BY - SRI.SAURAV CHANDRA, MEMBER

1. Brief facts of the Complainant’s case are that the Opposite Party is an insurance company from whom the Complainant purchased a Health Suraksha Policy on 23.09.2019 with a Sum Assured of Rs.3,00,000.00 for the period from 23.09.2019 to 22.09.2020.

2. Owing to illness with acute headache and hypertension, the Complainant got admitted in NH Rabindranath Tagore International Institute of Cardiac Science during the period from 11.11.2019 to 13.11.2019 for Cashless treatment of diagnosed LS Radiculopathy, Acute Symptomatic Headache (ICD 10 cm diagnosis code R51) and Hypertension for which total hospitalization bill was Rs.51,949.00 and accordingly denied by the OP on the ground of Hypertension is a pre-existing disease.

3. After releasing from hospital and post rejection of the Cashless claim, the Complainant again claimed for reimbursement of hospitalization expenses on 18.11.2019 which the Op wholly repudiated by mentioning “…..As the date of inception of policy is 23.09.2019 and the ailment was diagnosed 6 months back, the ailment is pre-existing in nature. Hence the claim is repudiated….”  

4. The Complainant also further states, he has made several representation before the Op including the Banking Ombudsman but, the Op paid no heed and remained  strict on their absurd, unjust and fictitious positions. Therefore, as per the advice of the Banking Ombudsman, the Complainant filed the instant case before this Commission.

5. The Complainant has cited one judgment of the Hon’ble Delhi State Consumer Disputes Redressal Commission and two judgments of the Hon’ble National Consumer Disputes Redressal Commission respectively in its favour in the cases of :-

1. Oriental Insurance Co. Ltd. – Vs. – Kaushalya Verma & Another [Appeal No.412/2016, 05.05.2021] – which justifies, even though there were pre-existing disease, it will not completely disentitle the respondent from indemnification of the claim from the Insurance Company for such common lifestyle diseases.

2. Neelam Chopra – Vs. – Life Insurance Company of India [Revision Petition No.4461 of 2012] – which clarifies, the disease of “Cardio Respiratory Arrest” was existing for only five months prior to the death of the deceased therefore, it is clear the disease was not prevailing when the proposal form was filled.

Although the disease of “Diabetes” existed for some time but was under control at the time of filling up of the proposal form. Moreover, the non disclosure of information in respect of this lifestyle disease of diabetes, will not totally disentitled the complainant for indemnification of the claim.

If the disease was not active at the time of filing of the proposal form and if the disease of “LL Hansen” has no relationship with the actual cause of death i.e. “Cardio Respiratory Arrest”, its suppression would not lead to total denial of the claim. So, even if any information was suppressed in the proposal form, it cannot be treated as material information. Therefore, the petitioner/complainant would be entitled to the insurance claim.

3. The National Consumer Disputes Redressal Commission (NCDRC) said during rejecting the revision plea filed by the Reliance Life Insurance Co. Ltd. against the Maharashtra State Commission’s order dismissing its appeal challenging the District Commission’s direction to pay Rs.1,12,500.00 to the husband of one of its policy holders who died of diabetic ketoacidosis; even if the insured person was suffering from a disease and did not know about it nor was taking any treatment for the same, the claim cannot be denied by an insurance company. Diabetes was a lifestyle disease in India and the whole insurance claim cannot be rejected only based on this ground.

6. The cause of action of this case arose on and from 18.11.2019 when the OP repudiated the Complainant’s genuine claim.

 The Complainant, therefore, prays for:-

1. To pay the full and final Claim amount of Rs.51,949.00 by OP with Interest @18% p.a.

2. To pay Compensation of Rs.50,000.00 towards gross      negligence and deficiency in service.

3. To pay Litigation Cost of Rs.10,000.00 to the Complainant for conducting the case.

4. Any other reliefs.

7.  The Op being represented by its’ Learned Advocate has filed written version against the complaint. But after filing of the examination in chief by the complainant, the op did not prefer to contest the case by filing Questionnaire Ultimately the case proceeded exparte against the op.

8. Points for determination are:

I.  Is the case maintainable in its present form and in law?                     

II. Is the Complainant entitled to the relief(s) as sought for?

9. Decision with reasons

1. Both the points I and II, being inter related to each other, are taken up together for discussion for sake of brevity and convenience.

2. We have carefully perused the Affidavit and Examination-in-Chief of the Complainant, along with all receipts and other documents.

3. Having regards had to the facts and circumstances of the case in the light of evidence, it is evident that there is no dispute that Complainant is a consumer having grievances against the OP, as such the case is maintainable in its present form and in law.

4. The claim of the Complainant was raised for treatment of headache with hypertension and as per the treatment papers; insured had been suffering from Hypertension since past six months i.e. prior to issuance of the policy. Therefore, the claim was simply rejected by OP without application of mind as pre-existing disease which has a waiting period of 48 months.

5. This Commission has again and again pointed out that pre-existing disease does not automatically follow a valid repudiation of claim. There should be an independent application of mind and recording of satisfaction that the infringement was induced by a motive to misrepresent of fact or created a possibility of dishonesty in fraudulent manner.

6. In the instant case, the Complainant never had any such complications prior to inception of policy or prior to his ailment on 11.11.2019, even though if the disease of Hypertension was pre-existing, it will not completely disentitle the Complainant from indemnification of the claim from the Insurance Company for such common lifestyle diseases. If the disease of “Hypertension” existed for some time but it may be under control at the time of filling up of the proposal form. Moreover, the non disclosure of information in respect of this lifestyle disease of “Hypertension”, will not totally disentitled the complainant for indemnification of the claim.

7. Therefore, it clearly transpires from uncontroverted evidence, decisions cited by the complaint and other materials on record that there are not only elements of negligence, unfair trade practice and gross deficiency in service by the op. The op subjected the Complainant to suffer a severe economic loss, harassment and mental pain by the whimsical and illegal act of the OP.

8. Now, coming to the matter of reliefs, we find that the Op can’t get absolved from the mischief of negligence, unfair trade practice, harassment and deficiency in service. The claim for reimbursement of hospital expenses for Rs.51,949.00 should have been entertained by the Op for necessary settlement according to the Insurance Regulatory & Development Authority (Protection of Policyholders’ Interest) Regulations, 2002;

1. So, we think it would be just and proper if we direct the OP to pay a sum of Rs.51,949.00 as towards costs of medical treatment i.e. reimbursement of the hospitalization bills, Rs.10,000.00 towards compensation and Rs.3,000.00 as litigation costs to the Complainant .

10.  Accordingly, both the points are decided in favour of the Complainant.

11.  Thus, the complaint case succeeds.

Hence, it is

          O R D E R E D

That the CC-60 of 2020 be and the same is allowed ex-parte against the OP.

The OP is hereby directed to pay a sum of Rs.51,949.00 towards costs of medical treatment i.e. reimbursement of the hospitalization bills along with simple  interest @ 8% per annum over the said amount from the date of this order till the date of actual payment, Rs.10,000.00 towards compensation and Rs.3,000.00 as litigation costs to the Complainant. The Op will comply the above direction within 30 days from the date of this order in default the OP will have the liberty to put the order into execution .

Let a copy of this judgment be provided to all the parties free   of cost.

The judgment be uploaded forthwith on the website of the Commission.

File be consigned to the record keeping section along with a copy of this judgment.