Chandigarh

DF-I

CC/893/2022

LEENA - Complainant(s)

Versus

RELIGARE HEALTH INSURANCE COMPANY LIMITED - Opp.Party(s)

ANCHAL JAIN

03 Jan 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/893/2022
Date of Institution	:	1.11.2022
Date of Decision	:	3/1/2024

 

Leena W/o Balbir Singh R/o H. No.2144, Sector 62, SAS Nagar Mohali.

 

… Complainant

V E R S U S

1. Religare Health Insurance Company Limited, GYS Global, plot No.A3, A4, A5, Sector 125, NOIDA, UP 201301 through its authorized signatory.
2. Branch Manager, Religare Health Insurance Company Ltd. SCO 56-57-58, Sector 9-D, Chandigarh.    

 .  … Opposite Parties

 

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR	MEMBER

                       

ARGUED BY	:	Ms. Anchal Jain, Advocate for complainant.
	:	Ms. Niharika Goel, Advocate proxy for Sh. Paras Money Goyal, Advocate for OPs.

Per SURJEET KAUR, Member

     Briefly stated the son of the complainant availed health policy of the OPs valid w.e.f. 16.3.2016 to 15.3.2019 and got the same further renewed w.e.f. 16.3.2019 to 15.3.2022 by paying premium of Rs.36,329/-. The complainant was the nominee in the said policy. Unfortunately the son of the complainant died on 31.8.2020 during the treatment in the Grecian Super Specialty Hospital, Mohali during the currency of the policy in question. The complainant being nominee in the policy  filed claim  on 12.12.2020 with  the OPs alongwith requisite documents as per advice of the OPs. Thereafter the complainant requested the Ops to settle the claim but no response was received from the OPs and ultimately the complainant sent legal notice dated 2.8.2021 to the OPs and in response to the legal notice the OPs vide reply dated 17.8.2021 denied the claim of the complainant on unreasonable grounds. Alleging the aforesaid act of Opposite Parties deficiency in service and unfair trade practice on their part, this complaint has been filed.

2. The Opposite Parties in their reply while admitting the factual matrix of the case stated that a cashless request was received from the treating hospital Fortis  on behalf of the insured admitting on 29.8.2019.  As per pre-authorization form the insured was having past medical history of diabetes mellitus since 5 years  with peripheral neuropathy with moderate non proliferative retinopathy diabetic ulcer left foot obesity OSA, fatty liver grade 3. Thus the answering OPs had rightly rejected the claim of the complainant for non-disclosure of material facts as the complainant had not disclosed the said disease at the time of filling the proposal form. Hence, there is no deficiency on the part of the answering OPs. All other allegations made in the complaint has been  denied being wrong.
3. No rejoinder filed.
4. Contesting parties led evidence by way of affidavits and documents.
5. We have heard the learned counsel for the contesting parties and gone through the record of the case.
6. It is evident from Annexure C-1 that the deceased son of the complainant  availed health policy w.e.f. 16.3.2016 to 15.3.2019 after paying premium amount of Rs.29,995/- and the sum insured was to the tune of Rs.20,00,000/-. Thereafter the policy was renewed w.e.f. 16.3.2019 to 15.3.2022 and premium amount of Rs.36,329/- was paid by the insured.
7. As per case of the complainant the OPs have illegally and arbitrarily repudiated the genuine claim of Rs.1,15,496/- spent on the treatment of the insured son of the complainant.
8. After going through the documents on record it is abundantly clear that the complainant’s son i.e. the insured had bought the policy in question in 2016 and as per death summary Annexure C-3 the complainant was admitted in the Grecian Super Specialty Hospital  on 29.8.2020 and died on 31.8.2020 due to severe covid 19 Pneumonia, type I respiratory failure and cardiac arrest.  An amount of Rs.1,15,496/- was spent on the treatment of the insured as is evident from Annexure C-2.
9. The Ops have taken the stand that the insured has not disclosed the pre-existing disease  of being diabetic at the time of filling proposal form and thus the claim was rightly rejected on account of non disclosure of material facts.
10. Admittedly the policy in question was purchased by the complainant’s son in the year 2016 and again it was renewed in 2019 meaning thereby the OPs were well aware about the health conditions of the complainant’s son i.e. the insured, thus, in our opinion it is the duty of the OPs to do  the complete health check up of the insured specifically in case of health insurance policy.
11. Pertinently,  as per death summary Annexure C-3 the cause of death was severe COVID 19 pneumonia, respiratory failure and cardiac arrest and the Ops have utterly failed to prove on record the connection of the  pre-existing disease with the cause of death  of the insured.   
12. Moreover, in our opinion, it is the duty of the insurer to get due information regarding the health condition of the insured before issuing any policy after assessing the medical condition of the insured  to fill in the proposal form prior to issuance of policy. The Hon’ble Apex Court in its latest judgment in the case of Manmohan Nanda Vs. United India Assurance Co. Ltd. & Anr., 2022(1) RCR (Civil) 449, after considering the various judgments passed by it in earlier cases, held that following principles emerged in the cases of medical claims repudiated on the ground of pre-existing disease:-

“52. On a consideration of the aforesaid judgments, the following principles would emerge:

(i)      There is a duty or obligation of disclosure by the insured regarding any material fact at the time of making the proposal. What constitutes a material fact would depend upon the nature of the insurance policy to be taken, the risk to be covered, as well as the queries that are raised in the proposal form.

(ii)    What may be a material fact in a case would also depend upon the health and medical condition of the proposer.

(iii)   If specific queries are made in a proposal form then it is expected that specific answers are given by the insured who is bound by the duty to disclose all material facts.

(iv)    If any query or column in a proposal form is left blank then the insurance company must ask the insured to fill it up. If in spite of any column being left blank, the insurance company accepts the premium and issues a policy, it cannot at a later stage, when a claim is made under the policy, say that there was a suppression or non­disclosure of a material fact, and seek to repudiate the claim.

(v)     The insurance company has the right to seek details regarding medical condition, if any, of the proposer by getting the proposer examined by one of its empanelled doctors. If, on the consideration of the medical report, the insurance company is satisfied about the medical condition of the proposer and that there is no risk of pre­existing illness, and on such satisfaction it has issued the policy, it cannot thereafter, contend that there was a possible pre­existing illness or sickness which has led to the claim being made by the insured and for that reason repudiate the claim.

(vi)    The insurer must be able to assess the likely risks that may arise from the status of health and existing disease, if any, disclosed by the insured in the proposal form before issuing the insurance policy. Once the policy has been issued after assessing the medical condition of the insured, the insurer cannot repudiate the claim by citing an existing medical condition which was disclosed by the insured in the proposal form, which condition has led to a particular risk in respect of which the claim has been made by the insured.

(vii) In other words, a prudent insurer has to gauge the possible risk that the policy would have to cover and accordingly decide to either accept the proposal form and issue a policy or decline to do so. Such an exercise is dependant on the queries made in the proposal form and the answer to the said queries given by the proposer.”

 

 

13.      Further the Hon’ble Apex Court in case titled as Kanwaljit Singh vs. National Insurance Company Limited  (2019) SSC Online 1033;  held as under:-

“It may be noticed that the claim could not have been repudiated by the Insurance Company as there was no pre-existing disease when the initial individual Mediclaim Policy of Master Jasnoor Singh was taken in the year 2007-2008. Since then the policy was regularly renewed up to the year 2014-2015. Thus in the facts of the present case, the respondent – Insurance Company cannot take the plea of any pre-existing disease of Master Jasnoor Singh. Even otherwise, after having initially repudiated the claim of the appellant, the Insurance Company had itself allowed the claim to the extent of Rs.27,550/-, which amount was deposited in the account of the appellant, meaning thereby that the question of pre-existing disease in the case of the claimant was not considered to be material by the Insurance Company.”

 

14. The Hon’ble National commission in Neelam Chopra vs Life Insurance Corporation Of  India  decided  on 8 October, 2018   held as under:-

“11.      “From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases.  The person insured may suffer consequences in terms of the reduced claims.”

 

14. Moreover, the non-disclosure of information in respect of this life style disease of diabetes, will not totally disentitle the complainant for indemnification of the claim in the light of the judgement of Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., (supra)."

 

15. The principle of law laid dawn by the Hon’ble Apex court and the Hon’ble National Commission in the afore-extracted cases is squarely applicable to the fact and circumstances of the instant case. Hence, there is deficiency on the part of the OPs by repudiating the genuine claim of the complainant. 
16. In view of the above discussion, the present consumer complaint succeeds and the same is accordingly allowed. OPs are directed as under:-

1. to pay Rs.1,15,496/-  with interest @9 P.A.from the date of filing of complaint till onwards.
2. to pay Rs.20,000/- to the complainant as compensation for causing mental agony and harassment to her;
3. to pay Rs.10,000/- to the complainant as costs of litigation.

17.      This order be complied with by the OPs within 45 days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
18. Pending miscellaneous application(s), if any, also stands disposed off.
19.      Certified copies of this order be sent to the parties free of charge. The file be consigned.

			sd/- [Pawanjit Singh]
			President
			Sd/-
			[Surjeet Kaur] Member