BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.409 of 2019
Date of Instt. 13.09.2019
Date of Decision: 30.05.2023
Daljit Kaur, aged 65 years, wife of Surinder Singh, resident of House No.38, Nakodar Road, Link Colony, Jalandhar.
..........Complainant
Versus
1. Religare Health Insurance, Vipul Tec Square, Tower C, 3rd Floor, Sector 43, Golf Course Road, Gurgaon, through its authorized representative.
2. Religare Health Insurance, S.C.O.44, PUDA Complex, Opp. District Administrative Office, Jalandhar-144001, through its Manager/Authorized Signatory.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. S. C. Sood, Adv. Counsel for the Complainant.
Sh. R. K. Sharma, Adv. Counsel for the OPs No.1 & 2.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the OPs approached the complainant with an offer that they are engaged in providing medical health insurance services to the people at large. The OPs further assured that they provide medical health insurance services in the most timely professional and legal manner. The complainant believing the assurances of the OPs accepted the offer and became a consumer for consideration in lieu of the premium to be paid to the OPs. Initially the complainant had taken the medical health insurance policy from the OPs bearing No.114060629 against premium of Rs.27,081/-. The said policy was to subsist from 22.07.2097 to 21.07.2018. During the subsistence of the above mentioned policy no claim was lodged and thereafter for the next successive year the OPs again approached the complainant for renewal of the insurance policy and wrote a letter dated 27.07.2018 confirming the renewal of the policy for the subsequent period of 24.07.2018 to 23.07.2019 and separate premium for the subsequent policy was also paid to the extent of Rs.22,099/-. At the time of issuing the policy the complainant had provided all the truthful detail to the OPs, but unfortunately during the subsistence of the policy for the second year i.e. 24.07.2018 to 23.07.2019 the complainant suffered an accident after being hit by a Dog in street which resulted into fracture of the left hip of the complainant on 24.02.2019 and the complainant was immediately taken to Guardian Hospital, Jalandhar. On account of fracture and injuries the complainant was diagnosed with "COMMUNITED INTER-TROCHANTE RIC FRACTURE LEFT SIDE", "CLOSED COMMUNITED FRACTURE DISTEL RADIUS LEFT SIDE" and "HYPOTHYROIDISM". As per medical record the complainant was medically treated at Guardian Hospital and the complainant had to undergo surgical procedure, but separate medication during the emergency and also after discharge. The complainant was admitted in Hospital on 24.02.2019 and was eventually discharged on 05.03.2019. The complainant remains admitted in the Hospital for more than seven days and had to incur a total amount of Rs.2,25,297/- on the treatment. The complainant had to undergo surgery, medical tests, radiological procedure and medication. An amount of Rs.7,391/- was also incurred on account of post hospitalization charges. The entire claim of the treatment was lodged with the OPs and all the invoices and medical record had been provided to the OPs by the complainant. The OPs have been provided the original medical record and copies of the entire medical record including treatment record, invoices, medical report, discharge summary are attached alongwith the present complaint. The complainant had provided best and available information to the OPs and all the efforts were made for settlement of the claim in a timely and professional manner, but unfortunately the OPs breached the agreement and the complainant was shocked to receive repudiation letter on 21.05.2019 on a ground that there was no information of disclosure of Osteoporosis and Asthma by the complainant in the repudiation letter dated 21.05.2019 and copy of the said repudiation letter is attached. The said repudiation is wrong and is against the terms of insurance policy. The complainant has never been diagnosed with any of the ailment under the garb of which the OPs have repudiated the claim. Even at the time of taking the medical policy the complainant was medically examined by the Doctor of the OPs. Moreover, the rejection of the claim on the ground of Osteoporosis and Asthma is nothing to do with the injuries suffered by the complainant as explained has taken place on account of falling down after being hit by a Dog. The fracture on the complainant has also occurred because the complainant fell down and the same has no relation with the ground of repudiation. It is clear that the claim has been repudiated only because the OPs wanted to resile from the agreement and the OPs have defeated the very purpose of availing the insurance policy. The OPs have themselves offered for insuring the complainant for the subsequent year from 24.07.2019 to 23.07.2020. It may be mentioned that the claim was repudiated on 21.05.2019 and the OPs have re-insured the complainant after taking premium of Rs.22,099/-. It is clear that the intention of the OPs is only to take the premium from the complainant without providing any reciprocal insurance services. The OPs are engaged in unfair trade practice and as a matter of fact there has never been any non- disclosure on the part of the complainant. The complainant have suffered immense loss on account of wrongful repudiation and is entitled to the claim amount and on account of mental tension, harassment, financial loss and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay Rs.2,25,297/- as compensation being the amount of claim. Further, OPs be directed to pay Rs.50,000/- as damages for mental tension, harassment, financial loss and agony caused to the complainant with interest @ 18% per annum on the claim amount from the date of accident till realization and Rs.30,000/- as litigation expenses.
2. Notice of the complaint was given to the OPs, who filed written reply and contested the complaint by taking preliminary objections that the complaint is not maintainable against the OPs as the complainant cannot take advantage of his own wrongs. The complainant himself is guilty of Non-Disclosure of material facts at the time of taking policy, as such the complaint is liable to be dismissed. It is further averred that the complainant was issued Insurance policy bearing No.11460629 for the period 22-07-2017 to 21-07-2018 and further renewed for the period 24-07-2018 to 23-07- 2019 subject to terms and conditions of the insurance policy by OPs after taking proposal form from the complainant. Insurance policies issued by the OP to the complainant bearing No. 11460629 for the period 22-07-2017 to 21-07-2018 and renewed for the period 24-07-2018 to 23-07-2019 along with its terms and conditions. The complainant approached the OP with a reimbursement claim with pertaining to the hospitalization of the Complainant at Guardian Hospital, Jalandhar from 24-02-2019 till 05-03-2019. On receipt of claim papers and scrutiny thereof, OPs vide letters dated 31-03-2019 and 18-04-2019 has asked the complainant to furnish documents mentioned therein. The OP also triggered a claim investigation. On the basis of documents submitted along with the claim form, query reply and investigation, it came to light that the complainant herein is a known case of Asthma since 10 years and Osteoporosis since 2010 and the same was not disclosed by the complainant at the time of taking the Policy. Therefore, the reimbursement claim of the Complainant was rejected by the Respondent Company vide letter dated 21-05- 2019 under Clause 7.1 of the Policy Terms and Conditions for Non-Disclosure of Material Information. It is further averred that as per the Discharge Summary dated 05-03-2019 prepared by Guardian Hospital, Jalandhar the Complainant is specified to be a Known case of Asthma since past 10 years. Also, as per the Doctor's Consultation papers dated 15-02-2010, 16-09-2011, 29-06-2012 and 19-08-2013 (i.e. before Policy Inception) prepared by Orthopedician Dr. Sanjiv Goel the Complainant has been prescribed medications including Tab Gemphos 35mg, Tab Flexilor, Tab Joincerin m, all of which are used for the treatment of Osteoporosis. The Complainant had the opportunity to disclose her history of Asthma and Osteoporosis at the time of filling of the Proposal Form. However, no such disclosure was made by the Complainant. It is further averred that there is neither any deficiency in service nor any negligence in service nor any unfair trade practice on the part of the opposite parties. Repudiating the claim which is not payable as per terms and conditions of the insurance policy does not amounts to any deficiency in service nor any negligence in service nor any unfair trade practice, as such the complaint is liable to be dismissed. The claim of the complainant was repudiated as per terms and conditions of the insurance policy after due application of mind vide letter of repudiation dated 16-04-2018 on the ground of Non-Disclosure of Pre-Existing Hypertension. On merits, the factum with regard to issuance of the policy bearing no.11460629 for the period 22.07.2017 to 21.07.2018 to the complainant and further renewed for the period from 24.07.2018 to 23.07.2019 alongwith its terms and conditions is admitted. The factum with regard to lodging of the claim and repudiated of the same is also admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.
6. It is admitted and proved fact that the complainant was issued insurance policy bearing No.114060629 for the period 22.07.2017 to 21.07.2018 and further renewed for the period 24.07.2018 to 23.07.2019. The earlier policy effective from 22.07.2017 to 21.07.2018 has been proved as Ex.C-1 and the renewed policy has been proved as Ex.C-2/O-1. It is also proved that the premium for both the policies was paid by the complainant. The policy certificate has been proved by the complainant Ex.C-3, membership card has been proved as Ex.C-4 and the receipt acknowledging the receipt of the premium is Ex.C-5. The complainant has alleged that on 24.02.2019, during the subsistence of the policy for the second year i.e. 24.07.2018 to 23.07.2019, the complainant suffered an accident after being hit by a Dog in the street, which resulted into fracture of the left hip of the complainant and he was taken to Guardian Hospital Jalandhar, where he was medically treated and had to undergo surgical procedure. He was discharged on 05.03.2019. The complainant submitted claim with the OP, but the same was repudiated by the OP wrongly.
7. The OPs have admitted that they had received the reimbursement claim pertaining to the hospitalization of the complainant at Guardian Hospital, Jalandhar. They had relied upon the letters asking the complainant to complete the documents vide Ex.O-3 and Ex.O-4. It has further been alleged by the OPs that the investigation and query was duly made after the receipt of the documents and it was found that the complainant was a known case of Asthma since 10 years and Osteoporosis since 2010, which fact was never disclosed by the complainant at the time of taking the policy therefore as per the Clause 7.1 of the terms and conditions of the policy, the repudiation was done rightly.
8. The OPs have relied upon the medical record of the complainant to show that the complainant has not disclosed the pre-existing disease. The OPs have relied upon the medical record of Dr. Sanjiv Goel’s Bone & Joint Centre Ex.O-6 to Ex.O-9 and the discharge summary from Guardian Hospital, Jalandhar Ex.O-5/C6/3. Perusal of Ex.O-5/C6/3 shows that on 24.02.2019, when the complainant was admitted he was diagnosed with Communited Inter-Trochanteric Fracture Left Side, Closed Communited Fracture Distal Radius Left Side and Hypothyroidism. In the column of past medical history, it has been mentioned K/C/O Asthma since 10 years and Hypothyroidism since 10 years. The OPs in the written statement as well as in the repudiation letter has alleged that the complainant is guilty of non-disclosure of Osteoporosis and Asthma prior to the policy. In all the documents, which relate to the complainant Ex.O-5 to Ex.O-9, though it has been mentioned that the complainant was having Asthma since 10 years and Hypothyroidism since 10 years, but it has nowhere been mentioned that he was suffering from Osteoporosis. As per medical jurisprudence ‘Osteoporosis is the condition in which bones become weak and brittle. The body constantly absorbs and replaces bone tissue with Osteoporosis new bone creation does not keep up with old bone removal.’ The word Hypothyroidism mentioned in Ex.O-5 is the condition in which the thyroid gland does not produce enough thyroid hormone. As per the medical literature, there is no connection between Hypothyroidism and Osteoporosis. Ex.O-6 to Ex.O-9 nowhere shows that she was suffering from Osteoporosis. Even in the discharge summary Ex.O-5, it has nowhere been mentioned that the cause of fracture on the left side was due to the Osteoporosis as alleged by the OPs. It has specifically been mentioned in this discharge summary Ex.O-5 that the complainant was presented with severe pain in left hip and wrist join since few hours and unable to walk properly and bearing weight on left leg and history of fall in street by hitting with dog. So, there is no mention of the fact that the complainant fell in the street due to Osteoporosis.
9. So far as the Asthma is concerned, Ashtma is also called bronchial asthma, meaning thereby that a condition in which a person always become inflame, narrow and swell and produce extra mucus, which makes a difficult to breath. The meaning of Asthma clearly shows that it has nothing to do with the fall in the street by hitting the dog nor it is the cause of any injury to the complainant. The OP has not produced on record any history to show that the complainant is suffering from disease Osteoporosis or the disease for which she took treatment from Dr. Sanjiv Goel’s Bone & Joint Centre. We are supported by the law laid down by the Hon’ble National Consumer Disputes Redressal Commission, New Delhi, in III (2021) CPJ 66 (NC), case titled as ‘PNB Metlife India Insurance Company Ltd. Vs. Godavariben Kalubhai Vaghela’ that ‘Insured had suffered a heart attack and he died - Complainant being nominee, claimed amount under the policy, which was denied by the petitioner on ground that insured had concealed material fact at the time of buying policy- Insured was not suffering from any heart ailment when he filled up proposal form- only defence taken is that insured had underwent treatment for T. B. and this fact was concealed – insured had died after about six months of buying the policy – Concealment of fact regarding treatment of T. B., if any, cannot be termed as concealment of material fact – There is no nexus between concealment of alleged fact and cause of death.’ It has been held by the Hon’ble Delhi State Commission Disputes Redressal Commission, New Delhi, in I (2022) CPJ 112 (Del.), case titled as ‘Gurpreet Kaur Vs. Bajaj Allianz Life Insurance Co. Ltd. & Ors., that ‘Death of life assured occurred due to heart attach/cardiac arrest, which is not connected with pre-existing disease and nor there is any evidence to show that death was on account of pre-existing disease of life insured- Repudiation of claim is not justified.’ It has been held by the Union Territory Consumer Disputes Redressal Commission, Chandigarh, in (2006) CPJ 270, case titled as ‘Life Insurance Corporation of India & Ors. Vs. Shiv Singh’ that ‘insured got examined from insurance doctor, found healthy – Deceased allegedly suffered from chronic obstructive pulmonary disease and chronic asthma – No nexus between cause of death and alleged ailment of deceased – Fraudulent suppression of material facts not proved- insurer liable.’
10. In view of the above detailed discussion, the complaint of the complainant is partly allowed and OPs are directed to pay hospital expenses, medicine expenses and other charges etc. as per bills submitted in the Court by the complainant. Further, OPs are directed to pay a compensation including litigation expenses of Rs.20,000/- for causing mental tension and harassment to the complainant. The entire compliance be made within 45 days 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.
11. 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 Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
30.05.2023 Member Member President
