Chandigarh

DF-II

CC/806/2022

HARI CHAWLA - Complainant(s)

Versus

SBI GENERAL INSURANCE CO LTD - Opp.Party(s)

SATEEKSHAN SOOD

02 Aug 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	806 of 2022
Date  of  Institution	:	06.12.2022
Date   of   Decision	:	02.08.2023

 

 

 

 

 

1]  Hari Chawla s/o Late Sh.Hans Raj Chawla,

2]  Sarita Chawla w/o Sh.Hari Chawla,

Both residents of H.No.3023, Sector 21-D, Chandigarh 160022

             …..Complainants

 

Versus

SBI General Insurance Company Ltd., SCO 335-336, 1^st & 2^nd Floor, Sector 35-B, Chandigarh 160035

   ….. Opposite Party

 

 

BEFORE:  MR.AMRINDER SINGH SIDHU,       PRESIDENT

                MR.B.M.SHARMA                 MEMBER

 

Argued by: -

Sh.Sateekshan Sood, Counsel for the complainant

Sh.J.P.Nahar, Counsel of OP

 

PER B. M. SHARMA, MEMBER

 

        Briefly stated, the complainants obtained a health insurance policy from the OP in the year 2019 namely “Arogya Plus Policy” – Family Floater and got it renewed from time to time and lastly it was renewed from 3.6.2022 to 2.6.2023. It is stated that in the policy the pre-existing disease of complainant No.1 as Diabetes & Dyslipidemia had also been mentioned. Unfortunately, the complainant No.1, feeling uncomfortable on 29.8.2022 visited PGIMER, Chandigarh, where he was admitted on that day-29.8.2022 vide CR No.202203916298, treated for heart-ailment by insertion of two stunts and discharged on 30.8.2022 (Ann.A-3).  It is stated that the total expenditure incurred by the complainant on the said treatment was Rs.3,40,655/- (Ann.A-4) and to get its reimbursement, the complainant lodged claim with the OP Insurance Company. It is submitted that the complainant also submitted a certificate issued by the treating doctor of PGI dated 26.9.2022 (Ann.A-6) to the effect that exact cause of present heart ailment cannot be defined as there are multiple risk factors for the heart disease and diabetes is just one of them. However, the OP repudiated the claim vide letter dated 12.10.2022 on the ground that the insured had history of Diabetes Mellitus which is pre-existing in nature, which is a risk factor for Coronary Artery Disease, hence not payable under the purview of policy.  Hence, this complaint has been preferred alleging the said act & conduct of the OP as deficiency in service and unfair trade practice.

 

2]       The Opposite Party has filed written version and while admitting the factual matrix of the case, stated that the insurance policy was taken for Rs.3 lacs but it is denied that there is any Top Up Cover of Rs.7 lacs.  It is admitted that the policy was renewed and because of the bad risk factors, the loading of premium was done.  It is submitted that as per Investigation Report Ann.OP-3, the complainant was diagnosed   hematemesis NASH related chronic liver disease, DM and chronic cholelithiasis on 5.11.2021 at Paras Hospital, he was suffering from hyperlipidemia since 2007 as gathered from prescription dated 12.12.2018 and he was also suffering from tuberculosis and these new facts came to light during the investigation. It is submitted that admittedly the complainant is diabetic and diabetes is a strong risk factor for causing heart problem.  It is also submitted that the doctor has given the certificate just to help the complainant and the doctor should have pinpointed the cause of the heart disease of the complainant. It is pleaded that the doctor has not specified whether any of the causes given below his signatures have caused the heart disease and thus the diabetes is the only cause in the present case for causing heart ailment to the complainant.  It is also pleaded that since diabetes has caused the present heart ailment and the complainant is the known case of diabetes mellitus for last 10 years, the repudiation of claim is justified as per terms & conditions of the policy. Denying other allegations, the OP has prayed for dismissal of the complaint.

3]       Replication has also been filed by the complainant controverting the assertions of the OP made in its reply.       

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have gone through the documents on record including written arguments.

 

6]       The Policy document Ann.AA-3 bearing No.0000000013343744-03 proves that the complainants were insured with OP Company under Family Floater cover for sum insured of Rs.10 lacs valid from 3.6.2022 to 2.6.2023.  The OP has not disputed that the complainant No.1/insured, was treated for heart ailment at PGIMER, Chandigarh during said policy period and incurred expense of Rs.3,40,655/- on the said treatment.

7]       The OP repudiated the claim for reimbursement of said medical expenses vide letter dated 12.10.2022 (Ann.OP-4) stating that as per letter from treating doctor (Dr.Rajesh Vijayvergiya), Diabetes mellitus is a risk factor for Coronary Artery Disease and the insured has history of Diabetes Mellitus for 10 years, which is pre-existing in nature and current ailment is complication of the same and thus the claim as per policy is not payable.  The OP in its written version specifically stated that since diabetes has caused the present heart ailment and the complainant is the known case of diabetes mellitus from last 10 years, the repudiation of claim is fully justified.

 

8]       We do not find force in the contention and plea of OP.   It is clear from the previous as well as present policy (Ann.A-1 & AA-3) that Sh.Harish Chawla, complainant No.1 had already disclosed about his being diabetic, which is mentioned in the policies. Therefore, it is clear that the OP was well aware of the fact that the insured was a diabetic and was taking all necessary medication for preventing further complications and controlling the disease, so there was no suppression of the fact of the complainant No.1 being diabetic.

 

9]       The certificate issued by the treating doctor (Dr.Rajesh Vijayvergiya) (Ann.A-6), which has also been relied upon by the OP in its repudiation letter dated 12.10.2022, states as under:-

“…Coronary angiography revealed a significant block in one of the coronary artery, which was successfully stented.  He is a known case of diabetes mellitus from last 10 years, which is under control with medicines.  The exact cause for present heart ailment cannot be defined as there are multiple risk factors for heart disease and diabetes is one of them…
 

10]      It is clear from the said certificate that the diabetes of the complainant Hari Chawla  was under control with medicine and that the heart ailment suffered by him is not due to diabetes mellitus but there are multiple risk factors for heart disease and diabetes is just one of them.  The doctor also certified that the diabetes mellitus of complainant Hari Chalwa is under control with medicines. Thus it is clear that the OP misinterpreted the certificate of treating doctor and concluded otherwise.

 

11]      More so, there is no evidence led by the OP to establish that the pre-­existing condition of Diabetes Mellitus­ Type II was the cause for the heart ailment/attack suffered by the complainant No.1 or that the complainant No.1 had any pre-­existing heart related illness, disease or condition.  Further, it is not the stand of the OP that the diabetes mellitus cannot be controlled by medicines. In this view of the matter, we are of the opinion that the OP Company has wrongly & illegally repudiated the genuine claim of the complainant No.1, which amounts to deficiency in service and unfair trade practice on their part and it certainly has caused loss and harassment to him.    

 

12]      Reliance has also been placed on the latest decision of Hon’ble Apex Court in Civil Appeal No.8386/2015 – Manmohan Nanda Vs. United India Assurance Co. Ltd. & Anr., decided on 6.12.2021 wherein similar issue, as in present case, has been dealt with.

 

13]      Taking into consideration the discussion & findings aforesaid, we are of the opinion that the deficiency in service as well as unfair trade practice on the part of the OP has been proved. Therefore, the present complaint is allowed with direction to the Opposite Party to reimburse an amount of Rs.3,40,655/- to the complainant No.1 along with interest @10% p.a. from the date of discharge – 30.8.2022 till the date of its realization. The OP is also directed to pay compensation amount of Rs.25,000/ to the complainant No.1 for the harassment, mental agony and loss caused to him due to their deficient service coupled with unfair trade practice, along with litigation cost of Rs.15,000/-.

 

         This order shall be complied with by the OP within a period of 45 days from the date of receipt of copy of this order, failing which the OP shall be liable to pay additional cost of Rs.20,000/- apart from above relief.

         Certified copy of this order be sent to the parties, free of charge. After compliance, file be consigned to record room.

Announced

02.08.2023                             

Sd/-

 (AMRINDER SINGH SIDHU)

PRESIDENT

 

Sd/-

 (B.M.SHARMA)

MEMBER