BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMRITSAR.
Consumer Complaint No. 348 of 2019
Date of Institution: 26.4.2019
Date of Decision:13.12.2022
Sharanjit Singh S/o Balwant Singh R/o H.No. 7 , Suraj Avenue, Outside Chatiwind Gate, Tarn Taran Road, Amritsar 8437829002
Complainant
Versus
Religare Health Insu.Co. Ltd., Branch Office, 28, Ist Floor, Taneja Tower, Distt. Shopping Complex, Ranjit Avenue, Amritsar through its Branch Manager/Principal Officer
Opposite Party
Complaint under section 12 & 13 of the Consumer Protection Act, 1986 Now u/s 35 of the Consumer Protection Act, 2019)
Result : Complaint Allowed
Counsel for the parties :
For the Complainants : Ms.Jasneek Kaur,Adv.
For the Opposite Party : Sh.R.P. Singh, Advocate
CORAM
Mr.Jagdishwar Kumar Chopra, President
Mrs.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 11 & 12 of the Consumer Protection Act, 1986 Now u/s 35 of the Consumer Protection Act, 2019.
Brief facts and pleadings
1. Brief facts of the case are that the complainant got himself insured alongwith his wife since 29.1.2017 and continuously renewing the policy . At present complainant is insured under the policy No. 10982270 valid from 29.1.2018 to 28.11.2019. During the period of insurance complainant fell ill suffered abdominal pain and admitted in Smt. Parvati Devi Hospital, Ranjit Avenue, Amritsar on 14.5.2018 where he was treated and was discharged on 25.5.2018,. The cashless request was made to the opposite party but the same was denied by the opposite party vide letter dated 15.5.2018 on false and frivolous ground. It is worth to mention here that the complainant is not alcoholic nor having any knowledge regarding DM and HTN and the rejection of claim was totally wrong, incorrect and was on false and frivolous grounds . It is also pertinent to mention here that at the time of issuance of policy only cover note was supplied and no terms and conditions were supplied. The complainant has spent an amount of Rs. 1,84,103/- on his treatment and the opposite party is liable to reimburse the same. The aforesaid act of the opposite party in rejecting the claim on false and frivolous grounds amounts to deficiency in service, malpractice, unfair trade practice and has caused lot of mental agony, harassment, inconvenience besides financial loss to the complainant. Vide instant complaint, complainant has sought for the following reliefs:-
- Opposite party be directed to reimburse the claim amount of Rs. 1,84,103/- alongwith interest @ 18% p.a.
(b) Opposite party be also directed to pay compensation to the tune of Rs. 50,000/- to the complainant.
( c) Opposite party be also directed to pay adequate litigation expenses to the complainant.
(d) Any other relief to which the complainant is entitled be also awarded to the complainant.
Hence, this complaint.
2. Upon notice, opposite party appeared and filed written version in which it was submitted that complainant was admitted for the treatment of Acute Abdominal plan Type II DM and HTN SAIO and pancreatitis on 14.5.2018 in Smt.Parvati Devi Hospital, Amritsar for which cashless claim was lodged. On receipt of cashless claim query letter dated 14.5.2018 was sent to the complainant for providing information and reply of same was given and a prescription dated 16.2.2018 was provided by the complainant wherein medicine for DM and HTN was prescribed . To verify the facts, an investigator was appointed and during investigation, it was found that as per indoor case papers, the complainant was occasionally using alcohol and that the complainant had history of hypertension and diabetes since 4 years. However, in the record the word years has been overwritten with “months” which shows that the complainant tried to manipulate the facts regarding history of diabetes and hypertension with the duration of 4 years. Moreover the statement of complainant’s son to the investigator in which he stated that he came to know regarding the DM and hypertension when he was admitted in the hospital but the treating doctor stated in the questionnaire given to the investigator that the complainant was suffering from DM and HTN since 4 months prior to hospitalization, therefore, there is contradiction between the statements of doctor and complainant’s son and also t he duration of HTN and DM has been written over in the indoor case papers. Therefore, the claim was repudiated under clause 4.2(23) for usage of Alcohol and under clause 7.1 of the policy terms and conditions of the policy. While submitting that there is no deficiency in service and while denying and controverting other allegations, dismissal of complaint was prayed.
Evidence of the parties and Arguments
3. Alongwith the complaint, complainant has filed his self attested affidavit Ex.C-1, copy of policy Ex.C-2, copy of denial letter Ex.C-3, copy of reply of denial causes Ex.C-4, copy of discharge card Ex.C-5, copy of medicine bills Ex.C-6 to Ex.C-9, copy of receipts of payment amounting to Rs . 1,15,470/- Ex.C-10 to Ex.C-17, copy of Nijjar Scan report Ex.C-18.
4. On the other hand opposite party alongwith written version has filed copy of authority letter Ex,OP1, affidavit of Kashif Nazki, Manager Legal Ex.OP2, copy of policy certificate Ex.OP3, copy of policy terms and conditions Ex.OP4, copy of proposal form Ex,OP5, copy of pre-authorization form Ex.OP6, copy of query letter dated 14.5.2018 Ex.OP7, copy of prescription Ex.OP8, copy of patient history Ex.OP9, copy of questionnaire of complainant’s son Ex.OP10, copy of doctor questionnaire Ex.OP11, copy of denial letter Ex.OP12 and Ex,OP1`3, copy of claim denial letter dated 5.8.2018 Ex.OP14, affidavit of investigator Ex,.OP15.
5. We have heard the Ld.counsel for the parties and have carefully gone through the record on the file . We have also gone through the written arguments submitted by both the parties.
Findings
6. From the appreciation of the facts and circumstances of the case, there was not denial the fact that complainant got himself and his wife insured with the opposite party since 29.1.2017 and the current policy bearing No. 10982270 was effective from 29.1.2018 to 28.1.2019. There was also not denial the fact that during the subsistence of the policy period i.e . on 14.5.2018 complainant remained admitted in Parvati Devei Hospital and was discharged on 25.5.2018. It is the case of the complainant that the cashless request was denied by the opposite party vide letter dated 15.5.2018 on the ground that patient is known alcoholic and mis-represented the facts related to history of DM and Hypertension. Ld. Counsel for the complainant has vehemently contended that complainant is not alcoholic nor having any knowledge regarding DM and HTN. Not only this the complainant was only provided the cover note and no policy terms and conditions were ever provided to the complainant. On the other hand the plea taken by the opposite party in rejecting the claim of the complainant is that complainant was admitted for the treatment of Acute Abdominal plan Type II DM and HTN SAIO and pancreatitis on 14.5.2018 in Smt.Parvati Devi Hospital, Amritsar for which cashless claim was lodged. On receipt of cashless claim query letter dated 14.5.2018 was sent to the complainant for providing information and reply of same was given and a prescription dated 16.2.2018 was provided by the complainant wherein medicine for DM and HTN was prescribed . To verify the facts, an investigator was appointed and during investigation, it was found that as per indoor case papers, the complainant was occasionally using alcohol and that the complainant had history of hypertension and diabetes since 4 years. However, in the record the word year has been overwritten with “months” which shows that the complainant tried to manipulate the facts regarding history of diabetes and hypertension with the duration of 4 years.. Therefore, the claim was repudiated under clause 4.2(23) for usage of Alcohol and under clause 7.1 of the policy terms and conditions of the policy. But we are not agreed with this plea of the opposite party as the opposite party only relied upon the prescription dated 16.2.2018 wherein the medicine for DM and HTN was prescribed. However, perusal of prescription slip Ex.OP8 shows that there was no mention of said disease of DM and HTN and how the opposite party can tell that the medicines as prescribed in the prescription slip were for the treatment of DM and HTN as the opposite party has not produced any doctor who prescribed these medicines. As such no reliance can be placed upon the prescription slip Ex.OP8. Not only this the opposite party also relied upon the indoor papers of Parvati Devi Hospital Ex.OP9 wherein under the column of chief complaint history of DM/HTN as well as using alcohol (occasionally) was mentioned since 4 years. The another plea of the opposite party is that in the record i.e. indoor case papers word “years” has been overwritten with “months”. But we are also not agreed with this plea of the opposite party as the opposite party itself placed on record certificate issued by hospital Ex.OP1 wherein it was certified that the patient was admitted with past history of HTN and DM II since last 4 months only. The opposite party has not tried to summon the doctor of the hospital who issued the said certificate . So once the hospital which treated the complainant duly certified that the patient had past history of HTN and DM since last 4 months, the plea of the opposite party that the patient was admitted with past history of HTN and DM II since last 4 years is not sustainable in the eyes of law. The opposite party could not produce any evidence to the effect that complainant had knowledge about the abovesaid diseases prior to obtaining the policy. Opposite party could not produce any evidence in the form of medical treatment record of the complainant or in the form of affidavit of any medical expert /doctor to prove that the complainant had ever taken medicines or he was ever medically treated by any doctor for disease of diabetes prior to obtaining of the present policy from the opposite party. It has been held by the Hon'ble State Commission of Punjab in case Life Insurance Corporation of India Vs. Miss Veenu Babbar and another 2000(1) CLT 619 that repudiation on the basis of history recorded in the hospital records is illegal and arbitrary and the same could not be treated as substantive material to base any decision. Same view has been taken by the Hon'ble National Commission in case Life Insurance Corporation of India & Ors. Vs. Kunari Devi IV(2008) CPJ 89 (NC) that where no document has been produced in support of allegation of suppression of disease at the time of taking policy or revival of policy, history recorded in hospital's bed ticket, not to be treated as evidence as doctor, recording history not examined, suppression of disease not proved, insurer was held liable under the policy. Facts of authority ‘supra’ are fully applicable to the case in hand on all its fours. Moreover the contention of the complainant is that he was only supplied with the cover note and no policy terms and conditions were ever supplied .On the other hand opposite Party could not produce any evidence to prove that terms and conditions of the policy were ever supplied to the complainant insured, 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. From the perusal of the entire evidence produced on record by the Opposite Party, it is clear that Opposite Party has failed to prove on record that they did supply the terms and conditions of the policy to the complainant insured. As such, these terms and conditions, particularly the exclusion clause of the policy is not binding upon the insured. Reliance in this connection can be had on Modern Insulators Ltd.Vs. Oriental Insurance Company Limited (2000) 2 SCC 734, wherein it is held that “In view of the above settled position of law, we are of the opinion that the view expressed by the National Commission is not correct. As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclosed to the appellant, the respondent can not claim the benefit of the said exclusion clause. Therefore, the finding of the National Commission is untenable in law. The other plea taken by the opposite party in its denial letter that complainant is known Alcoholic. But again we are not agreed with this plea of the opposite party as perusal of indoor papers of patient Ex,OP9 shows that under the column Psychosocial history it was written Alcohol (Occasionally). Because taking of liquor is not a disease .Reliance in this connection can be had on Life Insurance Corporation of India-Appellant Vs. Smt.Sukhwinder Kaur-Respondent 2008(1) CPC 675 of our own Punjab State Consumer Disputes Redressal Commission, Chandigarh wherein it has been laid down that the appellants had not only failed to lead reliable evidence to prove if Kulwant Singh was taking alcohol for the last 20 years prior to his death but even the law has not been produced that if the factum of taking alcohol was suppressed while filling the proposal form. We find no merit in appeal which is dismissed with costs of Rs. 10000/-.
7. Moreover there was no bar on the Opposite Party to get the thorough medical check up at the time of issuance of the policy. The Opposite Party was within their right to cancel the policy if it doubted or found any information supplied by the life assured being false or wrong, but this has not been done by the Opposite Party. The investigation has been got done at the time when the claim was lodged by the complainant. It was for the Opposite Party to ensure about the health of the insured before issuance of the policy of such amount. Many times a person may not know himself/ herself if he/ he is suffering from any particular disease. Moreover, prior to issuance of the policy, it was required to check up life assured thoroughly. It was the bounden duty of the Opposite Party to make thorough investigation at the initial stage. It appears that the Opposite Party has different yard stick at the time of accepting the policy for procuring the business and different face at the time of discharge of its lawful liability. The act of the Opposite Party firstly in declining the cashless facility and secondly not settling the claim on false and frivolous ground for such a long period, amounts to deficiency in service. This is a common practice of the Insurance Companies to repudiate the claim on flimsy grounds without any justification. In this regard, we are supported with the rulings: Life Insurance Corporation of India Vs. Ambika Prasad Pandey, AIR 1999 MP 13 and Life Insurance Corporation of India Vs. Narmada Agarwalla, AIR 1993 Ori 103. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., 2008(3) CPJ 377 (SC) is fully attracted. It was held that :
“Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.”
8. On this point, Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
9. In view of the above discussion, the opposite party is found guilty of deficiency in service in repudiating the genuine claim of the complainant. Regarding the quantum of claim the complainant was assured for a sum of Rs. 5,00,000/- and the complainant had incurred an expenditure of Rs. 63,633/- on his medicine bills vide bills Ex.C-6 to Ex.C-9, Rs. 1,15,470/- as bills of hospital Ex. C-10 to Ex.C-17 and bill of Nijjar Scan centre of Rs. 5000/- Ex.C-18 i.e. total Rs. 1,84,103/- ,as such the complainant is liable for the full claim amount of Rs. 1,84,103/-.
10. Resultantly, we allow the complaint with costs and the Opposite Party is directed to pay the claim amount of Rs. 1,84,103/- alongwith interest @ 9% p.a. from the date of filing of the complaint till realization. Opposite party is also directed to pay compensation to the tune of Rs. 10000/- as well as litigation expenses to the tune of Rs. 5000/- to the complainant. Compliance of this order be made within 30 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 (Jagdishwar Kumar Chopra) President
Dated: 13.12.2022
( Mandeep Kaur )
Member
