BY - SRI.SAURAV CHANDRA, MEMBER

1. Brief facts of the Complainant’s case are that the Opposite PartyNo.1 is an insurance company from whom the Complainant purchased a Family Health Insurance Policy through the Opposite Party No.2 which is a bank, on 09.01.2018 with a Sum Assured of Rs.2,00,000.00 for the period 09.01.2018 to 08.01.2019.
2. Due to sudden illness with complaint of head reeling followed by weakness of right side body, associated with slurring of speech, the Complainant admitted in Apollo Hospitals at Bhubaneshwar, Orrisa during the period from 02.03.2018 to 07.03.2018 for treatment of diagnosed Left Gangilo Capsular Acute Infarct. Mild Atherosclerotic Wall Thickening, Diabetes and Hypertension for which total hospitalization bill was Rs.82,894.00 and accordingly denied by the OP No.1 on the ground of Cerebro Vascular Accident with Right Hemiparesis, with Hypertension and Diabetes Mellitus is a pre-existing disease and will not be covered until 36 months of continuous coverage.

3. After releasing from hospital, the Complainant claimed for reimbursement of hospitalization expenses on 11.04.2018 which the Op No.1 wholly repudiated by mentioning “…..As per the terms and conditions of the policy any preexisting condition will not be covered until 36 months of continuous coverage with us. The disease/symptom starts on Cerebrovascular accident and the policy start date is 09.Jan 2018. Hence we regret to inform you that your claim is repudiated….”

4. The Complainant also further states, he has made several representation before the Ops No.1 and 2 , but the Ops paid no heed and remain strict on their absurd, unjust and fictitious positions. Therefore, the Complainant filed the instant case before this  Commission.

5. The cause of action of this case arose on and from 06.12.2018 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.82,894.00 by OP with Interest @10% 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.20,000.00 to the Complainant for conducting the case.
4. Any other reliefs.

6. The Ops , being represented by its’ Learned Advocates have contested the case by filing Written Version against the complaint. While resisting the claim of the Complainant, the Ops in its’ Written Version stated inter alia that this complaint is not maintainable in its present form and in law because there is a breach of fundamental policy condition by the policy holder with suppressing the past medical history of Hypertension and Diabetes since last 10 years i.e. prior to issuance of the policy and hence the claim was liable to repudiated.

7. The Op No.1 has also cited many judgments of the Hon’ble Supreme Court of India and Hon’ble National Commission Disputes Redressal Commission to justify the doctrine of “Uberrimae Fides”, interpretation of Deficiency of Service and the terms ofNon Disclosure/Suppression/Concealment of Material Facts, Misrepresentation of Facts in a Dishonest and Fraudulent Manner etc. while construing the Terms of the Contract of Insurance.
8. Under the above circumstances, the Ops have prayed for dismissal of the present case with costs.

9. Points for determination are:
1. Is the case maintainable in its present form and in law?  II.Is the Complainant entitled to the relief(s) as sought for?

10. 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 Examination-in-Chief on Affidavit of the Complainant, Written Version filed by the Ops, Evidence-in-Chief, Questionnaire, Reply, Written Argument etc. 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 OPs, as such the case is maintainable in its present form and in law.

4. The claim of the Complainant was raised for treatment of diagnosed Left Gangilo Capsular Acute Infarct. Mild Atherosclerotic Wall Thickening with Diabetes and Hypertension as per the treatment papers; insured had been suffering from Diabetes and Hypertension since past ten years i.e. prior to issuance of the policy. Therefore, the claim was simply rejected by OP No.1 without application of mind as pre-existing disease which has a waiting period of 36 months.
5. It is now the settled law 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.  Diabetes and Hypertension are common lifestyle diseases; these can not be treated  as  pre-existing diseases.

6. In this context, we rely upon the decisions of the judgment of the Hon’ble Delhi State Consumer Disputes Redressal Commission and two judgments of the Hon’ble National Consumer Disputes Redressal Commission respectively as follows :-

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 is entitle 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 disentitle 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) observed 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. 

1. In the instant case, the Complainant never had any such complications prior to inception of policy or prior to his ailment on 02.03.2018, even though if the disease of Hypertension and Diabetes were 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” and “Diabetes” were 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” and “Diabetes”, will not totally disentitle the complainant for indemnification of the claim.

2. Therefore, it clearly transpires that, there are not only elements of negligence, unfair trade practice and gross deficiency in service but also forced the Complainant to suffer a severe economic loss, harassment and mental pain by the whimsical and illegal act of the OPs.

7. Now, coming to the matter of reliefs, we find that the Ops 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.82,894.00 should have been entertained by the Ops for necessary settlement according to the Insurance Regulatory & Development Authority (Protection of Policyholders’ Interest) Regulations, 2002, so the complainant is entitled to get the said amount along with  simple interest @8% per annum from the date of filing of this case till the date of payment and compensation of Rs.5,000.00 and litigation costs of Rs.3,000.00 from the Ops.

8. Accordingly, both the points are decided in favour of the Complainant.
9. Thus, the complaint case succeeds.

Hence, it is

          O R D E R E D

That the CC-454 of 2019 be and the same is allowed on          contest against the OPs.

The OPs, who are jointly and severally liable, are hereby directed to pay Rs.82,894.00 along with  simple interest @8% per annum from the date of filing of this case till the date of payment and compensation of Rs.5,000.00 and litigation costs of Rs.3,000.00 to the complainant within 45 days from the date of this order; in default the complainant will be at 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 for the perusal of the parties.

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