Order by:
Aparana Kundi, Member
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that in the year of 2021, the complainant purchased the policy from the opposite party No.2 at Moga, which is still continue till May 2024. Submitted that at the time of inception of the policy in the year 2021 the complainant already described to the official of opposite party No.2 regarding his disease of hypertension and the said fact is mentioned in the policy which is started in the year of 2021, 2022 and 2023. In the month of May, 2023 blood pressure of complainant was highly raised and he took various medicines but his blood pressure was not controlled, then complainant went to PGI Chandigarh for routine check up and Doctor gave an advised to complainant for MRI and other tests. Thereafter on the instruction of the doctor of PGI Chandigarh, complainant got various blood tests, echo graphy and MRI done from Jalandhar and Chandigarh and atlast, doctor gave an advise to the complainant to get the right adrenal mass operated. Then on the advise of doctor of PGI Chandigarh, on 15.07.2023, the complainant got admitted at PGI Chandigarh and on 24.07.2023 operation of complainant was conducted and he was discharged from the Hospital on 29.07.2023. Thereafter entire medical tests and hospital bill were paid by the complainant which was approximately Rs.2,09,145/-. The complainant also submitted the entire documents with the Opposite Parties for the reimbursement of medical expenses, but the Opposite Parties vide letter dated 08.01.2024 repudiate the claim of the complainant. Thereafter complainant sent an email to Opposite Parties on 19.01.2024, but on 4th April, 2024, Opposite Parties again repudiated the claim of the complainant on the ground of non disclosure of disease. The Opposite Parties were asked many times to pay the claim amount, 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.2,09,145/- with regard to the policy no.P/211222/01/2024/001365.
b) To pay a sum of Rs.1,00,000/- as compensation on account of mental tension, and harassment.
c) To pay Rs.50,000/- 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 appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present false complaint is filed without any cause of action, as the claim of the complainant was initially repudiated by the answering Opposite Party for want of documents. Averred further that the present application pertains to insurance claim under the “Young Star Insurance Policy” bearing number P/211222/01/2024/001365 valid from 19.05.2023 to 18.05.2024 covering the complainant self and his spouse Neha Gupta and Krishna Gupta and Avika Gupta-dependant children for a sum of Rs 10,00,000/- It is worth to note here that the insured availed the said policy through online proposal form and in the online proposal form the insured verify the fact by confirming the OTP sent on his mobile number. And hence the insured himself authenticated the details through OTP at May 11th 2021, 6:14 pm received by SMS. 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 insured 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 RT Adernal Mass, at PGI Hospital from dated 15.07.2023 to 29.07.2023. On scrutiny of the claim documents, the following documents were found necessary to process the claim, hence Opposite Parties advised the insured vide letters dated 21.10.2023, 05.11.2023, 20.11.2023 and 24.01.2021 to furnish the following documents:-
i. Clarify from treating doctor stating the exact duration of present complains when was it first diagnosed and any past history of the same.
ii. As per records the patient is known case of primary hyperaldosteronism, submit first consultation paper and all supporting reports.
Further insured had submitted the query reply. On scrutiny, it was observed that the insured had not submitted the documents which were mandatory for claim processing called for by Opposite Parties, which amounts to non submission of required documents. In the absence of the above documents/details, Opposite Parties were not able to further process the claim. As per Condition No.18 of the above policy, the insured person had to submit all the required documents and details called for by Opposite Parties. But for the reasons stated above Opposite Parties were unable to settle the claim under the above policy and Opposite Parties had repudiated the claim for want of details etc. and the claim was repudiated vide letter dated 08.01.2024. Further Opposite Parties had received rejection reconsideration request from the insured and the team had re-examined the claim records and was of the opinion that the CT report dated 06.07.2020 and its findings mentioned in the submitted discharge summary shows hypodense lesion noted in right adrenal gland and adrenal adenoma which confirms that the insured patient has above disease prior to inception of medical insurance policy. The present admission and treatment of the insured patient is for non disclosed disease.
As per discharge summary, since July, 2020 treatment was going on for this disease. The investigation section of discharge summary shows the CT 2020 reports saying Right adranal gland shows hypodense lesion 13 x 10 mm with averago CT value of 6- 7 HU. At the time of inception of the policy which was from 19.05.2021 to 18.05.2022, the insured had 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, if there is any misrepresentation / nondisclosure of material facts whether by the insured person or any other person acting on his behalf, the Company is not liable to make any payment in respect of any claim. Further as per Condition No.7, the policy was also liable to be canceled and necessary action was to be taken by the Corporate Office. Averred further that complainant availed policy through online and has deliberately answered "None" to the query raised in the online proposal form regarding Health history of insured patient, which is reproduced as under:-
"Health History:
Do you have any health problems (if any) in the below field.
NONE"
Have you or any member of your family proposed to be insured, suffered or are suffering from any disease/ailment/adverse medical condition of any kind especially Heart/Stroke/Cancer/Renal disorder/Alzheimer's disease/ Parkinsons's disease- "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. 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 complainant not come with clean hands. He has not disclosed the entire true facts. 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.C66.
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 & 2/16.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. Availing of the policy namely “Young Star Insurance Policy” bearing number P/211222/01/2024/001365 for the period 19.05.2023 to 18.05.2024, hospitalization of the complainant at PGI, Chandigarh from 15.07.2023 to 29.07.2023, treatment of the ailment ‘Right Adernal Mass’ and operation of the same on 24.07.2023 and lodging of the claim by the complainant are admitted. The only dispute arises in the instant complaint is that Opposite Parties repudiated the claim of the complainant on the ground of non disclosure of material facts.
7. The contents of repudiation letter dated 08.01.2024 (Ex.OP1 & 2/13) is reproduced as under:-
“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of RT Adrenal Mass.
It is observed that the insured has not submitted the documents which are mandatory for claim processing/called for by us which amounts to non submission of required documents.
In the absence of above documents/details, we are not able to further process your claim.
As per Condition No.18 of the 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. Now, we have to see whether the repudiation of the claim by Opposite Parties is genuine or not? We have carefully perused the discharge summary of PGI, Chandigarh duly placed on record by both the parties (Ex.C12 & Ex.OP1&2/6), wherein in the heading investigations against “CECT Abdomen” test reports, it is mentioned as under:-
Jul 6, 2020:- CT Multiphase Study of 06-JUL-2020:Results: Volumetric scanning for the triple phase study was obtained on a MDCT 16 slice scanner using 70 cc of I/V contrast The liver is enlarged, measures 22 cm craniocaudally. It is normal in shape and attenuation. No focal lesion is seen. No intra hepatic biliary radicle dilatation seen. Portal vein and CBD are not dilated. Portal vein shows normal opacification. Gall bladder is partially distended and shows normal wall thickness. No hyperdense calculus seen.- Suggested USG correlation. Pancreas, Spleen and left adrenal gland are is normal in size, shape and attenuation. Right adrenal gland shows hypodense lesion 13 x 10 mm with average CT value of 6-7 HU.
Further in the discharge summary against the ‘MRI’ test report, it is mentioned as under:-
Jun 28, 2023:- Liver measures -21 cm in length and shows normal outline with mild diffuse fatty Infiltration. Hepatic veins and portal vein are normal. No focal lesion/IHBRD seen. Gall bladder is distended and shows dependant sludge. CBD is normal.? Spleen measures-12.3 cm and shows normal outline and signal intensity. No focal lesion seen. ? Pancreas is normal in bulk and signal intensity. No focal lesion seen. MPD is not dilated. Bilateral kidneys are normal in size and signal intensity. No e/o hydronephrosis. A few subcentimetric simple cortical cysts are seen in both kidneys. A well-defined T1/T2 hypointense lesion measuring-2.2 x 1 cm is seen in the medial limb of the right adrenal gland.
Hence from the discharge summary it is well proved that the complainant has been suffering the ailment in question i.e. “Right Adrenal Mass” from 6th July, 2020 i.e. before the inception of the policy, as in the policy document ‘date of inception of first policy is mentioned as 19th May, 2021 and the complainant has not disclosed about his ailment at the time of availing the policy in question, which amounts to concealment of material facts.
9. In this regard, ld. counsel for the Opposite Parties put reliance on the pronouncement of Hon’ble National Consumer Disputes Redressal Commission, New Delhi, in case LIC Vs Kuldeep Singh decided on 03.06.2015, wherein Hon’ble National Commission held as under:-
“Though the term "material fact" has not been defined in the Insurance Act, it is understood to mean any fact which would influence the judgment of a prudent insurer in fixing the premium or determining whether he would like to accept the risk. Any fact which goes to the root of the Contract of Insurance and has a bearing on the risk involved would be "material".
Another Reference be made on Judgement of Hon’ble Supreme Court of India in case Satwant Kaur Sandhu Vs New India Assurance Co. Ltd.- 2009(4) RCR Civil 692), wherein, it has been held:-
“At the time of taking policy insured was suffering from Diabetes Nephropahy/Chronic Renal Failure- Insured did not disclose this fact of ailment while taking policy-Held fact suppressed was a material fact-Insurance Co. justified in repudiating the claim.”
10. Keeping in view the aforesaid facts and circumstances and relying upon the judgements of Hon’ble Supreme Court of India as well as Hon’ble National Commission, New Delhi (supra), we are of the view that Opposite Parties have rightly repudiated the claim of the complainant as per terms and conditions of the policy.
11. From the above discussion, the present complaint is hereby dismissed. Keeping in view the aforesaid facts and circumstances of the complaint, 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 in Open Commission
