BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL FORUM, JALANDHAR.

Complaint No.495 of 2016

Date of Instt. 22.12.2016

Date of Decision: 02.04.2019

Narinder Singh Gambhir son of Darshan Singh resident of #156, Chhoti Baradari, Part-I, Jalandhar-144001.

..........Complainant

Versus

1 Religare Health Insurance Co. Ltd. Registered Office D-3, P3 B, Distt. Centre Saket, New Delhi through its Regional Manager, also at Plot No.A-3, A-4, A-5, Sector 125, Noida.

2. The Branch Manager Religare Health Insurance Co. Ltd. SCO- 44, PUDA Complex, Jalandhar.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before: Sh. Karnail Singh (President)

Smt. Jyotsna (Member)

Present: Sh. Jatinder Arora, Adv Counsel for the Complainant.

Sh. R. K. Sharma, Adv Counsel for the OPs No.1 and 2.

Order

Karnail Singh (President)

1. This complaint has been filed by the complainant, wherein alleged that the complainant got the health insurance policy No.10240532 with the OPs on the inducement of their authorized representative. The complainant had been paying the regular premium and relevant expenses. It is not out of place to mention here that this policy was cashless policy.

2. That the complainant suffered from some gastric and intestinal problem on 21.04.2016 and got the medical treatment from Talwar Hospital, Model Town, Jalandhar. Copy of prescription slips and medical bills are attached herewith. Intimation with regard to this was given to the OPs and relevant documents were also supplied by the complainant. But to the utter surprise of the complainant that the claim submitted by the complainant was rejected on 02.08.2016 on the ground that the complainant did not disclose material facts about pre-existing ailments and hypertension. The complainant was never suffering from hypertension and even otherwise the disease of hypertension is nothing to do switch the Gastri problem, which was caused to the complainant. The claim of the complainant has been wrongly rejected by the OPs in order to defeat the rights of the complainant. The act and conduct of the OPs is tantamount to deficiency in service and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay a sum of Rs.10,00,000/- along with interest @ 24% per annum till its realization against the claim amount including all the charges i.e. for mental tension, harassment, humiliation and on account of financial loss incurred by the complainant and for causing negligence on the part of the OP, deficiency of service etc. plus costs and litigation expenses of Rs.22,000/-.

3. Notice of the complaint was given to the OPs and accordingly, both the OPs appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that the complaint is not maintainable against the OPs as the complainant cannot take advantage of his own wrongs. The complainant himself is guilty of non-disclosure of material facts at the time of taking policy, as such, the complaint is liable to be dismissed. It is further submitted that the complainant had purchased health insurance policy for himself, his wife, son and daughter for a period April 2016 to April 2017 subject to the policy terms and conditions. The complainant was admitted on 21.04.2016 at Talwar Hospital, Jalandhar with diagnose of Sub Acute Intestinal Obstruction and got discharged on 23.04.2016. Thereafter, the OP received the reimbursement claim from the complainant on 03.05.2016 for above mentioned hospitalization amounting to Rs.26,692/-, but during the investigation, it has come to the notice of the OP as well as as per the doctor's statement dated 22.04.2016, the complainant is suffering from Hypertension since 2-3 years and is on medication of Telma-40 and further as per the statement of the complainant dated 22.04.2016 procured from the complainant, wherein stated that he was suffering from Hypertension since 2-3 years and is on medication of Telma-40 and further as per statement of the complainant dated 22.07.2016, the complainant was on medication of Telma-40 two years back for blood pressure and is still on medication of Amlong 5 on irregular basis since July 2015, which is not disclosed to the company at the time of filling of proposal form and as such, there is a concealment of pre-existing disease and as per Clause 6.1 Disclosure of Information Norm, the case of the complainant has been repudiated rightly for concealment of the true facts. It is further averred that there is neither any deficiency in service nor any negligence in service on the part of the OP and as such, the claim of the complainant has rightly been repudiated as per the terms and conditions of the insurance policy. On merits, it is admitted that the complainant got insurance policy and also submitted a claim, but the same was rightly repudiated as per terms and conditions of the insurance policy. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.

4. In order to prove the case of the complainant, the complainant along with his counsel tendered into evidence his own affidavit Ex.CA along with some documents Ex.C-1 to Ex.C-15 and closed the evidence.

5. Similarly, counsel for the OPs No.1 & 2 tendered into evidence affidavit of Sh. Ramnique Sachar as Ex.OP/A along with some documents Ex.OP/1 to Ex.OP/14 and thereafter, the evidence of the OPs No.1 and 2 closed by order on 27.02.2018.

6. We have gone through the written arguments of the respective counsels and also gone through the pleadings as well as documents very minutely.

7. In this complaint, the factum in regard to purchase of insurance policy as well as submitting of insurance claim, is not in dispute and further it is also admitted that the complainant got treatment from Talwar Hospital, regarding that the bills are available on the file Ex.C-2 to Ex.C-10 and insurance policy is available on the file Ex.C-1.

8. The main issue in dispute in this case is only whether the insurance claim of the complainant has been rightly repudiated by the OP on the basis of concealment of pre-existing disease and the same has been tried to establish by the OP by bringing on the file some relevant document i.e. Ex.OP-3 Statement of the Doctor, wherein on the second page at Colomn No.11 simply mentioned as “known Hypertension 2-3 years (On Telma-40)”. Further, OP referred document Ex.OP/4 i.e. Statement of the Complainant, wherein he categorically stated that he suffering from Hypertension since 2-3 years. Similarly, statement of the complainant Ex.OP/5 also showing that the complainant has hypertension and on the basis of these documents, the OP repudiated the claim of the complainant, vide repudiated letter dated 02.08.2016, which is Ex.OP/6 and further the counsel for the OPs made reliance upon two judgments as referred in the Written Statement i.e. 2009 (8) SCC 316, titled as “Satwant Kaur Sandhu Vs. New India Assurance Company Ltd.” and further “Life Insurance Corporation of India Vs. Smt. Neelam Sharma”.

9. We have considered all the factors and also gone through the documents referred by learned counsel for the OPs i.e. Ex.OP/3, Ex.OP/4 and repudiation letter Ex.OP/6 and find that the document Ex.OP/3 is in the nature of form with blank column and the same has been filled by the signatory doctor, but it has not been mentioned therein where-from the complainant has been taking treatment of hypertension rather this form is without any medical test of the complainant. Further the OP placed on the file statement of the complainant Ex.OP/4 and Ex.OP/5, no doubt both are signed by the complainant, but it is again not clear whether it was made known to the complainant at the time of filling of the same or not. So, we are of the opinion that these documents are not sufficient to prove that the complainant is a patient of Hypertension last 2-3 years until the OP has not brought on the file specific evidence of any doctor from whom the complainant is taking the medicine or treatment.

10. Apart from above, we have considered the ruling referred by learned counsel for the OPs and find that these rulings are not applicable in the present case being not having identical facts to the case in hand and accordingly, now coming to the repudiation letter Ex.OP/6, wherein categorically mentioned for non-disclosure of material facts/pre-existing ailment at the time of proposal i.e. hypertension two years back, is the main cause for rejection of the insurance claim of the complainant. No doubt, the OP has brought on the file copy of the Proposal Form Ex.OP/8 and if we go through the Proposal Form Ex.OP/8 on the relevant page, wherein it has been categorically mentioned as under:-

“Has anyone been diagnosed/hospitalized or under any treatment for any illness/injury during the last 48 months or is suffering from any illness/disease? If yes, please specify details on a separate sheet.”

From the above declaration/information, which is alleged to be given by the complainant is not clear whether the complainant was specifically asked that he was got diagnosed from any doctor or getting treatment from any doctor of hypertension, if so, then we cannot say that the complainant has concealed any material facts from the OP.

11. Furthermore, as per settled law, Hypertension is a life style disease and it can be easily controlled with the conservative medication and therefore, concealment of Hypertension cannot be termed as, non-disclosure of pre-existing disease and in support of these observations, we like to refer a pronouncement of Hon'ble National Commission, cited in 2016(1) CPJ 613, titled as “Satish Chander Madan Vs. M/s Bajaj Allianz General Insurance Co. Ltd.”, wherein his Lordship held as under:-

“Consumer Protection Act, 1986 Sections 2(1) (g) and 21(b) Insurance Policy-Bypass surgery- Claim for insurance- Repudiation of claim – Grounds of concealment of pre-existing disease – Alleged deficiency in service – Compliant filed – Allowed by District Forum – State Commission allowed appeal – Hence, revision petition before National Commission – Fact that, petitioner prior to obtaining insurance policy was having history of hypertension – Hypertension is a common ailment and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack – Treatment for heart problem cannot be termed as claim in respect of pre- existing disease - claim was wrongly repudiated – Finding of the State Commission regarding suppressing of material fact is based upon surmises and conjectures and it cannot be sustained – Revision petition allowed.” Further, on the same aspect, we like to refer an other pronouncement of our Hon'ble State Commission, cited in 2011(3) CLT 549, titled as “Life Insurance Corporation of India Vs. Priya Sharma and Others”, wherein his Lordship held as under:-

“Insurance Claim-Repudiation – On account of pre- existing disease- Burden of proof- Record does not indicate any proof to the effect that deceased/life assured was suffering from any pre-existing disease at the time of purchasing the policy- The onus to prove was on the appellant/Insurance Company to prove that the deceased/life assured suppressed the material facts- The doctor who examined to prove that the deceased was ever admitted or took any treatment from any hospital or the doctor regarding the alleged pre-existing disease- Forum order upheld.

Similarly, we further made reliance upon an other pronouncement of Hon'ble National Commission, cited in 2012(4) CPJ 839, titled as “Bajaj Allianz General Insurance Co. Ltd. Vs. Valsa Jose”, wherein his Lordship held as under:-

“Consumer Protection Act, 1986 Sections 2(1) (g), 14(1) (d) and 21(a) (ii) Mediclaim policy- Medical reimbursement – Mediclaim policy – Medical reimbursement – Repudiation of claim – Angiogram and Angioplasty of right coronary artery – Respondent had been taking medicine for hypertension and for cholesterol which was reportedly normal – Patient was taking medicine for hypertension for some time does not amount to suppression of material fact because as is well known hypertension is usually a lifestyle disease and easily controlled with conservative medication- There is no evidence that it was so acute or high that it was responsible for respondents subsequent Angioplasty or any other past major illnesses – Repudiation of claim rightly held to be unjustified.”

Further, on the same point, we like to refer a pronouncement of our Hon'ble State Commission, cited in 2017(3) CLT 140, titled as “Religare Health Insurance Company Ltd Vs. Subhash Chander Aggarwal”, wherein his Lordship held as under:- “Whether Hypertension is a disease, which is required to be referred in proposal form – Hypertension is a common disease and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack and repudiation on account of pre-existing disease was not justified, therefore, ground that complainant suffering from hypertension not corroborated on basis of evidence on record, claim was wrongly repudiated by the OP”

12. In the light of above detailed discussion, we came to conclusion that the OP has wrongly and illegally repudiated the claim of the complainant, whereas the complainant is entitled for the relief and insurance claim and accordingly, the complaint of the complainant is partly accepted and OPs are directed to pay medical expenditure incurred by the complainant for his treatment i.e. Rs.26,692/- along with interest @ 12% per annum from the date of repudiation i.e. 02.08.2016, till realization and further OPs are directed to pay compensation, to the tune of Rs.15,000/- and litigation expenses of Rs.5000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

13. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated Jyotsna Karnail Singh

02.04.2019 Member President