BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

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Deepak Raj Ahuja s/o Sh. Harnam Dass Ahuja, aged 56 years, r/o H.No.526, Sector 10, Panchkula.

….…Complainant

                           V E R S U S

1.      Royal Sundaram Alliance Insurance Company Limited, Sundaram Towers 45 & 46, Whites Road, Chennai 600014, through its Managing Director.

2.      Managing Director, Royal Sundaram Alliance Insurance Company Limited, Towers 45 & 46, Whites Road, Chennai 600014.

3.      Royal Sundaram Alliance Insurance Company Limited c/o Sundaram Finance Limited SCO No.11, 1^st Floor, Sector 26, Chandigarh.

                                  ..…Opposite Parties

CORAM:  SH.JAGROOP SINGH MAHAL        PRESIDENT

              DR.(MRS) MADHU BEHL       MEMBER

              SH. RAJINDER SINGH GILL  MEMBER

Argued by: Sh. Amit Rajan, Adv. for complainant.

Sh. R.K. Bashamboo, Adv. for OPs.

PER SHRI JAGROOP SINGH MAHAL, PRESIDENT

             Succinctly put, allured by the assurances given by the executive of the OPs, the complainant took the Health Shield Policy, which was valid upto 31.12.2008, and paid the premium of Rs.8,492/-. However, as luck would have it, on 17.12.2008 he felt a bit of pain in his left arm and consulted Dr. D.K. Chopra who advised him for a thorough check up.   On 20.12.2008 he visited the Fortis Hospital and consulted Dr. Rakesh K. Jaswal who after a number of tests opined that the was having CAD angima and advised him to undergo Coronary Angiography and Angioplasty.  On 22.12.2008 he was admitted for treatment of his heart ailment and on the same day underwent Coronary Angiography and Angioplasty and was discharged on 26.12.2008.  He incurred a total expenditure of Rs.5,46,153/- on his treatment.  Thereafter he informed the executives of the OPs telephonically, wrote letter dated 31.12.2008 and also lodged claim alongwith the required documents.  However, vide letter dated 8.4.2009 his claim was rejected on the ground that the complainant was known case of hypertension since 2000.  He vide letter dated 24.4.2009 informed the OPs that he never suffered from any said disease but to no avail.  Hence this complaint alleging that the aforesaid acts of the OPs amount to deficiency in service and unfair trade practice.

2.             In their written reply the OPs admitted the facts with regard to taking of the insurance policy and the claim filed by the complainant.  However, it has been submitted that the complainant concealed the fact that he suffered from heart disease alongwith hypertension since the year 2000. It has been pleaded that the claim was rightly rejected as heart ailment alongwith pre-existing hypertension (for 10 years) & diabetes (for 5 years) was specifically excluded by the policy terms and conditions. It has been further submitted that even the claim for Rs.5,46,153/- was not tenable as the policy was taken for Rs.4,00,000/- only. Denying all the material allegations of the complainant and pleading that there has been no deficiency in service or unfair trade practice on their part prayer for dismissal of the complaint has been made. 

3.             Parties led evidence in support of their contentions.

4.             We have heard the Learned Counsel for the parties and have also perused the record. 

5.             The contention of the Learned Counsel for the OPs is that the complainant was suffering from hypertension for the last 5 to 10 years but he did not disclose this fact in his proposal form.  It is argued that the heart problem, for which the complainant was subsequently admitted in the hospital and was treated, is linked to the hypertension and in view of the exclusion clause-1(b) any heart, kidney and circulatory disorders in respect of insured person suffering from pre-existing hypertension/diabetes are excluded.  In support of his contention the Learned Counsel for the OP has referred to Part D. Exclusions of Health Forever Insurance Policy Annexure R-3, which provides that the company shall not be  liable under this policy for any claim in connection with or in respect of clause-1(a)………, (b) any heart, kidney and circulatory disorders in respect of insured person suffering from pre-existing hypertension/diabetes  which provides that these diseases shall however be covered after 5 years from the commencement date of the cover with OP under this Health Forever Policy.  The OPs referred to the affidavit of G.Vinay Prakash who in para number 4 has deposed that the complainant was admitted for coronary artery disease alongwith pre-existing hypertension since year 2000. The OPs then referred to affidavit of Dr. Sunil Gala who was cross examined through interrogatories and in reply to question number 3 he admitted that the complainant had applied for ICICI Pru Forever (RP) Application no.50183973 in April, 2003 and MER was done, during MER hypertension since 3 years on Amlong 5 mg was disclosed, for which XRT consent was taken and charged accordingly.  Copy of the proposal form was enclosed with this affidavit but when we go through the same we find that the answers to all the questions in para number 23 of the proposal form have been given by the complainant in negative.  The Learned Counsel for the OPs could not point out as to under which column the complainant is alleged to have admitted that he was suffering from hypertension.  The complainant also submitted his reply to interrogatories, he admitted having filled in the proposal form/application form for taking ICICI Prudential Life Insurance Policy.  According to him he never admitted, if he was suffering from hypertension since 2000 and if he was on Amlong.  He also attached the copy of the proposal form Annexure C-27 in which no such admission appears to have made by him.  It therefore cannot be said if the complainant was suffering from hypertension nor can it be said if he concealed the disease when he filled up the application form/proposal form for buying the policy in question.

6.             When the complainant was taken to the hospital his PR was 78/min and BP 130/90 mmHg as mentioned in the discharge summary Annexure R-1.  This document also does not show if the complainant was suffering from hypertension or he concealed this disease from the OPs.

7.             Needless to mention that CAD is totally a different disease than hypertension. The Learned Counsel for the OPs has not been able to prove any correlation between the two.  The claim for CAD therefore cannot be repudiated on the ground that the complainant was suffering from hypertension.

8.             In view of the above discussion, we are of the opinion that the claim could not be repudiated by the OPs on any such ground.  The complaint is therefore liable to succeed.  We accordingly allow the same.  The insurance policy Annexure C-1 shows that the sum insured was Rs.4,00,000/-, the complainant claims to have spent Rs.5,46,153/- on his treatment but he cannot claim more than Rs.4,00,000/- from the OPs.  We therefore allow the complaint and direct the OPs to pay to the complainant within 30 days a sum of Rs.4,00,000/- alongwith litigation costs of Rs.5,000/-.  If the amount is not paid within the aforesaid period, the OPs would be liable to pay the same alongwith penal interest @12% p.a. since 9.05.2009 [one month after letter of repudiation Annexure C-21] till the amount is actually paid to the complainant.

              Certified copies of this order be sent to the parties free of charge.  The file be consigned.