DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

Udyog Sadan, C-22 & 23, Qutub Institutional Area

(Behind Qutub Hotel), New Delhi-110016

Case No.411/2016

Sh. Rajiv Sharma

S/o Late Shri P.C. Sharma,

R/o Bungalow-6, Red Square, Jatkhedi,

Near Ashima Mall, Bhopal (MP)

And also permanent

R/o C-702, Geetanjali Apartment,

Karkardooma, New Delhi-110092                         ….Complainant

Versus

Religare Health Insurance Co. Ltd.

Regd. Office: D-3, P3B, District Centre,

Saket, New Delhi-110017.                                         ….Opposite Party  

                                             Date of Institution  :         08.12.2016   Date of Order            :         06.02.2020

Coram:

Ms. Rekha Rani, President

Ms. Kiran Kaushal, Member

Ms. Kiran Kaushal, Member

ORDER

1. As stated the case of the complainant in nutshell is that the complainant purchased an Insurance Policy on 31.12.15 from Religare Health Insurance Company Ltd. hereinafter referred to as OP. The said policy was issued for the period from 30.12.15 to 29.12.16 and providing coverage upto Rs.8,00,000/-. 
   1. It is next averred that on 08.03.2016 the complainant got ill and was admitted in National Hospital Bhopal due to back and chest pain. Thereafter, he was referred to Max Hospital Saket New Delhi for further evaluation and management where he was operated on 16.03.2016 and was discharged from the hospital on 26.03.2016. Pursuant to the treatment the complainant filed the claim for medical reimbursement amounting to Rs.6.38 lakhs on 06.05.2016 along with the Hospital charges and Medicine bills. After consistent follow up, the complainant was informed by OP on 11.05.2016 that his claim has been rejected on account of non-disclosure of material facts/ pre-existing ailments at the time of proposal. It is averred that the complainant clarified to the OP that he had no pre-existing ailment or disease prior to the said treatment taken in the hospital. Despite reminders and follow-ups the claim of the complainant was finally rejected on 20.06.2016 without any reasonable ground.
   2. Aggrieved, the complainant approached this Forum with the prayer that OP be directed to pay the complainant amount of Rs.6.38 lacs along with interest @18% PA from the date of due till realization and to pay a sum of Rs.1,00,000/- towards harassment and mental agony and Rs.25,000/- towards cost of litigation.
2. OP resisted the complaint inter-alia stating that the complainant after being acquainted with the benefits of different policies had opted for policy “GROUP CARE (Scheme 2-IIB)”. The OP issued the Group Insurance Policy bearing No. 10087119 to Indusind Bank Ltd. and further issued a certificate of insurance No.10495335 which was valid for the period 30.12.15 to 29.12.16. Copy of the insurance policy is annexed as Annexure OP-3.
   1. It is submitted that during the continuance of the said policy the complainant had reported to have been admitted in National Hospital Bhopal on 08.03.2016 for treatment of Loculated Pleural Effusion right side. Subsequently, he was referred to Max Super Speciality Hospital, New Delhi. It is submitted that as the patient had not disclosed the material facts therefore the pre-authorization facility was denied. The denial letter is annexed as Annexure OP-7. It is further reiterated that by not declaring correct and accurate information at the time of filing up proposal form the complainant has acted in breach clause-9 of the policy.
   2. It is further stated by OP that complainant had falsely filed the declaration form under the heading ‘Pre-existing Diseases Details’. The complainant has answered ‘No’ to the questions that:

Q. Has anyone been diagnosed/ hospitalized or under any   treatment for any illness/ injury during the last 48 months or is suffering from any illness/ disease.

• Diabetes
• Hypertension/ High Blood Pressure

Answer to question is “No”

Q. Has anyone been under any medication/ tablets for any illness/ injury?

The answer is this is “No”.

1. Hence, on perusal of the claim documents submitted by the complainant it came to the knowledge of the OP that the complainant was suffering from hypertension and diabetes for the past 15 years and three years respectively and was on insulin. This material fact was not disclosed to OP at the proposal stage hence the claim of complainant was rejected vide letter dated 11.05.2016 annexed as Annexure OP-11 for non-disclosure of pre-existing diseases under clause 9 of the policy terms and conditions.
2. Denying any deficiency in service on the part of OP it is prayed that the complaint be dismissed with exemplary costs.

3. Rejoinder is filed on behalf of the complainant reiterating the facts of the complaint. Evidence by way of affidavit is filed by the complainant. On the other hand, evidence of Shri Ankit Shankar Bhardwaj, Manager of OP has been filed.
4. Written arguments have been filed on behalf of the parties.
5. Submissions made by parties are heard and material placed on record is perused carefully.
6. It is not disputed that Health Insurance policy was issued to the complainant on 31.12.2015 for premium of Rs.26,640/- providing a coverage of Rs.8,00,000/- to the complainant, his wife Ms. Aarti Sharma and his son Master Rikki Sharma for a period from 30.12.2015 to 29.12.2016.
7. Dispute between the parties arose when the cashless claim and the reimbursement claim request of the complainant was denied by OP vide its letter dated 15.03.2016 and 11.05.2016 appended at page No. 40 & 41 respectively with the complaint.
8. As per the proposal form appended at page-24 of the complaint, no disclosure as regards pre-existing disease or illness was made. Rather under the Heading-  ‘Pre-existing diseases details’ – complainant has made  mis-declaration stating that he is not suffering from any diabetes and hypertension. The claim was further denied as per clause 9 of the policy terms and conditions reproduced below:-

“As per Clause-9 – Disclosure to information Norm if any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particulars or any material information having been withheld or if a claim is fraudulently made or any fraudulent means or devices are used by the Insured members or any one acting or his/ their behalf. We shall have no liability to make payment of nay claims and premium paid shall be forfeited to Us.”

9. OP in support of its arguments has annexed a Pre-Authorization Form as Annexure OP-6 wherein under past history of any chronic illness of the complainant diabetes and hypertension are mentioned. Further on the Progress Notes of Max Hospital dated 16.03.2016 and 17.06.2016, it is mentioned under the Heading ‘Comorbidities’ that the complainant was suffering from :

• That the Hypertensions since 15 years.

• Diabetes since 3.5 years

The said Progress Notes are annexed as Annexure-OP-9. The discharge summary of Max Hospital also mentions under medical history and past history of the complainant that the complainant was a known case of Hypertension and Diabetes and was on regular medications. The said document is annexed as Annexure OP-10.

10. On perusal of the pleadings it is noticed that complainant has been denying the fact that he had Hypertension and Diabetes. Rather, after having received the repudiation letter from OP, complainant again stated that he had no pre-existing disease. We are of the opinion that the complainant’s stand in the complaint is apparently false as during his treatment in Bhopal and Max Hospital he had himself disclosed that he had pre-existing ailments and was taking medicine for the same. Complainant in his pleadings had made false assertions and is found to be cooking up stories. The legal notice sent by the complainant through his counsel also states that he was neither suffering from hypertension nor and diabetes.
11. Further in rejoinder the complainant has stated that he signed a blank proposal form which was subsequently filled up by Executive of OP.  This Forum is the opinion that the complainant is trying to wriggle out of the signed contract by saying that he had left it blank. No prudent man would sign blank documents. By leaving the document blank he has given an authority to OP to fill in the blanks and by signing the documents, he is now bound by the contract arrived at.
12. There is no denying the fact that the Contracts of Insurance is contract of Uberrimaefidei, and by not declaring correct and accurate information even when it is specifically asked complainant is guilty of breach of the principle of utmost good faith. In this regard, the apex court in Satwant Kaur Sandhu vs. New India Assurance Co. Ltd. (2009)8 SCC 316(2009) 8 SCC 316, it has been observed by the Supreme Court that the expression ‘material fact’ is to be understood in general terms to mean as any fact which would influence the judgment of a prudent Insurer, in deciding whether to accept the risk or not. If the proposer has knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal form. Any inaccurate answer will entitle the Insurer to repudiate their liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a contract of insurance, which is based on the principle of utmost faith uberrima fides. Good faith forbids either party from non-disclosure of the facts which the party privately knows, to draw the other into a bargain, from his ignorance of that fact and his believing the contrary. (See: United India Insurance Co. Ltd. Vs. M.K.J. Corporation [(1996) 6 SCC 428].
13. In Subinoy Majumdar vs. Life Insurance Corporation pronounced in May, 2016 while uploading the orders of the State Commission, the Hon’ble National Commission has relied on the judgment of Satwant Kaur Sandhu. The essence of judgment is that irrespective of the fact that some diseases like Diabetes are attributed to life style of a person but if they are not disclosed at the time of taking the policy and stand material to the policy, the insurance company can repudiate the claim on the ground of non-disclosure and the same cannot be held as a deficiency in service.
14. Sequel to the above discussion, we are of the view that OP is justified in repudiating the claim and have not committed any deficiency in service in doing so. Resultantly the complaint is dismissed with no order as to costs.

Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.  

Announced on 06.02.2020.