Chandigarh

DF-I

CC/598/2019

Harjinder Singh Sohal - Complainant(s)

Versus

Religare Health Insurance Co. Ltd. - Opp.Party(s)

N.S. Jagdeva

16 Jun 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                                    ========

 

                                     

Consumer Complaint No.	:	CC/598/2019
Date of Institution	:	12/06/2019
Date of Decision	:	16/06/2021

 

Harjinder Singh Sohal, S/o Late Sh. Bahal Singh, R/o H.No.315, Phase-2, SAS Nagar, Mohali – 160055 (Punjab).

…..Complainant

 

V E R S U S

 

1.      Religare Health Insurance Co. Ltd., through its Managing Director, Regd. Office D-3 Distt. Center, Saket, New Delhi – 110017.

 

2.      Religare Health Insurance Co. Ltd., through its Branch Manager, SCO No. 56-57-58, Sector 9-D, Chandigarh.

 

…… Opposite Parties

QUORUM:	SURJEET KAUR	PRESIDING MEMBER
	SURESH KUMAR SARDANA	MEMBER

                                                                       

PRESENT:	:	Sh.N.S.Jagdeva, Counsel for Complainant.
	:	Ms.Niharika Goel, Vice Counsel for Sh.Paras Money Goyal, Counsel for Opposite Parties.

 

Per Suresh Kumar Sardana, Member

 

1.         Succinctly put, the material facts giving rise to the present Consumer Complaint are, the Complainant planned to visit aboard to his children and thus, took International Medical Health Insurance Policy from the Opposite Parties, which was valid from 17.09.2018 to 05.03.2019 i.e. 170 days, by paying the requisite premium of `17,864/-. The sum insured was USD 50,000/-. It has been averred that while in Australia, the Complainant suffered sudden chest pain on 29.09.2018 and was referred to a Hospital, where all the tests had been conducted and after conducting Stents procedure the Complainant was discharged on 03.10.2018. Thereafter, the Complainant was called for regular follow-up and the third stent was put on 22.11.2018 and he was discharged on 23.11.2018. After taking treatment from the Hospital in Australia, Complainant submitted claim for cashless benefit of the Policy, along with all the requisite documents. However, on 07.12.2018, the Opposite Parties rejected the cashless payment of the Mediclaim on the ground of non-disclosure of pre-existing medical condition Coronary Artery Disease (CAD) & Dyslipidemia. In these circumstances, the Complainant had to foot the hospital bills raised to the tune of 31499 Australian Dollars from his own pocket. On reaching India in March, 2019 the Complainant filed reimbursement claim with the Opposite Parties supported by requisite bills/reports etc., but his claim was rejected on 16.04.2019 on the ground of non-disclosure of pre-existing illness. With the cup of woes brimming, the Complainant has filed the instant Consumer Complaint, alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties.
2.         Notice of the complaint was sent to Opposite Parties seeking their version of the case.
3.         Opposite Parties contested the Complaint and filed their reply, inter alia, admitting the basic facts of the case. It has been pleaded that the cashless request of the Complainant was denied vide claim denial letter dated 07.12.2018 on the ground of non-disclosure of material facts, as the Complainant has a pre-existing ailment of Coronary Artery Disease and Dyslipidemia prior to policy inception. It has been further pleaded that thereafter the Complainant filed a reimbursement claim on 30.09.2013 which was also rejected vide letter dated 16.04.2019 under clause 5.1 of the policy terms & conditions for non-disclosure of material information. Pleading that there was no deficiency in service on their part, a prayer has been made for dismissal of the complaint.
4.         The complainant has filed rejoinder, wherein he has reiterated all the averments, contained in the complaint, and repudiated those, contained in the written version of Opposite Parties.
5.         Parties were permitted to place their respective evidence on record, in support of their contentions.
6.         We have gone through the entire record, along with the written arguments advanced by both the sides and heard the arguments addressed by the Ld. Counsel for the Parties.
7.         The core question for consideration is whether the fact that at the time of taking out the mediclaim policy, the policy holder was suffering from Coronary Artery Disease (CAD) and Dyslipidemia was a material fact and, therefore, on account of non-disclosure of this fact in the proposal form, the OP– Insurance Company was justified in law in repudiating the claim of the Complainant.  
8.         Having bestowed our anxious consideration to the matter, we are of the opinion that in the light of the material on record, answer to the question posed has to be in affirmative.
9.         Admittedly, the Complainant purchased a Travel Insurance Policy with effect from 17.09.2018 till 05.03.2019 (Total No. of travel days 170), covering the Complainant for a sum insured of USD 50000 subject to policy terms & conditions. It is also not in dispute that the Complainant applied for Cashless Claim Request pertaining to his hospitalization at Australia and thereafter, filed the reimbursement claim, which the Opposite Parties rejected under Clause 5.1 of the Policy Terms & Conditions for non-disclosure of material information.
10.         Per contra, Learned Counsel for the Opposite Parties argued that the claim of the Complainant was rightly repudiated on the basis of the documents submitted along with the claim form i.e. Out Patient Card dated 27.10.2014 which was prior to policy inception, prepared by the PGIMER, Chandigarh, wherein the Complainant was shown to be having Coronary Artery Disease (CAD) and Dyslipidemic, which was not declared by the Complainant at the time of policy inception and basing on the same, the claim of the Complainant was rejected by the Opposite Parties.
11.         We have perused Clause 5.1 of the policy terms & conditions which deals with disclosure of information norm. Clause 5.1 of the Policy Terms & Conditions reads as under: -

Clause 5.1 – “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 policy holder or the insured person or anyone acting on his/their behalf, the company shall have no liability to make payment of any claims and the premium paid shall be forfeited to the company.”

                There is no dispute that the present case relates to a mediclaim policy, which is entirely different from a life insurance policy. A mediclaim policy is a non-life insurance policy meant to assure the policy holder in respect of certain expenses pertaining to injury, accidents or hospitalizations. Nonetheless, it is a contract of insurance falling in the category of contract uberrimae fidei, meaning a contract of utmost good faith on the part of the assured. Thus, it needs like emphasis that when an information a specific aspect is asked for in the proposal form, an assured is under a solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge. Thus, as per clause 5.1 of the policy terms and conditions, the Complainant was under obligation to disclose all material facts at the time of inception of the policy. However, no such disclosure was made by the Complainant.  

12.         We have scanned the Out Patient Card dated 27.10.2014 prepared by the PGIMER, Chandigarh and find that the same runs counter to the cause of the Opposite Parties (Annexure OP-6). The OPD card shows that the Complainant is a known case of Coronary Artery Disease (CAD) and Dyslipidemia.  Although the Complainant had the opportunity to disclose his history of aforesaid disease at the time of filling the online proposal form at the time taking the policy (Annexure OP-8), yet he chose not to disclose the same. The Complainant has disclosed only about his ailment of High Blood Pressure and no answer was marked against the option of Coronary Artery Heart Disease.
13.         In Satwant Kaur Sandhu vs. New India Assurance Company Ltd. (2009) 8 SCC 316, it has been observed by the Supreme Court that the expression “material fact” is to be understood in general terms to mean as any fact which would influence the judgment of a prudent Insurer, in deciding whether to accept the risk or not.  If the proposer has knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal form.  Any inaccurate answer will entitle the Insurer to repudiate their liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a contract of insurance, which is based on the principle of utmost faith – uberrima fides.  Good faith forbids either party from non-disclosure of the facts which the party privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary. (See: United India Insurance Co. Ltd. Vs. M.K.J. Corporation [(1996) 6 SCC 428].  It has also been emphasized that it is not for the proposer to determine whether the information sought for is material for the purpose of the policy or not. Of course, obligation to disclose extends only to facts which are known to the applicant and not to what he ought to have known.
14.         In view of the foregoings, we are of the concerted opinion that the answers given by the Insured in the proposal form were untrue to his knowledge. There was clear suppression of “material facts” in regard to the health of the Insured.  It was not for the Insured to determine whether the information sought for in the aforesaid questionnaire was material for the purpose of the policy.  At any rate, the statements made in the proposal form were untrue and incorrect, falling foul of the above-extracted condition no. 5.1 in the policy.  We are, therefore, of the opinion that the OP-Insurance Company was justified in repudiating the claim of the Respondent.
15.         Henceforth, judged from every angle and in view of the foregoings, we have no hesitation to conclude that the complainant has not been able to prove his case of alleged deficiency on the part of Opposite Parties. Therefore, we do not find any merit, weight and substance in the present complaint. Thus, the same is accordingly dismissed with no order as to costs.
16.         Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

16^th June, 2021

Sd/-

 (SURJEET KAUR)

PRESIDING MEMBER

 

Sd/-

 (SURESH KUMAR SARDANA)

MEMBER

 “Dutt”