CONSUMER DISPUTES REDRESSAL COMMISSION – X
GOVERNMENT OF N.C.T. OF DELHI
Udyog Sadan, C – 22 & 23, Institutional Area
(Behind Qutub Hotel)
New Delhi – 110016
Case No.149/2018
SH. ASHOK CHADHA,
S/o LATE SH. S.C. CHADHA,
R/o 79-B, M.I.G. FLATS,
MADHUBAN APARTMENT,
SECTOR-82, NOIDA,
DADRI, UTTAR PRADESH- 201304.…..COMPLAINANT
Vs.
- RELIGARE HEALTH INSURANCE COMPANY LTD.
THROUGH ITS DIRECTORS (S),
REGD. OFFICE AT:- 5TH FLOOR, CHAWLA HOUSE,
NEHRU PLACE, NEW DELHI – 110019.
ALSO AT:-
VIPUL TECH SQUARE TOWER – C,
3RD FLOOR, SECTOR-43, GOLF COURSE ROAD,
GURUGAON-122009.
- ANUJ GULATI,
DIRECTOR- RELIGARE HEALTH INSURANCE COMPANY LTD.
LABURNUM APARTMENTS,
LCG-8, GFB SUSHANT LOK-1, BLOCK-A,
GURUGRAM, HARYANA-122002.
- DALJIT SINGH,
DIRECTOR- RELIGARE HEALTH INSURANCE COMPANY LTD.
B-6/9, DLF, PHASE-I,
GURUGRAM, HARYANA-122001.
- SHAMSHER SINGH MEHTA
DIRECTOR- RELIGARE HEALTH INSURANCE COMPANY LTD.
T/16, HARMITAGE FLORIDA ESTATE....OPPOSITE PARTY
Date of Institution-06.07.2018
Date of Order- 20.10.2022
O R D E R
MONIKA SRIVASTAVA – PRESIDENT
The complainant has instituted the present complaint against OP- an insurance company inter-alia claiming reimbursement of a sum of RS. 2,88,093/- incurred by them towards his treatment at Jaypee Hospital situated at Noida. Initially, the complaint was filed against OP1 to OP4 however, OP2 and OP4 were dropped by the complainant himself on 27.07.2018. A sum of Rs. 5,00,000/- has been claimed towards mental harassment.
- The medical insurance policy was taken by the daughter of the complainant having its validity between 29.10.2014 to 28.10.2015 for an assured amount of Rs. 5,00,000. The policy was renewed multiple times between 29.10.2015 till 16.11.2018. The policy for the period between 29.10.2014 till 28.10.2017 was issued from Saket, New Delhi, however the policy between the period 17.11.2017 till 16.11.2018 was issued from Gurugram.
- The complainant is a resident of Noida, Uttar Pradesh. The complaint was initially filed against the insurance company, who was impleaded as OP 1 and directors of OP 1 who were impleaded as OP 2-4 however the complainant removed OP 2-4 from the array of parties which is reflected in order dated 22.7.2018
- The Complainant has stated that in the month of December 2017, the complainant complained of heaviness in the chest for which he was underwent Angiography and remained in the hospital between 09.12.2017 till 11.12.2017. A sum of Rs. 2,88,093/- was incurred towards his treatment for which the reimbursement claim was lodged with the OP on 12.12.2018.
- The OP vide its letter dated 11.01.2018 repudiated the claim by falsely alleging that the complainant did not disclose the hypertension and diabetes in its proposal form. A legal notice dated 30.05.2018 was served upon the OP who despite the service of notice did not pay up the claim of reimbursement.
- OP filed its written statement in which a preliminary objection was taken about the territorial jurisdiction of this Commission. It is stated that the complainant is a resident of Noida, Uttar Pradesh, the treating hospital is situated at Noida and the policy service branch is situated at Gurugram therefore this Commission does not have jurisdiction to entertain this matter.
- It is further stated that complainant has concealed material fact about his pre-existing disease of hypertension and diabetes. It is stated that the prescription dated 09.12.2017 recorded that complainant was suffering from hypertension for past ten years and diabetes for last five years which fact is reiterated in the discharge summary and reply to the questionnaire filled by the treating doctor. It is further stated that the complainant at the time of taking of policy responded in negative to the queries about pre-existing disease, hypertension, blood pressure and Diabetes. Relying upon the judgment of Hon’ble Supreme Court in the matter of Satwant Kaur Sandhu vs New India Assurance Company Limited (2009) 8 SCC 316 it is thus submitted on account of concealment of material facts the claim has been rightly repudiated and policy cancelled.
- A replication was filed by the complainant. Parties filed their respective evidence by way of affidavit and written submissions.
- As regards jurisdiction of this Commission, it is noted, undoubtedly, the complainant resides at Noida, hospitalization was done at Noida and applicable policy at the time of hospitalization was issued from Gurugram, which raises doubts about the jurisdiction of this Commission. This Commission however notes that policy in the year 2017-18 was a renewal of prior policies which was issued in 2014 and continued to be renewed thereafter. The original policy and subsequent renewals till 17.11.2017 were issued from Saket, New Delhi, therefore it is held that this Commission has territorial jurisdiction to entertain the present complaint.
- The Hon’ble Supreme Court in the matter of Manmohan Nanda vs United India Assurance Company Limited (2022) 4 SCC 582 held that it is the duty or obligation of disclosure upon the insured to disclose material fact pertaining to his proposal. What may be a material fact in a case would also depend upon the health and medical condition of the proposer. Further, if specific queries are made in a proposal form then it is expected that specific answers are given by the insured who is bound by the duty to disclose all material facts. The insurance contracts are governed by the principle uberrima fides which means that insurance contracts are special contracts based on the general principles of full disclosure since a person seeking insurance is bound to disclose all material facts relating to the risk involved. Law demands a higher standard of good faith in matters of insurance contracts.
In the present matter, the insured withheld the information relating to him suffering from diabetes and hypertension in his proposal form and in reply to specific queries raised, which fact, in the opinion of this Commission, is a material fact considering the complainant suffered uneasiness in chest leading to angiography. It is a common knowledge the patients suffering from diabetes and hypertension are more prone to the risk of heart disease.
This Commission is thus of the view that the complaint is liable to be dismissed because the complainant is guilty of withholding material facts thereby depriving OP to take an informed decision about granting policy to the complainant.
No order as to costs. The parties may be given copy of the order as per rules. File be consigned to record room.
