Complainant Mohinder Singh has filed the present complaint against the opposite parties U/S 35 of the Consumer Protection Act (for short, C.P.Act.) seeking necessary directions to the opposite party no.1 to pay the compensation to the tune of Rs.1,00,000/- i.e. Rs.83,886/- as claimed amount and Rs.16,000/- as mental agony pain and suffering.
2. The case of the complainant in brief is that he had taken a Health Insurance Policy No.0200212502 from opposite party no.1 in collaboration with the opposite party no.2 and regularly paying the premium to the opposite party no.1 till the repudiation of the claim raised by the opposite party no.1. Thus, he is consumer of the opposite party. He has next pleaded that unfortunately he met with an accident and got admitted in Abrol Hospital Gurdaspur on 10.12.2019 on account of injuries sustained on Left Lower Limb as he suffered fracture on the Lateral Condy Tibia and tight compartment with Hemarthrosis. After admission he raised his claim for medical treatment expenditure through opposite party no.3 incurred in the hospital bearing claim No.19121000427 bearing ID No.ZZZZ421099001058 which was repudiated by the opposite party no.1 by giving intimation to the opposite party no.3 on the ground that "based on the discharge summary enclosed the complainant was suffering with diabetics mellitus since 7-8 years HTN since 8-10 year which is prior to the policy inception of 2013 and this was not disclosed at the time of policy inception in the proposal form. As per clause 4 general condition section 7 being non disclosure on material facts we fail to honor the claim." The grounds mentioned in the repudiation letter are illegal and no justified as the policy in question was taken from opposite party no.1 in the year 2013 and the same was renewed from time to time and at the time of taking the policy the thorough body test and checkup was conducted by the medical experts as duly authorized by the opposite party no.1 and only after thorough medical checkup the policy was issued by the opposite party no.1 and thereafter the opposite party no.1 was receiving the premium of the policy from time to time uptil 2019 and secondly he was operated in the said hospital on account of fracture which had nothing to do with the Diabetes or Hypertension regarding which a justification letter was already sent to the opposite party no.1 by the Abrol Hospital on 14.12.2019. Thirdly the ground on which the claim was repudiated was not considered as diseases hence there is deficiency in service on the part of the opposite party no.1. He has next pleaded that he got discharge from the hospital on 13.12.2019 and thereafter again raised the claim of Rs.83886/- bearing claim no.200130000227 but the opposite party no.1 not honored his claim on the ground of past history duration of DM, HTN, CAD, Dyslipedemia which is unjustified as the opposite party no.1 medical experts had got the medical checkup of the above stated health problems. He also sent a legal notice to the opposite party to honour of the claim amount of Rs.83,886/- but till date no reply had been received. Hence this complaint.
3. Notice of the complaint was issued to the opposite parties. Opposite party no.1 appeared through its counsel and filed its written reply taking the preliminary objections that the complainant has no cause of action and locus standi to file the present complaint; the insurance is a contract between the two parties and both the parties binding with the terms and condition of the policy. Any claim under the policy is payable subject to it's terms and conditions; It is the duty of the insured to disclose all the material facts regarding his health at the time of getting the policy. In the present case, the complainant concealed the material facts at the time of getting the policy regarding his health i.e. he did not disclose that he was suffering from DM and hypertension. If complainant would have disclosed said facts regarding his health, then the company would have issued the policy with appropriate conditions/exceptions attached to it. Since the complainant have concealed the material facts and breached the utmost good faith of the opposite party, hence the policy is treated as void ab-initio and there is no deficiency in services on the part of the insurance company. The matter of fact is that the complainant was admitted with Abrol Medical Centre on 10.12.2019 with h/o fall from scooty and was treated for fracture Lateral condyl with Intra articular extention. A pre-authorization request dated 10.12.2019 was raised by the hospital, however, the same was rejected by the opposite party vide letters dated 10.12.2019 and 11.12.2019 for want of following details:-
a) Treating doctors certificate for details and circumstances of injury, MLC copy of applicable.
b) Treating doctors certificate for past history of DM2, when it was diagnosed first time alongwith first prescription letter.
On merits, it was submitted that the policy has been issued. The liability of the insurance company is only as per policy terms and conditions. Any claim under the policy is payable subject to it's terms and conditions. It was next submitted that justification letter given by the Abrol Hospitalf is wrong and denied and is having no help for the insured. The material fact is tht the complainant got the policy by concealing the true facts and concealed the abovesaid diseases at the time of getting the policy and gave wrong declaration in the proposal form and as such, there is no liability of the Insurance Co. The claim of the complainant has been rightly repudiated. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed.
4. Opposite party no.2 appeared through its counsel and filed its written reply taking the preliminary objections that the complaint is not maintainable against the opposite party as the complainant is not consumer of the opposite party; opposite party no.2 bank cannot carry on insurance business as per the provisions of Banking Regulations Act 1949, therefore does not offer insurance products; opposite party is neither proper nor necessary party in the present case therefore the complaint is liable to be rejected against the opposite party and it is settled principal of law u/s 230 of The Indian Contract Act that an agent can neither sue nor be sued except under the special circumstances mentioned therein. On merits all averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.
5. Opposite party no.3 appeared through its counsel and filed its written reply taking the preliminary objections that the complaint is not maintainable and the complainant unnecessary arrayed as opposite party in the complaint just to harass him and as such, the complaint is liable to be dismissed with special costs. On merits all averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.
6. Ld.counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A alongwith copies of documents Ex.C-1 to Ex.C-30.
7. Alongwith the written reply the opposite party no.1 filed affidavit of Sh.Amit Chawla, Chief Manager Ex.OP-W-1/A alongwith copies of documents Ex.OP-1/1.
8. Alongwith the written reply the opposite party no.3 filed affidavit of Dr.Ajay Abrol (Prop) M.M.Medical C/o Abrol Medical Centre, Gurdaspur Ex.OP-W3/A.
9. Rejoinder filed on behalf of complainant to the reply of opposite party no.1.
10. Written arguments not filed by the parties.
11. We have carefully gone through the pleadings of counsel for the opposite parties; oral arguments advanced by their respective counsel for the parties and have also appreciated the evidence produced on record with the valuable assistance of the learned counsels for the purposes of adjudication of the present complaint.
12. Present complaint has been filed by complainant Mohinder Singh against opposite parties for repudiation of health insurance claim. The complainant had a health insurance policy of opposite party no.1 issued through opposite party no.2 as a broker which is valid from 27.7.2019 to 26.7.2020 (copy placed at Ex.C-1). Complainant met with an accident on 10.12.2019 and got himself treated from opposite party no.3 from 10.12.2019 to 13.10.2019 as per discharge slip placed at Ex.C-8. The date of accident and treatment falls within the validity period of the policy. As per repudiation letter of opposite party no.1 sent to opposite party no.3 (Ex.C-3) it is stated that
"current hospitalization is claimed for surgical management (lateral condylar fracture) admission on Dec. 10 2019. Based on enclosed Discharge summary member suffering with diabeties mellitus since 7-8 years HTN since 8-10 year which is prior to policy inception of 2013 and this was not disclosed at the time of policy inception in proposal form. As per clause 4 of general conditions section 7 being non-disclosure of material facts; hence we regret our inability to honour this claim"
The complainant placed a justification letter of hospital from opposite party no.3 which state that "Pt.Mohinder Singh admitted in this hospital on10.12.2019 with fracture lateral candyle with intra articular extension with tight compartment and multiple laceration. Patient was treated in this hospital for fracture management, not diabetes mellitus.
13. Opposite party in their written statement denied all the allegations made by the complainant and claimed that repudiation is done as per terms and conditions of the policy which is binding on both the parties.
14. From the above facts of the case, it can be made out that the repudiation of the claim is done by opposite party no.1 on the basis of a symptom regarding suffering of complainant from diabetic mellitus prior to the policy and failed to honour the claim on non-disclosure of the facts during issue of the policy. But it is evident from discharge slip and justification slip that complainant has been operated/treated for fracture due to accident and not for the said disease as mentioned in the repudiation letter. Moreover, it is understood that opposite party no.1 must have conducted the full medical checkup before issuance of the policy.
15. We can also rely upon the various judgments quoted during arguments by Ld.counsel for complainant such as "Abedin S.Baldiwala 325/b, Rampark Society, Behind Gulistan Masjid, Ajwa Road Vadodara-390019 Gujrat Vs. United India Insurance Co. Ltd. First Floor, Vakaskar Chambers, Pro. Manerko Road, Opp:Navrang Cinema Vadodara Gujarat 2016 (3) CLT 584 National Consumer Disputes Redressal Commission, New Delhi" And "Life Insurance Corporation of India Versus Sudha Jain 2007(2) C.P.J. 452 : 2007 (2) CLT 423 : 2006 (47) R.C.R. (Civil) 14 of Delhi State Consumer Disputes Redressal Commission, New Delhi" Hence the repudiation of the claim by opposite party is unjustified.
16. Hence, we are of the opinion that ground on which the claim is repudiated is totally unjustified and complainant deserves the reimbursement of the medical claim.
17. In view of the aforesaid discussion, considering the facts and circumstances of the case, complaint is partly allowed and opposite party no.1 is hereby directed to reimburse the full medical claim submitted by the complainant within 30 days from the receipt of copy of the order. Opposite party no.1 is also directed to pay Rs.10,000/- as lumpsum as harassment and litigation expenses to the complaint.
18. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.
19. Copy of the order be communicated to the parties free of charges. file be consigned.
(Naveen Puri)
President
Announced: (B.S.Matharu)
September 09, 2022 Member
*MK*
