STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA
Date of Institution: 14.11.2017
Date of final hearing: 26.07.2023
Date of pronouncement: 13.09.2023
First Appeal No.1370 of 2017
IN THE MATTER OF:-
Roshan Lal Garg S/o Sh. Jai Narain, R/o H.No.495, Housing Board, Jind, Haryana. ....Appellant
Versus
Religare Health Insurance Company Ltd., GYS Global, Plot No. A3, A4, Sector-125, Noida U.P-201301, through its Manager.
…..Respondent
CORAM: Naresh Katyal, Judicial Member
Argued by:- Sh. Abhimanyu Batra, counsel for the appellant.
Sh. Sachin Ohri, counsel for respondent.
ORDER
NARESH KATYAL, JUDICIAL MEMBER:
Challenge in this appeal No.1370 of 2017 has been invited by unsuccessful complainant-Roshan Lal Garg, to legality of order dated 17.10.2017 passed by District Consumer Disputes Redressal Forum-Jind (In short “District Consumer Commission”) in complaint case No.69 of 2015, vide which his complaint has been dismissed.
2. As per complainant’s case; he obtained Health Insurance Policy from United India Insurance Company Limited in year 2007. It was renewed from time to time and continued till 12.09.2014. Agent of OP allured him; obtained his consent to port his policy from United India Insurance Company Limited to OP (Religare Health Insurance Co. Ltd.). Complainant handed over cheque No.612443 dated 04.08.2014 of Rs.13,208/- drawn on PNB-Jind in favour of OP, to cover risk of Rs.4.00 lacs i.e. much prior to expiry of earlier policy issued by previous insurer. OP issued policy No.10134171 for the period from 13.09.2014 to 12.09.2015, vide ID No.51173134 and its agent told that: in case of any illness & hospitalization; 100% reimbursement will be made by OP and it will continue, even in first year of policy, because he (complainant) has ported the policy.
3. On 17.02.2015, he got pain in his chest & back and was examined by doctor of Sir Ganga Ram Hospital-New Delhi. It was diagnosed that: there was blockage in heart vein and thus he (complainant) got himself admitted in said hospital. He submitted medical reimbursement card to hospital. Hospital sent mail to OP. They (OP) refused to entertain his requests under garb of Pre-existing disease & its complications (K/C/O CAD since 2006). Under compelling circumstances, complainant spent Rs.1,83,267/- on his treatment and was discharged from hospital on 20.02.2015. He requested OP to accept his claim, but they did not pay attention to his genuine request. Legal notice dated 07.04.2015 was served upon OP; it was replied on 29.04.2015 by OP on twisted facts by backing out from terms & conditions of policy and with lame excuse that ‘the decline reason was initially inadvertently mentioned as falling under clause 4.1 (c) i.e. four years waiting period of treatment of pre-existing disease and its complications” instead of non-disclosure of pre-existing disease as per clause 6.1 of the terms of policy. Complainant has pleaded that OP has adopted unfair trade practice towards him and is also deficient in providing proper services to him which caused him mental & physical harassment.
4. Upon notice, OP in its defence, in preliminary objections thereof has pleaded that complainant suppressed material facts from Hon’ble Forum; he has no locus-standi & cause of action to file complaint. As per terms & conditions of policy, there is no deficiency in service of OP. It has been admitted by OP that it has issued policy in question to complainant, after taking premium from him for the period from 13.09.2014 to 12.09.2015 and got ported the same from United India Insurance Company Ltd., subject to certain terms & conditions of policy. Further, it has been admitted that cashless request of complainant for treatment of chest & back pain was received but same was declined vide its letter dated 17.02.2015 on the ground that: Non-Disclosure of material facts/Pre-existing ailments at the time of proposal by complainant being “known case of coronary artery disease since 2006” i.e. (K/C/O CAD since 2006). OP also pleaded that: complainant was found to have ‘Acute Myocardial Infection’ as per discharge summery of Dharma Vira Heart Centre of Sir Ganga Ram Hospital dated 16.06.2006 and had undergone Coronary Angiogram on 07.06.2006. Hence he was known case of Percutaneous Transluminal Coronary Angioplasty (PTCA) and stent to LAD since 2006, which was never disclosed by complainant to OP at the time of taking/porting policy, so his claim was denied as per clause 6.1 of policy’s terms & conditions. There is no deficiency in service as well as unfair trade practice on its part. Inter alia on above pleas; dismissal of complaint has been prayed.
5. Parties to this lis led evidence, oral as well as documentary.
6. On subjectively analyzing the same; learned District Consumer Commission-Jind vide order dated 17.10.2017 has dismissed the complaint thereby giving rise to filing of this appeal by complainant.
7. Learned counsel for parties have been heard at length. With their able assistance; record too has been perused.
8. On behalf of complainant/appellant, it is contended that impugned order dated 17.10.2017 is erroneous on all fronts. Complainant did not have any past medical history; that is why; his Health Insurance Policy was being continuously renewed from time to time by previous insurer. He was never diagnosed with any heart disease or any other disease by any doctor. As per contention, complainant has rightly given answer ‘NO’ qua the query which recites: “Has anyone been diagnosed/ hospitalized or under any treatment, illness/injury during last 48 months?” Once, OP has accepted the premium and ported complainant’s policy from previous insurer to it, then, it was liable to indemnify insured by paying amount of Rs.1,87,267/- which he (complainant) had incurred in relation to his medical treatment at Sir Ganga Ram Hospital-New Delhi. Plea of pre-existing disease taken by insurer (OP) is untenable, as appellant was not aware of any heart related disease and had not ever felt chest and back pain. Insurer has illegally repudiated his genuine claim. It is urged that impugned order dated 17.10.2017 has no legs to stand and be set aside, by accepting this appeal.
9. Per contra, learned counsel appearing for OP/respondent-insurer has supported the impugned order dated 17.10.2017 and urged that learned District Consumer Commission has meticulously analyzed all facets of this case and its decision dated 17.10.2017 does not call for any interference in this appeal.
10. This Commission has subjectively and critically analyzed the rival submissions. The poser before this Commission is: “as to whether OP has rightly repudiated the claim of complainant to reimburse him Rs.1,87,267/- or not”? Admittedly, OP has ported to it; the Health Insurance Policy of complainant, which he had obtained earlier from United India Insurance Company Ltd. In that process, OP had admittedly received premium amount of Rs.13,208/-. Currency of Health Insurance Policy was from 13.09.2014 to 12.09.2015. As per complainant’s stance, he felt pain on chest and back on 17.02.2015; was hospitalized in Sir Ganga Ram Hospital-New Delhi; was diagnosed regarding blockage in his heart vein. He was discharged on 20.02.2015 and had spent Rs.1,87,267/- on his treatment. His claim for reimbursement of this amount has been declined by OP on the pedestal that: complainant had not disclosed about his pre-existing ailments of coronary artery disease suffered in year 2006, while filing proposal form at the time of porting his policy from previous insurer. Thus insurer has invoked clause 6.1 of policy in order to repudiate his claim.
11. Having regards to above facts, documents Annexure R-5 and Annexure R-6/Ex.C-20 have acquired an important bearing on nucleus of controversy of this case. Ramification and legal implications flowing from these documents are immense and manifold. Documents Annexure R-5 is concerning complainant. It is dated 17.02.2015. It is issued by Dr. Rajiv Passey, Senior Consultant Interventional Cardiologist, Dharma Vira Heart Centre, Sir Ganga Ram Hospital-New Delhi. Admittedly, complainant had landed in this hospital on 17.02.2015. It unequivocally recites that complainant was a case of PTCA + stent to LAD since year-2006. Resume of History mentioned in discharge summary (Annexure R-6/Ex.C-20) of Sir Ganga Ram Hospital dated 12.06.2006 reads as under:-
“Mr. Roshan Lal, 45 years old gentleman is normotensive, non diabetic not a known case of CA/COPD, non-smoker, alcoholic with positive family history of CAD to mother and father. He presented with history of chest pain associated with sweating ghabrahat and radiation of pain to left arm on 02/06/06. He was found to have acute AWMI (Non STP). He was treated conservatively with LMWH and other supportive treatment. Subsequently he underwent CAG on 07/06/06 at Hissar which revealed triple vessel disease with tights stenosis in LAD. He was admitted here for further management.”
12. Document Annexure R-6/Ex.C-20, dated 12.06.2006 has formed a formidable and acceptable base. Even document Annexure R-5 dated 17.02.2015 reflects some medical procedure on complainant of the year 2006. Policy in question has the currency from 13.09.2014 to 12.09.2015. No doubt treatment on complainant on 17.02.2015 at Sir Ganga Ram Hospital-New Delhi for chest pain was during the currency of policy period, but nevertheless there is sufficient indication deciphered from document Annexure R-5 and Annexure R-6/Ex.C-20 about complainant’s past medical history of chest pain. In backdrop of this scenario; it was required on the part of complainant to disclose his past medical history regarding earlier disease of chest pain suffered by him and his previous hospitalization in Sir Ganga Ram Hospital from 12.06.2006 to 16.06.2006, while filing proposal form of OP at the time of porting his policy from previous insurer. He has given answer ‘No’ and thus landed himself to be guilty of concealment/suppression of material facts regarding pre-existing ailments. It would disentitle to him from any equitable relief.
13. Hon’ble Apex Court in case titled as “Satwant Kaur Sandu Vs. New India Assurance Company Ltd.”, Civil Appeal No. 2776 of 2002 decided on 10.07.2009 has held as under in Para 12 of its judgment:-
- There is no dispute that Section 45 of the Insurance Act, 1938 (for short “the Act”), which places restrictions on the right of the insurer to call in question a life insurance policy on the ground of mis-statement after a particular period, has no application on facts at hand, inasmuch as the said provision applies only in a case of life insurance policy. The present case relates to a mediclaim policy, which is entirely different from a life insurance policy. A mediclaim policy is a non-life insurance policy meant to assure the policy holder in respect of certain expenses pertaining to injury, accidents or hospitalizations. Nonetheless, it is a contract of insurance falling in the category of contract uberrimae fidei, meaning a contract of utmost good faith on the part of the assured. Thus, it needs little emphasis that when an information on a specific aspect is asked for in the proposal form, an assured is under a solemn obligation to make a true and full disclosure of the information on the subject which is within his knowledge. It is not for the proposer to determine whether the information sought for is material for the purpose of the policy or not. Of course, obligation to disclose extends only to facts which are known to the applicant and not to what he ought to have known. The obligation to disclose necessarily depends upon the knowledge one possesses. His opinion of the materiality of that knowledge is of no moment. (See: Joel Vs. Law Union & Crown Ins. Co.1 )
Hon’ble Apex Court in this judgment has also observed that: the expression “material fact” is to be understood in general terms 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-uberrima fides. Good faith forbids either party from non-disclosure of the facts which the party privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary.”
14. Having given anxious consideration to the material on record of this appeal, in the light of above cited pronouncement; this Commission of firm opinion that: answer given by insured in the proposal form was untrue to his knowledge. There was clear suppression of material fact in regard to the health of insured. It was not for the insured to determine whether information sought for through questionnaire was material for the purpose of policy, when he was porting it from previous insurer (United India Insurance Company Ltd.) to OP/respondent (Religare Health Insurance Co. Ltd.). At any rate, statement made by him was untrue and incorrect, falling foul of condition No. 6.1 of policy.
15. Thus, the answer to this poser is that: insurance company (OP) has successfully proved the exclusion clause No. 6.1 and rightly repudiated the claim. It is more than clear from the evidence that information about the past medical history of complainant should have been supplied by him. Had, it been supplied, then insurer/OP might not had ported the complainant’s policy to it, from previous insurer. However, complainant in his wisdom has withheld material information regarding his past medical history while filing proposal from of OP. Hence, on that pedestal he (complainant) has been rightly non-suited by learned District Consumer Commission through its order dated 17.10.2017 (impugned herein). This order dated 17.10.2017 does not carry any manifest error, legal or factual. It is accordingly affirmed and maintained. Present appeal, being devoid of merits, is hereby dismissed.
16. Application(s) pending, if any stand disposed of in terms of the aforesaid judgment.
17. A copy of this judgment be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986/2019. The judgment be uploaded forthwith on the website of the Commission for the perusal of the parties.
18. File be consigned to record room.
Date of pronouncement: 13th September, 2023
Naresh Katyal
Judicial Member
Addl. Bench-II
