DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No. 384/16
Smt. Ritu Arora
W/o Sh.Praveen Kumar
R/o 6/341, Geeta Colony,
Delhi-110031
….Complainant
Versus
M/s Religare Health Insurance Company Ltd.
D3, P3B, District Centre,
Saket, New Delhi-110017
….Opposite Party
Date of Institution : 21.11.2016
Date of Order : 28.01.2023
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Sh. U.K. Tyagi, Member
ORDER
President: Ms. Monika A Srivastava
Complainant has filed the present complaint seeking compensation of Rs.5,78, 797/- with 18% interest from 17.11.2015 along with compensation. The OP in this case is Religare Health Insurance Ltd.
- It is stated by the complainant that Health policy was purchased from the OP vide policy no. 10195867 by paying the premium of Rs.5,924/-was paid by husband dated 20.01.2015for the sum insured Rs.5,00,000/- which was further renewed vide policy certificate dated 20.01.2016 till 19.01.2017 for a sum of Rs.10,00,000/- by paying premium of Rs.9,801/-.
- It is further stated by the complainant that she was admitted in Max Super Speciality hospital and diagnosed with ‘malignant neoplasm of cervix u’ and the request for the pre authorization was made but the same was denied vide letter no. 80057812 updated 17.11.2015 and again another request was made dated 22.08.2016 which is exhibit CW 1/5 on the ground:
“Care 6.1
non-disclosure of material facts/pre-existing elements at the time of proposal, patient is very obese (120kg) but as per proposal for weight is 60 kg and as per statement of patient has no weight gain since last one year. Hence cashless claim has been rejected.”
- It is further stated by the complainant that while rejecting the claim of the complainant vide letter dated 17.11.2015 and 22.08.2016,OP has not given any list of discrepancy in documents which complainant could have completed. No demand/ letter of documents was ever issued by the OP showing any discrepancy in the medical documents of the complainant. It is also stated that the complainant has no pre-existing element or disease as stated by the OP while rejecting the claim.
para 6.1 states
if any untrue or incorrect statements are made or there has been a misrepresentation 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 there behalf the company shall have no liability to make payment of any claim and the premium paid shall be forfeited to the company.
- It is further stated that there is no misrepresentation or non-disclosure of any material particulars which goes to the root of the case for rejecting the claim of the complainant and the weight and height of the complainant does not affect or violate any terms of policy as nothing is mentioned in the said policy about weight for rejecting the claim. It is also stated that the disease malignant neoplasm of cervix u was not pre-existing as has been quoted in the rejection letter by the OP.
- It is stated that once the OP was aware of the alleged ailment/reason for rejecting claim on the ground, if any, OP should not have renewed the policy for the next year till 19.01.2017 and should have rather terminated the same as the whole facts were in their knowledge. On this ground the present complaint has been filed.
- The OP, in their reply have stated that the complainant duly filled the proposal form which is annexed as Annexure OP 2. The OP has also not denied that a policy certificate bearing no. 10195867 which was valid for the period 20.01.2015 to 19.01.2016 was issued to the complainant, however it is stated that the policy was erroneously renewed due to a technical error till 19.01.2017. The copy of the insurance policy is annexed as Annexure OP 3.
- It is stated that during the continuation of the policy, the complainant had requested for cashless facility from 28.10.2015 to 02.11.2015 for carcinoma cervix and hypothyroidism for an estimated expense of Rs 2,65,000/-. Investigations were carried out and it was noticed that as per the statement of the husband of the complainant and the pre-operative anaesthesia form, the complainant weighed 120 kgs and there has been no weight gain since the past one year. Hence cashless facility request was denied on 30.10.2015 as per clause 6.1 of the policy terms and conditions for non-disclosure of material facts. The said denial letter has been duly annexed as Annexure OP 8.
- It is further stated by the OP the during the continuation of the policy the complainant again requested for cashless facility for the chemotherapies vide request dated 17.11.2015 reference number 80057812 for an estimated expense of Rs.2,00,800/- which was denied on the same ground of non-disclosure of material information.
- It is further stated by the OP that the complainant with malafide intention of misusing and abusing the process of law got her policy renewed online for fulfilling hideous motive of extracting money from the OP. It is stated that no prudent man would pay and renew or policy with increased sum insured after the cashless claims were rejected on genuine ground of concealment of material facts.
- It is stated by the OP that the complainant committed a breach of contract of insurance which is based on the principle of uberrimae fides by not disclosing her true health condition not only at the time of issuance of policy but also at the time of renewal.
- It is stated that the complainant after getting the policy renewed online filed reimbursement claim vide claim number 90238311-00 and 9023 8343-00 for an estimated expense of Rs. 4,58,856/- and Rs.1,97,991/- for 5 days of chemotherapies (18.11.2015, 25.11.2015, 02.12.2015, 09.12.2015 and 16.12.2015). It is stated by the OP that the complainant filed the reimbursement claim 8 months after the discharge from the hospital. The claim documents were received by the OP on 29.07.2016 which is against the policy terms and conditions as all the reimbursement requests and supporting documents should have been submitted to the OP within 15 days of discharge from the hospital.
- The private OPD card of Max healthcare pertaining to the weight of the complainant is annexed as Annexure OP 12. It is further stated by the OP that as per the WHO recommendation, at the weight of 120 kgs the complainant’s BMI would have been 44.02 which is beyond the acceptance criteria and this fact was not correctly disclosed at the time of taking the policy. It is further stated that it is more likely for obese people to develop a potentially serious health problems including cancer.
- The OP has also placed reliance on the judgment of the Hon’ble Supreme Court in Satwant Kaur Sandhu vs New India Assurance Co. Ltd. (2009) 8 SCC 316 wherein it has been held
material fact is to be understood to mean as any fact which influence the judgement of a prudent insurer in deciding whether to accept the risk or not….. any inaccurate answer will entitle the insurer to reputed their liability because there is a clear presumption that any information sought for in the proposal form is material for the purpose of entering into contract of insurance which is based on the principle of utmost good faith uberrimae fides.
The OP has also placed reliance on the judgment of the Hon’ble NCDRC in Life Insurance Corporation of India vs Smt. Neelam Sharma wherein it was stated that the statements made in the proposal form were untrue and incorrect and therefore in breach of the policy terms and conditions..
- It is also stated by the OP that the complainant has contended that cancellation notice of the policy was not served to her properly however, it was served on the complainant 2 months prior to the cancellation date i.e17.10.2016 notice of cancellation was sent while the policy was finally cancelled on 16.12.2016.
- The OP has also placed reliance on the judgment passed by the Hon’ble Supreme Court in United India Insurance Co.Ltd vs Harchand Rai Chandan Lal CA No. 6277/04
The terms of the policy shall govern the contract between the parties, they have to abide by the definition given therein and all those expressions appearing in the policy should be interpreted with reference to the terms of future policy and not with reference to the definition given in other laws…..
Both the parties have filed their respective rejoinder evidence affidavits and written submissions.
This Commission has gone through the entire material on record and it is seen that in the proposal form filed on record by the OP, the husband of the complainant has disclosed the weight of the complainant as 60 kgs whereas at the time of her surgery she weighed 120 kgs and there had been no weight gain in the last one year. It is also seen that despite rejection of the pre-authorization claim of the complainant, the complainant has again opted to go in for renewal of the policy and has then sought for reimbursement of medical bills.
This Commission is of the view that at the time of inception of the policy the husband of the complainant has provided false information regarding her weight which is a material fact and which as per the judgment pronounced by the Hon’ble Supreme Court in Satwant Kaur Sandhu vs New India Assurance company Ltd.It is a fact which would influence the judgement of the prudent insurer in deciding whether the risk should be accepted or not. Therefore, this Commission is of the view that the claim of the complainant has been rightly rejected however, since the OP has stated that the policy was renewed due to a technical error they are bound to return the pro rata premium of the complainant of the renewed policy. We direct the OP to return the premium of the complainant on a pro rata basis for the policy pertaining to the second year along with interest @ 5%from the date of deposit till realization within two months from the date of receipt of this order failing which the interest would be calculable at 7%.
The complaint is disposed of in these said terms.
Parties be provided copy of the order as per rules. File be consigned to the record room. Order be uploaded on the website.
