DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No.110/19
Gopal Gupta
S/o Shri Manohar Lal Gupta
R/o C-11,1st Floor
Model Town, Phase-III
New Delhi-110009. .…Complainant
Versus
M/s Oriental Insurance Company Ltd.
G-8, NDSE Part-I
New Delhi-110049.
Also At:
A-25/27, Asaf Ali Road
New Delhi-110002. ….Opposite Parties
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Sh. U.K. Tyagi, Member
ORDER
Date of Institution :22.04.2019
Date of Order : 15.09.2022
Member: Shri U.K.Tyagi
Complainant has requested to pass an award directing the Oriental Insurance Company Ltd. (hereinafter referred to as OP) to pay a sum of Rs. 2,79,315.60, with interest @ 12% per annum from the date of claim till date of final payment; (ii) to pay a sum of Rs.30,000/- as compensation towards mental harassment and agony and Rs.15,000/- towards cost of litigation etc.
Brief facts of the case are as under:-
The complainant purchased health insurance policy namely, “Happy Family Floater Policy” for himself and his family covering the value of Rs.6,00,000/- and a sum of Rs.22,371/- was paid as premium for the said policy. The instant policy was renewed having validity from midnight of 13.12.2014 till midnight of 12.12.2015 and paid a sum of Rs.21,252/- as premium. On 26.03.2015, Shri Manohar Lal, the father of the complainant was admitted in Vinayak Hospital. He was diagnosed DM with HTN with PUO with septicaemia with TB Pulmonary Lymphadentis, Malignant LN. The case was also processed for cashless treatment through TPA of OP namely, M/s Raksha TPA Private Ltd. The TPA vide its letter dated 06.04.2015 informed the approval of the amount of Rs.1,78,848/- and same was paid to the Hospital. Since there was no major improvement in the cough & fever of his father, therefore, he consulted Dr. Rajesh Gupta on 01.04.2015 at Pentamed Hospital Gujrawalan Town. His father was discharged from the Hospital and came back but still on medication. On 11.04.2015 his health condition deteriorated badly and he was taken to Pentamed Hospital with preliminary examinations, he was diagnosed with LRTI with severe sepsis? Auto Immune Disroder (SLE) and also admitted in ICU where he remained till 15.4.2015. Thereafter shifted to room, where he remained till 25.04.2015 and thereafter discharged from the hospital.
The Hospital processed his case for cashless treatment against the policy. The same was rejected vide letter of TPA dated 15.04.2015. After discharge, his father was also having certain test from Ganga Ram Hospital for further detection of cause of cough and fever. The complainant lodged his claim with OP for re-imbursment of amount/bill of Rs.2,79,315/- from Pentamed Hospital. On some objections, the said bill was reduced to the tune of Rs.2,35,598/-. The TPA processed the claim and approved the claim of Rs.2,08,832/- and sent to OP on 05.08.2015. It was mentioned by TPA that claim for LRTI with severe sepsis with shock passed and HTN treatment not payable. The complainant ultimately vide letter dated 06.10.2015, from the office of OP, was informed that the claim has been repudiated. The matter was taken up with OP. The OP vide its letter dated 25.01.2016 told that the claim was repudiated under clause 4.1, 4.3 and 5.10 of the policy for non-disclosure of pre-existing disease of HTN/DM.
The complainant further stated that discharge summary of his father from Vinayak Hospital also indicates that the patient is a known case of HTN and DM and cashless claim for the said hospital was passed by OP through TPA on 06.04.2015. It is not understood why the claim was repudiated whereas his father was primarily diagnosed for severe chest infection not for HTN.
OP, on the other hand, filed its written statement inter alia raising some preliminary objections. There was not any of obligation on the part of OP. Hence in the absence of deficiency in service, the complaint is liable for dismissal. Further, it was asserted that the father of the claimant was also known case of HTN and DM etc. The clause 4.3 clearly provide exclusion of HTN and diabetes… are excluded for 2 years. Further Clause 4.1 of the policy’s terms & conditions speaks that “Pre-existing health conditions or disease or ailment/injuries if not declared in proposal form, the insured is excluded upto 4 years”. Clause 5.10 speaks that policy shall be void and all premium paid shall be forfeited in the event of mis-representations, non-disclosure of any material fact.
In view of above, OP rightly repudiated the claim after thorough investigation by TPA and investigator. It may be relevant to point out here that the OP raised the question of maintainability of the complaint on the ground of territorial jurisdiction in Central District Forum. Hence, the Hon’ble Forum after sustaining the objection, the complaint was allowed to be withdrawn with the liberty to file within 30 days in appropriate forum. Hence the matter is being adjudicated upon here.
Both the parties have filed evidence-in affidavit and written submissions. Written statement is on record so is rejoinder. Oral arguments were heard and concluded.
This Commission has gone into the material placed on record. Due consideration was also given to the arguments. The contention of the OP remains around this fact that the complainant’s father was suffering from pre-existing disease, as is evident from the discharge summary of both the Hospitals. The OP further contended that the complainant had not disclosed the material information in the proposal form. The Hon’ble Supreme Court in the case of P.C. Chacko have held that if material information is withheld and not shown in the proposal form. The policy contract becomes voidable as the policy contract works on principle of ‘uberrimae fides’. We have also examined the fact of HTN/diabetes and these pre-existing diseases were not disclosed in the proposal form. The Hon’ble State Commission in the catena of judgments has explained the existence of these diseases as a present style of living. The Hon’ble State Commission in such cases, has not considered the HTN/DM as essential disclosure in the proposal form.
In view of the above, this Commission feels that the representation of the claim of the complainant warrants re-consideration which ought to be completed within 3 months from the date of this order. A reasoned order is to be passed by the OP and the amount if any found admissible should be released within 1 month thereafter failing which the interest shall be levied @ 9% on the claim so approved till its realisation.
File be consigned to the record room after giving copy of the order to the parties as per rules.
