DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

C.C. No.253/2020

Date of Institution: 23.11.2020

Judgment Reserved on: 12.08.2024

Judgment Passed on: 12.08.2024

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

Judgment By: Shri Ravi Kumar (Member)

JUDGMENT

The Complainant has alleged deficiency in service on the part of OP in rejecting his claim towards medical expenses despite having valid Insurance Policy. 

1. The Complainant in his complaint has contended that he has Medicliam Policy No.023856904000 from OP covering the period from 18.07.2020 to 17.07.2022. He has stated that the date of first inception of the policy was on 14.02.2011 from some another insurance company and the above said policy was ported from the last insurance company to the OP.
2. On 19.08.2020 Complainant was admitted in Max Hospital,  Patparganj as he was feeling uneasy and shortness of breath. He was given medical treatment in the hospital and he was discharged on next day i.e. 20.08.2020. During this process medical treatment bill of Rs.32550/- and post hospitalization cost of Rs.6500/- was paid by the Complainant. Initially when the Complainant was admitted in the hospital, his cashless claim was rejected by the OP. After that Complainant had sent a letter alongwith certificate of Dr. Manish Aggarwal dated 25.08.2020 wherein he had explained that why his claim should not be declined.
3. The Complainant thereafter submitted the claim form alongwith all relevant documents to the OP and he was informed that he would but the reimbursement claim shortly. However the same was not done and he was informed that his claim paper was under scrutiny and vide letter/email dated 09.11.2020 his claim was rejected by the OP citing the reason :

‘we may at any time terminate this policy on grounds of mis-representation, fraud, non discloser of material facts or non-cooperation by you or any insured person or any one acting or on behalf of as insured person by sending you an endorsement to your address shown in the schedule of this policy. In the event of termination of this policy on the grounds of misrepresentation, fraud, non discloser of material facts the policy shall stands cancelled ab-initio and there will be no refund of premium.

The claim does not fall within the ambit of the policy in the light of facts given above read with the relevant policy condition/exclusion cited. We regret, therefore, that we are unable to entertain this claim’.

4. It is admitted fact that the complainant had previous history of CAD (Coronary Artery Disease) but Dr. Manish Agarwal specifically mentioned in his certificate that this hospitalization was not related to the under lying CAD/Post ETCA 2013. Even otherwise the previous history of CAD was informed by the Complainant to the insurance company of that time in the year 2013.

The Complainant has sought following prayers in his complaint:

• To direct the OP to reimburse Rs.39050/- alongwith 18% per annum interest till actual realization and direct the OP to continue the policy.
• To direct the OP to pay Rs.15000/- towards compensation for mental agony and harassment.
• To direct the OP to pay Rs.10000/- toward legal charges.

To pass any other order which this Forum deems fit and proper in the facts and circumstances of the case in favour of the Complainant in the interest of justice.

5. Complainant has enclosed with his complaint copy of Insurance Policy bearing No.023856904000, Cashless denial letter dated 20.08.2020, Certificate dated 25.08.2020, Claim Form alongwith Discharge Summary and bills and claim rejection letter.
6. Notice was issued to the OP and OP has filed reply wherein it has specifically stated that the Complainant has not come before the Commission with clean hands and has concealed the true facts. The Complainant had obtained Medical Policy bearing Policy No.023856904000 on Floater basis for himself, his wife and daughter for the period from 18.07.2020 to 17.07.2022. The policy was issued subject to terms & conditions mentioned therein.
7. When the Complainant was admitted in the hospital on 19.08.2020 then for cashless claim OP had demanded certain information vide their letter dated 19.08.2020 and 20.08.2020. Subsequently Complainant submitted his claim related documents alongwith treatment expenses with estimate of Rs.31,100/- . On perusal of the Discharge Summary dated 20.08.2020 of Max Health Care it was noted that the Complainant had past history of Coronary Artery Disease (CAD) and had undergone post PAT and stent LAD and LCX in 2013. This material fact was not disclosed by the Complainant while obtaining for the Medicare Policy from the OP.
8. OP stated that insurance contract is a contract based on principle of utmost good faith and it is imperative that the policy holder acts in good faith by fully disclosing all information/facts that affects the insurance company’s level of risk. The Complainant did not disclose the previous health conditions of treatment history and at the time of obtaining policy he gave wrong information to the OP in order to get the policy and save the premium amount. In view of the same and relying on violation of Section 4(7) i.e. General Exclusion, OP vide letter dated 20.08.2020 rejected the claim of the Complainant for cashless. The Complainant subsequently filed reimbursement claim and the claim was rejected on the aforesaid grounds and the policy was also cancelled.
9. OP has further stated that Complainant in para 4 of his complaint himself admits that he never made disclosure regarding history of CAD in the year of 2013. It is therefore state that the complainant concealed material facts and accordingly his claim was denied. In view of the above OP submits that the complaint of the Complainant is not maintainable and the same may be dismissed.
10. Complainant has not filed rejoinder to the reply of the OP and has filed his evidence by way of affidavit.
11. OP has filed its evidence by way of affidavit of Sri Amit Chawla, AVP-Legal Claims and has marked following documents as exhibits:-
    • Copy of Policy with terms and conditions as exhibit R/1.
    • Copy of letter dated 19.08.2020 and 20.08.2020 as exhibit R/2.
    • Copy of Discharge Summary dated 20.08.2020 as exhibit R/3.
    • Copy of previous Medical Records of 2013 of Complainant as exhibit R/4.
    • Copy of cashless claim denial letter as exhibit R/5.
    • Copy of claim form submitted by Complainant as exhibit R/6.
    • Copy of letter dated 15.09.2020 as exhibit R/7.
    • Copy of policy cancellation letter as exhibit R/8.

Both the sides have filed written arguments.

12. This Commission has heard the arguments and perused the records. The issue involved in the case falls in the narrow compass as to whether OP rightly relied upon para 4(7) of the Policy while rejecting the claim of the Complainant.
13. It is a matter of record and not denied by the OP that the Complainant was having Medicare policy from the year 2011 from different insurance companies. The last insurance policy which the Complainant was holding was from ICICI Lombard and prior to it the Complainant had policy from Bajaj Alliance and National Insurance Co.
14. It is also not disputed rather it is admitted by the Complainant that he had CAD (Coronary Artery Disease) in the year 2013 for which he underwent medical treatment. The Complainant has enclosed copy of the Medicare policy of the OP on which it is written as ‘new business’ which means that the Complainant when approached OP, he presented himself  that he is taking the policy for the first time and he did not disclose to OP with respect to his previous ailment of CAD done in 2013. This was a material information and should have been informed by the Complainant to the OP which would have given the chance to the OP to weigh the insurance risk it was going to take while issuing policy to the Complainant and as the Complainant had under gone CAD in 2013 then OP could have taken the decision to put extra load on the premium on the Complainant if at all it was ready to accept the proposal for issuance of health care policy to the Complainant. Thus Complainant deprived the OP to assess the correct risk involved in the issuance of Policy which was very much material for the OP before it issued Insurance Policy to the Complainant.
15. The Complainant withheld material information about his previous heart ailment (CAD) on 2013 and therefore the reliance by the OP under para 4(7) of the Policy is correct and so is the decision of the OP rejecting the cashless claim initially and finally the claim after the hospitalization. Though the OP has stated in their Reply that on coming to know about the misrepresentation by the complainant about his previous ailment it has cancelled the policy vide letter dated 09.11.2020. However there is no such remark in their letter dated 09.11.2020. OP has filed evidence in which it has relied upon para 4(7) of the policy which states that such case policy shall be void-ab initio without any premium refund.
16. For the reason stated above, this Commission holds that the complainant had concealed material facts from the OP and therefore has not been able to establish deficiency in service on the part OP. Accordingly, the complaint filed by the Complainant is dismissed.

Copy of the order be supplied/send to parties free of cost as per rules.

File be consigned to Record Room.

Announced on 12.08.2024