Order by:
Sh.Mohinder Singh Brar, Member
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that the complainant through his banker got insurance policy from Opposite Parties No.1 to 3 for the period from 08.06.2020 to 07.06.2021, which was renewed regularly. Lastly the complainant got renewed the said policy, vide policy no.P/211222/01/2022/002093 for the period 16.06.2023 to 15.06.2024 covering himself, his wife and his son. Unfortunately, wife of the complainant namely Parminder Kaur suffered Right knee problem and as per medical advice she undergone surgery for Right Knee on 4.11.2023 and she remained admitted in Sandhu Bone & Joint Hospital, Near Hotel Dev, Main Bazar, Moga for the period 03.11.2023 to 08.11.2023. The complainant spent huge amount of Rs.2,33,823/- on treatment of his wife. Alleged that the concerned doctor had asked the wife of the complainant from last how much period she has been suffering the problem in right knee, then she had replied that problem in right knee started about 3 years ago, whereas infact problem was started about 2 years ago. On 17.11.2023, the complainant lodged the claim form alongwith all the requisite medical reports and bills etc. with opposite party no.3, but the complainant received letter dated 28.11.2023 sent by opposite party no.1 to 3, vide which they required some documents. Then, the complainant submitted additional documents i.e. Certificate dated 29.11.2023 issued by Dr.R.S.Sandhu of Sandhu Bone & Joint Hospital, Moga alongwith other relevant record to the opposite party no.3. Thereafter, the complainant has received letter dated 15.12.2023 issued by opposite party no.1 to 3, whereby they have wrongly and illegally repudiated the claim of the complainant. The complainant requested the Opposite Parties to do the needful and to pass genuine claim of the complainant, but to no effect. Complainant also issued legal notice dated 23.02.204 to Opposite Parties, but to no effect. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to make payment of genuine claim of Rs.2,33,823/- alongwith interest @ 12% p.a. from 08.11.2023.
b) To pay an amount of Rs.5,00,000/- as damages.
c) To pay an amount of Rs.33,000/- as litigation expenses.
d) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite Parties No.1 to 3 appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present pre mature complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Parties as per policy terms and conditions. Averred that the present complaint pertains to insurance claim under ‘Family Health Optima Insurance Plan’ bearing No.P/211222/01/2024/002404 valid from 16.06.2023 to 15.06.2024 covering the complainant self, his spouse Parminder Kaur and Gursimran Singh Brar dependent Child for a sum of Rs.5,00,000/-. However it is submitted that the aforesaid insurance policy was issued to the insured by the answering Opposite Party subject to the terms and conditions of the insurance policy. The said terms and conditions were handed over and supplied to the insured at the time of the contract. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Averred further that the insured submitted claim documents for reimbursement for the treatment of 3 years O/C TKR (B/L) with Right Knee Stiff Painful at Sandhu Bone, Moga on dated 03.11.2023 to 08.11.2023. On scrutiny of claim documents, the following documents were necessary to process the claim, hence Opposite Parties advised the insured vide letter dated 28.11.2023 to furnish following details within 15 days:-
i. Letter from the treating doctor stating the exact duration of present illness.
ii. First consultation report, previous treatment taken details.
iii. Any past history of similar episode? If yes, to submit previous all consultation papers and prior treatment records taken since diagnosed.
In order to process the claim, the Opposite Parties had requested the insured to furnish previous TKR hospitalization documents and past treatment records which were not furnished by the insured. In the absence of the above documents/details, the Opposite Parties were not able to further process the claim of the insured. As per condition no.18 of the above policy, the insured person has to submit all the required documents and details called for by Opposite Parties. Since, the insured had failed to submit above said details and documents despite receiving the request letter from Opposite Parties, the claim was repudiated vide letter dated 15.12.2023.
Averred further that the insured patient herself had disclosed the past history to the treating Doctor as mentioned in the discharge summary that she had been having 3 years old complaint bilateral total knee replacement and now she was having complaint of pain in right knee since then and having complaint of stiff knee restricted and painful Range of motion cannot flex the knee beyond a few degree. This means that the insured patient had already undergone total knee replacement since 3 years ago that is before purchasing insurance from OPs where as the insured had not disclosed such previous ailments in the proposal form and which also amounts to misrepresentation and it is clearly evident that the insured was well aware of the past medical history of the insured person and failed to disclose the same in the proposal form during the purchase of policy, amounting to non disclosure of material facts thus violating the Cardinal Principle of the Insurance, making the Contract of Insurance voidable and unenforceable. The insured has omitted to disclose the material facts at the time of purchase of policy, which amount to non disclosure of material facts.
Averred further that the instant complaint is neither maintainable in law nor on facts; no deficient services have been rendered by the answering Opposite Parties as alleged by the complainant; the complaint being pre-mature and false is not maintainable; the complainant has not come with clean hands and has not disclosed the entire true facts. The complainant has suppressed the material facts from this Commission as well as from the Opposite Parties. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. Opposite Party No.4 appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complaint is neither maintainable against the answering OP Bank. No consideration or premium has been paid with respect to the insurance policy in question by the complainant or insured to the OP No.4 Bank; the complainant has got no cause of action against the answering bank; no deficient services have been rendered by the answering Opposite Party Bank as alleged by the complainant. The complainant has neither lodged any alleged claim with Opposite Party Bank nor the Bank has got any authority to entertain any claim whatsoever as alleged in the complaint; the answering Bank has acted as only facilitator for its customers to get insurance policies from the Opposite Parties No.1 to 3 as per their own will and Opposite Party Bank has got not interference either in the issuance of the insurance policy or entertaining of any subsequent claims or in the management of Opposite Parties No.1 to 3. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
4. In order to prove the case, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C51.
5. On the other hand, Opposite Parties No.1 & 2 have placed on record affidavit of Sh.Sumit Kumar, Authorized Signatory, Star Health & Allied Insurance Co. Ltd. Ex.OP1 to 3/A alongwith copies of documents Ex.OP1 to 3/1 to Ex.OP1 to 3/9. Whereas, Opposite Party No.4 has placed on record affidavit of Sh.Zorawar Singh, Senior Branch Manager, Bank of Baroda as Ex.OP4/A.
6. We have heard the ld. counsel for both the parties and also gone through the record.
7. It is well proved on record that the complainant is the holder of Insurance policy namely “Family Health Optima Insurance Plan” having no.P/211222/01/2024/002404 for the period 16.06.2023 to 15.06.2024 covering the complainant self and his spouse Parminder Kaur and dependent Child Gursimran Singh Brar for a sum of Rs.5,00,000/-. It is also proved on record that during the policy coverage, wife of the complainant namely Parminder Kaur suffered Right Knee Pain and got admitted in Sandhu Bone & Joint Hospital, Moga on 03.11.2023 where he was diagnosed a 3 years O/C TKR (B/L) with Knee Stiff Painful and treated for the same and after treatment got discharged from the hospital on 08.11.2023. After getting discharge from the hospital the complainant lodged the claim with the Opposite Parties for the reimbursement of expenses incurred on the treatment. On receipt of the claim, the Opposite Party-insurance policy issued a letter dated 28.11.2023 requiring some documents, which the complainant failed to supply. Thereafter, the Opposite Parties No.1 to 3, vide letter dated 15.12.2023 repudiated the claim of the complainant for want of documents.
7. The Opposite Parties rejected the claim of the complainant vide letter dated 15.12.2023 (Ex.OP1 to 3/9), the contents of letter is reproduced as follows:-
“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of 3 Years O/C B/L TKR with Right Knee Stiff Painful.
In order to process the claim, we had requested you to furnish previous TKR hospitalization documents and past treatment records. We note that you have not furnished the required documents and details. In the absence of the above documents/details, we are not able to further process your claim.
As per Specific Conditions No.18 of the above policy, the insured person has to submit all the required documents and details called for by us.
We therefore regret to inform you that for the reasons stated above we are unable to settle your claim under the above policy and we hereby repudiate your claim.
8. Perusal of the discharge summary (Ex.C6) reveals that wife of the complainant admitted in Sandhu Bone & Joint Hospital with complaint/history of 3 Years O/C TKR (B/L) now patient c/o Pain (R) Knee since then c/o Shift Knee Restricted & Painful ROM. In the said discharge summary under the treatment Course, it is mentioned that “Revision TKR (R) side done”. Hence, it is proved from the discharge summary that wife of the complainant suffering from the disease in question since 3 years and she admitted in the hospital for Revision of the said ailment.
9. Further in the policy document (Ex.OP1 to 3/4) the definition of pre existing disease is mentioned, the contents of which are reproduced as under:-
Pre-Existing Disease: Pre-existing Disease means any condition, ailment, injury or disease:
a) That is/are diagnosed by a physician within 48 months prior to the effective date of the policy/issued by the insurer or its reinstallment.
Or
b) For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstallment.
It is proved on record that wife of the complainant diagnosed with the disease in question within 48 months prior to the effective date of the policy, so her ailment falls under the definition of pre existing disease. Furthermore, the wife of the complainant had not disclosed about her such ailment in the proposal form while availing the policy in question, which also amounts to misrepresention. We find that there is sufficient reason to believe that the life assured suppressed the material facts of existence of her disease while issuance of the policy. Reliance in this regard can be placed on judgement of Hon’ble Supreme Court of India in case (1) Chachochan Vs. LIC (2007 X AD (SC) 429 Civil Appeal No. 5322 of 2007, Hon’ble National Commission in case LIC Vs. Mansa Devi-II 2003 CPJ 135 (NC). In these judgements (supra), it has clearly been held that the insurer is justified in repudiating a claim wherever there is a suppression of material fact. In the instant case, the DLA/policy holder did not disclose even in the proposal form about her pre existing disease and hence suppressed/ concealed the material facts from the Opposite Parties. . Hence we find no deficiency in service on the part of the Opposite Parties while repudiating the claim of the Complainant.
10. In view of the discussion above, the instant complaint is hereby dismissed. However, keeping in view the peculiar circumstances of the case, the parties are left to bear their own costs. Copies of the order be furnished to the parties free of cost. File be consigned to record room after compliance.
Announced on Open Commission