BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.452 of 2018
Date of Instt. 30.10.2018
Date of Decision: 04.02.2020
- Harwant Singh aged 68 years S/o Sh. Amar Singh, R/o H.No. B-32/182, Jalandhar Vihar, Kapurthala Road, Jalandhar – 144011, Punjab.
- Ajinder Kaur W/o Jasmeet Singh R/o H.No. B-32/182, Jalandhar Vihar, Kapurthala Road, Jalandhar – 144011, Punjab.
..........Complainants
Versus
- Religare Health Insurance Company Limited, SCO No. 1st Floor, above Oriental Bank of Commerce, PUDA Complex, Ladowali Road, Jalandhar City – 144001.
2. Religare Health Insurance Company Limited, Vipul Tech Square, Tower-C, 3rd Floor, Sector-43, Golf Course Road, Gurgaon- 122009.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Smt. Harleen Kaur, Adv. Counsel for the Complainant.
Sh. Raman Sharma, Adv. Counsel for the OPs No.1 and 2.
Order
Karnail Singh (President)
1. The instant complaint has been filed by the complainants wherein alleged that the complainant No.1 is law abiding senior citizen. Complainant No.2 is daughter in law of complainant No.1 had taken health insurance mediclaim policy as a proposer on the life of Harwant Singh complainant No.1 (Father in law) and Parvinder Kaur (Mother in law) as insured from authorized agent. Proposal Form No. 4100100090584 for the period 12/4/2018 to 7/10/2018 and policy No. 12347762 was allotted for insured amount of Rs. 1,00,000 US Dollar for each i.e. complainant and his wife Parvinder Kaur.
2. That authorized agent of opposite parties obtained signatures on dotted lines on requisite blank proposal form and its allied supported other forms in mechanical and routine manner for Overseas Mediclaim Insurance Policy under plan name “EXPLORE CANADA +” for travel period of 179 days. Complainant paid the insurance premium for the above said period. Complainant No.1 insured had perfect good health profile, insurability with no physical impairment and pre-existing disease/ illness except those mentioned in proposal form. Complainant No.1 was not afflicted with Hypertension and Hyperlipidemia at the time of taking of insurance policy. The details of the benefits and perils covered in the policy document containing terms and conditions and exclusion clause were not supplied by opposite parties during subsistence of policy though it, whereas it is mandatory. The OPs have agreed and undertaken to indemnify to the insured for medical expenses for illness/ sickness, accident sustained or contracted within the period of insurance. Accordingly, complainant had got the right of indemnification/ reimbursement for all medical expense incurred and for any loss or damage of peril covered during the terms of the policy.
3. That complainant No.1 proceeded to Canada after obtaining insurance policy. During stay there, complainant No.1 complained unwellness and consulted Survey Memorial Hospital and got treatment. He was admitted on 3/5/2018 and discharged on 11/5/2018. He had also taken treatment from medical cleaning family physician and also underwent treatment from medical tests as required. Complainant No.2 submitted medical health insurance claim for reimbursement of the expenses incurred and paid from own sources and pocket with opposite parties and submitted all the requisite documents relating to treatment but surprisingly insurance claim of the complainant was rejected vide letter dated 23/7/2018 on the purported reason. The rejection of bonafide and genuine, rightful and legitimate mediclaim health insurance was arbitrary, malafide, unilateral without application of independent mind otherwise than in good faith against the principle of natural justice. The rejection of the legal claim of the complainant tantamount to deficiency in service and accordingly necessity arose to file the present complaint with the prayer that complaint of the complainant may be accepted and complainant has paid for medical treatment Canadian Dollar 38040 which comes to more than Rs. 20 Lakhs Indian Currency but the complainant only make a request to direct the OP to pay Rs. 20,00,000/- amount of the insurance claim and further prayed for any other relief for which the complainant is entitled.
4. Notice of the complaint was given to the OPs, who appeared through its counsel and filed a joint written reply and contested the complaint by taking preliminary objections that the complaint is not maintainable against the answering OPs No. 1 & 2 as the complainant cannot take advantage of his own wrongs. The complainant is guilty of non-disclosure of material facts of Hypertension and Hyperlipidemia at the time of taking policy, as such the complaint is liable to be dismissed. It is further aware that complainant was issued a Travel Insurance Policy vide No. 12347762 covering the complainant and his spouse for their travel to Canada with effect from 12/4/2018 to 7/10/2018 for a sum insured of 100000USD and subject to policy terms and conditions. It is further alleged that complainant approached the respondent company with a cashless claim with respect to the hospitalization of the complainant in Surrey Memorial Hospital, Canada with complaints of fever and mild cough with effect from 3/5/2018 to 10/5/2018. Complainant was diagnosed with Febrile illness that ultimately was found to have evidence of a liver abscess as well as a possible small right lower lobe lung abscess. Complainant was further diagnosed for hyperglycemia as well as found to have marked elevation of liver function tests as well as elevated blood pressure. The sake of necessary documents alongwith cashless claim form and perusal of the said documents, company found that complainant has concealed the pre-existing disease and as such, the claim of the complainant was rejected vide letter dated 23/7/2018. On merits, it is admitted that complainant got insurance policy and also submitted claim which was rejected. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.
5. Rejoinder to the written reply of OPs No.1 and 2 filed by the complainants, whereby reasserted the entire facts as detailed in the complaint and denied those of the written statement.
6. In order to prove their case, both the parties produced on file their respective evidence alongwith pleadings.
7. We bestowed our thoughtful consideration to the submissions made by learned counsel for the respective parties and also gone through the written arguments submitted by learned counsel for the parties as well as case file very minutely.
8. From the overall circumstances, we find that the factum in regard to purchase of insurance policy for sum insured of Rs. 1,00,000 USD for each complainant No.1 and his wife Parvinder Kaur and further complainant No.1 remained admitted in hospital and his medical claim was submitted to the OP but the same was rejected vide letter dated 23/7/2018 are admitted facts. There is no dispute regarding the above facts.
9. Now, question remains before us whether the rejection letter dated 23/7/2018 is legal, valid or not. In order to evaluate the genuineness of the said letter, it is necessary to consider the contents of that letter and accordingly we have gone through the letter dated 23/7/2018 Ex. C4 and find that claim of the complainant was rejected by invoking clause 5.1 of the terms and conditions, non-disclosure of pre-existing medical condition:
1. HYPERTENSION
2. HYPERLIPIDEMIA
The OP alleged that complainant No.1 while filled the proposal form Ex. R7 did not disclose the aforesaid two diseases i.e Hypertension and Hyperlipidemia and whenever any concealment is made by the complainant then he is not entitled for the insurance claim and accordingly claim of the complainant allegedly rejected according to terms and conditions. We have gone through the proposal form Ex. R7 and find that the said proposal form has been filled by both the insured by figuring insured No.1 and insured No.2. It is necessary to make it clear that complainant No.1 is insured No.1 as described in the said proposal form Ex. R7. In the column of ‘Details’, complainant No.1 categorically gave reply that he was suffering from some illness i.e. diabetes and in the second column, he disclosed the disease i.e. diabetes. If we go through the second column under the heading of details then we can say without any hesitation that insured was not asked to give any information qua disease Hypertension and Hyperlipidemia and accordingly complainant No.1 disclosed the virtually disease suffered to him i.e. diabetes. Then in the Fourth column regarding information diagnosed treatment for any illness from any hospital, complainant No.1 neither reply yes nor no means no reply was given. So then how OP can allege that complainant has concealed any pre-existing disease. So, we find that complainant has not concealed anything in the proposal form whatsoever asked to him by the agent of the insurance company.
10. Further, it is our opinion that OP has to bring on the file cogent and convincing evidence to establish that there was any pre-existing disease i.e Hypertension and Hyperlipidemia. No doubt, OP has bring on the file single document Ex. R5 dated 9/4/2015 issued by Makkar Hospital but in the said description slip, the name of the complainant is not mentioned rather the name thereon is readable Harbans Singh whereas the name of the complainant is Harwant Singh. This prescription slip does not relate to the complainant in any manner. If arguments sake, we take into consideration the said description slip then it is clear the medicine recommended to the patient for Hypertension as well as diabetes but this slip shows that medicine was recommended for one time in the year 2015 and the policy was obtained by the complainant after about three years i.e. in the year 2018 and in between there is no medical evidence came on the file that complainant No.1 was having continuously taking any medicine of the said disease and as such, we find that OP has miserably failed to establish on the file that there was any pre-existing disease and moreover it is settled law that diabetes and hypertension are normal wear and tear of the life, cannot be termed as concealment of pre-existing disease and in support of this wording, we like to refer a pronouncement of Hon’ble Delhi State Consumer Commission cited in II(2007) CPJ 452 titled as “Life Insurance Corporation of India Versus Sudha Jain”.
11. In the light of above detailed discussion, we find that insurance claim of the complainant has been wrongly and illegally repudiated by the complainant. Further, during the course of arguments, counsel for OP submitted written arguments wherein took one new plea which has never been taken in the written statement nor the claim of the complainant has been rejected on this plea and if so then the plea cannot be considered at this stage, but for the reference sake, we like to refer the said new plea of the OP wherein alleged that as per clause 2.1.1 (H) of the terms and conditions, the liability of the insurance claim is limited one and according to that clause total amount payable to the complainant is Rs. 8,87,628/- as per detail given in the schedule column in the written arguments.
12. First of all, the plea which was not taken in the rejection letter cannot be termed as condition for rejecting the claim of the complainant and if claim of the complainant has not been rejected on the said new plea then the same plea is not required to consider in this complaint and as such, we came to the conclusion that complainant No.1 is entitled for amount claimed by the complainant i.e. Rs. 20,00,000/-, whereas total expenditure of the complainant is more than Rs. 20,00,000/-. In view of the above, complaint of the complainant is partly accepted and OPs are directed to pay medical insurance claim to the tune of Rs. 20,00,000/- to the complainant No.1. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
13. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Karnail Singh
04.02.2020 Member President
