Nidhi Verma, Member
1 The present complaint has been received from the District Consumer Disputes Redressal Commission Amritsar by the order of the Hon’ble State Consumer Disputes Redressal Commission Punjab, Chandigarh for its disposal.
2 The complainant has filed the present complaint by invoking the provisions of Consumer Protection Act under Section 12 against the opposite party on the allegations that the complainant used to get health insurance cover for him and his family. Firstly he got health insurance policies continuously from National Insurance Company for Rs. 3.00 Lacs. As per record available with the complainant policy No. 40190048138500002097 which expiry date 4.11.2014, policy No. 401900/48/14/8500002043 with expiry date 4.11.2015, policy No. 401900/48/15/8500001983 with expiry date 4.11.2016. His family members were also covered under this policy. Hospitalisation medical claim of the complainant for CTS done in KD Hospital at Amritsar was sanctioned by the said insurance company. Mr. Manohar Lal Mehra employee/ representative having code No. 20039777 contracted the complainant and allured him that their company Religare Health Insurance is giving more benefit than National Insurance Company and advised him to shift to their company and get their medical health plan and further assured that the opposite party will give the benefit of continuity of policy from National Insurance Company Policies. The complainant being allured by the opposite party gave his consent for port/ shift his insurance policy cover from National Insurance Company to opposite party company and a policy No. 10858859 with sum assured Rs. 5.00 Lac for period 5.11.2016 to 4.11.2017 and charged premium of Rs. 17,721/- from the complainant. At the time of filling the proposal form the opposite party received Photostat copies of his previous policies of national Insurance Company from which the complainant has given consent for port of policy to the opposite party. From the perusal of this policy of opposite party clearly reveals that complainant was first enrolled for the scheme on 5.11.2009 and opposite party has given number of last policy No. 401800/48/15 of the complainant, which is clear that the policy was issued to the complainant by opposite party in continuity of his previous policies with National Insurance Co and as such, he is entitled for all the benefits of continuous policy. The complainant was again hospitalized with ailment of CST and remained admitted in hospital from 22.12.2016 to 23.12.2016 for which he submitted his claim of Rs. 16397/- with opposite party alongwith all relevant documents which was registered against claim No. 90291121-00. The opposite party has rejected the claim of the complainant vide their letter dated 11.3.2017 on the following grounds:-
Rejected-CTS Since 2013
Non disclosure of material facts/ pre-existing ailments at time of proposal.
This act of the opposite party has caused great mental tension, harassment agony to the complainant because he had shifted to the opposite party company from National Insurance Company for better benefits and services. The rejection of claim by the opposite party is totally arbitrary and illegal because the opposite party themselves admitted in their policy that complainant was enrolled first time in the year 2009 and continued with National Insurance Company up to 2016 and thereafter he had been enrolled in their company and also received copies of previous policies of National Insurance Company under which medical claim of the complainant was sanctioned for the same ailment of CTS. As such, the complainant had not concealed any alleged material facts/ pre-existing ailment from the opposite party at the time of port of his policy to their company. And as such, rejection of claim by the opposite party is totally illegal, unlawful and arbitrary and is unfair trade practice on the part of the opposite party. The complainant has prayed that the opposite party may be directed to make the payment of claim amount alongwith interest at the rate of 12% per annum from delayed period till its payment and Rs. 50,000/- as compensation and costs of complaint.
3 The opposite party appeared through counsel and has filed written version by interalia pleadings that the complainant has to come to the court with clean hands and has suppressed true and material facts from this commission. In this case after receiving the claim and documents, it was transpired that the claimant had not disclosed Pre-existing ailment of Carpal Tunnel Syndrome (CTS) since 2013 and earlier taken the claim from previous insurer for CTS, but this fact was not disclosed at the time of taking the policy, therefore, the claim was rejected and notice for exclusion and cancellation of policy was sent to the complainant dated 12.5.2017, in which it was specifically stated that post review of claim, it has been decided that the CTS will be marked as pre-existing disease. This disease will be excluded for first four years of continuous coverage as per the guidelines and request was made to the complainant to provide consent to continue the policy with revised policy terms and conditions within 15 days from the date of this letter, failing which the company will be entitled to cancel the policy as per terms and conditions and forfeit the entire premium. On that the complainant accepted the proposal to exclude the CTS for first four years, Acceptance duly signed dated 23.6.2017. The complainant has already given consent to exclude the claim for CTS for first four years, therefore, the present complaint is not maintainable and is liable to be dismissed. The complainant was issued health insurance policy (Plan-Care) being No. 10858859 insuring his spouse and himself for a period ranging from 5-11-2016 till 4.11.2017 with a coverage of Rs. 5,00,000/- subject to the policy terms and conditions. The complainant availed cashless facility for admission at K.D. Hospital, Amritsar from 20.12.2016 and submitted medical documents alongwith the cashless form. On perusal of documents submitted it came to the front of opposite party that
As per Raj Kumar Aggarwal OPD prescriptions:-
-Dated 23.1.2015, the complainant is a known case of Carpal Tunnel Syndrome (CTS) since 2013
-dated 9.8.2016, also corroborates that complainant is a known case of CTS
In light of non disclosure of Carpal Tunnel Syndrome (CTS), the opposite party denied the cashless facility request vide letter dated 20.12.2016 for non disclosure of pre-existing ailments at the time of proposal in accordance to clause 7.1 of policy Terms and conditions. The complainant filed for reimbursement claim for the hospitalization at K.D. Hospital, Amritsar from 22.12.2016 till 13.12.2016. the complainant had a history of Carpal Tunnel Syndrome (CTS) since 2013 basis OPD prescription of Dr. Raj Kumar Aggarwal. Hence in light of non disclosure of pre existing ailment the opposite party thereby rejected the claim vide letter dated 11.3.2017 in accordance with clause 7.1 of Policy Terms and Conditions. The contract of insurance is contract of uberrimae fides, and by not declaring correct and accurate information at the time of proposing for the referred policy, the complainant is guilty of breach of the principle of utmost good faith. As per clause 7.1 of the policy terms and conditions , the complainant was under obligation to disclose all material facts at the time of taking the policy. The complainant was a known case of Carpal Tunnel Syndrome was not disclosed to the opposite party. The complainant had the opportunity to disclose it at the time of filing up Proposal form dated 1.11.2016 but no such disclosures were made by the complainant. The declaration made by the complainant in the proposal form was as under:-
- Has any proposed to be insured been diagnosed with or suffered from/ is suffering from or is currently under medication for the following ? If your response is yes to any of the following questions, please specify details of the same in the additional information Section
- Any Neuromuscular (muscles or nervous system) disorder or Psychiatric disorders including but not limited to Motor Neuron Disease, Muscular dystrophies, Epilepsy, Paralysis, Parkinsonism, multiple sclerosis, stroke, mental illness.
- Any other disease / health adversity/ condition/ treatment not mentioned above ?
Answers to the questions asked above was marked as “No”
That the declaration by the complainant in the details of previous or existing health insurance was as under:-
- Have any of the person (s) to be insured ever filed a claim with their current/ previous insurer ? If yes, please provide details on a separate sheet
The complainant has mentioned in the complaint that the previous insurer, National Insurance Co. had sanctioned the claim of hospitalisation at K.D. Hospital for CTS. However, on above question being asked in the Proposal Form, the complainant had marked “No” against the same.
That the complainant herein further read & signed the Proposal form wherein the following declarations are enumerated:-
I/ We hereby declare, on my behalf and on behalf of all persons proposed to be insured that the above statements, answered and or particulars given by me are true and complete in all respects to the best of my knowledge and that I/We am/ are authorized to propose on behalf of these other persons.
That even though the complainant had ported his policy from National Health Insurance Co Ltd. but still the complainant was cast under a duty to furnish all the correct details related to the health of members purported to be insured at the time of filling the proposal form. Even if the policy is being ported, the insured is required to fill a proposal form so that the insured can divulge all the necessary details about the medical condition and the company could rely on that information and simultaneously decide whether to take the risk and issue the policy or otherwise, depending upon the underwriting guidelines of the company and the risk appetite of the Company. Had the complainant disclosed about the pre-existing disease at the time of proposal, then the opposite party would have issued the policy on different terms and conditions.
In the light of Non disclosure of Material information, notice dated 12.5.2017 regarding exclusion and cancellation was sent apprising the complainant that post review of the claim, it has been decided to Mark Carpal Tunnel Syndrome since 2013 under Pre-existing disease and this will be excluded for first four years of conditions coverage as per the undertaking guidelines. In regard to this, please provide your consent to continue the policy with revised policy terms and conditions within 15 days from the date of this letter, failing which we would be entitled to cancel the policy as per policy terms as mentioned in the letter dated 12 May, 2017 by giving signed consent on 23th June 2017 and post receipt which policy was not cancelled. The claim is not payable as the complainant gave its consent to include Carpal Tunnel Syndrome since 2013 under 4 years waiting clause under Pre existing disease in accordance to clause 4.1(iii) of Policy Terms and conditions.
clause 4.1(iii) waiting period state as under:-
4.1 Waiting Periods
(iii) pre existing disease: Claims will not be admissible for any Medical Expenses incurred for Hospitalization in respect of diagnosis/ treatment of any Pre-existing disease until 48 months of continuous coverage has elapsed since the inception of the first policy with the company.
The present complaint has been filed without any cause of action against the opposite party and that the complainant has already given consent to exclude the claim for CTS for the first four years therefore, the present complaint is not maintainable and is liable to be dismissed. The complainant is estopped by his own act and conduct from filing the present complaint. The complainant has no locus standi to file the present complaint. The opposite party has denied the other contents of the complaint and prayed for dismissal of the same.
4 To prove his case, the Ld. counsel for the complainant has tendered in evidence affidavit of complainant Ex. C-1 along with documents i.e. policy certificate Ex. C-2, premium acknowledgement Ex. C-3, copy of claim rejection letter Ex. C-4, copies of policy of National Insurance Company Ex. C-5 to Ex. C-7, copy of bank detail Ex. C-8, copy of discharge card Ex. C-9, copy of Bill Ex. C-10, copy of medical store bill Ex. C-11, copy of the cash receipt Ex. C12 to Ex. C15, copy of medical bill Ex. C-16 and closed the evidence. On the other hands, Ld. counsel for the opposite party tendered in evidence affidavit of Ankit Shanker Bhardwaj Manager Legal Ex. OP1/1 copy of letter dated 12.5.2017 Ex. OP1, copy of policy along with terms and conditions Ex. OP2, copy of the medical record dated 23.1.2015 Ex. OP3, copy of medical record dated 9.8.2016 Ex. OP4, copy of the letter dated 20.12.2016 Ex. OP5, copy of letter dated 11.3.2017 Ex. OP6, copy of proposal form Ex. OP7, copy of receipt of notice Ex. OP8, notice for cancellation Ex. OP9 and closed the evidence.
5 We have heard the Ld. counsel for the parties and have carefully gone through the record.
6 In the present complaint, the complainant earlier had health insurance cover for him and his family from National Insurance Company for Rs. 3 Lac policy No. 4090048138500002097 with expiry date 04.11.2014 , policy no. 40190048148500002043 with expiry date 04.11.2015 , policy no. 40190048158500001983 with expiry date 04.11.2016. In the said insurance company the hospitalization medical claim of the complainant for CTS done in KD hospital at Amritsar. Mr. Manohar Lal Mehra employee having Code No. 20039777 contacted the complainant and allured him that their company Religare Health Insurance is giving more benefits than National Insurance company and advised him to shift to their company and get their medical health plan and Further assured that the opposite party will give the benefit to continuity of policy from National Insurance company policies. The complainant being allured by the opposite party gave his consent to port his insurance policy cover from National Insurance Company to opposite party company and the policy number 10858859 with sum assured ₹5,00,000 for period 5th November 2016 to 4th November 2017 and charged premium of ₹17,721 from the complainant . At the time of filling the proposal form the opposite party received Photostat copies of his previous policy of National Insurance Company from which the complaint has given consent to port the policy to the opposite party. The complainant was again hospitalised with ailment of CST and remained admitted in hospital from 22nd December 2016 to 23rd December 2016 for which he submit his claim of ₹16,397 with opposite party along with all relevant documents which was registered under claim number 90291121 –00. The opposite party has rejected the claim of the complainant vide their letter dated 11.3.2017 on grounds :-
- Rejected -CTS Since 2013
- Non disclosure of material facts /pre existing ailments at time of proposal.
The National Insurance Company ( previous company) under which medical claim of the complainant was sanctioned for the same ailments of CTS . As such the complainant had not concealed any alleged material facts / pre existing ailments from the OP at the time of port of his policy to their company. Hence , rejection of claim by the OP is illegal unlawful and arbitrary and is unfair trade practice on the part of the OP.
OP stated in their written version that ,In this case after receiving the claim and documents it was transpired that the claimant had not disclosed Pre – existing ailment of CTS since 2013 and earlier taken the claim from previous company for CTS, but this fact was not disclosed at the time of taking policy, therefore the claim was rejected and notice for exclusion and cancellation of policy was sent to the complainant dated 12th May 2017, In which it was specifically stated that post review of claim it has been decided that the CTS will be marked as pre existing disease. This disease will be excluded for first 4 years of continuous coverage as per the guidelines and request was made to the complainant to provide consent to continue the policy with the revised policy terms and conditions within 15 days from the date of this letter failing which the company will be entitled to cancel the policy as per policy terms and conditions and forfeit the entire premium. On that the complainant accepted the proposal to exclude the CTS for first 4 years as such, acceptance was duly signed on dated 23rd June 2017 (Ex. OP-1). Further, even though the complainant had ported his policy from National Insurance Company but still the complainant was cast under the duty to furnish all the correct details related to the health of members proposed to be insured at the time of filling the proposal form. (Proposal form Ex. OP 7) .
7 The declaration made by the complainant in the proposal form was as under :-
- Has any proposed to be insured been diagnosed with or suffered from/ is suffering from or is currently under medication for the following ? If your response is yes to any of the following questions, please specify details of the same in the additional information Section
- Any Neuromuscular (muscles or nervous system) disorder or Psychiatric disorders including but not limited to Motor Neuron Disease, Muscular dystrophies, Epilepsy, Paralysis, Parkinsonism, multiple sclerosis, stroke, mental illness.
- Any other disease / health adversity/ condition/ treatment not mentioned above ?
Answers to the questions asked above was marked as “No”
That the declaration by the complainant in the details of previous or existing health insurance was as under:-
Have any of the person (s) to be insured ever filed a claim with their current/ previous insurer ? If yes, please provide details on a separate sheet.
Answers to the questions asked above was marked as “No”
It is worthwhile to mention here that at the time of procuring the policy from the OP , the complainant did not disclose pre existing disease of CTS and also not disclosed the claim taken from the National Insurance Company. Thereby concealed the material facts of his health and the complainant is guilty of non disclosure of material facts thereby violated the close 7.1 of the terms and condition of the policy which stated as below:-
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.
From the facts mentioned above, the complainant is not entitled for the claim and claim was rightly repudiated vide letter dated 11.03.2017 (Ex. OP-6)
8 In this view of the above discussion, we are of the considered view that as per the declaration made by the complainant in the proposal form (Ex. Op 7) , all the questions asked about the medical history was marked as ‘NO’ by the complainant . Moreover, the complainant has mentioned in the complaint that the previous insurer, National Insurance Co. had sanctioned the claim of hospitalization at KD hospital for CTS . however , on proposal form question about the claim from previous company was marked by the complainant as ‘NO’ . Even though the complainant had ported his policy from National Insurance Company but still the complainant was cast under the duty to furnish all the correct details related to the health of members proposed to be insured at the time of filling the proposal form. Even if the policy is being ported , the insured is required to fill a proposal form so that the insured can divulge all the necessary details about the medical condition and the company could rely on that information and simultaneously decide whether to take the risk and issue the policy or otherwise, depending upon the underwriting guidelines of the company and the risk appetite of the company. Moreover, In the light of Non disclosure of material information, notice dated 12.05.2017 regarding Exclusion & Cancellation was sent appraising the complainant that post review of the claim, it has been decided to mark CTS Since 2013 under pre existing disease and this will be excluded for first 4 years of continuous coverage as per the underwriting guidelines. In this regard, the complainant himself accepted the terms and conditions in the Letter dated 12.05.2017 by giving a signed consent on 23.06.2017. Hence, the claim is correctly repudiated by the OP as the complainant gave it’s consent to include CTS Since 2013 under pre existing disease and this will be excluded for first 4 years of continuous coverage as per the underwriting guidelines. (Ex.OP-1). The opposite party has placed reliance upon Satwant Kaur Sandhu vs. New India Assurance Company Ltd. (2009) 8 SCC 316, in which it has been observed by the Supreme Court that the expression "material fact" is to be understood 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 - Uberrimae fides. It has also been held in Life Insurance Corporation of India Vs Smt. Neelam Sharma pronounced by the National Commission on 30th September 2014 that the statements made in the Proposal Form were untrue and incorrect and therefore in breach of the Policy Terms and Conditions. Thus, it was held that it is not for the Insured to determine whether the information sought for in the questionnaire was material for the purpose of the policies. It has also been held in Pravesh Kumar Vs Religare Health Insurance in District Consumer Forum, Ludhiana dated 17 July 2017, that the complainant after being understood with the terms and conditions of the Policy signed the declaration confirming abiding by the terms and conditions of the policy and ported with Religare Health Insurance. It was further held that at the time of filling up of Proposal Form or Portability Form, the complainant was under obligation to disclose all the material information regarding previous health condition.
9 In view of the above discussion, we do not find any merit in the present complaint and the same is hereby dismissed with no order as to costs. Copy of order will be supplied by District Consumer Disputes Redressal Commission, Amritsar to the parties as per rules. File be sent back to the District consumer Disputes Redressal Commission, Amritsar.
Announced in Open Commission
03.11.2022
