BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No. 142 of 2017
Date of Institution: 8.3.2017
Date of Decision: 20.11.2017
Mohinder Singh S/o Sh. Hukam Singh R/o B-359, Ranjit Avenue, Amritsar
Complainant
Versus
Star Health & Allied Insurance Company Limited through its Chairman/Managing Director/Principal Officer through its Branch office at District Shopping Complex, Ranjit Avenue, Amritsar through its Branch Manager
Opposite Party
Complaint under section 12 & 13 of the Consumer Protection Act
Present: For the Complainant : Sh.Deepinder Singh, Advocate.
For the Opposite Party: Sh. S.S. Salaria,Advocate
Coram:
Sh.Anoop Sharma, Presiding Member
Ms. Rachna Arora,Member
Order dictated by:
Sh.Anoop Sharma, Presiding Member
- Sh.Mohinder Singh complainant has brought the instant complaint under section 12 & 13 of the Consumer Protection Act on the allegations that complainant got Worldwide Health Benefit Mediclaim Insurance policy for himself from the opposite party covering the risk period from 18.3.2016 to 4.8.2016. The complainant went abroad and unfortunately fell ill and had to take the treatment . The total expenditure incurred on the medical treatment of the complainant was for USD $2724/48 & $ 421.85 . The opposite party was immediately informed about the said hospitalization and the treatment to be taken thereof as the said policy was issued on cashless basis. The sum assured for the medical benefit is for USD $2.5 Lakh and the complainant has to pay the hospital expenditure from his own pocket. The opposite party instead of making the said payment for the genuine claim of the complainant repudiated the same on the frivolous ground vide letter dated 17.10.2016 that the complainant was having the history of hypertension and was pre existing disease. It is pertinent to mention over here that the complainant never ever had hypertension and taken any treatment thereof. The said ground of repudiation is frivolous and false in nature. It is worth to mention here that no policy conditions were ever conveyed to the complainant and only cover note was issued to the complainant. The act of the opposite party in repudiating the genuine claim of the complainant amounts to deficiency in service. Vide instant complaint, complainant has sought for the following reliefs :-
- Opposite party be directed to pay the amount of USD$2724/48 and US$421.85 i.e. total $3146.33 or the amount equivalent in Indian currency alongwith interest @ 12% p.a. from 17.10.2016 till realization ;
- Compensation to the tune of Rs.50000/- alongwith adequate litigation expenses be also awarded to the complainant.
Hence, this complaint.
2. Upon notice, opposite party appeared and filed written version in which it was submitted that the complainant obtained the policy as Overseas Insurance policy from the opposite party vide policy No. P/211111/03/2016/000477 for his travel to Canada for the period from 18.3.2016 to 4.8.2016 for sum insured USD2,50,000. The policy was issued on the basis of proposal form submitted by the complainant. During his visit to Canada, complainant availed treatment for (a) palpitations on 6.5.2016 and (b) hypertension on 26.6.2016. The complainant lodged claim with the opposite party for his said treatment and the claim documents were received on 27.8.2016. However, after going through the hospital records, it was noticed that the complainant had past history of hypertension. The documents were placed before the Panel doctor of the company and as per his opinion, the current treatment of Palpitations and Hypertension is a complication of his pre-existing condition of hypertension. At the time of taking the policy, it was important for the complainant to declare his health condition truthfully in the proposal form. As per claim form, the complainant had not disclosed about his past medical health status of hypertension and he had answered ‘No’ against specific question in the medical history of the proposal form. It is, therefore, very clear that the insurance policy was obtained by the complainant by non-disclosing his true health status and as such, the contract of insurance is void ab-initio. As such the claim of the complainant was not payable and was rejected and the complainant was informed accordingly vide letter dated 17.10.2016 issued to the complainant by Heritage Health TPA Pvt.Ltd. However, the complainant represented to the opposite party on 17.1.2017 for reconsideration of his claim by submitting certificate of doctor mentioning that he had no pre-existing disease before taking this policy, for which reply was given to the complainant that the claim cannot be considered and rejection of claim is confirmed . It was denied that the claim is genuine and is repudiated on frivolous ground as alleged. It was denied that the complainant never ever had hypertension and taken any treatment thereof, as alleged. It was denied that no policy terms and conditions were ever conveyed to the complainant and he was only issued the cover note, as alleged. While submitting that the claim is not payable and the same has rightly been repudiated and while denying and controverting other allegations, dismissal of complaint was prayed.
3. In his bid to prove the case Sh. Deepinder Singh,Adv.counsel for the complainant tendered into evidence duly sworn affidavit of the complainant Ex.C-1, copy of cover note Ex.C-2, copies of claim form Ex.C-3 and Ex.C-4, copy of repudiation letter Ex.C-5, copy of medical bills Ex.C-6 and closed the evidence on behalf of the complainant.
4. To rebut the aforesaid evidence Sh.S.S.Salaria,Adv.counsel for the opposite party tendered into evidence affidavit of Sh.P.C. Tripathy, Zonal Manager Ex.OP1, Star Travel Product Insurance policy terms and conditions Ex.OP2, copy of policy schedule Ex.OP3, copy of advance premium receipt Ex.OP4, copy of passport of Mohinder Singh Ex.OP5, copy of proposal form Ex.OP6, copy of the questionnaire to be completed by the attending doctor Ex.OP7, copy of claim form dated 26.8.2016 Ex.OP8, copy of claim form Ex.OP9, copy of emergency/ambulatory care clinical record Ex.OP10, copy of certificate from the doctor Ex.OP11, copy of rejection letter dated 17.10.2016 Ex.OP12, copy of receipts Ex.OP13 to Ex.OP21, copy of letter from the opposite party dated 21.3.2017 written to the DCF ,Amritsar Ex.OP22, copy of letter from Mohinder Singh to Star Health Insu.Co.Ex.OP23 and closed the evidence on behalf of the opposite party.
5. We have heard the ld.counsel for the parties and have carefully gone through the record on the file.
6. Ld.counsel for the complainant has reiterated the facts narrated in the complaint and has submitted that complainant got Worldwide Health Benefit Mediclaim Insurance policy for himself from the opposite party covering the risk period from 18.3.2016 to 4.8.2016. It was submitted that the complainant went abroad and unfortunately fell ill , where he had taken the treatment and incurred USD $2724/48 & $ 421.85 on his treatment. As the policy issued to the complainant was cashless policy, as such the opposite party was immediately informed about the said hospitalization and the treatment to be taken thereof . The sum assured for the medical benefit is for USD $2.5 Lakh but the complainant has to pay the hospital expenditure from his own pocket. The opposite party instead of making the said payment for the genuine claim of the complainant repudiated the same on the frivolous ground vide letter dated 17.10.2016 that the complainant was having the history of hypertension and was pre existing disease. It was further submitted that no policy conditions were ever conveyed to the complainant and only cover note was issued to the complainant. Ld.counsel for the complainant submitted that all this amounts to deficiency in service.
7. On the other hand ld. Counsel for the opposite party has repelled the aforesaid contentions of the complainant on the ground that the complainant obtained the policy as Overseas Insurance policy from the opposite party vide policy No. P/211111/03/2016/000477 for his travel to Canada for the period from 18.3.2016 to 4.8.2016 for the sum insured USD2,50,000. It was submitted that the policy was issued on the basis of proposal form submitted by the complainant. It has further been submitted that during the visit of complainant to Canada, he availed treatment for (a) palpitations on 6.5.2016 and (b) hypertension on 26.6.2016. The complainant lodged claim with the opposite party for his said treatment and the claim documents were received on 27.8.2016. However, after going through the hospital records, it was noticed that the complainant had past history of hypertension. It was submitted that the documents were placed before the Panel doctor of the company and as per his opinion, the current treatment of Palpitations and Hypertension is a complication of his pre-existing condition of hypertension. It was submitted that while obtaining the policy, the complainant has failed to declare his health condition in the proposal form. The complainant had not disclosed about his past medical health status of hypertension and he had answered ‘No’ against specific question in the medical history of the proposal form. It is, therefore, very clear that the insurance policy was obtained by the complainant by non-disclosing his true health status and as such, the contract of insurance is void ab-initio. As such the claim of the complainant was not payable and was rejected and the complainant was informed accordingly vide letter dated 17.10.2016 issued to the complainant by Heritage Health TPA Pvt.Ltd. Ld.counsel for the opposite party has prayed for dismissal of the complaint.
8. But, however, from the appreciation of the facts and circumstances of the case, it becomes evident that complainant obtained Worldwide Health Benefit mediclaim Insurance for himself covering the risk period from 18.3.2016 to 4.8.2016. It was the case of the complainant that during his visit to Abroad unfortunately he fell ill and after the medical investigations, he got treatment and incurred expenditure on his medical treatment for USD $ 2724.48 and $ 421.85 . Thereafter the complainant filed claim with regard to reimbursement of his aforesaid claims . However, the opposite party repudiated the genuine claim of the complainant vide letter dated 17.10.2016 on the ground that the complainant was having the history of hypertension which was pre existing disease. But, however, the complainant never suffered from hypertension nevertheless no medical record showing such hypertension has ever been produced by the opposite party on the record. Vide instant complaint, complainant has sought for reimbursement of the expenditure incurred on his treatment i.e. USD $ 2724.48 and $ 421.85 (in Indian currency to the tune of Rs. 1,64,000/-). But, however, this figure has nowhere been controverted by the opposite party in their written version . However, the opposite parties declined the claim of the complainant in toto without any explanation only on the ground of concealment of material facts of ailment allegedly at the time of obtaining the policy in question by the complainant. The ground on which the claim of the complainant has been repudiated has been that the complainant was suffering from hypertension which was a pre-existing disease. In such a situation, it is preposterous to presume that said disease was pre-existing or that non disclosure thereof at the time of obtaining the insurance policy on the same amount to concealment. During these days, hypertension is not a material disease, therefore, non disclosure thereof does not amount to concealment. We draw support from Life Insurance Corporation of India Vs. Sushma Sharma from II (2008) CPJ 213 wherein Hon'ble State Commission has held as under:-
“So far as hypertension is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.
We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease.
9. Moreover the claim was rejected vide letter dated 17.10.2016 by Heritage Health TPA Pvt. Ltd, who has no authority to reject the claim as only the Insurance companies after making investigations can decide the claim. Reliance in this connection can be placed upon Sukhdev Singh Nagpal Vs. New Karian Pehalwal Cooperative Agriculture Service Society & others in First Appeal No. 1105 of 2014 decided on 25.4.2017 of our own Hon’ble State Consumer Disputes Redressal Commission, Chandigarh wherein it was held that “The TPAs have no authority to reject the claim – Such power lies , exclusively with the Insurance Companies – The TPA can only process the claim and forward the same to the Insurance Company and the competent authority of the Insurance company is to decide about the same-The claim of the complainant was illegally and arbitrarily rejected by the TPA, against the instructions of the IRDA”.
10. In such a situation the repudiation made by Opposite Party regarding genuine claim of the complainant appears to have been made without application of mind. It is usual with the insurance company to show all types of green pastures 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.
11. From the aforesaid discussion, it transpires that Opposite Party has wrongly repudiated the claim of the complainant . As such, opposite party is directed to reimburse the amount USD $ 3146.33 (i.e. in Indian currency to the tune of Rs. 1,64,000/-) incurred on the treatment of the complainant. The costs of the litigation are assessed at Rs.2,000/-. Compliance of this order be made within 30 days from the receipt of copy of the order; failing which, awarded amount shall carry interest @ 9% p.a from the date of filing of the complaint until full and final recovery. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
Dated : 20.11.2017
