The complainant Gurwinder Singh Brar (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986, ( Now C.P. Act, 2019 here-in after referred to as 'Act') before this forum (Now Commission) against SBI General Insurance Company Limited (here-in-after referred to as opposite party).
Briefly stated, the case of the complainant is that he was having saving account in State Bank of India Bathinda and he was allured by the representatives & advertisements of opposite party being the customer of State Bank of India, to purchase the "Group Health Insurance Policy" for his better future. Accordingly, complainant asked the opposite party to issue such policy in the year 2018 and adequate premium was adjusted from the account of the complainant being maintained by the complainant with State Bank of India. After completing all the formalities & medical tests of the complainant by the opposite party, the insurance was done but the opposite party did not issue any policy to the complainant and asked that the policy will be sent lateron. However policy/proposal number was disclosed as 00000000009108914 and it was also told to the complainant that it is the cashless policy valid from 4.5.2018 to 3.5.2019. The complainant was asked to collect insurance card from the office of opposite party and was further told that terms and conditions of the policy and other documents related to policy will be sent to the complainant through post, but till date no terms and conditions alongwith documents of the policy have been sent to the complainant.
The complainant alleged that he fell ill on 30.1.2019 and remained under treatment of doctors of Pragma Hospital, Bathinda and the claim was lodged for cashless treatment through Pragma Hospital, Bathinda. The complainant requested the opposite party to admit his rightful claim and make payment of treatment/ Medical bills, but the opposite party has denied his claim with false excuse “that relation of the presenting condition with the stated ailment, the said ailment condition falls within one year waiting period of the policy” but no such term was explained to the complainant at the time of insurance nor any document regarding the said conditions was provided to the complainant at the time of effecting insurance. The ailment of complainant did not fall within one year waiting period as alleged in denial letter by the opposite party.
It is also alleged that the purpose for which the complainant got himself insured with the opposite party has not been fulfilled as the opposite party has received the premium but now the opposite party is dilly dallying the payment of medical bills for which the opposite party is liable. The opposite party failed to comply with its own terms and conditions. The complainant alleged that due to act and conduct of the opposite party, he has suffered mental tension, humiliation and harassment for which he claims compensation to the tune of Rs.1,00,000/-.
On this backdrop of facts, the complainant has prayed for directions to the opposite party to make the payment of medical bills of Rs.1,50,000/- as per terms and conditions of the policy and pay compensation to the tune of Rs. Rs.1,00,000/- on account of mental tension and harassment besides any other additional, alternative and consquential relief.
Upon notice, opposite party appeared through counsel and contested the complaint by filing written written reply raising legal objections that the claim petition is premature as the complainant has lodged claim for reimbursement with the opposite party with Claim No. HI-163963 which is pending decision and complainant has filed the complaint without waiting for decision thereof as such the present Complaint is liable to be dismissed being premature. That intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure under the 'Act'. That the complainant has concealed material facts and documents from this Commission as well as the opposite party, therefore, the complainant is not entitled to any relief.
It has been pleaded that the complainant has concealed the fact that a Group Health insurance policy No. 0000000009108914 was purchased by complainant for the period 04.05.2018 to 03.05.2019. The complainant has himself mentioned that he fell ill and on 30.01.2019 he visited Pragma Hospital, Bathinda where he remained under treatment of doctors and claim was lodged with the opposite party for cashless treatment regarding treatment of complainant for Coronary Artery Disease and since the policy is in first year, case is denied mentioning the first year exclusion clause 3.9 related heart diseases.
Further legal objections are that there is no cause of action or locus standi against the opposite party. That the complainant is not consumer and that the complaint is bad for misjoinder of necessary parties as the complainant has not joined/impleaded State Bank of India as party in the present complaint who is otherwise necessary party for just and proper decision of the present complaint.
On merits, opposite party has reiterated its version as pleaded in legal objections and detailed above.
In support of his complaint, the complainant has tendered into evidence his affidavit dated 27.3.2019 (Ex. C-4) and documents (Ex.C-1 to Ex.C-3).
In order to rebut the evidence of complainant, the opposite party has tendered into evidence affidavit of Jitendra Dhabhai Manager (Legal) dated 27.5.2018 (Ex. OP-1//5) and the documents (Ex. OP-1/1 to Ex.OP-1/4).
The learned counsel for the complainant has argued that complainant had purchased policy of insurance of opposite party which was valid from 4-5-2018 to 3-5-2019. It is further argued that complainant was handedover insurance card and was not supplied with terms and conditions of the policy and other related documents and till date terms and conditions and documents have not been supplied to the complainant inspite of assurance. It is also argued that during continuation of policy of insurance, complainant fell ill and thereafter on 30-1-2019, he visited Pragma Hospital, Bathinda and remained under treatment and the claim for cashless treatment was lodged but the said claim was rejected by the opposite party with the excuse that relation of the presenting condition with the stated ailment, the said ailment condition falls within one year waiting period of the policy, but the said terms and conditions were never supplied to the complainant. It is further argued that complainant was not suffering from any problem when he took policy of insurance and opposite party got the complainant medically examined before issuance of policy of insurance. The denial of payment of claim amounts to deficiency in service on the part of the opposite party.
On the other hand, learned counsel for the opposite party argued that claim of the complainant was declined as claim was in respect of Coronary Artery Disease and since the policy is in first year, case is denied mentioning the first year exclusion clause 3.9 related heart disease. The said clause 3.9 of policy reads as under :
3. Exclusion applicable to first year of cover from commencement of the policy, from the following disease/illness and related complications unless an add on cover waiving this exclusion is purchased by payment of additional premium to us: ix. Hypertension, Heart Disease and related complication .
Accordingly, claim of the complainant for cashless was rightly rejected by the opposite party. However, thereafter complainant lodged claim for reimbursement which is still pending decision and the complainant had submitted some documents i.e. medical bills, admission, discharge record of the hospital etc., and claim is pending. It is further argued that complaint is pre-mature and is liable to be dismissed as there is no deficiency in service on the part of the opposite party.
We have considered the rival contentions and have gone through the record carefully.
It is admitted fact that complainant had obtained policy of insurance from the opposite party which is Ex. OP-1/1 and it is further admitted fact that complainant suffered from health problem during continuation of policy and remained under treatment on 28-1-2019 as per discharge summary Ex. OP-1/4. It is further admitted fact that claim of the complainant for cashless insurance was declined by the opposite party vide Denial of Cashless Access letter Ex. C-3.
The disputed question before this Commission is whether the decision of the opposite party of having denied cashless access and thereafter keeping the claim lodged by the complainant pending since 30.1.2019 is right. This Commission has gone through the record produced by the opposite party. As per Ex. OP-1/1, terms and conditions produced by the opposite party wherein as per Exclusion Clause, hypertension and heart disease have been excluded for one year but it has been vehementally argued by learned counsel for the complainant that such terms and conditions were never supplied or explained to the complainant by the opposite party when policy of insurance was issued. It has further come on record that complainant was not suffering from any health problem at the time of issuance of policy of insurance. As such, this Commission is of the view that since there is nothing on record to prove that complainant was suffering from any health problem at the time of issuance of policy of insurance, as such, merely by saying that heart disease is excluded for first one year, opposite party cannot decline the claim of the complainant. As per anatomy of the body, when there is blockage in any artery and in some subordinate arteries is formed, if a person has no problem, he will not go for angiography or an angioplasty. There is no evidence on record to show that complainant was having any pre-existing disease on the date of proposal. The opposite party has not produced on record any opinion of doctor/medical expert in evidence to corroborate its version. Even the opposite party has not been able to produce a single document to show that complainant ever remained admitted in any hospital for treatment of heart problem before issuance of policy of insurance. Moreover, this Commission is of the view that heart problem, diabetes and hypertension are most common diseases and more than 70% of population is suffering from such problems. As such, this Commission is of the view that declining of cashless claim of the complainant was not justified on the part of the opposite party especially in the case when there is no evidence on record that complainant was suffering from any heart problem at the time of issuance of policy of insurance.
A perusal of Discharge Summary (Ex. OP-1/4) shows that 'History of Ilness' is mentioned as 'patient presented to the hospital with chief complaints of chest pain' and 'Hospital Course' is mentioned as 'Patient was admitted for coronary artery status evaluation. CAG was performed which revealed single vessel disease. Patient was advised PTCA to Lcx. However, patient and his relatives are not willing for the same at present. Patient is now being discharged in better state.' Thus, perusal of discharge summary reveals that there was no such major heart problem as defined by the opposite party in Ex. OP-1/1.
During the course of arguments, learned counsel for the complainant has also relied upon the judgement of Hon'ble Supreme Court reported in 2018 (1) Law Herald Supreme Court 832 wherein Hon'ble Supreme court has laid down as under :-
“Insurance – Life insurance and premium accepted without conducting medical examination amounts to waiving of condition transcripted in proposal form. Insurance held liable to pay”
In an another judgement 2019 (3) Law Herald Supreme Court 2378 wherein it has been laid down by Hon'ble Supreme Court as under :-
“Consumer Act – Medi-claim Policy – during the time of taking individual policy, there was no pre-existing disease. At the time of renewal, family medi-claim policy was taken. Claim under family medi-claim policy cannot be repudiated on the ground of non-disclosure of pre-existing disease.”
Therefore, by taking into consideration the entire evidence and documents on record and by relying upon the judgement of Hon'ble supreme Court, this Commission is of the view that cashless claim of the complainant was wrongly declined by the opposite party on false grounds and the act on the part of the opposite party of having kept the claim of the complainant pending after rejection of cashless, since 2019, amounts to deficiency in service.
Accordingly, present complaint is partly allowed and opposite party is directed to settle and pay the claim of the complainant within 45 days from the date of receipt of copy of this order. The complainant is further held entitled to damages to the tune of Rs. 5,000/- on account of mental tension, harassment and litigation expenses.
The compliance of this order be made by the opposite party within 45 days from the date of receipt of copy of this order.
The complaint could not be decided within the statutory period due to heavy pendency of cases.
Copy of order be sent to the parties concerned free of cost and file be consigned to the record room.
Announced:-
17-05-2023
- (Lalit Mohan Dogra)
President
(Shivdev Singh)
Member
