BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMRITSAR.

Consumer Complaint No. 291 of 2021

Date of Institution: 15.6.2021

                                                          Date of Decision:10.10.2024   

Anil Kumar aged about 50 years son of Sh. Madan Gopal R/o H.No. 3210/14, Street No. 7, Haripura, Amritsar (Mobile No. 8837890347)

Complainant

Versus

1. Religare Health Insurance  Company Limited having its local branch office at SCO 28, Taneja Towers, B-Block, Ranjit Avenue, Amritsar through its Branch Manager/Person over all Incharge
2. Carewell Heart and Super Speciality Hospital, Model Town, G.T.Road, Amritsar through its Medical Superintendent/Treating Doctor/Authorized Signatory/Person over all Incharge Dr. Rohit Kapoor

Opposite Parties

Complaint under section 35 of the Consumer Protection Act, 2019

Result : Complaint Allowed

Counsel for the parties  :

For the  Complainant               : Sh. Munish Kohli, Advocate    

For the Opposite Party No.1     : Sh. R.P. Singh, Advocate

For the Opposite Party No.2     : Sh. Puneet Krishan Joshi, Advocate

Coram

Mr. Jagdishwar Kumar Chopra, President

Ms. Mandeep Kaur, Member

ORDER:-

Mr. Jagdishwar Kumar Chopra, President :-Order of this commission will dispose of the present complaint filed by the complainant u/s 35 of the Consumer Protection Act, 2019.

Brief facts and pleadings

1.       Brief facts of the case are that   complainant has obtained mediclaim family floater policy from the opposite party bearing policy No. 14429709 for the period from 2.7.2019 to 1.7.2020 for the sum assured of Rs. 5,00,000/- covering the risk of complainant and his family members consisting of his wife Smt.Simmi Sharma, daughter  Ms. Angel Sharma, son Master Nokesh Sharma and  premium of Rs. 20611/-0 was duly paid. It is important to mention here that only policy schedule was supplied  but the opposite party never supplied any terms and conditions of the impugned   insurance to the complainant. At the time of obtaining the impugned mediclaim insurance policy, the complainant was hale and hearty and he was quite fit and was enjoying good health and not suffering from any kind of illness and was not getting any medication  before taking the said mediclaim Insu. policy. During the currency of the policy period  , complainant suffered from severe pain in his chest  and sweatiness  on 31.8.2019 and immediately approached Care Well Heart & Super Speciality Hospital, Amritsar where the concerned treating doctor namely Dr. Rohit Kapoor after examination of the complainant got conducted various ECG’s and medical tests  and the complainant was diagnosed with Acute IWMI T2 DM (Detect First Time) CAD-Tripple Vessel Disease (LAD & LCX & RCA)  and the concerned doctor advised the complainant for stunt implant operation which was accordingly done successfully in the said hospital and he remained admitted in the said hospital on 31.8.2019  and discharged on 6.9.2019  and in respect thereof bill for a sum of Rs. 3,62,923/- was issued by the opposite party No.2, copies of bills are Ex.C-2 to Ex.C-20. It is pertinent to mention here that it was a cashless policy and the opposite party was under obligation to pay the entire amount towards the medical treatment but  the opposite party denied the cashless claim of the complainant and the complainant was compelled to pay the said amount of Rs. 3,62,923/- from his own pocket after arranging the same from his friends and relatives.  Thereafter opposite party was requested to reimburse the aforementioned amount  spent by the complainant towards his medical treatment  to the tune of Rs. 3,62,923/- but the opposite party vide letter dated 22.9.2019 repudiated the claim  by alleging that there is discrepancy in the submitted records and in medical documents.” It is pertinent to mention here that due to some clerical and typographical error of the hospital the date and time printed by the concerned hospital’s ECG machine on ECG reports were incorrect and wrong due to non updating of date and time into hospital’s ECG machine. Even the concerned treating doctor has given clarification of ECG dated 2.9.2019 regarding date and timing of ECG  in which concerned doctor Rohit Kapoor advised the opposite party No.1 to consider the handwritten date and timing on all ECG’s got conducted by opposite party No.2  and the said doctor Dr. Rohit Kapoor has also made statement in his own handwriting on the letter had of the hospital  concerned duly signed and stamped by the concerned treating doctor  that such minor discrepancy regarding date and time has happened just because of non-updating/non calibration of the ECG machine. Not only this, even the concerned treating doctor has also given self attested statement in writing that all ECG’s done on 31.8.2019 and not before that, copy of ECG is Ex.C-50. Even clarification regarding treatment of complainant vide letter dated 16.12.2019 i.e. Ex.C-54 has been replied by the concerned doctor  in his own handwriting and the same is Ex.C-55 in which   it is clearly mentioned that date i.e. 10.4.2019 is also made by Dr. Rohit Kapoor inadvertently instead of 10.9.2019. Thereafter the complainant personally approached the office of Insu. Ombudsman on 7.2.2020 and the same was fixed for 11.8.2020 for video conferencing, but however the complainant was not conversant with the English language as well as technicalities of law  and as such he could not put his case property before the Insu. Ombudsman . As such   the  Insu. Ombudsman dismissed the complaint vide order dated 21.8.2020. In order to file the present complaint, the complainant has sent notice to opposite party No.2 for submission of complete treatment record  but the opposite party No.2 has not provided any single document , copy of notice is Ex.C-57. The opposite party was under legal obligation to pay the claim amount of Rs. 3,62,923/- and the  aforesaid act of the opposite party No.1 in repudiating the genuine claim of the complainant amounts to  deficiency in service, malpractice, unfair trade practice which  has caused lot of mental agony, harassment , inconvenience besides financial loss to the complainant.  Vide instant complaint, complainant has sought for the following reliefs:-

(a)      Opposite party No.1 be directed to pay the impugned claim of Rs. 3,62,923/- alongwith interest @ 12% p.a.

(b)     Opposite party No.1 be also directed to pay compensation  of Rs. 50,000/-  for causing mental agony and harassment to the complainant.

(c )     Opposite party No.2 be  also directed to pay Rs. 50000/- as compensation on account of violating the medical council rules  as well as professional etiquette and ethics;

(d)     Opposite parties be also directed to pay Rs.22000/- as  litigation expenses to  the complainant ;

(e)      Any other relief to which the complainant is entitled be also awarded to the complainant.

Hence, this complaint.

2.       Upon notice, opposite party No. 1 appeared and filed written version taking preliminary objections  that  complainant had earlier approached the Hon’ble Ombudsman, Chandigarh who after going through the complaint and hearing both the parties   dismissed the complaint and held that replying opposite party’s rejection  was done as per terms and conditions of the policy, hence the case should be dismissed in limine ; that complainant has not come to this Hon’ble Commission with clean hands. It is submitted that insured had applied for cashless claim for hospitalization from 31.8.2019 with chief complaint of chest pain with perfuse sweating on sudden onset  and was finally diagnosed with Acute IWMI, Type Two Diabetes Mellitus and CAD Tripple Vessel Disease (LAD & LCS & RCA). Accordingly  the replying opposite party triggered a claim investigation in order to check the veracity of the claim and raised query vide letter dated 1.9.2019 and sought the following documents:-

1.       Address proof of proposer/nominee as mentioned in policy. Mr. Anil Kumar HNO-3210/14, Gali No. 7, Hari Pura, Amritsar 143001 Punjab.

2.       Exact Duration and Past History of present ailment  with Ist Consultation paper and all past treatment records.

3.       Pre-Hospitalization OPD treatment record.

4.       Recent Passport Size Photograph of Proposer/Nominee.

The complainant/insured did not gave proper reply to the queries and accordingly the replying opposite party rejected the claim on non disclosure of acute myocardial infarction and intimation in this regard was given to the complainant vide letter dated 2.9.2019  mentioning the following grounds:-

1. Non disclosure of material facts/pre-existing ailments at  the time of proposal. Patient is known case of Acute Myocardial Infarction prior to policy inception.

Non Disclosure

Thereafter the insured applied for reimbursement claim with replying opposite party for the diagnosis of Acute IWMI, Type II Diabetes  Mellitus and CAD Tripple Vessel Disease (LAD & LCX & RCA). After proper investigation and evaluation of the claims documents made available to the replying opposite party it was found that there were discrepancies in the medical documents submitted. Accordingly, the replying opposite party rejected the reimbursement claim of the insured in accordance with clause 7.1 of the policy terms and conditions and intimation in this regard  was given to the complainant vide letter dated 22.9.2019 mentioning the following grounds:-

1. Claim is rejected as there is discrepancy in the submitted records.
2. Discrepancy in medical documents.

Following discrepancies were found in the medical documents provided to the replying opposite party:-

1. That as per ECG report dated 8.3.2019 duly signed by the treating hospital insured was diagnosed with Acute Myocardial infraction. It is pertinent to mention here that a false calibration of ECG machine is not possible as insured had series of ECG done on midnight of 8^th March 2019 with RBS 226 Machine.
2. That as per  first consultation was taken from Dr. Rohit on 31.8.2019 and after surgery, insured had follow up with Dr. Rohit  on 10.9.2019  but there is mismatch in writing and signature of Dr. Rohit in both consultation.
3. That insured’s sugar level was high from first day but  no medication or insulin advised as per ICP report, though as per discharge summary patient was given insulin.
4. As per the Discharge Summary, insured was diagnosed with Type 2 DM, however , as per the insured’s spouse’s statement, he didn’t have history of DM or HTN.

From the abovesaid facts and circumstances, it is clear that there are serious discrepancies in the medical documents and same have been procured to lodge a false claim with the replying opposite party. As per policy terms and conditions, the complainant is not entitled for any claim. The relevant clause is reproduced herein through which the replying opposite party process the claim:-

7.       General Terms & Conditions

7.1     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 any one acting  on his/their behalf, the company shall have no liability to make payment of any claims and the premium paid shall be forfeited ab initio to the company.”

It is pertinent to mention here that the insured/complainant was having opportunity to disclose the facts regarding his pre-existing disease, but he intentionally  misrepresented the facts in the proposal form at the time of obtaining the policy from the replying opposite party. The following question was asked in the proposal form:-

Any heart disease or disorder, chest pain or discomfort irregular heartbeats, palpitations  or heart murmur Insured I Insured 2 Insured 3 Insured 4     : No

Diabetes Mellitus/High Blood Sugar/Diabetes or Insulin or medication                           : No

 It is also pertinent to mention here that history of  Acute Myocardial infarction and DM was important but the same was intentionally not disclosed by the insured , therefore, he is not entitled for any claim and as such the claim has rightly been repudiated vide mail dated 27.1.2020. Both the parties are bound with the terms and conditions  of the policy which are duly supplied to the complainant at the time of issuance of policy  and no claim can be passed beyond the terms and conditions of the policy and both the parties are  bound with the terms and conditions of the policy. Reliance in this connection has been placed upon Export Credit Guarantee Corpn of India Ltd. Vs. M/s. Garg Sons International . The opposite party further relied upon Oriental Insu.Co.Ltd. Vs. Sony Cheriyan AIR 1999(SC) 3252, Polymat India P.Ltd. Vs. National Insu.Co.Ltd. AIR 2005 SC 286, M/s. Sumitomo Heavy Industries Ltd. V . Oil & Natural Gas Company AIR 2010 SC 3400 and Rashtriya Ispat Nigam Ltd. V. M/s. Dewan Chand Ram Saran AIR 2012 SC 2829.  Further reliance has been placed upon Satwant Kaur Sandhu Vs. New India Assu.Co. Ltd. (2009) 8 SCC 316, LIC of India Vs. Smt. Neelam Sharma, Sh. Gulshan Rai Verma Vs. M/s. Religare Health Insu.  of the Hon’ble State Commission, Delhi . On merits, opposite party No.1 has taken the similar  pleas  as were taken in the preliminary objections, as such there is no need to reproduce the same. While submitting that there is no deficiency  in service and while denying and controverting other allegations, dismissal of complaint was prayed.

3.       Opposite party No.2 also appeared and filed written version  in which it was submitted that due to  some technical errors in the ECG machine the dates were wrongly mentioned . However the same were corrected by hand, clarification on the handwritten dates and signatures of junior resident doctor  were also given handwritten as well as on the  letter pad of the hospital by  Dr. Rohit Kapoor, opposite party No.1 was also requested to consider handwritten dates  but the opposite party No.1 intentionally wanted to run from their liability and putting up the matter on one pretext or the other without any rhyme or reason. It was admitted that complainant was got admitted on 31.8.2019 and discharged on 6.9.2019  and thereafter he came for follow up on 10.9.2020 but inadvertently date was mentioned as 10.4.2019 which was totally a human error  the clarification was also given to opposite party No.1. While submitting that there is no deficiency  in service on the part of  replying opposite party No.2 and while denying and controverting other allegations, dismissal of complaint against replying opposite party No.2 was prayed.

Evidence of the parties and Arguments

4.       Alongwith the complaint , complainant has filed his affidavit Ex.CW-1/A, copy of Insu. cover note Ex.C-1,  copies of invoice/bills Ex.C-2 to Ex.C-20, copy of discharge card dated 6.9.2019 Ex.C-21,  copy of pre-authorization form request for cashless hospitalization Ex.C-22 , copy of reimbursement claim form Ex.C-23, copy of repudiation letter dated 22.9.2019 Ex.C-24,  copies of medical record Ex.C-25 to Ex.C-49, copy of ECG Ex.C-50, copy of statement issued by treating doctor  namely Dr. Rohit Kapoor Ex.C-51 & Ex.C-52 , copy of representation Ex.C-53,  copy of letter dated 16.12.2019 Ex.C-54, copy of concerned doctor  reply in his own handwriting Ex.C-55, copy of order dated 21.8.2020 Ex.C-56, copy of notice Ex.C-57, postal receipts Ex.C-58 &  Ex.C-59.

5.       On the other hand opposite party No.1  alongwith written version has filed affidavit of Ravi Boolchandani, Manager (Legal) Ex.OP1/1, cop of authority letter Ex.OP1/2, copy of policy Ex.OP1/3, copy of terms and conditions Ex.OP1/4, copy of query letter dated 1.9.2019 Ex.OP1/5, copy of query reply dated 1.9.2019 Ex.OP1/6, copy of pre-authorization request Ex.OP1/7, copy of pre-authorization denial letter  dated 2.9.2019 Ex.OP1/8, copy of claim denial letter  dated 22.9.2019 Ex.OP1/9, copy of discharge summary Ex.OP1/10, copy of complete ICP Ex.OP1/11, copy of order  of Insu. Ombudsman dated 21.8.2020 Ex.OP1/12, copy of proposal form Ex.OP1/13, copy of Dr. Rohit Kapoor’s letters 31.8.2019, 10.9.2019 Ex.OP1/14 and Ex.OP14-A, copy of ECG reports Ex.OP1/15, copy of certificate of incorporation Ex.OP1/16.

6.       Whereas  opposite party No.2 alongwith written version has filed affidavit of Dr. Rohit Kapoor, Authorized Signatory Ex.OP2/2 & Ex.OP2/A1,  cop of clarification regarding date Ex.OP2/1, letter dated 4.11.2019 regarding treatment of Anil Kumar Ex.OP2/2, letter dated 18.12.2019 Ex.OP2/3, copy of patient record Ex.OP2/4.

7.       We have heard the Ld.counsel for the parties and have carefully gone through the record on the file. Ld.counsel for the complainant suffered a statement that he does not want to file written arguments and the contents of complaint alongwith exhibited documents be read as part of written arguments. We have also gone through the written arguments submitted by opposite party No.1 as well as opposite party No.2.

Findings

8.       From the    pleadings of the parties and the evidence produced on record, the case of the complainant is that he has obtained  policy No. 14428709 for the period from  2.7.2019 to 1.7.2020 for the sum assured of Rs. 5,00,000/-, copy of policy cover note is Ex.C-1. It is case of the complainant that  during the subsistence of the policy period  he suffered from severe pain in his chest  and sweatiness  on 31.8.2019 and remained admitted in Carewell Heart & Super Specialty Hospital, Amritsar for the period from 31.8.2019 to 6.9.2019  and in this regard complainant has placed on record  copy of discharge card dated 6.9.2019 Ex.C-21.  It is also the case of the complainant that he spent Rs. 3,62,923/- on his treatment and in this regard  he has placed on record copies of medical bills Ex.C2 to Ex.C-20. However, when the complainant lodged cashless claim the same was denied  and the complainant has to pay the aforesaid charges from his own pocket. Thereafter the complainant lodged claim  alongwith all the requisite documents i.e. medical record issued by opposite party No.2  copies of which are Ex.C-25 to Ex.C-49 for reimbursement  vide claim form Ex.C-23, but again the opposite party vide letter dated 22.9.2019 repudiated the claim  on the ground that there is discrepancy in the submitted records and in medical documents. In this regard the contention of the complainant is that  due to some clerical and typographical error of the hospital the date and time printed by the concerned hospital’s ECG machine on ECG reports were incorrect and in this regard the concerned treating doctor has given clarification of ECG dated 2.9.2019, copy of which is Ex.C-51 & Ex.C-52. Even the said hospital    sent  representation to the queries raised by opposite party No.1 copy of which is Ex.C-53 and also clarification   regarding treatment of complainant  was replied by the said hospital to opposite party No.1 vide letter dated 16.12.2019 Ex.C-54 as well as Ex.C-55. Not only this the case filed by the complainant before the Insu. Ombudsman   was also dismissed vide order dated 21.8.2020, copy of order is Ex.C-56. It is also the case of the complainant that  only policy cover was provided and no terms and conditions were ever supplied by opposite partyNo.1 to the complainant.  Ld. Counsel for the complainant contended that the act of the opposite party No.1 in rejecting the genuine claim of the complainant amounts to deficiency in service.

9.       On the other hand opposite party No.1 has repelled the aforesaid contentions of the complainant and submitted that reimbursement claim was lodged with the  opposite party for the diagnosis of Acute IWMI, Type II Diabetes  Mellitus and CAD Tripple Vessel Disease (LAD & LCX & RCA) and after  proper investigation and evaluation of the claims documents ,it was found that there were discrepancies in the medical documents submitted. Accordingly, the replying opposite party rejected the reimbursement claim of the insured in accordance with clause 7.1 of the policy terms and conditions and intimation in this regard  was given to the complainant vide letter dated 22.9.2019 mentioning the following grounds:-

3. Claim is rejected as there is discrepancy in the submitted records.

5. Discrepancy in medical documents that as per ECG report dated 8.3.2019 duly signed by the treating hospital insured was diagnosed with Acute Myocardial infraction. That as per  first consultation was taken from Dr. Rohit on 31.8.2019 and after surgery, insured had follow up with Dr. Rohit  on 10.9.2019  but there is mismatch in writing and signature of Dr. Rohit in both consultation. That insured’s sugar level was high from first day but  no medication or insulin advised as per ICP report, though as per discharge summary patient was given insulin. As per the Discharge Summary, insured was diagnosed with Type 2 DM, however , as per the insured’s spouse’s statement, he didn’t have history of DM or HTN.

From the abovesaid facts and circumstances, it is clear that there are serious discrepancies in the medical documents and same have been procured to lodge a false claim with the replying opposite party.

10.     This Commission has given thoughtful consideration to the facts of the present case and the moot questions involved in this case are  (i) whether the terms and conditions were supplied to the complainant (ii) whether the ground taken by the opposite party No.1 in repudiating the claim is genuine. To meet these points this Commission has given thoughtful consideration to the records submitted by both the parties  . Opposite Party No.1 could not produce  any evidence to prove that terms and conditions of the policy were ever supplied to  the complainant  when and through which mode? It has been held by Hon’ble National Commission, New Delhi in case titled as The Oriental Insurance Company Limited Vs. Satpal Singh & Others 2014(2) CLT page 305 that the insured is not bound by the terms and conditions of the insurance policy unless it is proved that policy was supplied to the insured by the insurance company. Onus to prove that terms and conditions of the policy were supplied to the insured lies upon the insurance company.

11.       However for the sake of arguments the ground taken by the opposite party No.1  that there is discrepancy in the medical records i.e. as per ECG report dated 8.3.2019 duly signed by the treating hospital insured was diagnosed with Acute Myocardial infraction. That as per  first consultation was taken from Dr. Rohit on 31.8.2019 and after surgery, insured had follow up with Dr. Rohit  on 10.9.2019  . But we are not agreed with this plea of opposite party No.1 as  the complainant has placed on record clarification dated 2.9.2019 made by concerned doctor from whom the complainant has taken the treatment  who  in his clarification has stated  that  the date & timing on ECG for the patient mentioned above is that the patient was presented in the hospital on 31.8.2019 at around 2.30 p.m. with the complaint of chest pain and perfuse sweating from the last 2-3 hrs before admission.ECG was done which was having date printed as 8.3.2019 because of non calibration. Also after admission of the patient, again the ECGs were repeated at 5.00 p.m. on 31.8.2019 and at 7.00 a.m. on 1.9.2019. All the three ECGs got printed with the same date as 8.3.2019 with different timings.  Not only this opposite party No.2 i.e. Carewell hospital by appearing before this Commission filed written version in which it was admitted that due to technical errors in the ECG machine the dates were wrongly mentioned and also placed on record clarification dated 2.9.2019 as well as  reply  dated 4.11.2019 as well as dated 18.12.2019 to the queries raised by opposite party No.1 regarding treatment of Anil Kumar, complainant  for the period from 31.8.2019 to 6.9.2019. In support of the written version filed by opposite party No.2, they have  also placed on record affidavit of Dr. Rohit Kapoor Ex.OP2/A2 and Ex.OP2/A1. The opposite party No.1 has not made any effort to cross examine the said doctor  to prove its case . The other ground taken by the opposite party No.1 that insured’s sugar level was high from first day but  no medication or insulin advised as per ICP report, though as per discharge summary patient was given insulin. Again we are not agreed with this ground taken by the opposite party No.1 as  after getting admission by the complainant in the hospital,  the doctor after seeing the condition of the patient can decide what type of treatment the patient requires. Only doctor  and not the Insurance company can decide the line of  treatment is required to be given to a patient. The other ground as taken that as per the Discharge Summary, insured was diagnosed with Type 2 DM, however , as per the insured’s spouse’s statement, he didn’t have history of DM or HTN. Again we are not agreed with this ground taken by opposite party No.1 as the concerned doctor to whom the complainant was taken has given clarification dated 2.9.2019 that  the patient was presented in the hospital on 31.8.2019 at around 2.30 p.m. with the complaint of chest pain and perfuse sweating from the last 2-3 hrs. The burden of proof was upon the opposite party No. 1  to prove that the insured was suffering from any disease prior to taking the policy, but they have miserably failed to discharge this onus. Reliance in this connection has been placed upon Bajaj Allianz Life Insu.Co.Ltd. &  Ors Vs. Raj Kumar III(2014) CPJ 221 (NC) wherein it was held   that usually the authorized doctor of the Insu.company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. Thus the repudiation of the claim on the ground of pre existing disease was  held to be invalid. It has been held by the Hon'ble Punjab State Consumer Disputes Redressal Commission in case National Insurance Company Limited and Another Vs. Balwinder Singh 2012(1) CLT 34 that as regards pre-existing disease i.e. suppression of material fact, the appellants have not produced any evidence to prove that before the purchase of the policy, the insured/respondent had taken any treatment from any doctor or any hospital and the insured/respondent had the knowledge that he was suffering from the heart disease and concealed this fact from the appellants at the time of issuance of the mediclaim policy. In the absence of any reasonable evidence the insurance company was not correct in repudiating the claim under the policy. It has further been held by the Hon'ble National Commission in case Sahara India Life Insurance Co. Ltd. &Anr Vs. HansabenDeeepak Kumar Pandya IV(2012) CPJ 13(NC) that where the opposite party insurance company has failed to produce on record any evidence to show that deceased insured ever consulted doctor for taking treatment of heart disease, the repudiation of the claim on the ground of suppression of material fact is totally illegal. It has been  held by Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in case titled as Ashwani Gupta &Ors. Vs. United India Insurance Company Limited 2009(1) CPC page 561 that where the claim of the complainant has been repudiated on the ground that the assured had pre-existing disease of diabetes mellitus which was not disclosed- apparently, burden to prove lies  upon the insurer- If assured was suffering from pre-existing disease why insurer  had not checked it at the time when proposal form was accepted by its  staff-Respondent has failed to fulfill this requirement before repudiating the claim and the appellant was held entitled  to claim alongwith interest. Not only this diabetes  mellitus and hypertension  are not  material diseases, therefore, non disclosure thereof is not a concealment. We draw support from Life Insurance Corporation of India Vs. Sushma Sharma from II (2008) CPJ 213 wherein Hon'ble State Commission has held as under:- “So far as hypertension is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for  number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”. We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease. It fully proves that  only to escape themselves from paying the sum assured, opposite party No.1 has taken the false grounds  which are not sustainable in the eyes of law.

12.     In view of the above discussion, we allow the complaint and the opposite party No.1 is directed to pay the claim amount of Rs. 3,62,923/- as incurred by the complainant on his hospitalization  alongwith interest @ 6% p.a. from the date of filing of the complaint till its realization.  So far as compensation is concerned as the complainant has obtained the cashless policy with the hope that if any unforeseen occurrence develop   , he can seek the help of Insu. company but when the cashless claim was denied the complainant has to pay the hospitalization expenses which are on higher side by arranging the same from his friends and relatives for which the family members of the complainant has to face inconvenience and  then to indulge in unwanted litigation. Though admittedly compensation term has not been explained in the Consumer Protection Act, however  since this  Act is based on principle of equity, good concise  and natural justice and the Commission is empowered to provide compensation after assessing the facts of each case. This Commission relied upon the latest law on this point of compensation i.e. the  Hon’ble Supreme Court in case  Amitabha Dasgupta Vs. United Bank of India and others  AIR 2021 SC (Civil) 1457 wherein it has been held that “ Deficiency in service- Duty of care  should be exercised by bank irrespective of application of laws of bailment to contents of locker- Bank inadvertently broke customer’s locker, without giving prior notice, inspite of clearing pending dues by him- Bank acted in blatant disregard to responsibilities owned to customer as service provider- Case of gross deficiency in service- Imposition of costs of Rs. 5,00,000/- on bank, would be appropriate compensation to customer.”  as such the opposite party No.1 is directed to pay compensation of Rs. 30000/- as well as litigation expenses of Rs. 10000/-  to the complainant.  However, no case is made out against opposite party No.2 and the complaint against opposite party No.2 stands dismissed. Compliance of this order be made within 45 days from the date of receipt of copy of this order ; failing which complainant shall be entitled to get the order executed through the indulgence of this commission. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this commission.

Announced in Open Commission