Sh.Anoop Sharma, Presiding Member.
1. Smt.Sarita Kwatra has brought the instant complaint under section 12 & 13 of the Consumer Protection Act, 1986 on the allegations that the complainant got health benefit mediclaim insurance for herself and her husband from Opposite Party covering the risk period 6.5.2016 to 5.5.2017, copy of the cover note is annexed. The complainant is a consumer as provided under the Act and is competent to invoke the jurisdiction of this Forum. The husband of the complainant namely Yash Pal Kwatra unfortunately fell ill and as to be hospitalized at Nayyar Hospital, Amritsar from 19.8.2016 till 21.8.2016 and the treatment cost of the said hospitalization came to Rs.4,34,194/-. The Opposite Party was immediately informed about the said hospitalization and the treatment to be taken thereof as the said policy was issued on cashes basis and is worth mentioning over here that the sum insured for the medical benefit is for Rs.5 lacs. The Opposite Party instead of making the said payment repudiated the genuine claim of the complainant on the frivolous grounds vide letter dated 22.8.2016 that the husband of the complainant was on hypertension treatment which in fact was totally wrong and against the true facts. The aforesaid acts of Opposite Party in repudiating the genuine claim of the complainant is an act of deficiency in services, unfair trade practices, mal practices and is not sustainable in the eyes of law and has caused lot of mental tension, agony and harassment to the complainant besides financial loss to the complainant and for which the Opposite Party is liable to pay compensation of Rs.50,000/- to the complainant. Hence this complaint.
2. Upon notice, Opposite Party appeared and contested the complaint by written statement taking preliminary objections therein inter alia that the complainant is estopped by his own act and conduct to file the present complaint and the present complaint is not maintainable under law. In the light of terms and conditions of the policy in question, it was found that the claim was not payable as per denial/ exclusion clause. As per the said exclusion clause, the company shall not be liable to make any payment under this policy in respect of any expenses incurred by any insured person in connection with any pre existing health condition or disease, when the cover incepts for the first time, since pre existing diseases are excluded upto 3 years of the policy being inforce continuously. In the present case, it was found that the husband of the complainant was a known case of HTN. As the policy was a second year policy and the ailment/ disease was found pre existing which is not payable since there is a waiting period of 3 years for the same. Accordingly, the cashless facility was considered as inadmissible by the competent authority of Opposite Party. Therefore, the competent authority of Opposite Party denied the cashless facility in question on the basis of denial/ exclusion clause vide letter dated 22.8.2016 and intimated the same to the concerned hospital; that the complainant does not fall within the ambit of consumer under section 2 of the Consumer Protection Act; that no cause of action has arisen to the complainant to file the present complaint as the averments of the present complaint does not depict any consumer dispute between the parties; that the complainant has not come to this Forum with clean hands and has suppressed the material facts from this Forum; that the present complaint is hopelessly time barred; that the present complaint is bad for non joinder of necessary party. On merits, facts narrated in the complaint have been denied and a prayer for dismissal of the complaint with cost was made.
3. In his bid to prove the case, complainant made in the witness box as her own witness and filed duly sworn affidavit Ex.C-1 in support of the allegations made in the complaint alongwith copies of documents Ex.C2 to Ex.C10 and closed her evidence.
4. On the other hand, to rebut the evidence of the complainant, the Opposite Party tendered into evidence the affidavit of Sh.Gurdeep Singh, Senior Divisional Manager Ex.OP1, alongwith copies of documents Ex.OP2 to Ex.OP5 and closed the evidence on behalf of the Opposite Party.
5. We have heard the ld.counsel for the parties and have carefully gone through the evidence on record.
6. On the basis of evidence on record, ld.counsel for the Opposite Party has vehemently contended that the husband of the complainant was a known case of HTN. As the policy was a second year policy and the ailment/ disease was found pre existing which is not payable since there is a waiting period of 3 years for the same. Accordingly, the cashless facility was considered as inadmissible by the competent authority of Opposite Party. But however, the complainant did not disclose the factum of suffering of hypertension to the Opposite Party at the time of obtaining of the policy and the complainant is a such guilty of suppression of factum of previous disease to Opposite Party. The admission of the complainant from 19.8.2016 uptill 21.08.2016 for medical treatment in Nayyar Hospital, Amritsar is not disputed and the complainant spent Rs.4,34,194/- on the medical treatment of her husband. But however, his insurance claim has been rightly repudiated under exclusion clause of the terms and conditions of the policy and a such, the claim of the complainant has rightly been rejected and the complaint being false and frivolous is liable to be dismissed and the same may be dismissed accordingly.
7. However from the appreciation of the facts and circumstances of the case it becomes evident that the complainant obtained insurance policy in dispute cover risk period 6.5.2016 to 5.5.2017 from Opposite Party on payment of premium, copy of insurance cover accounts for Ex.C2. It is also not disputed that the husband of the complainant remained admitted in Nayyar Hospital, Amritsar for his treatment w.e.f. 19.8.2016 to 21.8.2016. It is further in evidence that the complainant incurred an expenses of Rs.4,34,194/-, copies of treatment pertaining to Nayyar Hospital, Amritsar accounts for Ex.C3. It is also an admitted fact that the claim was repudiated vide letter Ex.C4. The ground on which the claim of the complainant has been repudiated has been that the complainant was suffering from hypertension prior to the issue of the insurance cover in dispute. But hypertension is not a material disease, therefore, non disclosure thereof is not a concealment. We draw support from Life Insurance Corporation of India Vs. Sushma Sharma from II (2008) CPJ 213 wherein Hon'ble State Commission has held as under:-
“So far as hypertension is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.
We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease.
- In such a situation the repudiation made by Opposite Party regarding genuine claim of the complainant appears to have been made without application of mind. It is usual with the insurance company to show all types of green pesters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
- From the aforesaid discussion, it transpires that Opposite Party has wrongly repudiated the genuine claim of the complainant. Opposite Party is directed to make the payment of insurance claim of the complainant to the tune of Rs. 4,34,194/-. The costs of the litigation are assessed at Rs.2,000/-. Compliance of this order be made within 30 days from the receipt of copy of the order; failing which, awarded amount shall carry interest @ 9% p.a from the date of filing of the complaint until full and final recovery. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
