DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

C.C. No. 85/2018

Date of Institution: 07.03.2018

Judgment Reserved on: 24.08.2023

Judgment Passed on: 25.08.2023

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Ms.Rashmi Bansal (Member)

Judgment By: Shri S.S. Malhotra (President)

JUDGMENT

1. By this jugdment Commission shall dispose off the complaint of the complainant w.r.t. deficiency in not reimbursing the medical bill of the complainant’s wife.
2. Brief facts as stated by the Complainant in the complaint are that complainant is a policy holder alongwith his wife being Policy No. 10895900 which was taken in June 2016 and prior to the issuing of the policy of OP has got the health checkup of the complainant’s wife through panel hospital. It is further stated that the wife of the complainant was suffering from fever on 20.06.2017 & was admitted in Jeevan Anmol Hospital where she remained admitted upto 23.06.2017, and the complainant has spent Rs.27000/- towards her treatment. The bill was submitted to the OP but the OP had rejected the claim on the ground that the wife of the complainant was suffering from Diabetes Malitus and the same was not disclosed by the insured while applying/taking this policy, and it is further submitted that the OP had given the policy only after getting medical checkup of the wife of the complainant conducted and therefore the rejection is without any reasonable cause. Legal notice was served upon OP on 19.12.2017 which was not complied with and as such he has filed the present complaint case, claiming that OP be directed to reimbursing Rs.27000/- alongwith interest @24% p.a. with compensation of Rs.11000/- and legal expenses of Rs.11000/-. Copy of the letter w.r.t. cancellation of policy, bill to the extent Rs.28120/- alongwith rejection letter is filed.
3. The OP has filed its reply taking preliminary objections that complaint case of the complainant is not maintainable as it is without any cause of action, there is no deficiency on the part of OP, the complainant has not come to Commission with clean facts and perusal of the complaint shows that allegations made in the complaint are ill-found and malafide, with ulterior motives to get the blank order from the Commission and it is submitted that the exact facts are, that the complainant was insured and health insurance policy bearing no. 10895900 with spouse, daughter and two sons for a period of 07.12.2016 to 06.12.2017 for an amount of Rs. 7 lakh was issued. The present claim is regarding hospitalisation of the insured’s wife at Jeevan Anmol Hospital from 20.06.2017 to 23.06.2017 which diagnosed that the insured was having Diabetes Malitus Type-2  and when investigation was done, insured gave statement duly signed that she has been suffering from Diabetes Malitus Type-2 from the last 2 years and this copy of discharge summary and continuation sheet shows that complainant had been advised Tab-Gluconorm G2 which is for diabetes and for this reasons, when the medical examination of the insured was conducted, it did not show the result that complainant’s wife was suffering from Diabetes Malitus and therefore there is ‘non-disclosure of the fact w.r.t. suffering from Diabetes Malitus Type-2’ by the insured and only for these reason policy of the complainant was cancelled and amount was not reimbursed.
4. The complainant has filed rejoinder and reiterated and reaffirmed the contents of the complaint and also filed evidence by way of his own affidavit. The OP has filed evidence of Sh. Kashif Nazki, Attorney of the OP. Both parties have filed their written arguments. The Commission has heard the arguments and perused the record.
5. The fact in nut-shell are not much disputed and the only ground for cancellations of the policy or rejecting the claim is, that there was ‘non-disclosure’ of the pre-existing disease of Diabetes Malitus Type-2 to his wife by the complainant while taking the policy. The contention of the complainant  on the other hand is that, complainant has not concealed any fact rather the medical examination of the complainant was done before issuing the policy in which there was no clinical report suggesting that complainant was suffering from Diabetes Malitus Type-2 and even otherwise the complainant has not been admitted in the hospital with this disease, rather she was suffering from fever for which she was admitted in the hospital and therefore the cancellation of the policy and rejection of the claim was not valid.
6. On the other-hand the Counsel for OP has argued that from the discharge summary of doctor concerned it has been diagnosed that the patient is suffering with Diabetes Malitus Type-2 with acute febrile illness with Urinary Tract Infection and since she was suffering from Diabetes Malitus Type-2. This fact was concealed and therefore rejection of the claim was rightful.
7. The Commission has gone through the rival contentions of the Ld. Counsel of both parties. Now therefore, there are two propositions to deal with such an issue. No.1 that complainant was aware of this fact and she had not disclosed or she was not at all aware of this fact, and secondly even if she was suffering from it whether she is still covered on account of the judgment in Neelam Chopra’s case where it has been held that suffering from Diabetes is, an illness which is common day life disease and non-disclosure of the same is not fatal.
8. As far as first proposition is concerned the medical examination of the complainant was done in which there was no such clinical report w.r.t. complainant’s wife that she had been suffering from the Diabetes Malitus Type-2. The contention of OP that the complainant had been taking medicines for such Diabetes Malitus Type-2  and for that reason such ailment has been reflected in the diagnose. This contention is not supported by any documents. It is observed that some statement of the complainant was taken by the surveyor that she had been suffering from Diabetes Malitus Type-2 from the last two years. There is no other corroborative documents on record which may show that complainant was taking any medicines since last two years or was suffering from Diabetes Malitus Type-2 or that when the medical examination of the insured was conducted, she had taken that medicine, that day. Even there is no opinion of the expert filed by the OP that if insured is suffering from Diabetes Malitus Type-2 or that if she has taken the medicines & due to taking this medicines, it would not reflect in the clinical tests conducted by the panel doctor/hospital upon the insured before issuing the policy. Further if the documents are not supporting the contention of OP, then in what capacity the surveyor would take the statement of the complainant & even if that statement has been taken then, it was the duty of the OP1 to get the same corroborated with clinical report with which has not been done. Therefore this contention of the Ld. Counsel for OP that the Diabetes Malitus Type-2 could not be detected on account of the fact that insured has taken the medicines on the day of clinical test has not been proved.
9. As far as second proposition is concerned now it is settled law that even the complainant/insured has been suffering from Diabetes then its non-disclosure is not fatal to the claim of the complainant. Therefore on account of both these two propositions, the Commission is of the opinion rejection or cancellation of the policy by the OP amounts to deficiency in service hence the Commission orders hereby;-

• OP would pay Rs.27000/- to the complainant with interest @6%  p.a. from the date of filing the complaint till realization, alongwith compensation of Rs.5000/- including litigation cost of Rs.5000/- & revive  the policy of the complainant for that year with all benefits.    
• This Order is to be complied within 30 days from the receiving the same & in case the OP would not pay the amount within 30 days the rate of interest would be @9% from the date of filing the case upto the date of actual payment on the entire amount including of compensation and litigation expenses amount.           

10. Copy of the Order be supplied/sent to the Parties free of cost as per rules.
11. File be consigned to Record Room.
12. Announced on 25.8.2023.