District Consumer Disputes Redressal Commission, Aligarh

                                                Date of Institution : 05.08.2022

                                                            Date of final hearing:22.12.2022

                                                            Date of Pronouncement 02.01.2023

Case No. 151/2022   

IN THE MATTER OF

Nasreen Qazi W/o Qazi Parvez Akhtar age about 54 years R/o 3/3 Madpura, opposite Railway Station,Masjid wali gali Aligarh
 

                                                         V/s

Star Heathance  General Insurance Company Ltd. Office No.15 Balaji Complex ,First Floor Whites Lane,Royapettah,Chennai 600014 through servicing branch office 2^nd floor Krishna Complex, J-77 Janakpur Colony Ramghat Road, Aligarh represented by the authorized signatory                              

                                                    (Through: Navin Kumar Saxena)

CORAM

 Present:

1. Shri Hasnain Qureshi, President
2. Shri Alok Upadhayay, Member
3. Smt. Purnima Singh Rajpoot, Member

PERONOUNCED by Shri Hasnain Qureshi, President

JUDGMENT

1. The present complaint has been filed by the complainant before this commission for  the following reliefs-

1. The Op be directed to reimburse the complainant Sum Rs. 500000/ incurred by her in her treatment with pendente lite and future interest at the rate 9% per annum.
2. The Op be directed to pay the complainant Rs. 50000/ as compensation for harassment and Rs. 20000/ as litigation expenses.

2. The Complainant has stated that She had subscribed a family health optima insurance policy No. P/ 231120/01/2022/011386 issued by OP valid from 20.12.2021 to the mid night of 19.12.2022 with the limit of coverage Rs. 1000000/ and recharge benefit Rs. 150000/. The Complainant had suffered from breathing problem in the the month of January 2022 and she was admitted in Al Samad Hospital, Aligarh on 25.01.2022 from where she was referred to higher center for further management. She contacted Medanta Max City, Gurgram where she had undergone treatment. Complainant applied for preapproval for biopsy treatment and made a claim which was wrongly dined by the Op. Complainant also made a chemotherapy claim which also wrongly and illegally repudiated alleging that the insured patient had  carcinoma lung for the past three months prior to inception of the policy. Complainant had no knowledge about any disease like carcinoma lung at any time prior to making proposal to subscribe the policy. She had disclosed the information of the facts known to her and she was not under obligation to disclose the facts what she ought to have known. Complainant had incurred the amount Rs. 500000/ while undergoing treatment and she is entitled for reimbursement for the same with compensation for harassment and litigation.
3. Op stated in the WS that the insured had availed family health optima Insurance Policy covering Mr. Quazi Parvez Akhatar, spouse Mrs. Nasreen Quazi and dependent child Zaid Parvez Quazi for a floater sum  Rs. 1000000/ vide policy no.P/231120/01/2022/011386 for the period from 20.12.2021 to 19.12.2022.Insured Mrs. Nasreen Quazi was inttially hospitalized at Sir Ganga Ram, New Delhi for treatment and further at Medanta on 10.02.2022 for treatment of Mediasninal Lesion. Insured had raised pre authorization request to avail cashless treatment but it was observed on scrutiny of the documents that the insured was diagnosed for carcinoma lung. The Op was unable to consider for cashless treatment of the above disease  hence the request was rejected. On perusal of documents it was observed that insured had carcinoma lung prior to the inception of the policy which was not disclosed in the proposal. The case is frivolous and is liable to  dismissed.
4.  Complainant has filed his affidavit and papers in support of his pleadings. Ops have also filed affidavit in support of their pleadings.
5. We have perused the material available on record and heard the parties counsel.
6. The first question of consideration before us is whether the complainant can be held liable for non-discloser of preexisting disease?
7. It is alleged by the Op that the complainant had suffering from carcinoma lung for past three months prior to inception of the policy. Complainant has deposed in her affidavit that she had suffered from breathing problems in the month of January,2022 and she had no knowledge of having undergone any disease like carcinoma lung at any time prior to making proposal to subscribe the policy. She had disclosed at the time of making proposal to subscribe the policy whatever was within her knowledge and obligation to disclose the information on her part was extended only to the fact which were known to her and not to what she ought to have known. It is clear that the complainant can not be expected to know about the disease like carcinoma lung. The complainant is not expert in medical science and alleged disease could not be diagnosed by a person like the complainant and it is the person skilled in medical science may be capable of knowing the disease. An ordinary person like complainant is expected to know the symptoms and not cause of symptoms. Complainant has stated on oath that She had been suffering from breathing problems and there is no reason to disbelieve her statement. Under the circumstances it is inferred that the complainant was having the knowledge of disease like carcinoma lung and she had simply the knowledge of breathing problems at the time of subscribing the policy. Thus the complainant can not be held liable for not disclosing alleged preexisting disease.    
8.   The question formulated above is decided in favour of the complainat.
9. The Second question of consideration before us is whether the OP  is liable to reimburse the complainant for Sum Rs. 500000/ incurred in her treatment ?
10.  The complainant and Op are bound by contractual obligations of the insurance policy as a contract. The Op was under obligation to investigate the reality and op was competent to seek details regarding medical condition of the complainant by getting her examined by one of its empanelled doctors and through necessary medical tests. If on consideration of the medical reports the Op would have satisfied about the medical condition of the complainant than there was no risk of preexisting disease and thereafter Op could have issued the policy. Op did not conduct the enquiry and issuing the policy without necessary investigation and enquiry, it would be presumed to have waived the necessity of any   further information and the Op shall be presumed to have satisfied with the information given by the complainant. Op has failed in discharging its obligation and cannot thereafter contend that there was a preexisting disease. The Op is estopped from rejecting the claim on the ground of suppression of material facts.
11. The relevant law applicable to present case is laid down by Hon’ble Supreme Court in the case Mammohan Nanda Vs United India Assurance Company Ltd.  Decided on 06.12.2021.
12.  The question formulated above is decided in favour of the complainat.
13.  Keeping in view the facts of the present case, we hereby direct to Op to pay the assured sum Rs.500000/ with pendente lite and future interest at the rate 9% per annum. Op is also directed to pay to the complainant Rs. 20000/ as compensation for harassment and Rs. 10000/ for litigation expenses.
14. A copy of this judgment be provided to all the parties as per rule as mandated by Consumer Protection Act, 2019. The judgment be uploaded forthwith on the website of the commission for the perusal of the parties.
15. File be consigned to record room along with a copy of this judgment.

                                                                          ( Hasnain Qureshi )

President

                                                                              ( Alok Upadhayay)

    Member                                                              

Pronounced On:    2.1.2023