Order dictated by:
Sh.S.S.Panessar,President.
1. Sh. Subhash Chander complainant has filed the present complaint under section 11 & 12 of the Consumer Protection Act on the allegations that complainant got himself insured from Star Health and Allied Insurance Co.Ltd in the year 2010 which was commenced from 23.11.2010. In the year 2013 the official of opposite party contacted the complainant and requested to shift the policy from Star Health and Allied Co. to opposite party. The complainant shifted his health Insurance policy from Star Health Insurance to opposite party. The policy was commenced from 23.11.2013 to 22.11.2014. After the expiry of this policy, the same was renewed from 23.11.2014 to 22.11.2015 and again from 23.11.2015 to 22.11.2016. Copies of the policies are attached. Since the year 2010 till admission of the complainant in Parvati Devi Hospital , no claim was taken neither from the previous insurer nor from the opposite party. The complainant admitted in Parvati Devi Hospital on 16.7.2015 and remained admitted till 23.7.2015. Treatment was given and the complainant was advised for gastro surgical opinion. On his treatment the complainant has incurred an expenditure of Rs. 57,517/- at Parvati Devi Hospital. All original bills and treatment record were submitted to the opposite party for reimbursement of claim of Rs. 57,517/-. The complainant admitted in Medanta Hospital on 25.7.3015 and remained admitted there till 30.7.2015 and incurred an expenditure of Rs. 1,82,940/- on his treatment at Medanta Hosptial. All the treatment record and bills were submitted to the opposite party for reimbursement. The complainant lodged claim with the opposite party for the payments of Rs. 57,517/- as well as Rs. 1,82,940/- after completion of all the formalities and provided all the documents required for reimbursement of the claim. The complainant received claim rejection letters dated 29.10.2015 and 2.11.2015 vide which both the claims have been repudiated on the ground on non-disclosure of material facts and for the reason that hypertension since 2011 which is before policy inception. The complainant got himself insured since 2010 and he never concealed any fact from the opposite party and he was not suffering from hypertension, therefore, there was no question arises for concealment of hypertension arises. The policy is continuously in operation without any break since 2010. The rejection of claim is arbitrary, against the law, principles of natural justice and on flimsy grounds. The complainant has sought for the following reliefs vide instant complaint:-
- Opposite party be directed to reimburse claim amount of Rs. 2,40,457/- to the complainant alongwith interest @ 24% p.a.
- Compensation to the tune of Rs. 50000/- may also be awarded to the complainant alongwith adequate litigation expenses.
2. Upon notice, opposite party appeared and contested the complaint by filing written version in which certain preliminary objections have been taken inter alia that the complainant has concealed the true and material facts from this Forum. In this case as per medical record of the complainant, the insured was suffering from hypertension since 2011. This fact has been concealed by the insured at the time of obtaining the insurance policy therefore, complainant is not entitled for any claim. Had this been disclosed in the proposal form , the policy would not have been issued to the complainant on the same terms and conditions ; that as per terms and conditions of the policy, the complainant is not entitled for any claim as he was suffering from pre-existing disease ; that the claim was rejected as per clause 6.1 of the policy terms and conditions i.e. non-disclosure of the hypertension ; that complainant is estopped by his own act and conduct from filing the present complaint ; that complaint has been filed without any cause of action against the replying opposite party, therefore, the same is liable to be dismissed ; that the complainant has no locus standi to file the present complaint . On merits, it was submitted that after receiving the claim, opposite party’s investigator, investigated the hospital records and the complainant himself gave a statement regarding his pre-existing disease of hypertension since 2011. The said fact was concealed by the complainant at the time of obtaining the policy from the opposite party, as such the claim of the complainant was rejected vide letters dated 29.10.2015 and 2.11.2015. It was submitted that as the complainant was suffering from hypertension since 2011 and the said fact was concealed by the complainant at the time of obtaining policy, as such the claims of the complainant were rejected vide letter dated 29.10.2015 and 2.11.2015. Remaining facts mentioned in the complaint have been specifically denied and a prayer for dismissal of complaint was made.
3. In his bid to prove the case Sh.S.S.Channa,Adv. counsel for the complainant tendered into evidence his duly sworn affidavit Ex.C-1 alongwith documents Ex.C-2 to Ex.C-23 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.Ramnique Sachar Ex.OP1 alongwith documents Ex.OP2 to Ex.OP28 and closed the evidence on behalf of the opposite party.
5. We have heard the ld.counsel for the parties and have carefully gone through the record on the file.
6. Ld.counsel for the opposite party has vehemently contended that the claim of the complainant has rightly been repudiated on the ground that insured was suffering from hypertension since 2011. But this fact has been concealed by the insured at the time of obtaining the insurance policy . Had this fact been disclosed by the complainant in the proposal form , the policy would not have been issued to the complainant . So as per the terms and conditions of the policy the complainant is not entitled to any claim as he was suffering from pre-existing disease at the time of obtaining of the Insurance policy. It is submitted that after receiving the claim , the investigator of the opposite party investigated the hospital record and the complainant himself gave statement regarding his pre-existing disease of hypertension since 2011. In view of this , the claim of the complainant was rejected vide letters dated 29.10.2015 and 2.11.2015, copies whereof account for Ex. C-5 and Ex.C-6 respectively on record . Ld.counsel for the opposite party has vehemently contended that there is no deficiency in service on the part of the opposite party and a prayer for dismissal of the complaint with cost was made.
7. But, however, from the appreciation of the facts and circumstances of the case, it emerges that undisputedly the policy in question commenced w.e.f. 23.11.2010 and in the year 2013 on the advice of the official of the opposite party, the policy in question was shifted from Star Health and Allied Insu. Co. to opposite party. The policy in question was in operation w.e.f. 23.11.2013 to 22.11.2014 & thereafter from 23.11.2014 to 22.11.2015 and then to 23.11.2015 to 22.11.2016. Copies of the Insurance policy are Ex.C-2 to Ex. C-4 respectively on record. It is an admitted fact that the complainant remained admitted in Parvati Devi Hospital on 16.7.2015 to 23.7.2015 . It is the case of the complainant that he incurred an expenditure of Rs. 57,517/- on this treatment. Copies of bills of Parvati Devi Hospital account for Ex. C-7 to Ex.C-9. Not only that the complainant again remained admitted in Medanat Hospital from 25.7.2015 to 30.7.2015 , where he incurred a sum of Rs. 1,82,940/- on his treatment. Copies of medical bills are Ex. C-14 to Ex.C-22 on record. Thereafter complainant lodged claim with the opposite party for payment of Rs. 57,517/- (incurred at Parvati Devi Hosptal) and Rs. 1,82,940/- (incurred at Medanta Hospital) by completing all the requisite formalities and he also provided all the relevant documents required for the settlement of the claim. The complainant was continuously insuring himself since the year 2010 and the opposite party is duty bound to continue the policy and reimburse the expenditure incurred on the treatment duly covered under the policy. The only ground on which the claim of the complainant has been repudiated , has been that the complainant was suffering from hypertension since 2011 i.e. prior to the issuance of the insurance policy. But as per the numerous case law on the point, hypertension is not a disease. In such a situation, it is preposterous to presume that said disease was pre-existing or that non disclosure thereof at the time of obtaining the insurance policy amount to concealment. Even otherwise, hypertension is not a material disease, therefore, non disclosure thereof is not a concealment. We draw support from Life Insurance Corporation of India Vs. Sushma Sharma from II (2008) CPJ 213 wherein Hon'ble State Commission has held as under:-
“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.”.
8. We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease.
9. In such a situation the repudiation made by Opposite Party regarding genuine claim of the complainant appears to have been made without application of mind. It is usual with the insurance company to show all types of green pastures to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
10. From the aforesaid discussion, it transpires that Opposite Party has wrongly repudiated the claim of the complainant . As such, opposite party is directed to reimburse the amount of Rs. 2,40,457/- ( 57,517/- (incurred at Parvati Devi Hosptal) and Rs. 1,82,940/- (incurred at Medanta Hospital) as claimed by the complainant. The costs of the litigation are assessed at Rs.2,000/-. Compliance of this order be made within 30 days from the receipt of copy of the order; failing which, awarded amount shall carry interest @ 9% p.a from the date of filing of the complaint until full and final recovery. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
Dated: 15.09.2016.
