DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA.

Consumer Complaint No. 37 of 14.01.2015

Date of Decision            :   05.08.2015

Sham Goyal son of Shri Nand Lal, resident of House No.9-A, Kitchlu Nagar, Civil Lines, Ludhiana.

….. Complainant

Versus

1.Star Health and Allied Insurance Company Limited, 2716, Ist Floor, Gagan Complex, Backside Majestic Park Plaza Hotel, Gurdev Nagar, Pakhowal Road, Ludhiana-141001 through its Branch Manager.

2.Star Health and Allied Insurance Company Limited, KRM Centre, VI floor No.2, Harrington Road, Chetpet, Chennai-600031 through its Managing Director.

3.Harwinder Singh Code SH5787, Manager, Star Health and Allied Insurance Company Limited, 2716, Ist Floor, Gagan Complex, Backside Majestic Park Plaza Hotel, Gurdev Nagar, Pakhowal Road, Ludhiana-141001

…Opposite parties

                             (Complaint U/s 12 of the Consumer Protection Act, 1986)

QUORUM:

SH.G.K.DHIR, PRESIDENT

SH.SAT PAUL GARG, MEMBER

COUNSEL FOR THE PARTIES:

For complainant                      :         Ms.Neena Gupta, Advocate.

For OPs                         :           Sh.Rajeev Abhi, Advocate

PER G.K DHIR, PRESIDENT

1.                          Sh.Sham Goyal filed complaint under Section 12 of the Consumer Protection Act, 1986 against the OPs, by alleging that earlier he got Health insurance Policy from United India Insurance Company Limited for assured sum of Rs.5 lacs. This policy remained in existence for the last many years. Complainant was having desire to have policy with more assured sum, so that in case of illness and more expenses on treatment, he may get the amount reimbursed. In April 2011, OP3 approached complainant for disclosing about the insurance scheme of OP1 and OP2. It was disclosed that the said policy will be for hefty assured sum as a top off policy. That policy as per disclosure by OP3, may be considered as surplus (floater). It was further disclosed that sum assured in respect of the policy purchased from United India Insurance Company will remain of 5 lacs, but OPs will be responsible for expenses borne in excess of Rs.5 lacs. OP3 also assured to help complainant in case of need for getting any claim from the company. Signatures of complainant were obtained on blank forms and papers. Premium was received and thereafter, policy No.P-161114/01/2012/000241 was issued for period from 16.4.2011 to 15.4.2012. After the said period, this policy was renewed further from 16.4.2012 to 15.4.2013 and again from 16.4.2013 to 15.4.2014. Lastly, it was renewed from 16.4.2014 to 15.4.2015. Simultaneously the complainant kept on getting the policy from United India Insurance Company for initial assured amount of Rs.5 lacs. Complainant fell ill due to which he remained admitted in Global Health Private Limited Hospital from 21.9.2014 to 24.9.2014. Rs.7,08,069.99P were incurred as expenses on treatment. Complainant lodged claim by submitting the medical bills and complying with other formalities and thereafter, United India Insurance Company reimbursed the amount of Rs.2,08,069.99P after some deductions. However, claim for reimbursement of the remaining amount was repudiated by OPs by alleging that complainant did not disclose about the pre-existing disease and there was mis-representation and non-disclosure of material facts in that respect. Policy was issued by OPs after full satisfaction of the submitted particulars and as such, repudiation of the claim caused undue harassment, humiliation and mental tension to the complainant. Compensation for this harassment of Rs.1 lacs alongwith litigation expenses of Rs.20,000/- claimed in addition to the reimbursement of the amount of the medical bills of tune of Rs.2,08,069.99P alongwith interest @18% p.a.

2.                          In reply jointly submitted by OPs, it is pleaded interalia that the complaint is not maintainable; complaint is barred under Section 26 of the Consumer Protection Act, 1986; complaint is estopped by his own act and conduct from filing the present complaint; complaint is bad for mis-joinder of parties because OP3 is neither a necessary nor a proper party and moreover, complicated questions of law and facts requiring elaborate evidence are involved, due to which, the matter falls in the jurisdiction of Civil Court. Admittedly, complainant obtained Star Super Plus insurance policy for sum of Rs.10 lacs for period from 16.4.2011 to 15.4.2012, then from 16.4.2012 to 15.4.2013 and further from 16.4.2013 to 15.4.2014 and 16.4.2014 to 15.4.2015. As per condition no.7 of the policy, in case of mis-representation and non disclosure of material facts by the insured person or any other person acting on his behalf, the Ops not liable to make payment. Claim was submitted under the fourth year of the policy by submitting documents for reimbursement of the medical expenses incurred on treatment from 21.9.2014 to 24.9.2014. That treatment was for coronary artery disease (CAD) and triple vessel disease(TVD) at Medanta, the Medicity, Gurgaon. On scrutiny of the records, it was observed that as per discharge summary, the insured is a known case of CAD-Triple Vessel Disease with Post CABG since from 2003. This information was not supplied by the complainant at the time of purchase of the policy in the first instance. It was also revealed on scrutiny of records that complainant is a case of post PTCA-SVG-092 in 2012 and acute inferior wall MI(TNK 14.9.2014). Claim of complainant was rightly repudiated by OP1 and OP2 vide letter dated 9.12.2014. There was no deficiency in service or negligence on part of OPs. Each and every other averment of the complaint denied.

3.                Complainant to prove his case tendered his affidavit Ex.CA alongwith documents EX.C1 to Ex.C32 and then closed the evidence.

4.                On the other hand, counsel for OPs tendered in evidence affidavit Ex.RA of Sh.Rajnish Kohli, Assistant Vice President, claims of Star Health and allied Insurance and even tendered documents Ex.R1 to Ex.R10 and thereafter, closed the evidence.

5.                          Written arguments submitted by the OPs but not by the complainant. Rather, Ms. Neena Gupta Advocate represented complainant suffered statement on 4.8.2015 that she is not to submit the written arguments. Oral arguments addressed and were heard. Records gone through minutely. 

6.                Undisputed facts are that complainant purchased insurance policy from OP1 and OP2 in addition to the earlier purchased Health Insurance Policy from the United India Insurance Company Limited, so as to get additional benefit of reimbursement. Copy of Insurance Cover Note of policy purchased from United India Insurance Company Limited produced as Ex.C1, but of the policies purchased from OP1 and OP2 for period from 16.4.2012 to 15.4.2013 and 16.4.2014 to midnight of 15.4.2015 are produced on record as Ex.C2 and Ex.C3 by the complainant, but of period from 16.4.2011 to 15.4.2012 and 16.4.2012 to 15.4.2013 as well as from 16.4.2013 to 15.4.2014 and 16.4.2014 to 15.4.2015 are produced as Ex.R1 to Ex.R4 and Ex.R6 by the OPs. Proposal form for purchase of policy from Ops in the first instance on 13.4.2011 was submitted by the complainant and the copy of the same is Ex.R5. After going through that proposal form, it is made out that sum assured is of Rs.10 lacs with opted deduction of Rs.5 lacs. At the back of Ex.R5 there are columns aimed at providing information qua the earlier suffered diseases. Declaration thereunder is signed by the complainant for informing that the information supplied by him is correct. As per that declaration and information, the complainant claimed himself to be of good health and free from physical and mental disease or infirmity. Further information provided was that the complainant never suffered from diabetic, high blood pressure, heart disease, stroke, epilepsy, tuber culosis, Asthma or any other disease of bone joints or cancer etc. This information was supplied on 13.4.2011 by the complainant to Ops at the time of purchasing the policy in the first instance and on the basis of that provided information, the subsequent insurance coverage was continued to be provided. As per Exclusion clause No.1 on Ex.R1 to Ex.R4 and Ex.R6 or Ex.C2 and Ex.C3 each, benefits of pre-existing disease will not be available until 36 months of the continuous coverage have elapsed. The policy initially was purchased in April 2011, but reimbursement benefits claimed for treatment of complainant during period from 21.9.2014 onwards and as such, certainly these benefits claimed after lapse of 36 months of the purchased policy. Though, submissions of counsel for complainant in this respect has force, but by keeping in view the overall terms and conditions of the policy in question, it has to be held that the claim of the complainant has been rightly repudiated through Ex.C4 and Ex.C32.

7.                As per clause No.7 of terms and conditions of the insurance policy Ex.C5, the company shall not be liable to make any payment under the policy in respect of any claim, if such claim in any manner is fraudulent or supported by any fraudulent means or device, mis-representation of the insured person or by any other person acting on his behalf. In this case as declaration regarding not suffering of any heart disease in the past submitted by the complainant himself as referred above and as such, in case the previous history of complainant did show his sufferance from any such ailment, then the same will amount to mis-representation or suppression of material facts at the time of purchase of the policy. After going through Ex.C14=Ex.R7, it is made out that in the discharge summary of treatment of complainant got from Global Health Private Limited, it is mentioned that complainant was having previous history of CABG(2003); Post PTCA=Stent to SVG, OM2 (2012), Acute Inferior Wall MI(TNK+ - 14.09.2014). Further, in these documents, it is mentioned that the complainant is a known case of CAD-TVD, post CABG(2003). All these documents establishes that infact the complainant was suffering from heart disease, even prior to the purchase of the policy in 2011 from Ops. A person having history of heart disease since from 2003 must have disclosed about the same at the time of signing of declaration, but complainant did not disclose those facts at the time of purchase of the policy in 2011 and subsequently and as such, there is suppression of material facts.

8.                As per law laid down in case Rattan Chand J.Shah (since deceased) vs. Oriental Insurance Company Limited-III(2009)CPJ-111(Gujarat State Commission), in case the material facts qua history of heart disease or of undergoing treatment of CBGA not disclosed at the time of purchase of policy, then owing to suppression of material facts on part of complainant, his claim for reimbursement of the medical expenses liable to be repudiated. Same is the position in case before us and as such, repudiation of the claim owing to suppression of material facts is justified. Same is the proposition of law laid down in cases of National Insurance Company Limited vs. Satya Paul Tuli-IV(2003(CPJ-98(N.C.); LIC of India and others vs. Smt. Shashi Bala-IV(2003)CPJ-91(N.C.); Sapna Arora vs. Life Insurance Corporation and others-I(2009)CPJ-588(Punjab State Commission); Oriental Insurance Company Limited vs. Shanti Prasad Goyal and others-I(2013)CPJ-152(Haryana State Commission); United India Insurance Company Limited vs. Kanta Gupta-II(2012)CPJ-191(N.C.); Shakuntla vs. Life Insurance Corporation of India-III(2014)CPJ-517(N.C.). Version given by complainant in medical history recorded in the discharge summary to be taken as correct as per cases of Kulwant Sigh vs. United India Insurance Company Limited and others-IV(2008)CPJ-196(N.C.) and Dewar Surender Lal vs. Oriental Insurance Company Limited and another-I(2009)CPJ-117(N.C.). Written version of insurance company, if based on medical history disclosed by complainant at the time of hospitalization, the same to be taken as correct for repudiating the medical claim as per law laid down in case of Shakuntla R.Khosla vs. Oriental Insurance company Limited-II(2012)CPJ-78(Maharasthra State Commission). Same is the position in this case as revealed by the discharge summary and declarations discussed in detailed above.

9.                Terms and conditions of insurance policy contract is binding on the parties and nothing can be added or subtracted by giving different meaning to the words mentioned therein as per law laid down in cases Ind Swift Limited vs. New India Insurance Company Limited and others-IV(2012)CPJ-148(N.C.);  Usha Sharma and others vs. New India Assurance Co.Ltd. and others-I(2012)CPJ-488(N.C.). So assertions made in the proposal form by the complainant to be taken note of for finding, if really there is suppression of material facts. When those versions taken into consideration in this case in the light of condition no.7 referred above, then certainly repudiation of the claim for reimbursement is fully justified because of suppression of material facts qua the disease for which treatment was got by the complainant and on basis of which the claim is stacked.

10.              If complainant had been getting policies from United India Insurance Company for the last more than 10 years, then due to that alone, OPs not debarred from claiming suppression of material facts by complainant for repudiating the claim because the contract in this case arrived at after submission of the proposal form Ex.R5 by the complainant. The terms of Ex.R5 cannot be ignored at all because those formed the basis of the contract, on basis of which, the complainant was able to purchase the insurance policies from Ops. As fraudulent suppression of facts and mis-representation is a condition for repudiating the contract as per the agreement between the parties and as such in view of the suppressed material facts referred above, the claim has rightly been repudiated by the Ops. So, there is no deficiency in service on the part of the Ops.

11.              Therefore, as a sequel of the above discussion, the present complaint merits dismissal and same is hereby dismissed. Copy of this order be made available to the parties free of costs.

12.                        File be indexed and consigned to record room.

Dated:  05.08.2015

(Sat Paul Garg)                                                 (G.K.Dhir)

Member                                                               President