Punjab

Ludhiana

CC/21/161

Tehal Singh - Complainant(s)

Versus

SBI General Insurance Co.Ltd - Opp.Party(s)

G.P.S.Kahlon

19 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:161 dated 24.03.2021.                                                         Date of decision: 19.10.2023.

 

Tehal Singh aged about 54 years son of S. Santokh Singh, resident of 138-B, Police Line, Civil Lines, Ludhiana.                                                                                                                                                  ..…Complainant

                                                Versus

1. S.B.I. general Insurance Company Limited, 2^nd Floor, Takkar Towers, B-XIX-121/1, Mall Road, Adjoining Golden Plaza, Near Fountain Chowk, Civil Lines, Ludhiana.
2.  S.B.I. General Insurance Company Limited, Corporate & Registered Office at Natraj 301, Junction of Western Express Highway & Andheri, Kurla Road, Andheri (East), Mumbai-400069.

…..Opposite parties 

Complaint Under section 35 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. G.P.S. Kahlon, Advocate.

For OPs                          :         Sh. Vyom Bansal, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                In brief, the facts of the case are that on the repeated requests and visit of the representative of opposite parties, the complainant purchased Arogya Plus Policy No.0000000015515363 on 22.11.2019, which was further renewed vide policy No.0000000015515363-01 having validity from 23.11.2020 to 22.11.2021 for a sum assured of Rs.3,00,000/-. The complainant did not avail any claim during first policy period. The complainant stated that in the month of November 2020, he suffered acute chest pain radiating in left arm/sweetening due to which he was immediately moved to Randhawa Hospital, Amritsar where he was diagnosed of CAD AWSTEMI. The complainant underwent Primary PTCA + Stenting to LAD on 23.11.2020 and remained admitted in the hospital from 23.11.2020 to 25.11.2020 as indoor patient and spent Rs1,70,000/- approximately on his treatment. The complainant was assured by the opposite parties for cashless treatment up to Rs.3,00,000/- but when the complainant requested the opposite parties for providing cashless treatment, the representatives of the opposite parties lingered on the matter on one pretext or the other. Later on the opposite parties refused to fulfill the claim of the complainant. However, vide communication dated 16.02.2021, the opposite parties told the complainant to fulfill certain formalities with assurance to disburse the claim amount. The complainant duly complied with the formalities but finally the opposite parties rejected his claim without any reason and rhyme vide letter dated 28.02.2021. The complainant claimed to have suffered mental agony and harassment due to deficiency in service on the part of the complainant. In the end, the complainant requested for issuing direction to the opposite parties to pay the claim of Rs.1,70,000/- along with compensation of Rs.1,00,000/- and litigation expenses of Rs.33,000/-.

2.                            Upon notice, the opposite parties filed joint written statement and assailed the complaint by taking preliminary objections on the ground of maintainability of complaint; lack of jurisdiction; concealment of material facts etc.  

                   Under the column of factual submission, the opposite parties stated that the Complainant was issued a Family floater under Arogya Plus Policy subject to terms and conditions of the Policy No. 15515363 for the period of 23.11.2019 to 22.11.2020 and renewed vide Policy No. 15515363-01 for further period of 23.11.2020 to 22.11.2021 for a maximum sum of Rs. 3,00,000/- by the opposite parties. The complainant thoroughly read over and understood the policy terms and conditions.  The benefits under the policy are governed by the terms and conditions of the Policy and the liability of the opposite parties is limited to the insured perils occurring within the policy period subject to conditions and exceptions as mentioned in the terms and condition of the Policy. The opposite parties further stated that the complainant intimated a claim for treatment of CAD-AWSTEMI from Randhawa Hospital, Amritsar which was duly registered vide CCN No. 4848083 and thereafter it was being administered by Paramount Health Services & Insurance TPA Pvt. Ltd. A reimbursement claim was lodged by the insured whereupon an initial deficiency Letter dated 31.12.2020 was issued by the TPA wherein all the deficiency was listed and thereafter reminder letter dated 08.01.2021, 16.02.2021 were sent to the Insured raising query for;

a. As per the patient statement "patient had h/o HTN since 2 years hence kindly provide cause of CAD in view of HTN.

b. Reason for not revealing HTN history initially.

As per Indoor Case Paper it was observed that patient/complainant got admitted in the Randhawa hospital on 23.11.2020 with chief c/o chest pain radiating to left arm and sweating since 1 day and HTN. The patient/complainant diagnosed with CAD during hospitalization and underwent CAG on 23.11.2020 and Primary PTCA Stenting to LAD on the same day and Patient discharged from the hospital on 25.11.2020. Patient/complainant is suffering from hypertension since 2 years as specified by the doctor. Patient/complainant did mention the etiology of his diagnosis. The complainant had given a statement to investigation that he has suffering Hypertension since 2 years and used to take medicine when required" the said statement duly singed by the complainant on 07.01.2021 with photo ID proof. On the ground of the complainant statement the treating hospital authority has also confirmed that patient had hypertensive. The said authority statement duly sealed and signed by the treating hospital authority. Also as per treating doctor verification dated 09.01.2021 patient did not inform history of hypertension at the time of admission. The opposite parties further stated that it has also observed that the complainant had planned his hospitalization on 23.11.2020 and on the same date the said policy was renewed for second policy term and the complainant had meticulously planned that his claim did not fall under the 1 year exclusion (hypertension, heart disease and related complications are fall under the 1 year policy exclusion). Considering above mentions facts the Complainant had taken the undue advantage of insurance policy to plan his hospitalization after expiry of 1 year policy and cause loss to the insurance Company. After collecting the requisite medical documents, statements and enquiry, the authorized official of the Insurance Company applied his mind to the said documents and in terms of the coverage under the policy found the present claim to be misrepresented and thus not payable and the same was intimated to the Complainant vide letter dated 28.02.2021, which is reproduced as under:-

"The reported claim of Mr. Tehal Singh is for treatment of coronary artery disease with anterior wall myocardial infarct for which percutaneous transluminal coronary angioplasty was done. As per submitted documents and investigation report of claim, it is evident that the submitted claim documents are false in nature. As per the declaration letter from the patient dated 07.01.2021, it has been mentioned that insured is having hypertension since 2 years but as per treating doctor verification dated 09.01.2021 patient did not Inform history of hypertension at the time of admission. In view of misrepresentation of the fact the claim is declined for settlement and not admissible for the violation of the declaration made in the claim form which reads as "I hereby declare that the information furnished in this claim for is true & correct to the best of my knowledge and belief. If I have made any false or statement, suppression or concealment of any material fact with respect to questions asked in relation to this claim, my right to claim reimbursement shall be forfeited.” This claim for hospitalization falls beyond purview of policy coverage and hence not payable.”

                   On merits, the opposite parties reiterated the crux of averments made in the preliminary objections and facts of the case. The opposite parties have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

3.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1, Ex. C2 is the copy of insurance documents/policy w.e.f. 23.11.2020 to 22.11.2021, Ex. C2, Ex. C3 is the copy of I-cards of the complainant, Ex. C4 is the copy of redeficiency letter dated 16.02.2021, Ex. C5 is the copy of letter written by the complainant to the opposite parties, Ex. C6 is the copy of certificate dated 19.02.2021 issued by Dr. H.S. Randhawa, Chief Consultant Cardiologist, Randhawa Hospital, Ex. C7 is the copy of repudiation letter dated 28.02.2021, Ex. C8 is the copy of final bill, Ex. C9 to Ex. C15 are the copies of the receipts/bills, Ex. C16 is the copy of discharge summary, Ex. C17 is the copy of certificate of dated 25.11.2020 issued by Dr. H.S. Randhawa, Chief Consultant Cardiologist, Randhawa Hospital, Ex. C18 is the copy of angiography report, Ex. C19, Ex. C20 is the copy of lab report of Dr. Bhasin Path Labs, Ex. C21 is the copy of ECG report, Ex. C22 is the copy of text message and closed the evidence.

4.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RA of Sh. Arvind Singh Naruka Assistant Manager of SBI General Insurance Co. Ltd. New Delhi office along with documents Ex.  R1 is the copy of policy documents, Ex.  R2 is the copy of claim form, Ex. R3 is the copy of deficiency letter dated 31.12.2020, Ex. R4 is the copy of first reminder letter dated 08.01.2021, Ex. R5 is the copy of redeficiency letter dated 16.02.2021, Ex. R6 is the copy of discharge summary, Ex. R7 is the copy of questionnaire for insured, Ex. R8 is the copy of questionnaire for doctor, Ex. R9 is the copy of repudiation letter dated 28.02.2021 and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with documents produced on record by both the parties.

6.                It is an admitted case of the complainant having obtained insurance policies from opposite parties w.e.f. 23.11.2019 to 22.11.2020 and 23.11.2020 to 22.11.2021 for himself and his wife Smt. Amarjit Kaur. During the second policy year, the complainant was admitted in Randhawa Hospital, Amritsar from23.11.2020 to 25.11.2020 under the treatment of Dr. H.S. Randhawa. As per discharge summary Ex. C16 = Ex. R6, Tehal Singh, a 54 years male was admitted with chief complaints of chest pain radiating to left arm/sweating for one day. He was diagnosed as CAD-AWSTEMI with no past history of any illness. The complainant lodged claim Ex. R2 with the opposite parties which was repudiated vide letter dated 28.02.2021 Ex. C7 = Ex. R9 being not payable on the ground of misrepresentation of facts of the complainant having suffered from hypertension since 2 years.    

7.                Perusal of discharge summary Ex. C16 = Ex.R6 as well as certificate Ex. C6 of treating Dr. H.S. Randhawa, Chief Consultant Cardiologist Randhawa Hospital, Amritsar shows there is no past history of HTN in this patient’s history provided by the patient to the hospital and there is also no past cardiac history in this patient. The opposite parties got filled insured questionnaire form dated 07.01.2021 Ex. R7 from the insured in which the insured patient admitted the factum of having suffering from hypertension from last two years and used to take medicine when required. The opposite parties further got filled questionnaire dated 09.01.2021 from the doctor in which the treating Dr. H.S. Randhwa stated that as per patient statement he is suffering from HTN but during hospitalization they have not informed to the consulting doctor. However, the opposite parties have taken the ground of repudiation of the claim that in the proposal form no such pre-existing disease was disclosed.

8.                It is apposite to mention that neither the complainant nor the opposite party tendered copy of proposal form submitted by the complainant at the time of purchasing the insurance policy. In the absence of any duly signed and authenticated proposal form the matter in controversy cannot be adjudicated upon in favour of the opposite party. The proposal form is material document from which it could have been easily assessed whether there was concealment on the part of the complainant. Non-production of proposal form leads to inevitable inference that either the proposal form was not got executed before issuing the policy or there are certain anomalies and discrepancies in the proposal form, production of which may prove adverse to the rights of the opposite parties. It was also well within the legitimate rights of the opposite parties to get the complainant medically examined by the empanelled doctors but no such option was exercised.

9.                In this regard, reference can be made to Religare Health Insurance Company Ltd. Vs Subhash Chander Aggarwal in 2017(3) CLT 140 whereby it has been held by Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh that hypertension is a common disease and can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack. Further reference can be made to Tarlok Chand Khanna Vs United India Insurance Co. Ltd. 2012(1) C.P.J. 84 whereby it has been held by Hon’ble National Consumer Disputes Redressal Commission, New Delhi  that the onus to prove that the insured was suffering from pre-existing disease was on the insurer and if the insurer has not produced the expert opinion, the reasons for repudiation of the claim were held to be unjustified. A reference can be further made to Lakhwinder Singh and another Vs United India Insurance Company etc.  decided in Appeal No.29 of 2009 whereby it has been held by Hon’ble State Consumer Disputes Redressal Commission, U.T, Chandigarh that the maladies like diabetes, hypertension being normal wear and tear of the life cannot be treated as pre-existing diseases.

10.              Further in a case titled as Manmohan Nanda Vs United India Assurance Co. Ltd. and others 2022(I) CPJ 20 (SC) wherein the Hon’ble Supreme Court of India has observed as under:-

“(6)   The appellant’s argument that there is no hard and fast rule that every person with DM-II will necessarily have a cardiac disease merely because it is a risk factor holds water. A person who does not suffer from DM-II can also suffer from a cardiac ailment. He had disclosed his DM-II status for which he was under treatment. The ECG report and other tests also indicated normal parameters. Further, statins were a preventive prescription to prevent development of cardiac issues as DM-II is a risk factor, not because he had a cardiac ailment or hyperlipidaemia. Further, the examining physician was informed of the same before the policy was taken. Accordingly, there was no suppression of any material fact by the appellant to the insurer.

(7)     It was for the insurer to gauge related complications based on the information provided. The insurance company did not think that the medical and health condition of the appellant was such which did not warrant issuance of a medical policy. The insurance company therefore did not decline the proposal of the assured as a prudent insurer.”

Therefore, in our considered view, the repudiation of the claim on the basis of non-disclosure of pre-existing disease such as hypertension could not have been made a ground to reject the claim.  The insurance companies are required to be more liberal in their approach without being too technical. In the given set of above said facts and circumstances, it would be just and appropriate if the repudiation letter 28.02.2021 Ex. C7 = Ex. R9 issued by the opposite parties is set aside and the opposite parties are directed to settle and reimburse claim lodged by the complainant in respect of his treatment at Randhawa Hospital, Amritsar along with composite costs of Rs.10,000/-.

11.              As a result of above discussion, the complaint is partly allowed with an order that the repudiation letter 28.02.2021 Ex. C7 = Ex. R9 issued by the opposite parties is set aside and the opposite parties are directed to settle and reimburse claim lodged by the complainant in respect of his treatment at Randhawa Hospital, Amritsar as per terms and conditions of the policy within period of 30 days from the date of receipt of copy of the order failing which the opposite parties shall pay interest @8% per annum on the settled amount to the complainant from the date of order till its actual payment. The opposite parties shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Payment of costs shall be made within a period of 30 days from the date of the receipt of the copy of this order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.            

12.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)             (Sanjeev Batra)

Member                         Member                              President        

 

Announced in Open Commission.

Dated:19.10.2023.

Gobind Ram.