BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.
Complaint No.217 of 2016
Date of instt. 26.07.2016
Date of decision:03.04.2018
Gulshan Kumar, aged 47 years, son of Late Shri Ishar Dass, resident of house no.220, ward no.5, Old Post Office Street, Assandh, District Karnal, Policy Holder of Health Policy no.10106147.
…….Complainant.
Versus
Religare Health Insurance Company Ltd.
Regd. Office: D3, P3B, District Centre Saket, New Delhi-110017.
Corres Add : GYS Global, plot no.A3, A4, A5, Sector-125, Noida (UP)-201301.
…..Opposite Party.
Complaint u/s 12 of the Consumer Protection Act.
Before Shri Jagmal Singh……President.
Shri Anil Sharma……Member
Present Shri Naresh Setia Advocate for complainant.
Shri Rohit Gupta Advocate for opposite party.
ORDER:
This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant alongwith his wife namely Poonam have purchased a Health Insurance Policy no.10106147 paying single premium of Rs.7473/-, valid from 14.5.2014 to 13.5.2015. The aforesaid policy was got renewed for a sum of Rs.5 lakhs, paying premium of Rs.16,138/- valid from 14.5.2015 to 13.5.2016. The aforesaid policy again renewed for a sum of Rs.5 lakhs, paying premium of Rs.16,445/-, valid from 19.5.2016 to 18.5.2017. It is further alleged that complainant felt stress and pain, therefore, he was remained admitted as indoor patient from 5.6.2016 to 6.6.2016 with Kalyani Hospital, Karnal, where he has treated and charged for a sum of Rs.64500/-. On 6.6.2016 the complainant was admitted in Fortis Hospital, Mohali and the said Hospital seeing the health policy plus a health card valid for getting treatment in that hospital, asked the OP through e-mail to have pre-authorization request for treatment of the complainant and payment of treatment, medicines etc. from OP. It is further alleged that the complainant has to stay Fortis Hospital, Mohalli as indoor patient till 16.6.2016 and paid till that time a sum of Rs.3,61,744/-. Complainant requested the OP so many times for reimbursement of the claim but OP did not pay any heed to his request and lastly through email dated 7.6.2016 OP repudiated the claim of the complainant on the ground that “non-disclosure of material fact (K/C/O HTN 10-12 years and heart problem since 2-3 years.” In this way there was deficiency in service on the part of the OP. Hence complainant filed the present complaint.
2. Notice of the complaint was given to the OP, who appeared and filed written statement raising preliminary objections with regard to jurisdiction; maintainability; cause of action and concealment of true and material facts. On merits, it is submitted that the complainant was issued policy bearing no.10106147 for a period from 14.5.2014 to 13.5.2015 for a sum insured of Rs.3,00,000/- and thereafter the said policy was renewed till 19.5.2018 for a sum insured of Rs.5,00,000/- for insuring the complainant and his wife subject to the policy terms and conditions. However, since the complainant acted in breach of the policy terms and conditions, hence the policy is liable to be cancelled as per clause 6.1 of the policy terms and conditions on non-disclosure of material facts/pre-existing ailments at the time of proposal. The complainant approached the OP on 6.6.2016 via request for pre-authorization request of cashless hospitalization of the complainant for the ailment of cardiac problem at Fortis Hospital, Mohali. The said request was denied vide letter dated 7.6.2016 for non-disclosure of material facts as the patient have known case of hypertension since 10-12 years and heart problem since 2-3 years. Hence there was no deficiency in service on the part of the OP and prayed for dismissal of the complaint.
3. Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C10 and closed the evidence on 12.10.2017
4. On the other hand, OP tendered into evidence affidavit of Ramnique Sachar Corporate Manager Ex.OP1/A and documents Ex.OP1 to Ex.OP9 and closed the evidence on 21.2.2018.
5. We have heard the learned counsel for both the parties and perused the case file carefully and have also gone through the evidence led by the parties.
6. From the pleadings and evidence of the parties, it is clear that there is no dispute about the fact regarding purchase of Health Insurance Policy valid from 14.5.2014 to 13.5.2015 for insured sum of Rs.3 lakhs, the said policy was renewed for a sum of Rs.5 lakhs valid from 14.5.2015 to 13.5.2016 and again renewed from 19.5.2016 to 18.5.2017 for the same sum of Rs.5 lakhs. It is also not disputed that the complainant was admitted as indoor patient on 5.6.2016 in Kalyani Hospital Karnal and on 6.6.2016 complainant was admitted in Fortis Hospital, Mohali and discharged on 16.6.2016. The complainant spent Rs.64500/- at Kalyani Hospital, Karnal and Rs.3,61,744/- at Fortis Hospital, Mohali. It is also not disputed that Fortis Hospital asked the OPs through e-mail for pre-authorization for treatment of complainant and the said request was repudiated by the OPs through e-mail on 7.6.2016 and “Reason for Denial: Non-Disclosure of material facts (K/C/O) HTN 10-12 years and heart problem since 2-3 years.”
7. According to the complainant, the repudiation is unwarranted, illegal and against the policy and provisions of section 45 of the Insurance Act. Whereas, according to OP, the repudiation is in accordance with the policy as well as section 45 of the Insurance Act.
8. From the submissions of the parties, the main dispute between them is regarding the interpretation of section 45 of the Insurance Act, which is reproduced below:
“45 . Policy not to be called in question on ground of mis-statement after two years- No policy of life insurance effected before the commencement of this Act shall after the expiry of two years from the date of commencement of this Act and no policy of life insurance effected after the coming into force of this Act shall, after the expiry calf two years from the date on which it was effected be called in question by an Insurer on the ground that statement made in the proposal or in any report of a medical officer, or referee, or friend of the insured, or in any other document leading to the issue of the policy, was inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which it was material to disclose and that it was fraudulently made by the policy-holder and that the policy-holder knew at the time of making it that the statement was false or that it suppressed facts which it was material to disclose:
Provided that nothing in this section shall prevent the insurer from calling for proof of age at any time if he is entitled to do so, and no policy shall be deemed to be called in question merely because the terms of the policy are adjusted on subsequent proof that the age of the life insured was incorrectly stated in the proposal.
9. From the above provisions of section 45, it is clear that no doubt no policy of life insurance effected after the coming into force of this Act shall, after the expiry calf two years from the date on which it was effected be called in question by an Insurer on the ground that statement made in the proposal or in any other document leading to issue of the policy, was inaccurate or false, unless the insurer shows that such statement was on a material matter or suppressed facts which it was material to disclose. So this section has two parts, one is regarding the fact which shall not be called in question, whereas the second is an exception to the 1st part. Now the question arises that whether the case of the complainant come under the exception or not. The OPs have produced on the file Ex.OP-4, the medical record from the Fortis Hospital. From this document Ex.OP-4, it is clear that in the column of Hypertension under the head Significant History (present/past) at page 1, it is mentioned that “10-12 years on medication.” Similarly, at page 4 of this document i.e. Ex.OP4 under the head Current Medication it is mentioned “T.Ecosprin 75 mg, T.Termikind 40 mg since 2-3 years.” Again in document Ex.OP4 at page 5 under the head of Past Medical History in column Systemic Hypertension 10-12 years is mentioned. From this medical record, it is clear that the patient (complainant) has the history of Hypertension since 10-12 years on medication and was on medicines of Ecosprin and Termikind since 2-3 years. The OPs have also produced on the file copy of proposal form of the complainant as Ex.OP-5, wherein there were column for “Hypertension/Blood Pressure, Heart Disease and others” and these columns were left vacant by the complainant while filling the proposal form. These facts clearly show that the complainant has suppressed the facts which were material to disclose in his proposal form. In these facts and circumstances of the case, we are of the considered view that the OPs have succeeded in proving that the case of complainant comes under the exception and that the facts which were in the knowledge of the complainant and were material to disclose, have been suppressed by the complainant while filling the proposal form. We are further of the view that the complainant has failed to prove that his case does not fall under the exception of section 45 of the Insurance Act. Therefore, in our view the OPs have committed no mistake in repudiating the claim of the complainant. Hence we found no deficiency on the part of the OPs.
10. Thus, as a sequel of above discussion, we do not find any merit in the present complaint and the same is hereby dismissed. No order as to costs. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.
Announced
Dated: 03.04.2018
President,
District Consumer Disputes
Redressal Forum, Karnal.
(Anil Sharma)
Member
