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 complainant has taken the health insurance policy for himself and his family members on 13.07.2020 vide insurance policy no.P/21122/01/2021/001915 for the period 13.07.2020 to 12.07.2021, which was renewed from time to time. Lastly the complainant renewed the policy, vide policy no.P/211222/01/2024/005477, which is valid for the period from 08.09.2023 to 07.09.2024. Thereafter, the complainant suffered with the health problem and went to S.S.K. Neuro Phychiatry Hospital, Ferozepur on 02.-09.2023, but said hospital gave advice to complainant to got his checkup from Guru Gobind Singh Medical Collage Hospital, Faridkot and thereafter complainant visited Guru Gobind Singh Medical Collage Hospital Faridkot on 05.09.2023 and after checkup concerned doctor of said hospital gave advice to complainant to conduct his MRI-Brain etc and also advice to consult with the department of Endocrinology and thereafter on 09.09.2023 MRI of the brain of complainant was conducted and then complainant again visited the said hospital on 13.09.2023 and then the concerned doctor after seeing the said repot of MRI again gave advice to complainant for Endocrinology Consultation and thereafter complainant visited Radhey Radhey Welfare Societies Circular Road, Near Blind Home Near Makhu Gate Ferozepur on 18.09.2023 and then the concerned doctor of said hospital after checkup prescribed the medicine to complainant and referred complainant to Dr. Rakesh Goyal at Ludhiana and said concerned doctor also conducted the medical tests of complainant though laboratories namely Endocrine Lab and Dr. Mona Path Lab on 26.09.2023 respectively. After above said treatment when problem of complainant not resolved, then on 27.12.2023 complainant gone to Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh for his treatment and from where it came to the knowledge of complainant that he has suffered with the problem of Acromegaly and Diabetes and then he admitted in the said hospital for his treatment and remained admitted there for the period 27.12.2023 to 17.01.2024 and the said hospital authority duly informed the Opposite Parties about the hospitalization. Alleged that the complainant spent Rs.1,15,343/- on his treatment at the PGI. Thereafter the complainant submitted his claim of medical reimbursement alongwith original medical record of the hospitals and bills to the Opposite Parties at Moga and Opposite Parties also issued claim intimation no.CIR/2024/211222/1382056 to complainant. But however, to the surprise of the complainant, the Opposite Parties declined/repudiated the claim of the complainant and also cancelled the policy of the complainant. Alleged that the complainant has not concealed any material facts from the Opposite Parties and moreover the said policies have been issued by Opposite Parties after conducted the medical tests of the complainant and even complainant had continuously taken the above said health policies since 13.07.2020. The complainant also sent a legal notice dated 06.04.2024 to Opposite Parties to settle the claim of the complainant and not to terminate the above said medical policy and if terminated then restore the same, but to no effect. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to pay an amount of Rs.1,15,343/- with interest @ 12% per annum to the complainant from the date of filing of present complaint till the realization of the amount.
b) To restore the above said health policy of the complainant, which was cancelled by the Opposite Parties vide its letter dated 02.04.2024.
c) To pay a sum of Rs.50,000/- as compensation on account of mental tension and harassment.
d) To pay Rs.5500/- as costs of complaint.
2. Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Party on the ground of Pre-existing disease & Non-Disclosure of material facts. Averred further that the present complaint pertains to insurance claim under Family Health Optima Insurance Plan bearing No.P/211222/01/2024/005477 valid from 08.09.2023 to 07.09.2024 covering the Complainant self and his spouse Priyanka Batra and dependant child Vyan Batra for a sum of Rs 3,00000/-. The policy was in continuation since 13.07.2020. 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 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 had submitted for the reimbursement vide Claim no.CIR/2024/211222/1382056 for the expenses of the treatment of CAD on 17.12.2022 to 17.01.2024 in PGI. It has been observed from the submitted documents that the insured patient has history of Acromegaly since 2015, which is prior to inception of medical insurance policy. At the time of inception of the policy which is from 13.07.2020 to 12.07.2021, Insured had not disclosed the above mentioned medical history/ health details in the proposal form, which amounts to misrepresentation/ non-disclosure of material facts. As per Condition No.1 of the policy issued to insured, the policy shall become void and all premium paid thereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or non-disclosure of any material fact by the policy holder. Further as per Condition No.7, the policy was also liable to be cancelled and necessary action will be taken by our Corporate Office. Hence, the claim was rejected and the same was informed to the insured vide letter dated 02.04.2023.
Averred further that the Proposer, in the Proposal form has affirmed that the Insured person was in Good health and that he has not consulted or taken treatment which could be gathered from the following:-
1. Are you in good health and free from physical and mental disease or infirmity. If not give details - Yes
2. Have you consulted / taken treatment/been admitted for injury/Surgery - If yes, details - No any illness/disease
4. Have you ever suffered or suffering from any of the following
m) Any other problem (Please Specify) - No
From the above findings, it is clearly evident that the insured is well aware of the past medical history of the insured person and failed to disclose the same in the proposal form during the porting 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. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. In order to prove the case, complainant has placed on record his affidavit as Ex.C1 alongwith copies of documents Ex.C2 to Ex.C72.
4. On the other hand, Opposite Parties have placed on record affidavit of Sh.Sumit Kumar Sharma, Authorized Signatory, Star Health & Allied Insurance Co. Ltd. as Ex.OP1 & 2/A and copies of documents Ex.OP1 & 2/1 to Ex.OP1 & 2/12.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. It is admitted that the complainant has been availing the health insurance policy from the Opposite Parties since, 2020 and renewed it from time to time. Lastly the complainant availed the policy from the Opposite Parties, vide policy bearing no.P/211222/01/2024/005477 for the period 08.09.2023 to 07.09.2024 covering self, his spouse and his dependent child. It is also proved on record that during the policy coverage, complainant felt some health problem and visited many hospitals, when he got no relief from different hospital, he finally approached to PGI, Chandigarh, where he was diagnosed as ‘Acromegaly with Secondary DM with Hypogonadotropic Hypogonadism and remained admitted in the said hospital for the period 27.12.2023 to 16.01.2024. It is not disputed that after discharge from the hospital, the complainant lodged the claim for the reimbursement of the expenses incurred by him on his treatment, which was not admitted by the Opposite Parties, vide letter dated 02.04.2024. The said non admission of the claim has been challenged by the complainant through this complaint.
7. It is pertinent to mention here that vide instant complaint, the complainant has also prayed for the restoration of the policy in question, as the same was canceled by the Opposite Parties, but during the pendency of this complaint, the said policy of the complainant got renewed by the Opposite Parties and in this regard, the complainant had made a separate statement dated 23.07.2024 before this Commission, which is reproduced as under:-
“Stated that the policy in question still in force and even the same is renewed by Opposite Party for the period 8th Sep, 2024 to 7th Sep, 2025 and the copy of the same is Mark- P1. So, I withdraw the complaint in part qua the relief of revival of the policy in question.”
Now, the only relief of the complainant is regarding the non payment of claim in question.
8. The claim of the complainant was not admitted by the Opposite Parties and in this regard they issued a letter dated 02.04.2024 (Ex.OP1& 2/10). The contents of which are reproduced as under:-
“After a comprehensive assessment by our medical team, we’ve observed that we’re unable to admit the claim because of the below-mentioned reason(s):
Policy Exclusion Clause No./Condition(s), if any: NA
Detailed Remarks:
It is observed from the submitted documents that the insured patient has history of acromegaly since 2015, which is prior to inception of medical insurance policy.
At the time of inception of your policy which is from 13.07.2020 to 12.07.2021, you have not disclosed the above mentioned medical history/health details of the insured-person in the proposal form which amounts to misrepresentation/ non-disclosure of material facts.
As per Condition No.1 of the policy issued to you, the policy shall become void and all premium paid thereon shall be forfeited to the Company, in the event of mis-representation, mis description or non-disclosure of any material fact by the policy holder.
As per Condition No.7, the policy is also liable to be cancelled and necessary action will be taken by our Corporate Office.
9. However, the plea taken by the Opposite Parties for non-admitting the claim of the complainant is not genuine, as it is observed from the certificate duly issued by Dr.Pinaki Dutta, Endocrinology of the PGI, Chandigarh (Ex.C67) that patient has suffering from diabetes and Acromegaly for the last three months. For the sake of convenience, the contents of that said certificate is reproduced as under:-
“This is to certify that Mr.Paras Batra, s/o Ashok Batra, 37 Y/M; CR No.-202305595881 is under treatment in Endocrinology Department from December, 2023 till now under Dr.Pinaki Dutta. He has suffering from diabetes and Acromegaly for the last three months. This certificate is issue for the purpose of the Star Health Insurance Policy.”
We are of the concerted view that the certificate so issued by the doctor of PGI, Chandigarh is sufficient enough to prove that complainant has no history of Diabetes and Acromegaly prior to the inception of the policy. Thus, the non admitting the genuine claim of the complainant by the Opposite Parties on the ground of pre-existing disease or previous ailment is wrong and not justified. Further the onus to prove that the complainant was suffering from a pre-existing disease as per settled law is on the Opposite Parties, but the Opposite Parties have not produced any documentary evidence/expert medical opinion in support of its case. For this observations we are well guided by judgments of Hon’ble National Consumer Disputes Redressal Commission in case titled Reliance Life Insurance Co. Ltd & Anr. v. Tarun Kumar Sudhir Halder in Revision Petition No. 2097 of 2019 has also held so:-
"The Insurance Company has not filed any evidence to show that the DLA was taking treatment for the disease prior to filling up of the proposal form. Even if there was disease inside the body, but the life insured did not know about the disease and was not taking any treatment for the same, the insurance claim cannot be denied on mere presumption that the life assured might be suffering from pre-existing disease. Thus, on merits, I am convinced on the (FA-383/2016) PAGE 8 OF 10 basis of the entries in the Medical Attendant Certificate that the disease was complained for the first time by the DLA on 22.06.2011, which is much after the date of the proposal form. The onus to prove the pre-existing disease lies on the Insurance Company and no supporting documents have been filed by the Insurance Company in support of their assertion. "
10. In view of the above discussion, we are of the opinion that the Opposite Parties have wrongly and illegally repudiated the claim of the complainant.
11. Vide instant complaint, the complainant claimed the amount of Rs.1,15,343/-, which is duly proved on record vide Ex.C13 to Ex.C65. Hence, we allow the said amount.
11. In view of the discussion above, the instant complaint is allowed in part and Opposite Parties are directed to make the payment of Rs.1,15,343/- (Rupees One Lakh Fifteen Thousand Three Hundred Forty Three only) to the complainant. Further Opposite Parties are directed to pay compository cost of Rs.10,000/- (Rupees Ten Thousand only) as compensation and litigation expenses to the complainant. The pending application(s), if any also stands disposed off. The compliance of this order be made by the Opposite Parties within 30 days from the date of receipt of copy of this order, failing which, the Opposite Parties are further burdened with additional amount of Rs.10,000/- (Rupees Ten Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced on Open Commission
