Chandigarh

StateCommission

A/49/2021

Harjinder Singh - Complainant(s)

Versus

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

Nirmal Singh Jagdeva Adv.

04 Apr 2022

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

 

Appeal No.	:	49 of 2021
Date of Institution	:	04.08.2021
Date of Decision	:	04.04.2022

 

Harjinder Singh Sohal S/o Late S.Bahal Singh R/o H.No.315, Phase 2, SAS Nagar, Mohali 160055, Punjab.

…Appellant/Complainant

V e r s u s

1. Religare Health Insurance Company Ltd. through its Managing Director, Regd. Office D-3, Distt Center Saket, New Delhi-110017.
2. Religare Health Insurance Company Ltd. through its Branch Manager, SCO No.56-57-58, Sector 9-D, Chandigarh.

…..Respondents/opposite parties

BEFORE:              JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT.

                             MRS.PADMA PANDEY, MEMBER.

                             MR.RAJESH K. ARYA, MEMBER.

 

Present through Video Conferencing:-

                            

          Sh.Nirmal Singh, Advocate for the appellant.

          Ms.Niharika Goel, Advocate for respondents.

 

PER JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT

                   This appeal has been filed by the  complainant (now appellant before this Commission), feeling aggrieved by the order dated 16.06.2021 passed by the District Consumer Disputes Redressal Commission-I, U.T., Chandigarh (in short the District Commission), whereby the consumer complaint bearing no.598 of 2019 filed by him was dismissed.

2.           The facts necessary for disposal of this appeal are that the complainant planned to visit aboard to see his children and, as such, took International Medical Health Insurance Policy from the opposite parties, valid for the period from 17.09.2018 to 05.03.2019, on making payment of premium of Rs.17,864/-. The sum insured under the said policy was USD 50000/-. It was averred that while in Australia, the complainant suffered sudden chest pain on 29.09.2018 and was referred to a Hospital, where all his tests were conducted. After conducting stents procedure, the complainant was discharged from the hospital on 03.10.2018. Thereafter, he was called for regular follow-up. Thereafter, third stent was put on 22.11.2018 and he was discharged on 23.11.2018. After taking treatment from the Hospital in Australia, the complainant submitted claim for cashless benefit under the said insurance policy. However, on 07.12.2018, the opposite parties rejected the cashless payment on the ground of non-disclosure of pre-existing disease i.e. Coronary Artery Disease (CAD) & Dyslipidemia. In those circumstances, the complainant had to pay the hospital bills raised to the tune of 31499 Australian Dollars from his own pocket. On reaching India in the month of March 2019, the complainant filed claim with the opposite parties supported by requisite bills/reports etc. for reimbursement of the amount aforesaid, but his claim was rejected on 16.04.2019, on the ground of non-disclosure of pre-existing disease. Hence, he filed consumer complaint before the District Commission.  
3.           In the reply filed, the opposite parties, while admitting the factual matrix of the case with regard to issuance of policy in question in favour of the complainant pleaded that cashless request of the complainant and also his claim was rightly denied because he suppressed the material facts, with regard to his pre-existing ailment of Coronary Artery Disease and Dyslipidemia prior to obtaining the policy in question. Prayer was made to dismiss the complaint
4.           In the rejoinder filed, the complainant reiterated all the averments contained in his complaint and controverted those, contained in the written version of the opposite parties.
5.           The contesting parties led evidence before the District Commission.
6.           The District Commission after hearing the contesting parties and on going through the material available on record, dismissed the consumer complaint, as stated above. Hence this appeal.
7.           We have heard the contesting parties and gone through the material available on the record; including the written submissions/arguments.
8.           Counsel for the respondents while placing reliance on ‘Out Patient Card’ dated 27.10.2014, Annexure OP-6, issued by the PGIMER, Chandigarh, vehemently contended that since the appellant was suffering from Coronary Artery Disease (CAD) & Dyslipidemia, as such, his claim was rightly rejected by the respondents, as per terms and conditions of the policy in question.
9.           On the other hand, Counsel for the appellant submitted that the appellant had gone to the PGIMER, Chandigarh on 27.10.2014, for general checkup, at the age of 60 years and the doctor concerned had prescribed him some medicines. Thereafter, he never went to the PGIMER, Chandigarh or any other hospital, as he was running a good health, except high blood pressure. He further submitted that at the time of submission of proposal form, the appellant had categorically stated that he is suffering from high blood pressure for the last 5 years and has disclosed that he had PED (pre-existing disease).
10.           We have gone through the contents of the said proposal form Annexure OP-8 and find that against the column ‘Does Any insured has PED’, the appellant has answered as ‘Yes’. Furthermore, against the column ‘Other Diseases Description’, the appellant has answered ‘BLOOD PRESSURE LAST FROM 5 YEARS’.  Thus, In this situation, it was mandatory for the respondents to get the appellant medically examined from their empanelled doctors, before issuing the policy in question, especially when he was above 60 years of age, but they failed to do so.
11.           In order to buttress his case, Counsel for the respondents contended that the remaining columns with regard to disease, were left blank by the appellant, at the time of filling up the proposal form. In our considered opinion, once it was  brought into the knowledge of the respondents by the appellant that he was suffering from pre-existing disease and also he was having blood pressure for the last 5 years, even then, the respondents proceeded  further  and issued the insurance policy in question on receipt of premium from the appellant, as such, now they cannot wriggle out of the same, by rejecting the claim of the appellant on the ground that the columns in the proposal form were not filled by him. Even otherwise, if any column in the proposal form was left blank by the appellant, then the respondents could have asked him to fill it up. If, in spite of column being left blank, the respondents had accepted the premium from the appellant and issued the policy in question, later on, they cannot repudiate the claim by saying that there was  suppression or non-disclosure of a material fact on the part of the appellant.
12.           Be that as it may, not even an iota of evidence has been placed on record by the respondents to prove that except on 27.10.2014, the appellant had visited the PGIMER, Chandigarh or any other hospital for treatment of any disease including CAD and Dyslipidemia. At the time of obtaining the insurance policy, the appellant was running a good health, except high blood pressure, which is a life style disease, and significantly, the said fact stood disclosed by him in the proposal form, Annexure OP-8, in the manner stated above. A similar matter came up for consideration before the Hon’ble Supreme Court in Manmohan Nanda Versus United  India  assurance  co.  Ltd.  &  anr. Civil   Appeal no.8386/2015  decided on 6th  DECEMBER, 2021, which was decided in favour of the insured, by holding as under:-

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

1. 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.
2. What may be a material fact in a case would also depend upon the health and medical condition of the proposer.
3.  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.
4. 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 non-disclosure of a material fact, and seek to repudiate the claim.
5. 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 pre-existing illness, and on such satisfaction it has issued the policy, it cannot thereafter, contend that there was a possible pre-existing illness or sickness which has led to the claim being made by the insured. and for that reason repudiate the claim.
6. 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.
7. 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.           Keeping in view the above discussion, we are of the considered view that the impugned order passed by the District Commission, dismissing the consumer complaint, being not based on the correct appreciation of evidence and law on the point, suffers from illegality and perversity, needs interference of this Commission.  Consequently, this appeal stands allowed and the impugned order stands set aside. The consumer complaint filed by the complainant/appellant stands partly allowed. The respondents/opposite parties- Religare Health Insurance Company Ltd., jointly and severally, are directed as under:-
    1. To pay/reimburse the entire claim amount to the appellant/complainant, which fell under the policy in question, alongwith interest @9% p.a. from the date of repudiation of claim.
    2. To pay compensation to the tune of Rs.50,000/- to the appellant/complainant, for causing him mental agony, harassment and humiliation and also deficiency in providing service, negligence and adoption of unfair trade practice.
    3. To pay cost of litigation to the tune of Rs.25,000/- to the appellant/complainant.
    4. This order be complied within a period of 30 days from the date of receipt of a certified copy thereof, failing which the awarded amounts shall entail interest @12% p.a. from the date of default till realization.
14.           Certified copies of this order be sent to the parties, free of charge.
15.           The concerned file be consigned to Record Room, after completion.

 

Pronounced

04.04.2022

 Sd/-

[JUSTICE RAJ SHEKHAR ATTRI]

PRESIDENT

 

 

Sd/-

 (PADMA PANDEY)

          MEMBER

 

 

Sd/-

 (RAJESH K. ARYA)

MEMBER

Rg.