strength to the fact that as on the date of the issuance of the policy he was having good health and was not suffering from any disease.  It is also not the case of the respondent that the husband of the complainant had concealed the facts that he was suffering from Diabetes Mellitus or that he used to consume alcohol.  Further, on an indepth perusal of the Claim Form filed on record by the complainant as Ex. CW1/C, the Attending Medical Practitioner’s Statement dated 19/05/2009 which is filled by Dr. Lokesh Jain, Registration No.20241 on behalf of Dr. S. Saigal, the attending Medical Practitioner of Sir Ganga Ram Hospital it is specifically mentioned therein that Sh. Sapan Sadh, the insured suffered from the disease “Multiple Liver Abscess with Septicaemia,” at Seriatim No.6 it is stated that the first symptoms appeared on 04/02/2009 and at Seriatim No.7 in reply to the query as to whether the present ailment is pre-existing or caused by any pre-existing ailment,  the doctor has stated “No”.  The Attending Medical Practitioner’s Statement dated 19/05/2009 which forms part of the Claim Form has not been controverted by the Respondent.  This leaves no room for doubt that the complainant was not aware of the disease he was suffering from and which finally erupted on 04/02/2009 after taking the policy on 08/12/2008.

 

The private insurance companies in order to augment their business are indulging in malpractices to bring more and more people under the Health Insurance net.  They issue health insurance covers to them and collect premium from the persons so insured and thereafter repudiate their claim if the same is made by the insured within a short span of time after taking the policy by taking refuge of the Exclusion Clauses forming part of the Terms & Conditions of the Policy.  In this era of corporate culture booming in medical profession the need for health insurance cover has become a necessity as well as a priority for one and all to meet the exorbitant medical treatment costs.  The private insurance companies are taking to malpractices in their struggle to keep themselves at the top of the chart in the insurance sector with an edge over its competitors by rampantly increasing the number of insured persons with them.  This has become a practice with the private insurance companies to entrap the simple citizens on the pretext of providing health insurance cover to them and thereafter fleecing them and usurping their hard earned money.  The Forums are receiving large number of such complaints in which the Officers and Officials of such insurance companies just with the intention of earning more premium to augment the profits of their company are cheating the innocent citizens. These malpractices need to be taken care of by IRDA and other competent authorities besides the Government of India.  If need be the license of such insurance company, found indulging in unfair trade practice, should be terminated and they be prosecuted for defrauding the innocent customers under the guise of providing an insurance cover and later on repudiate their claims when made on flimsy grounds. 

 

Taking into consideration the observations and discussion made supra, we arrive at an inference that the repudiation of the claim of the complainant by the respondent is wholly illegal and, thus, not tenable.  We allow this complaint and direct the respondent insurance company to reimburse to the complainant the amount of Rs.2,82,815/- together with interest @ 9% p.a. from the date of submission of the claim till it is finally paid by the insurance company to the complainant.  Since the rejection in this case is found to be unjustified it has caused harassment, mental pain and agony to the complainant.  We award a compensation of Rs.30,000/- to be payable by the respondent to the complainant and it shall include the cost of the present litigation.  The respondent shall comply with the order within 45 days from the date of this order.  If this amount is not paid within 45 days from the date of the order, the complainant shall also be entitled to interest @ 9% p.a. on the amount of compensation and cost so awarded from the date of this order till it is finally paid to the complainant.

Copies of the order be supplied to the parties as per rule.

 

 

 (Poonam Malhotra)                                                                                                 (N.A. Zaidi)

        Member                                                                                                                President