DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION SAS NAGAR (MOHALI)
Consumer Complaint No. 965 of 2018
Date of institution: 12.09.2018 Date of decision : 21.06.2021
Jarnail Singh, resident of # 132, Ward No.11, Bank Colony, Morinda Road, Kurali, Punjab 140103.
…….Complainant
Versus
1. Religare Health Insurance Company Limited now known as Care Health Insurance Limited, Registered Office -5th Floor, 19 Chawla House, Nehru Place, New Delhi- 110019 (through its Managing Director).
2. Religare Health Insurance Company Limited now known as Care Health Insurance Limited- Correspondence Office- Vipul Tech Square Tower C, 3rd Floor, Golf Course Road, Sector 43, Gurgaon 122009 (Haryana).
(through its Managing Director).
……..Opposite Parties
Complaint under Consumer Protection Act.
Quorum: Shri Sanjiv Dutt Sharma, President.
Shri Inderjit, Member.
Present: Shri Pankaj Sharma, counsel for complainant.
Shri Sahil Abhi, counsel for the OPs.
Order dictated by :- Shri Sanjiv Dutt Sharma, President
Order
The present order of ours will dispose of a complaint under Consumer Protection Act, filed by the complainant (hereinafter referred as ‘CC’ for short) against the Opposite Parties (hereinafter referred as ‘OPs’ for short) on the ground that the CC subscribed to an insurance policy of the OPs by paying premium of Rs.15,391/- vide insurance policy No.11561922 under Group Policy (Group Care-PNB) dated 12.12.2017. As per the insurance policy, the CC and his wife were covered for medical benefits of Rs.5.00 lakhs each upto the midnight of 11.12.2018. It is averred that on 27.05.2018 the CC was admitted in Fortis Hospital, Mohali with some medical emergency under the supervision of Dr. Arun Kochar and was discharged on 02.06.2018. It is alleged that the CC never had any problem prior to this emergency. On 27.05.2018 the CC felt dizziness with vomiting and sweating. The CC went to a local hospital, where some changes were found in the ECG and subsequently the CC was referred to Fortis Hospital, Mohali. The CC never had any history of hypertension or any other disease. The treatment of the CC was done at Fortis Hospital, Mohali which issued a bill of Rs.5,34,258/- vide bill No.1002/18/I/CS/0002776 dated 02.06.2018. It is alleged that the OPs out rightly rejected the claim of the CC on false and flimsy objections. It is further averred that the CC had never hidden any information while subscribing the policy of the OPs. The CC has termed the reasons given for rejection of his claim as flimsy and without any substance. Legal notice was also sent to the OPs but of no use.
Thus, alleging deficiency in service on the part of the OPs, the CC has sought the following relief:
(a) That the OPs be directed to make payment of Rs.5,00,000/- as medical claim amount which the CC spent in the Fortis Hospital.
(b) That the OPs be directed to pay compensation to the tune of Rs.5,00,000/- for mental agony and harassment and Rs.50,000/- as litigation expenses.
The complaint of the CC is duly signed. Further the same is also supported by an affidavit of the CC.
2. OPs in the written statement have opposed the complaint of the CC on the ground of maintainability, concealment of facts etc. On merits, subscription of the policy is admitted by the OPs. It is averred that the claim of the CC was rejected for non disclosure of material facts of hypertension as per Clause 5.2 of the policy. It is alleged that the CC was a known case of hypertension since 10-15 years and was on treatment and this fact was not disclosed by the CC to the OPs, at the time of filling up the proposal form dated 15.12.2017. It is specifically alleged that under the specific column the CC was asked whether he was a patient of hypertension. It is further averred that the CC had the history of hypertension from past 10-15 years before inception of the policy period. The reimbursement claim of the CC was rejected in terms of clause 5.2 of the policy terms and conditions. The CC had the opportunity to state the true state of health at the time of taking the policy in the proposal form. However, the CC did not disclose the same that he had history of hypertension for 10-15 years. Even the policy of the CC was cancelled vide letter dated 09.08.2018. It is alleged that the cashless authorization of the claim of the CC for reimbursement was rightly rejected. Thus alleging no deficiency in service on their part, the OPs have prayed for dismissal of the complaint.
3. The CC in support of his complaint tendered in evidence his affidavit Ex.CW-1/1 and various documents Ex.C-1 to Ex.C-15 and thereafter closed evidence. On the other hand, counsel for OPs tendered in evidence affidavit of Mr. Kashif Nazki, Manager Legal Ex.OP-1 and document Ex.OP-1.
4. We have heard learned counsel for the parties and have gone through the file.
5. Admittedly the CC had subscribed the policy of the OPs for an amount of Rs.5.00 lakhs. The CC was also entitled for cashless treatment. It is also admitted fact that the CC had paid premium to the tune of Rs.15,391/- to the OPs at the time of subscription of the policy. The OPs have mainly repudiated the claim of the CC on the ground that in the application form at page-61 of the file, the CC was specifically asked whether he or his wife have been diagnosed/hospitalized or is currently under investigation for Cancer/Diabetes/Stroke/Heart Disease/Kidney Disease/ Liver Disease/ Hypertension (Blood Pressure) and in front of that he has ticked word ‘N’. It is further the version of the OPs that if any untrue or incorrect statements are made by the subscriber of the policy, the OPs will not be liable to make payment of any such claim and the premium will also be forfeited. Learned Advocate for the OPs has also submitted few judgments in support of this version. He has cited judgment of Hon’ble Supreme Court of India titled as Branch Manager, Bajaj Allianz Life Insurance Company Ltd. and others Vs. Dalbir Kaur, decided on 09.10.2020 and another judgment of the Hon’ble Supreme Court of India titled as Life Insurance Corporation of India Vs. Manish Gupta, decided on 15.04.2019.
6. It is to be seen whether the diseases like hypertension, diabetes etc. which are so common in these days and are controllable and until and unless a patient has undergone a long treatment including hospitalization for these type of diseases in the near proximity of taking the policy and then conceals it, can be termed to be a case of concealment of true facts. To our mind, blood pressure or hypertension is a symptom of some disease and is not a case of serious ailment. It is not the case of the OPs that due to high blood pressure or hypertension, the CC was hospitalized or was under serious kind of treatment. No such detailed record is submitted by the OPs at the time of evidence. Moreover, there is no substantial evidence on the file which will suggest that the CC despite having knowledge of hypertension was submitting wrong information. It is pertinent to mention here that in the proposal form, the CC was asked in one joint column whether he was suffering from Cancer/Diabetes/ Stroke/Heart Disease/Kidney Disease/ Liver Disease/ Hypertension (Blood Pressure). While answering to the same, the CC has ticked the word ‘N’. As we have discussed above, the CC was not specifically asked whether he was suffering from hypertension separately. We feel, that the CC had no option except to tick ‘N’ since the form was asking the question to the CC by mentioning all diseases in one column together, as such the CC had no option but to tick the word ‘N’ since he was not suffering from Cancer, Diabetes etc. To our mind, it was incumbent upon the OPs to conduct the medical examination of the CC in order to rule out whether the CC was suffering from hypertension before subscription of the policy. In such peculiar circumstances, we feel that repudiation of the claim of the CC by the OPs is not justified. We feel, that the judgments relied upon by the counsel for the OPs are not applicable in the present case since the facts and circumstances of the present case are altogether different.
7. From the perusal of proposal form and the column which has been ticked by the CC, it is not clarified by the Ld. Advocate for the OPs that why there was no specific separate column for the alleged disease hypertension and why all the diseases were written together in one column. We feel that the CC had no option except to tick the word ‘N’. There is no mistake of the CC in any manner while filling up the proposal form. The CC has not failed in any manner to disclose any information to the OPs. He has submitted accurate answers to the OPs at the time of filling up the proposal form. We feel that rejection of claim of the CC on this ground without perusal of proposal form by the OPs is definitely a deficiency in service. Ld. Advocate for the OPs has no answer to the question that why there was no separate column for hypertension. There is no malafide on the part of the CC. As we have already discussed above, this is not a case where the CC has failed to disclose any pre existing ailment. Rejection of the claim of the CC is purely based on surmises and conjectures.
8. In view of our above discussions, the complaint is allowed. It is ordered that the OPs will pay a sum of Rs.5,00,000/- (Rs. Five Lakhs only) to the CC alongwith interest @ 18% per annum from the date of his admission in the hospital. The OPs are further burdened with a consolidated amount of compensation to the tune of Rs.1.00,000/- (Rs. One Lakh only). The OPs are further ordered to make aforesaid payments to the CC within 30 days from the date of receipt of free certified copy of this order failing which the CC will be entitled to interest @ 18% per annum on the compensation amount also. Free certified copies of the order be supplied to the parties as per rules. File be indexed and consigned to record room.
Announced
June 21, 2021
(Sanjiv Dutt Sharma)
President
(Inderjit)
Member
