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.83/2018

BHAWESH ANAND,

S/O LATE SH. PREM PRAKASH ANAND,

R/O M-11, SAKET,

NEW DELHI-110017                                                              …..COMPLAINANT

Vs.

CARE HEALTH INSURANCE COMPANY LTD.

VIPUL TECH SQUARE, TOWER-C, IIIRD FLOOR,

SECTOR-43, GOLF COURSE ROAD, GURGAON,

GURGAON- 122009, HARYANA

REGISTERED OFFICE AT:

5^TH FLOOR, 19, CHAWLA HOUSE, NEHRU PLACE,

NEW DELHI, DELHI - 110019                                                                …..RESPONDENTS

                                                                                                                             Date of Institution-13.04.2018

Date of Order-01.03.2024

                                                ORDER

RITU GARODIA-MEMBER

1. The complaint pertains to deficiency in service on the part of OP in repudiating the claim of the complainant.

2. The complainant took a health insurance policy for himself and his family members for Rs.5,00,000/- valid from 20.08.2015 to 19.08.2016.  The policy was renewed for another year valid from 20.08.2016 to 19.08.2017.

3. On 05.06.2017, the complainant felt breathlessness and a pain in chest and left arm. He was admitted to Max Super Speciality Hospital, Saket for immediate treatment. The said hospital was listed in the network hospitals of OP wherein cashless facility could be availed.

4. The complainant was prescribed some medicine and tests. He continued to feel breathlessness. The symptoms were relating to acute Coronary Syndrome. An ECG was conducted which was normal. The doctors also performed 2D echo test, Left Ventricular Ejection Fraction Assessment L VEF-55% which was also normal. As the complainant was still not feeling well and continuously feeling breathlessness, the doctors on 06.06.2017 performed Coronary Angiography (CAG), the report of which came normal.

5. During the visit to the hospital, a surveyor representing OP requested the complainant to provide the report of CAG conducted in March 2012. The complainant clarified to the surveyor that, in 2012, he had opted for a full body check-up package at Max Super Speciality Hospital, Saket. Due to the complainant's father being a cardiac patient, doctors recommended a 64 Slice CT Scan Coronary Angiography, which was priced at approximately Rs. 11,000/-. However, the complainant chose to undergo a CAG, which cost around Rs. 5,000/-. The said CAG report indicated normal results.
6. Top of Form
7. Bottom of Form

6. The complainant’s cashless claim was denied on ground of non-disclosure of pre-existing disease. The complainant paid Rs.59,761/- to the hospital and filed a claim for reimbursement with OP. The OP repudiated the claim vide letter dated 19.06.2017.

7. The complainant clarifies that Coronary Angiography (CAG) is conducted in a coronary artery wherein a contrast dye will be injected into arteries through a catheter and a doctor examines the blood flows in heart of the patient on an X-ray screen. The proposal form submitted by complainant with OP also asked about any pre-existing disease details. The complainant had rightly answered in negative as CAG is neither any disease nor any treatment for any illness.

8. The complainant prays for reimbursement of the claimed amount of Rs.59,761/- with interest @24%, Rs.25,000/- compensation for mental agony and Rs.50,000/- towards litigation expenses.

9. OP in its reply submits that complainant and his family took a policy for Rs.5,00,000/- which was effective from 20.08.2015  and was renewed till 19.08.2017. It is alleged that the complainant had confirmed in the proposal form that he was not suffering any pre-existing diseases.

10. On 05.06.2017, the complainant was admitted at Max Super Speciality Hospital, Saket. A cashless claim was lodged. OP immediately sent query letters and an investigator. OP found that the complainant had undergone angiography (CAG) in 2012. Due to non-disclosure of this pre-existing disease, OP rejected the claim vide letter dated 19.06.2017, under Clause 6.1 of terms and conditions of the policy. OP prays for dismissal of the complaint.

11. Complainant has filed evidence by way of affidavit and exhibited the following documents:-

1. Copy of the company’s master data available on website of ROC Delhi is exhibited as Exhibit CW-1/1.
2. Copy of Proposal form is exhibited as Exhibit CW-1/2.
3. Copy of Policy Certificate is exhibited as Exhibit CW-1/3.
4. Copy of Health Insurance CARE Freedom Plan is exhibited as Exhibit CW-1/4.
5. Copy of the policy certificate is exhibited as Exhibit CW-1/5.
6. Copy of email is exhibited as Exhibit CW-1/6.
7. Copy of documents are exhibited as Exhibit CW-1/7 to CW-1/11.
8. Copy of email is exhibited as Exhibit CW-1/12.
9. Copy of claim rejection letter is exhibited as Exhibit CW-1/13.
10. Copy of legal notice is exhibited as Exhibit CW-1/14.
11. Copy of reply of legal notice is exhibited as Exhibit CW-1/15.

12. OP has filed evidence by way of affidavit and exhibited the following documents:-

1. Copies of the policy certificate and police terms and conditions are marked as Ex. R-1(Colly).
2. Copy of policy renewal is marked as Ex.R-2.
3. Copies of cashless claim form, query letters are marked as Ex.R-3.
4. Copy of the progress notes and statement are marked as Ex.R-4.
5. Copies of the pre-authorization denial letter is marked as Ex.R-5.
6. Copy of the clam rejection letter is marked as Ex.R-6.
7. Copy of proposal form is marked as Ex.R-7.
8. Copy of legal notice and reply to the legal notice is marked as Ex.R-8 (Colly).

13. The Commission has considered the materials and documents on record. It is admitted by both the parties that complainant was insured by OP for Rs.5,00,000/- from 20.08.2015. It is also admitted that the complainant was admitted at Max Super Speciality Hospital on 05.06.2017.

14. The discharge summary dated 07.06.2016 is as follows:

Atypical chest pain

CAG (06.06.2017): Normal Coronaries

LVEF – 55%

BRIEF CLINICAL HISTORY:

Mr. Bhawesh Anand, 45 years old gentleman, normotensive, non-diabetic, presented with complaints of retrosternal heaviness with left arm discomfort for about 1 hr. He was admitted here for further evaluation and management.

Hospital Course:

The patient was admitted with above mentioned complaints and investigated. ECG showed NSR no significant ST/T changes. 2D Echo showed no RWMA, LVEF-55%. He underwent Coronary Angiography on 06.06.2017 which revealed normal Coronaries. The procedures were uncomplicated and well tolerated by the patient. His subsequent stay in the hospital was uneventful. Now he is being discharged in stable condition.

15. OP vide letter dated 19.06.2017 repudiated the claim of the complainant on following ground:

• As per record patient had undergone CAG in 2012 which is non disclosure of material facts.
• Non disclosure.

16. The complainant has also filed CAG report dated 21.03.2012 is as follows:

Final Impression:

• Normal Coronaries.

Plan:

• Medical Therapy

17.  As per website MedlinePlus, (medlineplus.gov/ency/article/ 003876.htm) CAG means- “Coronary angiography is a procedure that uses a special dye (contrast material) and x-rays to see how blood flows through the arteries in your heart.”

Normal Result- There is a normal supply of blood to the heart and no blockages.

What Abnormal Results Mean- An abnormal result may mean you have a blocked artery. The test can show how many coronary arteries are blocked, where they are blocked, and the severity of the blockages.

18. The sequence of events reveals that CAG conducted on 21.03.2012 showed normal results. The policy came into effect on 20.08.2015. However, on 05.06.2016, the complainant was hospitalized due to typical chest pain despite having normal coronaries. Another CAG was conducted on 06.06.2017. The insurance company repudiated the claim on 19th June 2017, citing non-disclosure of the CAG conducted in 2012 as the reason.

19. The insurance company has provided no justification for requiring disclosure of normal medical test results. A policyholder is not obligated to disclose all normal medical test results at the time of policy application. Moreover, OP has also not requested this information from the complainant in the proposal form. It is unreasonable to penalize a complainant for undergoing precautionary tests, investigations, or procedures that yield normal results.

20. As per the Judgment of National Commission in Star Health & Allied Insurance Co. Ltd. and Ors. Vs. Atul Kumar and Ors. 2023 (4) CPR 60 has observed:

14. The learned counsel for the Appellants/ OPs argued that the child patient in this case was born on 08.08.2011. On 12.07.2012 when the child was 11 months old, an MRI of Brain was conducted. Therefore, the medical condition of the child was serious enough to go straight for MRI Brain as the previous treatment was ineffective. The diagnosis of Dr. PP Gupta, who referred for MRI was not disclosed. As this stage of treatment was prior to proposal to the insurance, it was the duty of the Complainants to disclose. The learned Counsel argued that the child was admitted to Primus Super Speciality Hospital on 28.8.2016. The Discharge Summary described that there was "history of febrile seizure one episodes 2 years back and is taking anti-epileptics. MRI suggested plexiform neurofibromatosis D3 to D8." This makes it clear that antiepileptic medication was continued from the date of episode 2 years back up to the date of admission to hospital on 28.08.2016. Prior to admission to the hospital, the Respondent provided history of patient that "On repeat telephonic conversation with patient's father, he reports an episode of febrile convulsion at around 11⁄2 years of age for which he was treated appropriately. He has not suffered another episode since then. The rest of the documents were attached except MRI images which are with the patient's father". The learned Counsel stressed that the details of episode, medical consultation and treatment ought to have been disclosed when subsequently obtaining insurance. After MRI on 12.07.2012 and further episode of febrile convulsion and antiepileptic treatment, the Respondent realized of expensive future treatment and obtained insurance on 28.02.2014 for himself, his wife and child, deliberately concealing the medical condition of the child. He signed a proposal form on 28.02.2014 misrepresenting material facts and misleading the insurers relating to the child that he was in good health and free from physical and mental disease or infirmity; no consultation, treatment and admission for any illness was done. The child did not suffer any stroke, epilepsy, fainting etc. No medical tests and not prescribed any medicines(Sic). He forcefully argued that there is active, deliberate concealment of material facts was done to mislead the insurers on facts. The policy is specific that if the proposal is not truthful, the basis of contract is vitiated and no benefits under it can be claimed.

21. It is a fundamental principle in the insurance contracts that the party claiming the exemption clause needs to establish the same. However, Appellants failed to substantiate that the insured child had such medical condition by birth and that, while being aware, Respondent No. 1 failed to notify the same to the Appellant the stage of making the proposal. On the other hand, Respondent No. 1 repeatedly asserted the absence of knowledge of such medical condition, if any, and that the first discovery of the same was made much after the insurance contract was entered into and, therefore, he is entitled for reimbursement of medical expenses under the scope of the policy.

22. It is in common amongst children of tender age to have convulsions during high fever conditions and recover after high temperature recedes. Therefore, mere isolated event of such incident cannot constitute knowledge of an entirely independent medical condition that may be revealed at a subsequent stage. The stated facts and records reveal that, while the Complainant No. 1 clarified the circumstances under which he

discovered the medical condition of his child, the Appellant/OPs failed to establish that Master Anshuman Rai was suffering from this disease by birth and there was concealment of fact at the time of taking the insurance policy. Therefore, the claim is liable to be allowed.

21. National Consumer Disputes Redressal Commission in Smt. Daya Rani Vs Life Insurance Corporation of India IV (2009) CPJ174 (NC) cited as under:

We have very carefully gone through the material brought on record by both the parties. There is no dispute, that as laid down by law in this country as well as, as per the judgements being relied upon by the respondent / opposite parties, that the contract of insurance is of utmost-good- faith.

The question before us is as to how does one articulate good-faith? In this regard, we wish to rely upon the para 366 of the Halsburys law of England (reproduced above), where it is clearly stipulated, In non-marine insurance it is common to introduce into the contract special stipulation which may, expressly or by implication, define, regulate or even limit the amount of disclosure which otherwise would be necessary. (emphasis supplied) and goes on to add, .. the mere asking of such questions, may, as a matter of interpretation of the contract, indicate a limitation of the field within which disclosure by the proposer is required but, unless it is clear that there has been by the terms of the contract a limitation of the field in this way, the full common law duty continues to be operative. (emphasis supplied)   It is not disputed before us that, as per prevailing law and practice of Insurance in this country, while taking Insurance Cover, the insured has to fill-in a proposal form which is prescribed by the Insurer. Taking into consideration the commentary given in Halsburys law of England, in a non-marine insurance Policy, which is the case before us, in our view, the insurer would be limiting-the amount-of disclosure, by what he asks the insured to in the proposal form.

In the instant case, there is no dispute that all the information given in the proposal form are correct and not under challenge. What is sought to be challenged is the facts lying outside the proposal form. We are constrained to observe that if the insurer has limited the amount of disclosure, i.e., limited to the reply to the question in the proposal form, then nothing should be expected from the insured, to give voluntarily information which is not sought for by the insurer, in this case, the respondent. The questions in the proposal form, i.e., the contract between the parties, would indicate the limitation of the field within which the disclosure by the proposer is required by the insurance company. In these facts and circumstances, we are not going into the question as to whether the non-disclosure of the deceased / the insured was expected to fill in the happenings outside the proposal form.

The insurance company itself has limited the information, sought by them, by specifically giving out the questions to be answered by the insured, which are contained in the proposal form.

As already stated no information given in the proposal form is under challenge.

With the written submissions / brief synopsis furnished by the respondent before us, a blank form relating to Agent Confidential Report / Moral Hazard Report has been enclosed, in which column 6 reads as under:-

Are aware of anything in the occupation, financial or social position of the life proposed, his/her personal habits or any other circumstances which might be likely to add to the risk?

As it is, we have got this form blank, which does not help the case of the Respondent. If a filled-in form was provided, only then it would have been germane to the issue before us. This form was to be filled-in by the agent, who is the agent of the Insurance Company.

Nothing has been brought on record, in any manner, whether such an information was sought for, from the deceased, and what information did he give?, to bring him within the ambit of suppressing material information. We draw a blank here. For fault of the Agent, the deceased / insured cannot be held responsible.”

22. Hence, in the light of above discussion, we find OP guilty in deficiency in serves and direct him to refund Rs.59,761/- with 9% interest from date of complaint till its realization.   We also direct OP to pay Rs.15,000/- as compensation, mental harassment, agony and physical inconvenience along with litigation expenses.

23. Order has to be complied with within the 30 days of this order. Order to be uploaded. File be consigned to record room.