PER
Charanjit Singh, President
1 The complainant has filed the present complaint by invoking the provisions of Section 34, 35 and 36 of the Consumer Protection Act against the opposite parties on the allegations that the opposite parties are doing the business of insurance through network of branches in India including the Branch Office at Amritsar. The complainant was approached by an agent of the opposite party and upon the assurance that the insurance service provided by the opposite party is best in their field and as such the complainant availed the health insurance for a sum of Rs.05 Lakh vide insurance policy No.16463443. The insurance policy was issued by the opposite party covering the risk for the period w.e.f. 24.12.2019 to 23.12.2020 and in respect thereof requisite premium was paid by the complainant to the opposite party. The opposite party satisfied itself regarding all the previous medical history of the complainant and as such the above mentioned policy was issued to the complainant. The opposite party at the time of giving health insurance cover to the complainant guaranteed hospitalization expenses, pre and post hospitalization expenses alongwith cashless hospitalization expenses shall be borne by the opposite party. Unfortunately couple of days prior to 06.03.2020, the complainant felt some mild health weakness. As such on 06.03.2020 the complainant consulted a neurologist practicing at Amritsar, namely Dr. Prabhjit Singh, who conducted several medical tests of the complainant and advised the complainant to get admitted in Nayyar Hospital Amritsar. Accordingly, the complainant immediately got himself admitted in Nayyar Hospital at Amritsar on the same day i.e. 06.03.2020. The complainant was diagnosed with Guillian-Barre Syndrome [In Short GBS] by the Medical experts and in such like syndrome the patient is unable to bear weight on his both the upper and lower limbs as well as suffers from severe weakness and pain. Thereafter, the complainant was provided treatment as prescribed in such like cases. The complainant before getting himself admitted in Nayyar Hospital, approached the representatives of the opposite party as he was medically insured by it and on the instruction of the opposite party, the complainant provided all the particulars as well as details regarding his health policy. Thereafter, the complainant was fully assured by the representative of the opposite party that the approval for the treatment of the complainant will received within an hour or so from the opposite party and as such the opposite party approved the admission of the complainant at the above mentioned hospital on 6.3.2020. Inspite of due intimation given to the opposite party by the complainant as mentioned above, no approval was granted by the opposite parties to continue the treatment of the complainant cashless. As it was matter of grave emergency, the complainant needs medical treatment immediately to save his life and thereafter, the complainant himself paid all the medical expenses for his treatment from his own pocket i.e. from 6.3.2020 to 11.3.2020 when he got discharged from the hospital. The complainant paid a sum of Rs.2,69,799/- for his treatment at Nayyar Hospital Amritsar, which includes hospital expenses, medical expenses, consultation fee etc. After getting discharge from the hospital on 11.03.2020, the complainant again approached the opposite party and requested for reimbursement of an amount of Rs.02,69,799/- from this party i.e. the expenses which he paid to the hospital on his treatment from his own pocket inspite of the fact that he was medically insured by the opposite party and in this event the opposite party has to pay these expenses to the hospital as the complainant obtained cashless policy. Thereafter, the opposite parties assured the complainant that the reimbursement regarding the claim will be made in couple of weeks to the complainant. During the course of proceedings and process of deciding the reimbursement case of the complainant, the opposite party told the complainant to get in writing regarding certification that the complainant was not suffering from any ailment such as diabetes and high or low blood pressure. Accordingly on the instruction of the opposite party, the complainant got it certified in writing from Dr. Prabhjit Singh on 12.03.2020 vide which the doctor certified in detail that the ailment from which the complainant was suffering and also detailed that the history of weakness or ailment is of two days only and moreover the complainant had no history of preexisting diabetes or fluctuating in blood pressure and this certificate was forwarded by the complainant to the opposite party immediately. Again after a couple of months instead of reimbursing the above mentioned amount to the complainant, the opposite party required the documents of treatment record etc. from the complainant and told the complainant to deposit these at Amritsar office of the opposite party i.e. with the opposite party No1 which was duly done by the complainant and the complainant obtained a receipt for the same on 10.7.2020 and after obtaining these documents, the opposite party No.1 assured the complainant that he has fulfilled all the requirements and the reimbursement for the claim will be immediately released to him. Again the opposite party asked the complainant to submit a certificate from the consultant neurologist so as to authentified that he was not suffering from the above said ailment in the past, as such Dr. Prabhjit Singh gave certificate regarding the history of any such ailment vide certificate dated 29.07.2020 which was forwarded by the complainant to the opposite party. The complainant was astonished when he received a letter dated 13.08.2020, vide which the opposite party declined the claim of the complainant by giving vague reasons of non-discloser of pre- existing ailment and as such the complainant applied for the review. The opposite party during the course of proceedings of review demanded that the certificate dated 29.7.2020 should be verified by the Nayyar Hospital as well for pursuing the review case. The complainant immediately verified the certificate on 2.9.2020 and submitted the same with the opposite party. Thereafter, the complainant again got the above mentioned certificate dated 29.7.2020 verified by Nayyar Hospital, Amritsar and the same was submitted by the complainant immediately after 2.9.2020 with the opposite party. The complainant has prayed that the present complaint may be allowed by granting the following reliefs in favour of complainant.
- The opposite party may kindly be directed to release the reimbursement of expenses of treatment amounting to Rs. 2,69,799/- to the complainant immediately.
- It is further prayed that an amount of Rs. 1 Lakh as compensation and Rs. 50,000/- as litigation expenses on account of mental and physical harassment caused to the complainant at the hands of oppose party, in the interest of justice, equity and fair play.
Alongwith the present complaint, the complainant has placed on record his affidavit Ex. C-1 alongwith documents i.e. Self attested copy of health Policy Ex. C-2, Self attested copy of Health Card Ex. C-3, self attested copy of treatment record Ex. C-4, Self attested copy of treatment record Ex. C-4, self attested copy of bills of treatment including medicines, hospital expenses, tests etc. and paid bills Ex. C-5, Self attested copy of OPD Slips Ex. C-6, Self attested copy of certificate dated 12.3.2020 Ex. C-7, Self attested copy of receipt of documents supplied to opposite party dated 10.7.2020 Ex. C-8, Self attested copy of letter dated 29.7.2020 Ex. C-9, Self attested copy of claim denial letter dated 13.8.2020 Ex. C-10, Self attested copy of e mail regarding review of claim denial Ex. C-11, Self attested copy of physiotherapy bill Ex. C-12.
2 Notice of this complaint issued to the opposite parties and opposite parties appeared through counsel and filed written version by interalia pleadings that the complainant has not come to the Commission with clean hands and has suppressed the true and material facts from this Commission. The company had issued health insurance Policy bearing no. 16463443 (Product: Care (Individual)) to the complainant/Insured i.e. Mr. Ankush Sood with effect from 24.12. 2019 till 23.12.2020 for a sum insured of Rs. 5,00,000/-subject to the Policy Terms and Conditions. He had not disclosed any of the disease or conditions or illness as pre existing. The insured approached the opposite party through his treating hospital i.e. Nayyar Hospital, Amritsar with a cashless request to get reimbursement of the hospitalization charges. As per the pre-authorization form, the insured was hospitalized w.e.f. 6.3.2020 with complaints of weakness in both limbs and legs, history of fever, vertigo. He was provisionally diagnosed with Gullian Barre Syndrome. As per the pre-authorization form, he had the present ailments since 2 days. After receiving the cashless request, the opposite party asked for few documents in order to properly assess the claim and sent deficiency letters dated 07-03-2020, 09-03- 2020 and thereafter, reminder dated 8.3.2020 to seek the following documents -
KINDLY PROVIDE
1 COMPLETE INDOOR CASE PAPERS WITH ADMISSION NOTES, HISTORY SHEET, DOCTOR'S NOTES, NURSING NOTES AND VITAL CHART.
2 EXACT DURATION AND PAST HISTORY OF PRESENT AILMENT WITH 1ST CONSULTATION PAPER AND ALL PAST TREATMENT RECORDS.
3 PRE HOSPITALISATION OPD TREATMENT RECORD.
4 RECENT PASSPORT SIZE PHOTOGRAPH OF PROPOSER / NOMINEE.
The company also triggered claim investigation for better analysis of the claim. Inspite of above said letters and reminder the complainant didn't submit all the documents, hence, the genuineness of the case could not be determined. As a good company gesture, the complainant was advised by the opposite party to file for reimbursement claim along with complete set of documents. On basis of the above findings, the opposite party rejected the claim of the complainant vide denial Letter dated 11.3.2020 and 12.3.2020 with the following observation: -
AS PER SUBMITTED DOCUMENTS, PAYABILITY OF THIS CASE CAN NOT BE ASCERTAIN AT THIS TIME, HENCE LIABILITY OF INSURER CANNOT BE TAKEN AT PRESENT JUNCTURE AND CASHLESS FACILITY IS BEING DENIED. PLEASE FILE FOR REIMBURSEMENT WITH ALL SUPPORTIVE DOCUMENTS.
DEFICIENCY NOT REPLIED
Post denial of the cashless claim, the complainant again filed a reimbursement claim for the above stated hospitalization w.e.f. 6.3.2020 till 11.3.2020 at Nayyar Hospital, Amritsar. As per the discharge summary, he was diagnosed with Gullian Barre Syndrome. After receiving the reimbursement request of claim, the opposite party demanded few documents in order to properly assess the claim. The opposite party raised deficiency letter dated 14.7.2020 and thereafter, reminders dated 24.7.2020, 3.8.2020 to seek the following documents -
1. TREATING DOCTOR'S CERTIFICATE FOR ETIOLOGY OF PRESENT AILMENT. 2. EXACT DURATION AND PAST HISTORY OF PRESENT AILMENT WITH 1ST CONSULTATION PAPER AND ALL
PAST TREATMENT RECORDS. 3. RECENT PASSPORT SIZE PHOTOGRAPH OF PROPOSER/ CASE PAPERS WITH ADMISSION
NOMINEE. 4. COMPLETE INDOOR
NOTES, HISTORY SHEET, DOCTOR'S NOTES, NURSING
NOTES AND VITAL CHART.
The company also triggered claim investigation for better analysis of the claim. But the complainant did not provide the above mentioned documents/information required to settle the claim. And on the basis of the documents which were supplied, the opposite party rejected the claim of the complainant vide Claim Denial Letter dated 13.8.2020 with the following observation:-
CLAIM REJECTED-NON DISCLOSURE OF GUILLAIN –BARRE SYNDROME PRIOR TO POLICY INCEPTION.
NON DISCLOSURE OF MATERIAL FACTS/PRE-EXISTING AILMENTS AT TIME OF PROPOSAL.
The opposite party provided questionnaire to the treating doctor to provide information regarding history of the ailment and treatment and the following questions were asked from the treating doctor Dr. Prabhjeet Singh -
Question 2- What investigations had been conducted on the patient and what diagnosis was made?
Answer Routine based investigation- ANA IFN Nerve conductive study. Motor axonal neuropathy (GBS since November 2019)
Question 6- Please specify the etiology of patient's ailment? Kindly specify if patient's ailments are due to hypertension or other previous medical illness?
The doctor answered -Motor axonal neuropathy, GBS since November 2019.
So from the facts mentioned above, it was found that the complainant was suffering from pre-existing disease and he intentionally not disclosed the facts regarding his pre-existing disease, therefore, the claim was rejected and due intimation of the same was given to the complainant vide letter dated 13.8.2020. It is pertinent to mention that the policy inception date was 24-12- 2019
The complainant has violated the terms and conditions of the policy as such he is not entitled for any claim. The Relevant clause is reproduced herein through which the opposite party process the claim:
7. General Terms and Conditions
7.1. Disclosure to Information Norm
If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particulars or any material information having been withheld or if a Claim is fraudulently made or any fraudulent means or devices are used by the Policyholder or the Insured Person or any one acting on his/their behalf, the Company shall have no liability to make payment of any Claims and the premium paid shall be forfeited ab initio to the Company.
The Insurance Regulatory and Development Authority of India (IRDAI) (Protection of Policy Holder's Interest) Regulations, 2017 under Clause 19(4) enumerating the "General Principles" casts an absolute duty to disclose all material facts to the Insurer in order to assess the risk as per it's capacity, which is reproduced herein below: -
"The policyholder shall furnish all information that is sought from him by the insurer, either directly or through the distribution channels which the insurer considers as having a bearing on the risk to enable the insurer to assess properly the risk covered under a proposal for insurance."
Thus the Policy Holder/ Complainant herein is not only acting in breach of the Policy Terms and Conditions governing the Policy, but also has acted in blatant violation of the above stated Principles and Regulations. As per the proposal form, no history was disclosed by the complainant while getting health insurance policy issued from the opposite party. In the proposal form, the complainant replied the questions regarding pre-existing disease as follows:
Additional details-
A Does any person (s) to be insured has any pre-existing diseases ?
The present complaint has been filed without any cause of action against the opposite parties. The complainant is estopped by his own act and conduct from filing the present complaint. The complainant has no locus standi to file the present complaint. The present complaint is not maintainable and is liable to be dismissed. It is the duty of the insured to provide material information regarding his pre- existing disease/health condition at the time of filing proposal form of the insurance policy, but in this case the complainant has intentionally concealed the material fact regarding his pre-existing ailment. So far as guaranteed hospitalization expenses, pre and post hospitalization expenses, cashless expenses are concerned, that are subject to the fulfillment of terms and conditions of the policy. The complainant was a known case of GBS since one month prior to the policy inception and the diagnosis of the current hospitalization is also GBS, hence, this is a clear case of intentional nondisclosure to get undue benefits from the policy which runs on the principle of Ubberima Fides. The opposite parties have denied the other contents of the complaint and prayed for dismissal of the same. Alongwith the written version, the opposite parties have placed on record affidavit of Ravi Boolchandani, Manager Legal O.P1,2/1, self attested copy of authority letter Ex. OP1,2/2 self attested copy of policy Ex.OP1,2 2/3 self attested copy of terms and conditions is OP1,2/4 , self attested copy of discharge summary is Ex.OP1,2/5, self attested copy of discharge summary is Ex.OP1,2/5, self attested copy of questionare to doctor is Ex.OP1,2/6, self attested copy of pre-authorisation form is Ex.OP1,2/7, self attested copy of denial letter dated 11.03.2020 is Ex.OP1,2/8, self attested copy of query letter dated 14.07.2020 is Ex.OP1,2/9, self attested copy of query letter dated 24.07.2020 is Ex.OP1,2/10, self attested copy of reminder of query letter dated 3.8.2020 is Ex.OP1,2/11, self attested copy of denial letter dated 12.3.2020 and 13.8.2020 is Ex.OP1,2/12, self attested copy of proposal form is Ex.OP1,2/13, self attested copy of claim form is Ex.OP1,2/14. Copy of certificate of incorporation is Ex. OP1, 2 /15.
3 We have heard the Ld. counsel for the complainant and opposite parties and have carefully gone through the record placed on the file.
4 From the combined and harmonious reading of the pleadings and documents is going to prove that the complainant has purchased a health insurance for a sum of Rs.5 Lakh vide insurance policy No.16463443. The insurance policy was issued by the opposite party covering the risk for the period w.e.f. 24.12.2019 to 23.12.2020 and in respect thereof requisite premium was paid by the complainant to the opposite party. Unfortunately couple of days prior to 06.03.2020, the complainant felt some mild health weakness. As such on 06.03.2020 the complainant consulted a neurologist practicing at Amritsar, namely Dr. Prabhjit Singh, who conducted several medical tests of the complainant and advised the complainant to get admitted in Nayyar Hospital Amritsar. Accordingly, the complainant immediately got himself admitted in Nayyar Hospital at Amritsar on the same day i.e. 06.03.2020. The complainant was diagnosed with Guillian-Barre Syndrome [In Short GBS] by the Medical experts. The complainant before getting himself admitted in Nayyar Hospital, approached the representatives of the opposite party as he was medically insured by it and on the instruction of the opposite party, the complainant provided all the particulars as well as details regarding his health policy. Inspite of due intimation given to the opposite party by the complainant as mentioned above, no approval was granted by the opposite parties. As it was matter of grave emergency, the complainant needs medical treatment immediately to save his life and thereafter, the complainant himself paid all the medical expenses for his treatment from his own pocket i.e. from 6.3.2020 to 11.3.2020. The complainant paid a sum of Rs.2,69,799/- for his treatment at Nayyar Hospital Amritsar. Thereafter, the complainant submitted his insurance claim for reimbursement with the opposite parties. During the course of proceedings and process of deciding the reimbursement case of the complainant, the opposite party told the complainant to get in writing regarding certification that the complainant was not suffering from any ailment such as diabetes and high or low blood pressure. Accordingly on the instruction of the opposite party, the complainant got it certified in writing from Dr. Prabhjit Singh on 12.03.2020 vide which the doctor certified in detail that the ailment from which the complainant was suffering and also detailed that the history of weakness or ailment is of two days only and moreover the complainant had no history of preexisting diabetes or fluctuating in blood pressure and this certificate was forwarded by the complainant to the opposite party immediately. Again after a couple of months instead of reimbursing the above mentioned amount to the complainant, the opposite party required the documents of treatment record etc. from the complainant and told the complainant to deposit these at Amritsar office of the opposite party i.e. with the opposite party No1 which was duly done by the complainant and the complainant obtained a receipt for the same on 10.7.2020 and after obtaining these documents, the opposite party No.1 assured the complainant that he has fulfilled all the requirements and the reimbursement for the claim will be immediately released to him. Again the opposite party asked the complainant to submit a certificate from the consultant neurologist so as to authentified that he was not suffering from the above said ailment in the past, as such Dr. Prabhjit Singh gave certificate regarding the history of any such ailment vide certificate dated 29.07.2020 which was forwarded by the complainant to the opposite party. The complainant was astonished when he received a letter dated 13.08.2020, vide which the opposite party declined the claim of the complainant by giving vague reasons of non-discloser of pre- existing ailment and as such the complainant applied for the review. The opposite party during the course of proceedings of review demanded that the certificate dated 29.7.2020 should be verified by the Nayyar Hospital as well for pursuing the review case. The complainant immediately verified the certificate on 2.9.2020 and submitted the same with the opposite party. Thereafter, the complainant again got the above mentioned certificate dated 29.7.2020 verified by Nayyar Hospital, Amritsar and the same was submitted by the complainant immediately after 2.9.2020 with the opposite party.
5 On the other hands, Ld. counsel for the opposite party contended that the company had issued health insurance Policy bearing no. 16463443 (Product: Care (Individual)) to the complainant/Insured i.e. Mr. Ankush Sood with effect from 24.12. 2019 till 23.12.2020 for a sum insured of Rs. 5,00,000/-subject to the Policy Terms and Conditions. He had not disclosed any of the disease or conditions or illness as pre existing. The insured approached the opposite party through his treating hospital i.e. Nayyar Hospital, Amritsar with a cashless request to get reimbursement of the hospitalization charges. As per the pre-authorization form, the insured was hospitalized w.e.f. 6.3.2020 with complaints of weakness in both limbs and legs, history of fever, vertigo. He was provisionally diagnosed with Gullian Barre Syndrome. As per the pre-authorization form, he had the present ailments since 2 days. After receiving the cashless request, the opposite party asked for few documents in order to properly assess the claim and sent deficiency letters dated 07-03-2020, 09-03- 2020 and thereafter, reminder dated 8.3.2020 to seek the following documents -
KINDLY PROVIDE
1 COMPLETE INDOOR CASE PAPERS WITH ADMISSION NOTES, HISTORY SHEET, DOCTOR'S NOTES, NURSING NOTES AND VITAL CHART.
2 EXACT DURATION AND PAST HISTORY OF PRESENT AILMENT WITH 1ST CONSULTATION PAPER AND ALL PAST TREATMENT RECORDS.
3 PRE HOSPITALISATION OPD TREATMENT RECORD.
4 RECENT PASSPORT SIZE PHOTOGRAPH OF PROPOSER / NOMINEE.
Inspite of above said letters and reminder the complainant didn't submit all the documents, hence, the genuineness of the case could not be determined. As a good company gesture, the complainant was advised by the opposite party to file for reimbursement claim along with complete set of documents. On basis of the above findings, the opposite party rejected the claim of the complainant vide denial Letter dated 11.3.2020 and 12.3.2020 with the following observation: -
AS PER SUBMITTED DOCUMENTS, PAYABILITY OF THIS CASE CAN NOT BE ASCERTAIN AT THIS TIME, HENCE LIABILITY OF INSURER CANNOT BE TAKEN AT PRESENT JUNCTURE AND CASHLESS FACILITY IS BEING DENIED. PLEASE FILE FOR REIMBURSEMENT WITH ALL SUPPORTIVE DOCUMENTS.
DEFICIENCY NOT REPLIED
Post denial of the cashless claim, the complainant again filed a reimbursement claim for the above stated hospitalization w.e.f. 6.3.2020 till 11.3.2020 at Nayyar Hospital, Amritsar. As per the discharge summary, he was diagnosed with Gullian Barre Syndrome. After receiving the reimbursement request of claim, the opposite party demanded few documents in order to properly assess the claim. The opposite party raised deficiency letter dated 14.7.2020 and thereafter, reminders dated 24.7.2020, 3.8.2020 to seek the following documents -
1. TREATING DOCTOR'S CERTIFICATE FOR ETIOLOGY OF PRESENT AILMENT. 2. EXACT DURATION AND PAST HISTORY OF PRESENT AILMENT WITH 1ST CONSULTATION PAPER AND ALL
PAST TREATMENT RECORDS. 3. RECENT PASSPORT SIZE PHOTOGRAPH OF PROPOSER/ CASE PAPERS WITH ADMISSION
NOMINEE. 4. COMPLETE INDOOR
NOTES, HISTORY SHEET, DOCTOR'S NOTES, NURSING
NOTES AND VITAL CHART.
The company also triggered claim investigation for better analysis of the claim. But the complainant did not provide the above mentioned documents/information required to settle the claim. And on the basis of the documents which were supplied, the opposite party rejected the claim of the complainant vide Claim Denial Letter dated 13.8.2020 with the following observation:-
CLAIM REJECTED-NON DISCLOSURE OF GUILLAIN –BARRE SYNDROME PRIOR TO POLICY INCEPTION.
NON DISCLOSURE OF MATERIAL FACTS/PRE-EXISTING AILMENTS AT TIME OF PROPOSAL.
6 The opposite party provided questionnaire to Dr. Prabhjeet Singh who was a treating doctor and he was asked to reply certain questions and in question No. 2
What investigations had been conducted on the patient and what diagnosis was made?
Answer Routine based investigation- ANA IFN Nerve conductive study. Motor axonal neuropathy (GBS since November 2019)
Question 6- Please specify the etiology of patient's ailment? Kindly specify if patient's ailments are due to hypertension or other previous medical illness?
The doctor answered -Motor axonal neuropathy, GBS since November 2019.
As such counsel for opposite party contended that it was found that the complainant was suffering from pre-existing disease as such his claim was duly rejected vide letter dated 13.8.2020. It is pertinent to mention that the policy inception date was 24.12.2019 and the complainant was suffering from the said disease since November 2019.
7 The claim of the complainant was rejected vide claim denial letter Ex. OP1, 2/12 on the ground of non disclosure of material facts, pre existing ailments at the time of proposal. The basis of rejecting the claim was as per TPA claim verification claim form Ex. OP1, 2/6, whereby, some questions were asked from the treating doctor i.e. Prabhjit Singh in which it has been written in the reply of question No. 6 GBS November 2019 but there is cutting in the said certificate. Moreover, this certificate has not been issued by the treating doctor i.e. Dr. Prabhjit Singh, as this certificate has been signed by some other person of Nayyar Hospital, Amritsar. On the other hand, the treating doctor i.e. Dr. Prabjit Singh of Neuro Centre Ex. C-9, it has been clearly mentioned that Mr. Ankush Sood was admitted under me at Nayyar Hospital, Amritsar for 6.3.2020 to 11.3.2020 and he was suffering from Guillain Barre Syndrome (AMAN) variant and the said ailment is auto immune (post infectious). Further in this, certificate, it has been clearly mentioned that he has not having any past history of any such ailment. This certificate is signed by treating doctor i.e. Dr. Prabhjit Singh dated 29.7.2020. The said certificate has been countersigned by the medical director of the concerned hospital. Meaning thereby this certificate carries more authenticity than the questionnaires which were submitted by the opposite party to the concerned treating doctor and in this certificate it has been clearly mentioned that the complainant has not having past history of any such ailment.
8 Moreover, patient discharge summary of Nayyar Hospital, Amritsar in the final diagnosis it has been clearly written the ailment of the complainant i.e. Guillain Barre Syndrome and in the column of past history it has been clearly written “No Past History” So it is crystal clear from the discharge summary of the hospital and the certificate of the treating doctor that the complainant is not suffering from any pre existing disease at the time of inception of insurance policy. However, it is pertinent to mention here that GBS is an ailment which has not a long gap between ailment and its treatment. It has to be treated in the emergency as it will effect the body of the patient immediately and if it is not treated within days, it can result to a severe paralytic attack. So, it has been established by the complainant on record that the complainant was not suffering pre existing disease at the time of inception of insurance policy.
9 However for the sake of arguments when we go through the repudiation letter the only ground taken by the opposite party No.1 while repudiating the claim is that “claim Rejected-Non Disclosure of Guillain-Barre Syndrome Prior to Policy Inception, Non Disclosure of Material Facts/ Pre Existing Ailments at the time of Proposal.” But we are not agreed with this ground taken by opposite parties as the opposite parties have failed to prove on record that the complainant ever has taken any treatment for the said disease from any hospital. It has been held by the Hon'ble National Commission in case New India Assurance Co.Ltd&Anr Vs. Murari Lal Bhusri 2011(III) CPJ 198 (NC) that where the Insurance company failed to produce any evidence to show that respondent was aware of any pre-existing disease at the time when insurance policy was taken, opposite party was not justified in repudiating the claim of the complainant on the ground of pre-existing disease. It has been held by the Hon'ble Supreme Court of India in case P.Vankat Naidu Vs. Life Insurance Corporation of India &Anr 2011(3) CPC 350 that where no cogent evidence was produced by the respondent to prove that insured/deceased had concealed any fact about his illness or hospitalization, it was held that no material fact was suppressed by the deceased in this respect. Moreover it is preposterous to presume that said disease was pre-existing or that non disclosure thereof at the time of obtaining the insurance policy amount to concealment. The burden of proof was upon the opposite party to prove that the insured was suffering from any ailment prior to taking the policy, but they have miserably failed to discharge this onus. Reliance in this connection has been placed upon Bajaj Allianz Life Insu.Co.Ltd. & Ors Vs. Raj Kumar III(2014) CPJ 221 (NC) wherein it was held that usually the authorized doctor of the Insu. Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. Thus the repudiation of the claim on the ground of pre existing disease was held to be invalid. Moreover, the opposite parties have also placed on record treatment record of Nayyar Hospital Ex. OP.1,2/5 in which Past history is shown as ‘NO PAST HISTORY’.
10 Furthermore, It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of DharmendraGoel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.UshaYadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
11 In light of the above discussion, the complaint succeeds and the same is hereby allowed with costs in favour of the complainant. The opposite Parties is directed to make the insurance claim i.e. 2,69,799/- to the complainant. The complainant has been harassed by the opposite parties unnecessarily for a long time. The complainant is also entitled to Rs. 25,000/- as compensation on account of harassment and mental agony and Rs 11,000/- as litigation expenses. Opposite Parties are directed to comply with the order within one month from the date of receipt of copy of the order, failing which the complainant is entitled to interest @ 9% per annum, on the awarded amount, from the date of complaint till its realisation. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Commission and due to COVID-19. Copies of the order be furnished to the parties as per rules. File is ordered to be consigned to the record room.
Announced in Open Commission
23.08.2023
