Haryana

Fatehabad

CC/8/2020

Hans Raj - Complainant(s)

Versus

Star Health and Allied Insurance - Opp.Party(s)

Manjeet Kajla

02 Jan 2024

ORDER

BEFORE THE  DISTRICT CONSUMER DISPTUES REDRESSAL COMMISSION, FATEHABAD.

Complaint No.08 of 2020.

Date of instt.09.01.2020. 

                                                          Date of Decision: 02.01.2024.

 

Hans Raj (now since deceased) son of Tej Bhan resident of village Madh Tehsil Ratia District Fatehabad through his legal heir and representative Smt.Renu Bala widow of the deceased Hans Raj son of Tej Bhan resident of village Madh Tehsil Ratia District Fatehabad.

 

                                                                             ..Complainant.

                                      Versus

 

1. Star Health and Allied Insurance Company Limited 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600 034 through its Chairman-cum-Managing Director/Managing Director.
2. Star Health and Allied Insurance Company Limited, Branch Office : SCO 149, IInd Floor, CUE-1, Red Square Market, Hisar-Haryana, 125001 through its Branch Manager.
3. Sonu Bala c/o Tarun Kumar son of Ramesh Kumar office Address Shop No.25, Jaat Dharamshala, Ist Floor, Fatehabad.

 

..Opposite parties.

     

      Complaint under Section 35 of Consumer Protection Act, 2019.          

 

Before              Sh.Rajbir Singh, President.

                        Smt.Harisha Mehta, Member.

     Dr.K.S.Nirania, Member.

Present:           Sh.Manjeet Kajla, Advocate for complainant.

                       Sh.Sachdev Bishnoi, Advocate for Ops No.1 & 2.            OP No.3 exparte.   

 

ORDER

SH.RAJBIR SINGH, PRESIDENT

 

                        Brief facts of the present compliant are that the complainant had obtained family health optima insurance plan covering 2 adults vide policy renewal endorsement No.P/211119/01/2019/011343 valid from 31.03.2019 to midnight of 30.03.2020 through Op No.3; that the complainant had also obtained similar policy and this fact was not concealed from the Ops; that due to stomachache, vomiting and infection in liver, the complainant visited Sir Ganga Ram Hospital, New Delhi on 29.08.2019 but he was denied pre-authorization by the Ops; that the complainant remained admitted in the hospital from 29.08.2019 to 30.08.2019; that vide letter dated 29.08.2019 the Ops made some queries from the hospital and on 30.08.2019 repudiated the claim of the complainant as per  condition No.12; that the complainant again remained admitted in the hospital for the period from 04.12.2019 to 05.12.2019 and further spent Rs.4,23,489/- on his treatment; that the complainant submitted all the requisite documents besides the bills with the Ops but instead of making the claim amount, the Ops repudiated  the claim of the complainant wrongly and illegally.  The repudiation of insurance claim of the complainant by the OPs amounts to deficiency in rendering service to the OPs.  Hence, this complaint.

2.                          On being served, Ops No.1 & 2 appeared through counsel and resisted the complaint by filing their joint written statemen wherein several preliminary objections such as maintainability, concealment of material facts, complaint being false and frivolous etc. have been taken.  It has been further submitted that the policy was issued upto the coverage of Rs.4,05,000/- but at the time of filing the proposal form the complainant had not disclosed the fact of having previous disease and treatment as he remained admitted in Sehgal Hospital, Fatehabad on 11.06.2019 and discharged on 13.06.2019; that as per record the complainant was the known case of HCV+ve for the last 4 years; that the medical record of complainant also shows that the insured had history of TACE in 2015; that the complainant had concealed the previous disease and obtained the policy in question by concealing this material fact, therefore, as per condition No.12, the policy in question was cancelled because the insured in the proposal form answered to all the questions in the medical questionnaire. The relevant questions are as under:

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 many illness/disease/injury/surgery-If yes, details- No.

4.                Have you ever suffered or suffering from any of the following disease of stomach, intestine, liver, gall bladder, pancreas, kidney, urinary tract, disease if yes since When- No.

5.                1.Undergone any Medical Test- No.

                   2.Prescribed any Medical Medication (Name the illness for which medicine has been prescribed)- No.

                  

The OPs No.1 & 2 have further prayed for dismissal of the present complaint being devoid of merits. OP No.3 did not appear before this Commission, therefore, she was proceeded against exparte vide order dated 24.02.2020.

3.                          The complainant in evidence has tendered affidavit Ex.CW1/A and documents Annexure C1 to Annexure C23. On the other hand, the learned counsel for the OPs tendered in evidence affidavit Ex.R1 with documents Annexure R1 to Annexure R17.

4.                          In the present matter the insurance company has cancelled the policy and denied the claim of the complainant on the ground that the DLA had concealed the material and vital information about his health and did not disclose each and every aspect qua his health position in the proposal form before obtaining the policy in question. Before proceeding further, let us have a look on the role of proposal form, the definition is a under:

When applying for insurance, a proposer has to fill out the proposal form of the life insurance company. The Insurance Proposal is an important document which provides the details of the proposer and the life assured and which is used as a basis to ascertain the insurability of an individual. The proposal form helps insurers evaluate the potential risks and determine the premium amount accordingly.

 

As per Ops No.1 & 2 the DLA had concealed the fact about having HCV+ as mentioned in Annexure R9 and Annexure R13, from them before inception of the policy in question as he has replied the relevant questions, which are as under, in negative:

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 many illness/disease/injury/surgery-If yes, details- No.

4.                Have you ever suffered or suffering from any of the following disease of stomach, intestine, liver, gall bladder, pancreas, kidney, urinary tract, disease if yes since When- No.

5.                1.Undergone any Medical Test- No.

                   2.Prescribed any Medical Medication (Name the illness for which medicine has been prescribed)- No.

 

Learned counsel for the Ops No.1 & 2 has drawn the attention of this Commission towards documents Annexure R9 and Annexure R9 wherein it has been clearly mentioned that the insured had past history of HCV+ + in Delhi for years back and  known case of HCV (TACE) 2015. The fact regarding the health condition was very much in the knowledge of the complainant. Moreso, the complainant has not placed any record/document to counter the pleadings put-forth by the Ops No.1 & 2. It is worthwhile to mention here that the preamble of Consumer Protection Act is benevolent in nature but it does not give liberty to misuse the same by concealing the relevant information from the service provider, which has happened in the case in hand.  Therefore, we are of the considered opinion that the complainant had concealed the material fact regarding his state of health and the previous disease intentionally for obtaining the insurance policy. It is a well settled principle of law that the contract of insurance is a contract of aberrima fides and there must be complete good faith on the part of the assured and thus the assured is under a solemn obligation to make full disclosure of material fact, which may be relevant for the insurer to take into account while deciding whether the proposal should be accepted or not. The declaration in the proposal form and the statement given by the life assured were the basis of contract of mutual trust between the insurer and the assured and any false statement given with respect to state of health or disclosing the false information would make the contract vitiate as has been done in the present  case. Reliance is placed on the case law titled Satwant Kaur Sandhu Vs. New India Assurance Company Ltd. reported in IV(2009)8 SCC Page 316 and P.C.Chacko and anr. Vs. Chairman L.I.C. India 2008 (1) SCC 321.

5.                          On the basis of above mentioned discussion, we are of the considered opinion that there was no deficiency in service at all or any unfair trade practice, on the part of any of the Ops, as alleged, so as to make any of them liable to any extent in this matter. Hence, the complaint is dismissed in view of the facts and circumstances stated above.  All the parties are left to bear their own costs. A copy of this order be supplied to both the parties free of cost as per rules.  This order be uploaded, forthwith, on the website of this Commission as per rules for the perusal of the parties. File be consigned to record room, as per rules, after due compliance.

Announced in open Commission.                                                            Dated: 02.01.2024

 

 

                                                                                                        

(K.S.Nirania)                       (Harisha Mehta)                (Rajbir Singh)                         Member                                     Member                                     President