Haryana

Karnal

CC/346/2021

Richa Rajpaul - Complainant(s)

Versus

Religare Health Insurance Company Limited - Opp.Party(s)

Sandeep Gupta

21 Nov 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 346 of 2021

                                                        Date of instt.23.07.2021

                                                        Date of Decision:21.11.2022

 

Richa Rajpaul aged about 35 years daughter of Ajay Kumar Rajpaul, resident of House no.301 Sector 7, Karnal.

 

                                               …….Complainant.

                                              Versus

 

1.     Religare Health Insurance Company Ltd. 5^th floor, 19 Chawla House, Nehru Palace New Delhi through its Manager.

 

2.     Sunil (agent code 20052104), Religare Health Insurance Company Ltd., Contact number 9416468660, c/o Vinod Chopra, near HDFC Bank Vasant Vihar, Karnal.

                                                                      …..Opposite Parties.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

      Dr. Rekha Chaudhary……Member

          

 Argued by: Shri Sandeep Gupta, counsel for the complainant.

                    Shri Ashwani Kumar Popli, counsel for the OP no.1.

                    OP no.2 exparte.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant purchased a health insurance policy from OP no.1 through OP no.2, vide policy no.11524524, valid from 13.08.2018 to 12.08.2019. Complainant paid the premium amount of Rs.5515/- as per instruction of the OPs. Complainant has been diagnosed with disease and got admitted in Life Care Hospital Sector 7, Karnal on 07.04.2019 and spent Rs.68058/- on the medicines and treatment etc. Thereafter, complainant submitted all the bills to the OPs and requested to reimburse the said amount but OPs did not pay any heed to the request of complainant and lingered the matter on one pretext or the other and lastly repudiated the claim of complainant, vide letter dated 02.08.2019 on the ground that non-disclosure of diabetes mellitus at the time of policy inception, while the same was intimated to the OP no.2 at the time of policy inception. In this way there is deficiency in service on the part of the OPs. Hence this complaint.

2.             On notice, OP no.1 appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; locus standi; cause of action and concealment of true and material facts. On merits, it is pleaded that OPs issued a health insurance policy bearing no.11524524 under the plan namely “Care Individual” to the complainant for a sum insured of Rs.3,00,000/- from 13.08.2017 to 12.08.2018. Thereafter, the policy was further renewed from 13.08.2018 to 12.08.2019 subject to policy terms and conditions. The policy was ported from The New India Assurance Co. It is further pleaded that complainant filed a reimbursement claim no.90952364 for her hospitalization at Life Care Hospital, Karnal from 07.04.2019 till 13.04.2019 and was diagnosed with Diabetic Ketoacidosis with Acute Gastroenteritis with Acute Acalculus Cholecystitis in a K/C/O Type 1 DM with dorsal pancreatic agenesis. Upon receipt of the reimbursement claim, queries dated 19.05.2019, 05.07.2019 and reminders thereof dated 29.05.2019, 08.06.2019, 15.07.2019, 25.07.2019 were sent to the complainant for the following documents/information. “Exact duration and past history of present ailment with first consultation paper and all past treatment record type 1 diabetes mellitus”. Upon receipt of the request an investigation was triggered to check the veracity of the request. Upon perusal of the submitted medical documents and findings of the investigation following observation were made:

i.      As per the letter issued by Dr. Gagan Kaushal of M/s Life Care Hospital dated 23.07.2019, it is mentioned that complainant is a known case of Type 1 diabetes mellitus since 2016.

ii.     As per the discharge summary of M/s Life Care Hospital dated 10.09.2019, it is mentioned that complainant is a known case of diabetes mellitus Type 2/Type 1.

iii.     As per the questionnaire for doctor form dated 28.05.2019 which is duly signed and stamped by Dr. Gagan Kaushal of M/s Life Care Hospital, it is mention that complainant is a known case of Type 1 diabetes mellitus since last 3 years.

iv.     As per the Multispecialty in Patient History and physical record dated 07.04.2019, it is mentioned that complainant is a known case of Type 1 diabetes mellitus since 3 years.

v.     As per the questionnaire for insured form dated 29.05.2019 which is duly signed by the complainant and her mother, it is mentioned that complainant is a known case of Type 1 diabetes mellitus since 2016 and was taking treatment M/s Life Care Hospital, Karnal.

vi.     As per the Discharge Summary of M/s Life Care Hospital dated 13.04.2019, it is mentioned that complainant is a known case of Type 1 diabetes mellitus.

Therefore, in the light of abovesaid findings, OP company rejected the claim of complainant, vide denial letter dated 02.08.2019 on the basis of non-disclosure of diabetes mellitus at the time of policy inception. It is further pleaded that complainant had chance to disclose her pre-existing disease of Diabetes Mellitus at the time of filling the proposal form. However, complainant did not disclose the same at the time of filling the proposal form. The contract of insurance is of uberriae fidei, and by not declaring correct and accurate information at the time of proposing for he referred policy, insured is guilty of breach of the principle of utmost good faith. As per the policy terms and conditions, the insured was under obligation to disclose all material facts at the time of taking the policy. Since there was non-disclosure of pre-existing ailment of Diabetes Mellitus which falls prior to policy inception, the OP company issued a Notice for Cancellation, vide letter dated 13.08.2019 and asked the complainant to furnish correct facts supported by documentary proof within 15 days. Since no reply was received to the said notice, OP company cancelled the insurance policy on 03.10.2019. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Initially, Shri Vinod Chopra, Insurance Advisor on behalf of OP no.2 appeared but did not file any written version after availing several opportunities despite last five opportunities. On 07.03.2022 none has put into appearance on behalf of OP no.2 and opted to be proceeded against exparte.

4.             Parties then led their respective evidence.

5.             Complainant has tendered into evidence her affidavit Ex.CW1/A, postal receipt of notice Ex.C1, insurance policy of 2018-2019 Ex.C2, copy of claim denial letter Ex.C3, copies of bills and receipt Ex.C4 to Ex.C27, copy of old policy document of New India Assurance Ex.C28 to Ex.C37, copy of Religare insurance policy of 2017-2018 Ex.C38 and closed the evidence on 13.05.2022 by suffering separate statement.

6.             On the other hand, learned counsel for the OP no.1 has tendered into evidence affidavit of Sahil Chauhan, Occupation-Service, an authorized Officer Ex.OP1/A, copy of policy certificate Ex.OP1, copy of policy renewal Ex.OP2, copy of terms and condition o policy Ex.OP3, copy of proposal form Ex.OP4, copy of probability for Ex.OP5, copy of bill receipt Ex.OP6, copy of claim form Ex.OP7, copy of discharge summary Ex.OP8, copy of final bill Ex.OP9, copy of query letter dated 19.05.2019 Ex.OP10, copy of reminders dated 29.05.2019, 08.06.2019, 05.07.2019, 15.07.2019, 25.07.2019 Ex. OP11 to Ex.OP15, copy of claim denial letter dated 02.08.2019 Ex.OP16, copy of discharge summary Ex.OP17, copy of doctor statement Ex.OP18, copy of patient history and physical record Ex.OP19, copy of investigation report Ex.OP20 and closed the evidence on 11.07.2022 by suffering separate statement.

7.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties

8.             Learned counsel of complainant, while reiterating the contents of the complaint, has vehemently argued that complainant purchased a health insurance policy from OPs. Complainant has been diagnosed with disease and got admitted in Life Care Hospital Sector 7, Karnal on 07.04.2019 and spent Rs.68058/- on the medicines and treatment etc. After getting discharge from the hospital complainant applied for reimbursement of the claim with the OPs but OPs did not pay any claim and repudiated the same on the false and frivolous ground. Learned counsel for complainant has relied upon the judgment of Hon’ble State Commission in case titled as Charanjeet Singh Vs. Religare Health Insurance, decided on 10.09.2021 and prayed for allowing the complaint.

9.             Per contra, learned counsel of OP no.1 while, reiterating the contents of written version, has vehemently argued that at the time of obtaining the policy in question complainant was suffering from Diabetes Mellitus and was under treatment for the same since 2016. This fact had not been disclosed by the complainant, at the time of filling of proposal form and has concealed the true and material facts with regard to her health and prayed for dismissal of the complaint.

10.           We have duly considered the rival contention of the parties.

11.           Admittedly, the complainant had purchased a Health insurance policy on 13.08.2017 to 12.08.2018 for the sum insured of Rs.three lakhs and the same was renewed for the period 13.08.2018 to 12.08.2019. It is also admitted that complainant was found suffering from Diabetes Mellitus during the subsistence of the insurance policy.

12.           The complainant was hospitalized in Life Care Hospital, Karnal from 07.04.2019 to 13.04.2019 and was diagnosed with Diabetic Ketoacidosis with Acute Gastroenteritis with Acute Acalculus Cholecystitis in a K/C/O Type 1 DM with dorsal pancreatic agenesis. The claim of the complainant has been repudiated the by the OP no.2, vide denial letter Ex. dated Ex.C3/Ex.OP16 dated 02.08.2019 on the grounds, which reproduced as under:-

                “The claim is not payable as per policy terms and conditions

listed below:

Non-disclosure of diabetes mellitus at time of policy inception.

Non-disclosure.

13.           The claim of the complainant has been repudiated by the OP on the ground of concealment of material facts with regard to her health at the time of obtaining the insurance policy.

14.           The onus to prove that the complainant was having pre-existing disease at the time filling of the proposal form lies upon the OP. To prove its case OP has placed on record discharge summary of Life Care Hospital as Ex.OP8, in which it is mentioned that complainant is a known case of diabetes mellitus Type 2/Type 1 since 2016. Furthermore, as per the questionare for doctor form Ex.OP18 dated 28.05.2019 which is duly signed and stamped by Dr. Gagan Kaushal of M/s Life Care Hospital, in which it is mentioned that complainant is a known case of Type 1 diabetes mellitus since last 3 years.  To rebut the abovesaid evidence complainant has not placed on record any evidence that she was not suffering from any disease at the time of filling the proposal form. Thus, it is proved on record complainant is having pre-existing disease and has concealed the true and material facts regarding her health at the time of obtaining the insurance policy. In this regard, we are fortified with the observations of Hon’ble Supreme Court in case titled as Branch Manager, Bajaj Allianz Life Insurance Company Ltd. and others Vs. Dalbir Kaur in civil appeal no.3397 of 2020 decided on 09.10.2020 wherein Hon’ble Supreme Court held that a policy of insurance is governed by the principles of utmost good faith. The suppression of material facts by the insured/policyholder entitles the OP to repudiate the policy under section 45 of the Insurance Act. The said authority is fully applicable to the facts of the present case.

15.           Further, it is settled principle of insurance law that contract of insurance is a contract uberrima fides and utmost faith must be observed by the contracting parties. Every material fact must be disclosed, otherwise there is good ground for rescission of contract. If, there are misstatements or suppression of material facts, the policy can be called into question. In this regard reference may be made to the judgments of the Hon’ble Supreme Court in case titled Satwant Kaur Sandhu Versus New India Assurance Co. IV( 2009) CPJ 8 and Relinace Life Insurance Co. Ltd. Versus Rekhaben Nareshbhai Rathore decided on 24.04.2019 and judgment of Hon’ble National Commission in case Life Insurance Corporation of India and another Versus Bimla Devi Revision Petition no.3806 of 2009 decided on 12.8.2015 and Sunita Rani Versus PNB Metlife India Insurance Company Limited in appeal no.1252/2015 dcided on 21.04.2017.

16.           In the present case complainant has concealed the true and material facts regard her health at the time of obtaining the policy in question. Hence, we are of the considered view that OP has rightly repudiated the claim of the complainant and there is no deficiency in service on the part of the OP, while repudiating the claim of the complainant.

17.           Thus, present complaint is devoid of any merits and same deserves to be dismissed 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.

Dated:21.11.2022

 

                                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 

 

(Vineet Kaushik)        (Dr. Rekha Chaudhary)

                    Member                         Member

 

Sushma

Stenographer