Order by:
Sh.Amrinder Singh Sidhu, President
1. The complainant has filed the instant complaint under section 12 of the Consumer Protection Act, 1986 (now section 35 of Consumer Protection Act, 2019) on the allegations that the complainant had purchased the life insurance policy bearing No.P/211226/01/ 2020/000114 from Opposite Party No.2 having coverage of Rs.5 lakhs valid for the period 14.05.2019 to 13.05.2020. Further alleges that during the policy period i.e. on 28.06.2019 the complainant suddenly felt chest pain and he was immediately brought to Moga Medicity, Hospital where the treating doctor diagnosed the complainant and on the same day, the stent surgery was conducted and the complainant remained in the hospital till 29.06.2020, where the hospital authority charged Rs.2,20,000/- from the complainant on account of hospitalization charges. After discharge, the complainant lodged the claim with the Opposite Parties for the reimbursement of his medical claim and also completed all the relevant formalities, but the Opposite Parties repudiated the claim of the complainant vide letter dated 24.12.2019 on the ground of concealment of pre existing disease, whereas the complainant was never diagnosed for such disease before the proposal of the policy. As such, there is deficiency in service on the part of the Opposite Parties. Vide instant complaint, the complainant has sought the following reliefs.
a) The Opposite Parties may be directed to reimburse the death claim amounting to Rs.2,20,000/- and also to pay Rs.50,000/- on account of compensation due to mental tension and harassment caused by the complainant besides Rs.11,000/- as litigation expenses.
b) And any other relief to which this Hon’ble Consumer Commission, Moga may deem fit be granted in the interest of justice and equity.
2. Opposite Parties-Insurance Company appeared through counsel and contested the complaint by filing the written version taking preliminary objections therein inter alia that the complaint filed by the complainant is not maintainable and is liable to be dismissed as the complainant has attempted to misguide and mislead this District Consumer Commission. Brief facts are that the complainant has concealed the material facts regarding his past health history. The claim is reported in the second month of 1st year of the policy. On scrutiny of the claim documents, it is observed that as per documents, he complainant submitted the claim for reimbursement of medical expenses towards the treatment of CAD-Acute Coronary Syndrome PWSTEMI, CAG TVD for the hospitalisation period of 28.06.2019 to 29.06.2019. The medical team of Opposite Parties observed that CAG report dated 28.06.2019 shows LAD 60-70% disease, LCX Proximal 100% disease, RCA proximal CTO and the findings of ECG submitted conform no evidence of actuates change. Based on these findings, the medical team of Opposite Parties is of the opinion that the insured patient has chronic, long sanding heart disease, existing prior to inception of the first medical Insurance policy, hence the above diagnoses is a pre existing disease and hence, the claim was denied vide letter dated 01.11.2019. On merits, the Opposite Parties took up almost same and similar pleas as taken up by them in the preliminary objections and hence no illegality has been committed by the Opposite parties while repudiating the claim of the complainant and the complaint may be dismissed with costs.
3. In order to prove his case, the complainant has tendered into evidence his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C34 and closed the evidence on behalf of the complainant.
4. On the other hand, to rebut the evidence of the complainant, Opposite Parties also tendered into evidence the affidavit of Sh.P.C.Tripathy, Zonal Manager Ex.Ops1/11 alongwith copies of documents Ex.Ops1/1 to Ex.Ops1/10 and closed the evidence.
5. We have heard the ld.counsel for the parties, perused the written submissions of the Opposite Parties and also gone through the documents placed on record.
6. During the course of arguments, ld.counsel for the Complainant as well as ld.counsel for Opposite Parties has mainly reiterated the facts as narrated in the complaint as well as in the written statement respectively. We have perused the rival contentions of the parties and also gone through the record on file.
7. The main contention of the complainant is that at the time of proposal the life assured complainant was not suffering any disease, but the opposite parties intentionally and knowingly repudiated the lawful and genuine claim of the complainant for the hospitalization of his medical treatment without application of mind. On the other hand, ld.counsel for the Opposite Parties has repelled the aforesaid contention of the complainant on the ground that on scrutiny of the claim documents, it is observed that as per documents, the complainant submitted the claim for reimbursement of medical expenses towards the treatment of CAD-Acute Coronary Syndrome PWSTEMI, CAG TVD for the hospitalisation period of 28.06.2019 to 29.06.2019. The medical team of Opposite Parties observed that CAG report dated 28.06.2019 shows LAD 60-70% disease, LCX Proximal 100% disease, RCA proximal CTO and the findings of ECG submitted conform no evidence of actuates change. Based on these findings, the medical team of Opposite Parties is of the opinion that the insured patient has chronic, long sanding heart disease, existing prior to inception of the first medical Insurance policy, hence the above diagnoses is a pre existing disease and hence, the claim was denied vide letter dated 01.11.2019.
8. The main point for adjudication vehemently contended before us by Opposite Parties is that on scrutiny of the claim documents, it is observed that as per documents, the complainant submitted the claim for reimbursement of medical expenses towards the treatment of CAD-Acute Coronary Syndrome PWSTEMI, CAG TVD for the hospitalisation period of 28.06.2019 to 29.06.2019. The medical team of Opposite Parties observed that CAG report dated 28.06.2019 shows LAD 60-70% disease, LCX Proximal 100% disease, RCA proximal CTO and the findings of ECG submitted conform no evidence of actuates change. Based on these findings, the medical team of Opposite Parties is of the opinion that the insured patient has chronic, long sanding heart disease, existing prior to inception of the first medical Insurance policy, hence the above diagnoses is a pre existing disease. But we do not agree with the aforesaid contention of the ld.counsel for the Opposite Parties. The onus to establish this fact is upon the Opposite Parties in this case. We have perused the copies of medical record placed by Opposite Parties of the treating hospital, but there is neither any affidavit nor complete particulars of the investigator recorded in them. Even the original certificate has not been placed on the record. There is no affidavit of doctor of the treating hospital to establish this fact on the record regarding previous disease of insured. He is a private doctor and not posted in any recognized health institute or government hospital. We are unable to rely upon the above referred investigation report appended with the Photostat copy of medical record of complainant. In the absence of any affidavit of investigator and the affidavit of treating doctor of the hospital, we do not place any reliance upon these documents, as pressed into service by the Opposite Parties in this case. Consequently, we are of this view that Opposite Parties have failed to discharge the onus solemnly laid upon it to prove this fact that life assured was suffering from above pre-existing disease before taking the policy and he deliberately and fraudulently concealed this material fact from Opposite Parties. We, thus, conclude that there is no substantive evidence on the record to prove this fact that life assured was suffering from any disease before he took the insurance policy and he willfully suppressed this fact fraudulently from the Opposite Parties. Moreover, if the life assured was suffering from any diseases prior to issuance of the policy, in question, the same must not have escaped the notice of the empanelled doctors of the Insurance Company. However, no such investigation record has been produced by the opposite parties. In case Bajaj Allianz Life Insurance Co. Ltd. & Ors. Vs. Raj Kumar III (2014) CPJ 221 (NC), it was held by the Hon’ble National Commission that “usually, the authorized doctor of the Insurance Company examines the insured to assess the fitness and after complete satisfaction, the policy is issued. It was held that the Insurance Company wrongly repudiated the claim of the complainant.”
9. Furthermore, as per the Customer Identity card, attached with the policy document, at the time of obtaining the policy, the life assured has duly mentioned his age as 01.01.1962 (meaning thereby which is more than 45 years, so it was the bounden duty of the Opposite Parties-Insurance Company to get the life assured medically examined before issuing the policy in his name who was above 45 years of age. In support of his contention Ld.counsel for the complainant placed reliance upon I.R.D.A.I Rules and Instructions with regard to thorough medical examination if the insured is more than 45 years which is reproduced as under:-
“As per instructions issued by the Insurance Regulatory and Development Authority of India (IRDAI), it was bounded duty of the insurer to put insured to thorough medical examination in case Mediclaim insured was more than 45 years and if insurance company failed to do so then insurance company has no right to decline the insurance claim on account of non disclosure of the facts of pre existing disease when the policy was taken. The above observations is supported by law cited in SBI General Insurance Company Limited Vs. Balwinder Singh Jolly” 2016(4) CLT 372 of the Hon’ble State Commission, Chandigarh.”
However, the Opposite Parties-Insurance Company has not placed on record any evidence that before issuing the policy they ever got medically examined the insured. So the abovesaid law squarely covers the case of the complainant that it was the duty of the insurer to get medically examined while issuing the policy and once the policy was issued the insurer cannot take the plea of pre-existing disease of the insured.
10. It also needs to be mentioned that Section 19 of the General Insurance Business (Nationalization) Act, 1972 states that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community. The denial of medical expenses reimbursement is utterly arbitrary on the ground that disease in question was pre-existing disease. It is mere an excuse to escape liability and is not bona fide intention of the insurance company. Fairness and non-arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State and public behavior. Any policy in the realm of insurance company should be informed, fair and non-arbitrary. When the insurance policy has exclusions/conditions to repudiate the claim or limit the liability, the same must be specifically brought to the notice of the insured and are required to be got signed to show that such exclusions and conditions have been brought to his/her notice. Recently, our own Hon’ble State Consumer Disputes Redressal Commission, Chandigarh in First Appeal No. 50 of 2019 titled as Bajaj Alliance General Vs. Arjan Singh decided on 04.03.2021 also held so.
11. The need for interpreting a contract always arises in two situations, (i) when a gap is needed to be filled in the contract and (ii) an ambiguity is needed to be resolved in the contract, then to find out correct intention of the contract, spirit behind it is required to be considered. Normally, the insurance policy is a contract of adhesion in which other party is left with hardly any bargaining power as compared to the insurer. Insurance contracts are standard form contracts and are drafted by the insurance company and as such, insurance company is at higher footing than the insured. The benefit of such clause, as exclusion clause, would go to the insured unless the same is explained in clear terms by the insurer. In such circumstances, the tribunal would be more oriented towards the interpretation which goes against the party who has inserted/drafted the disputed clause in the agreement/contract. The adjudicating authority is required to look into whether the intention of the party is to exclude or limit liability has been appropriately explained to the other party or not. This Commission while interpreting insurance agreement is to honour the intention of the parties, who have signed the agreement. Even if the agreement had general exclusion/condition for misrepresentation still fraudulent misrepresentation and non-disclosure may not be there. The innocent and negligent misrepresentations are to be ignored. On the other hand, the rulings (i) Satwant Kaur Sandhu Vs. New India Assurance Company Limited, (ii) Murti Devi Vs. Birla Sun Life Insurance and (iii) Mamohan nanda Vs. United India Insurance Company Limited, cited by the ld.counsel for the Opposite Parties are not applicable and relevant to the facts of the present case. The insurance companies are in haste to charge the premium, but when the time to pay the insurance claim comes, they generally take up one excuse or the other to avoid their liability. The reliance of counsel for the appellant on law laid down in “Life Insurance Corporation of India Vs. Priya Sharma & others” 2012(4)CPJ-646, “Life Insurance Corporation of India & others Vs. Harbans Kaur” 2009(3)CPC-677, and “Life Insurance Corporation of India & another Vs. Ashok Manocha” 2011(3)CPC-285, would have been applicable, had this fact been established that life assured suffered from pre-existing ailment of kidney and he deliberately suppressed this fact fraudulently from the Opposite Parties, when he took the insurance policy. In view of our finding recorded above that Opposite Parties had failed to prove this fact that complainant was suffering from any pre-existing ailment and hence these authorities would not be attracted in this case. In this regard, on the same and similar facts and circumstances of the case, Hon’ble State Consumer Disputes Redressal Commission, in First Appeal No.62 of 2015 decided on 02.02.2017 in case India First Life Insurance Vs. Ms.Sudesh Rani also held so.
12. In such a situation the repudiation made by Opposite Parties-Insurance Company regarding genuine claim of the complainant have been made without application of mind. It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
13. In view of the above discussion, we hold that the Opposite Party-Insurance Company have wrongly and illegally rejected the claim of the complainant.
14. Now come to the quantum of compensation. The complainant has claimed the amount of Rs.2,20,000/- allegedly spent on his medical treatment, but perusal of the record i.e. billing sheet shows that he has placed on record the medical bills for an amount of Rs.2,08,132/- and on the other hand, the Opposite Parties have also submitted that the complainant has claimed the amount as per billing sheet upto the extent of Rs.2,08,132/- and hence we hold that the complainant is entitled to the reimbursement of this amount.
15. In view of the aforesaid facts and circumstances of the case, we partly allow the complaint of the Complainant and direct Opposite Parties-Insurance Company to pay Rs.2,08,132/- (Rupees two lakh eight thousands one hundred thirty two only) to the complainant alongwith interest @ 8% per annum from the date of filing the present complaint i.e. 21.08.2020 till its actual realization. The compliance of this order be made by the Opposite Parties within 60 days from the date of receipt of copy of this order, failing which the complainant shall be at liberty to get the order enforced through the indulgence of this District Consumer Commission. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Commission.
