Order dictated by:
Anoop Sharma, Presiding Member
- Manjinder Singh complainant has brought the instant complaint under section 12 & 13 of the Consumer Protection Act on the allegations that complainant got health insurance from the opposite party vide proposal No. 1100400208660 dated 4.8.2014 ,Policy No. 10132148 by paying a premium of Rs. 11858/- and the sum assured was Rs. 5,00,000/-. Thereafter policy was renewed commencing for the period from 20.8.2015 to 19.8.2016 and the complainant paid the premium of Rs. 11858/- . At the time of taking of health policy the age of the complainant was more than 45 years . During the subsistence of the policy for the period from 2015-2016, complainant met with an accident and FIR No. 156 dated 22.5.2016 was registered against the offending vehicle under section 279/337 IPC in police station Ladnun of District Nagpur. In the said accident complainant suffered fracture of his left hand and remained under treatment of Parkash Hospital, G.T. Road, Putlighar, Amritsar and was operated upon in the said hospital and incurred an expenditure of Rs. 38,527/- on his treatment . The complainant alongwith bills and other required documents submitted the claim with the opposite party to the tune of Rs. 38,527/-. Thereafter on the request dated 23.6.2016 the remaining required documents were supplied to the opposite party. But the opposite party repudiated the claim of the complainant on flimsy ground vide letter dated 31.7.2016. The ground of rejection of the claim was that the complainant was suffering from hypertension for the last 10 years whereas the complainant suffered injuries in the vehicle accident and he was only occupant o the vehicle and as such hypertension and accident does not correlate with each other . The act of the opposite party in repudiating the genuine claim of the complainant amounts to deficiency in service and unfair trade practice. The complainant has sought for the following reliefs vide instant complaint :-
- Opposite party be directed to pay the claim amount of Rs. 38,527/- alongwith interest @ 18% p.a. thereon.;
- Compensation to the tune of Rs. 50000/- alongwith litigation expenses of Rs. 5500/- may also be awarded to the complainant.
Hence, this complaint.
2. Upon notice, opposite party appeared and filed written version in which it was submitted that a policy bearing No. 10132148 was issued to the complainant for the period from 6.8.2014 to 5.8.2015 and was further renewed till 19.8.2016. It was submitted that at the time of getting policy, the complainant did not disclose the fact that he was suffering from hypertension since last 10 years, therefore , his claim was rightly repudiated. It was further submitted that as per complainant’s record of Parkash Hospital , it was clearly mentioned that the complainant was suffering from hypertension since the past 10 years. The complainant was duly bound to disclose the information, but intentionally complainant did not disclose the hypertension, therefore, the claim was rightly repudiated . While denying and controverting other allegations, dismissal of complaint was prayed.
3. In his bid to prove the case Sh.Pardeep Mahajan,Adv.counsel for the complainant tendered into evidence duly sworn affidavit of the complainant Ex.C-1, copy of proposal form Ex.C-2, copies of bills Ex.C-3 to Ex.C-15, copy of FIR Ex.C-16, copy of letter dated 18.8.2016 Ex.C-17, copy of Insurance premium paid Ex.C-18, copy of query letter dated 23.6.2016 Ex.C-19, copy of reminder dated 21.7.2016 Ex.C-20, copy of rejection letter Ex.C-21 and closed the evidence on behalf of the complainant.
4. To rebut the aforesaid evidence Sh.R.P.Singh,Adv.counsel for the opposite party tendered into evidence affidavit of Sh. Ramneek Sachar Ex.OP1, proposal form Ex.OP2, notice for cancellation Ex.OP3, cancellation Ex.OP4, medical patient record Ex.OP5, check list Ex.OP6, policy from 2014-15 Ex.OP7, policy 2015-16 Ex.OP8, rejection letter Ex.OP9, terms and conditions Ex.OP10 , medical record Ex.OP11 and closed the evidence on behalf of opposite party.
5. We have heard the ld.counsel for the parties and have carefully gone through the record on the file.
6. On the basis of the evidence on record, ld. Counsel for opposite party has vehemently contended that it is an admitted fact that the complainant obtained a health Insurance Policy bearing No.101321148 for the period from 6.8.2014 to 5.8.2015 which was further renewed for the period from 20.8.2015 to 19.8.2016 . As per complainant version during the subsistence of the policy period, the complainant met with an accident and got a fracture . In this regard he remained admitted in Parkash Hospital, G.T. Road, Putlighar, Amritsar . It is further case of the complainant that he was medically operated and he spent Rs. 38,527/- on his treatment , which was paid by the complainant. It is an admitted fact that the opposite party was duly informed regarding the incident and all the relevant documents were supplied by the complainant to the opposite party within stipulated period. However, it is an admitted fact that mediclaim of the complainant was rejected by the opposite party vide letter dated 31.7.2016 on account of the fact that the complainant was suffering from hypertension for the last 10 years but he has concealed the said fact at the time of obtaining the Insurance policy. Since the complainant was guilty of suppression of material facts/information from the opposite party, as such the claim of the complainant had to be rejected vide repudiation letter Ex. OP9 on record. When the factum came to the knowledge of the opposite party that the policy has been obtained by concealment, the policy was cancelled .
7. But, however, from the appreciation of the facts and circumstances of the case, it becomes evident that it is an admitted fact that complainant Manjinder Singh had obtained insurance policy in his name . It is also an admitted fact that Manjinder Singh remained admitted for treatment w.e.f. 23,5,2016 to 25.5.2016 in Parkash Hospital, G.T. Road, Putlighar, Amritsar where he was medically operated . The complainant spent Rs. 38,527/- on his treatment and the bills/invoices regarding admission and expenses incurred by the complainant account for Ex.C-3 to Ex.C-15. It is further the case of the complainant that the claim for reimbursement of medical expenses was repudiated by the opposite parties vide repudiation letter, copy whereof is Ex.OP9. The ground for repudiating the claim has been that the life assured was suffering from Hypertension . However, the alleged disease has absolutely no nexus with the present treatment obtained by the complainant. In such circumstances it cannot be held that the patient was guilty of suppressing the material facts. Reliance in this connection can be had on Santosh Kanwar-Petitioner Vs. Life Insurance Corporation of India-Respondents 2008(3) CPC 562 (NC), wherein it has been held that “Insured allegedly suffering from various ailments which were not disclosed in proposal form-Insurance Corporation repudiated the claim-District Forum allowed the complaint with the opinion that trival ailment such as pain in abdomen or muscles was not a serious ailment and not required to be noted at the time of taking the policy-Order was set-aside in appeal giving rise to present revision petition- It is settled law that unless suppression of disease is material, it should not be made a ground for repudiation of claim-Death of insured had no nexus with ailment-Repudiation of claim is unjustified”
8. It has further been contended that insured patient had past history of hypertension for 15 years which the complainant did not disclose at the time of inception of the policy. . Hypertension and Diabetes Mellitus are no longer the material diseases as millions of people in this country are afflicted with these ailments. Reliance in this connection can be placed on Life Insurance Corporation of India Vs. Sushma Sharma II(2008) CPJ 213 wherein Hon'ble Mr. Justice S.N. Aggarwal and Mrs. Jasbir Kapoor member have held in an appeal titled as in para 18 of the judgement as follows:-
“So far as hypertension is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.
9. Further reliance can be had on Life Insurance Corporation of India Vs. Sudha Jain II(2007) CPJ 452, wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi have held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease.
10. From the aforesaid discussion, it transpires that the rightful claim of the complainant has been repudiated by the opposite party without any reasonable cause which amounts to deficiency in service on the part of the opposite parties. Consequently, we allow the complaint and the opposite party is directed to pay the amount of Rs. 38,527/- which was incurred by the complainant on his treatment ,to the complainant. Opposite party is also directed to pay litigation expenses to the tune of Rs. 2000/- to the complainant. Compliance of this order be made within a period of 30 days from the date of receipt of copy of this order ; failing which, awarded amount shall carry interest @ 9% p.a. from the date of passing of the order until full and final recovery. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Forum
Dated : 19.7.2017
