Ms.Rachna Arora, Member
1. Sh.Surinder Peshawaria, has brought the instant complaint under section 11 & 12 of the Consumer Protection Act, 1986 on the allegations that the complainant purchased mediclaim policy bearing No.233308/48/2016/1636 dated 18.2.2016 valid for the period from 19.2.2016 to 18.2.2017 in favour of complainant as well as in the name of his wife Smt.Aruna Peshawaria and paid premium of Rs.6960/-. The complainant was admitted to Fortis Escorts Hospital, Verka Majitha Bye-Pass, Amritsar for treatment of Parenchymal Hemorrage (Brain Hemorrhage) for which the complainant was diagnosed in the aforementioned hospital. The patient/ complainant was diagnosed for left cerebellar Acute Parenchymal Hemorrhage and a total amount of Rs.89081.36 paisa was spent on the treatment by the complainant. The policy issued by the complainant was cashless policy, but to the utter surprise of the complainant the cashless claim No. 12612510 was denied vide letter dated 6.5.2016 by the Opposite Parties stating that the complainant should submit complete claim papers for reimbursement and further stating that the policy is in second year and the complainant was a known case of CAD post CARG post 2005, Type 2 DM for last 4 years and HTN from 2005. But it is pertinent to mention over here that the policy is in its third year of inspection and the Ist policy was issued on 18.2.2014, second policy was issued on 17.2.2015 and third policy was issued on 18.2.2016 and the Opposite Parties has wrongly stated that the policy is in second year. The claim has been denied due to CAD post 2005, diabetes for last 4 years and hypertension from 2005, but medically Cardiac arrest and Parenchymal Hemorrhage (Branch Hemorrhage) has no inter-relation and both are separate disease and have no co relation with each other and can not be considered as pre existing disease. As far as diabetes and hypertension are concerned the Opposite Parties have itself mentioned in the terms and conditions of the policy in the exclusion clause, which clearly states waiting period of 2 years for diabetes and hypertension and the policy of complainant is in third year. Moreover, the diabetes and hypertension are considered as lifestyle and not a disease, therefore, the claim of the complainant can not be repudiated by the Opposite Parties. Vide instant complaint, the complainant has sought the following reliefs.
a) Opposite Parties may be directed to settle the claim of the complainant for Rs.79,081/- as cost of medical expenses incurred.
b) Damage to the tune of Rs.25,000/- being damages for the harassment suffered by the complainant at the hands of the Opposite Parties on account of mental tension agony, etc.
c) Entire costs of the present complaint.
d) Any other relief to which the complainant is found entitled to under law, equity and fairplay be also granted in favour of the complainant against the Opposite Parties.
Hence, this complaint.
2. Upon notice, opposite parties No.1, 2 appeared and contested the complaint by filing joint written statement taking preliminary objections therein inter alia that the complainant has violated the basic terms and conditions of the policy in question. As per the 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 in force continuously. In the present case, 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 claim was considered as inadmissible by competent authority of Opposite Parties, therefore, the competent authority of Opposite Parties recommended that the claim in question was not payable on the basis of denial/ exclusion clause. Accordingly, the Opposite Parties repudiated the claim vide letter dated 12.8.2016 and intimated the same to the complainant. On scrutiny of claim documents, it was found that the complainant was a known case of CAD post CABG post 2005, Type 2 DM for last 4 years and HTN from 2005. The contract of insurance is based on utmost good faith, but the complainant has concealed the material information and has intentionally mislead the Opposite Parties to get a false claim, hence the complainant is not entitled to get the relief claimed for. On merits, the Opposite Parties took almost same and similar pleas as taken by the Opposite Parties in preliminary objections. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.
3. In his bid to prove the case, complainant tendered into evidence affidavit Ex.CW1/A in support of the allegations made in the complaint and also produced copies of documents Ex.C1 to Ex.C19 and closed his evidence.
4. On the other hand, to rebut the evidence of the complainant, the Opposite Parties tendered into evidence the affidavit of Sh.Ravi Gupta, Deputy Manager Ex.OP1 alongwith copies of documents Ex.OP2 to Ex.OP5 and closed the evidence on behalf of the Opposite Parties.
5. We have heard the ld.counsel for the parties and have carefully gone through the evidence on record.
6. Ld.counsel for the complainant has reiterated the facts in the arguments as narrated in the complaint and argued that the complainant purchased mediclaim policy bearing No.233308/48/2016/1636 dated 18.2.2016 valid for the period from 19.2.2016 to 18.2.2017 in favour of complainant as well as in the name of his wife Smt.Aruna Peshawaria and paid premium of Rs.6960/-. The complainant was admitted to Fortis Escorts Hospital, Verka Majitha Bye-Pass, Amritsar for treatment of Parenchymal Hemorrage (Brain Hemorrhage) for which the complainant was diagnosed in the aforementioned hospital. The patient/ complainant was diagnosed for left cerebellar Acute Parenchymal Hemorrhage and a total amount of Rs.89081.36 paisa was spent on the treatment by the complainant. The policy issued by the complainant was cashless policy, but to the utter surprise of the complainant the cashless claim No. 12612510 was denied vide letter dated 6.5.2016 by the Opposite Parties stating that the complainant should submit complete claim papers for reimbursement and further stating that the policy is in second year and the complainant was a known case of CAD post CARG post 2005, Type 2 DM for last 4 years and HTN from 2005. But it is pertinent to mention over here that the policy is in its third year of inspection and the Ist policy was issued on 18.2.2014, second policy was issued on 17.2.2015 and third policy was issued on 18.2.2016 and the Opposite Parties has wrongly stated that the policy is in second year. The claim has been denied due to CAD post 2005, diabetes for last 4 years and hypertension from 2005, but medically Cardiac arrest and Parenchymal Hemorrhage (Branch Hemorrhage) has no inter-relation and both are separate disease and have no co relation with each other and can not be considered as pre existing disease. As far as diabetes and hypertension are concerned the Opposite Parties have itself mentioned in the terms and conditions of the policy in the exclusion clause, which clearly states waiting period of 2 years for diabetes and hypertension and the policy of complainant is in third year. Moreover, the diabetes and hypertension are considered as lifestyle and not a disease, therefore, the claim of the complainant can not be repudiated by the ops can not be repudiated by the Opposite Parties.
7. On the other hand, ld.counsel for the Opposite Parties has repelled the aforesaid contention of the ld.counsel for the complainant on the ground that the complainant has violated the basic terms and conditions of the policy in question. As per the 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 in force continuously. In the present case, 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 claim was considered as inadmissible by competent authority of Opposite Parties, therefore, the competent authority of Opposite Parties recommended that the claim in question was not payable on the basis of denial/ exclusion clause. Accordingly, the Opposite Parties repudiated the claim vide letter dated 12.8.2016 and intimated the same to the complainant. On scrutiny of claim documents, it was found that the complainant was a known case of CAD post CABG post 2005, Type 2 DM for last 4 years and HTN from 2005. The contract of insurance is based on utmost good faith, but the complainant has concealed the material information and has intentionally mislead the Opposite Parties to get a false claim, hence the complainant is not entitled to get the relief claimed for.
8. It is not the denial of the case that the complainant purchased mediclaim policy bearing No.233308/48/2016/1636 dated 18.2.2016 valid for the period from 19.2.2016 to 18.2.2017 in favour of complainant as well as in the name of his wife Smt.Aruna Peshawaria and paid premium of Rs.6960/-. It is also not denied that the complainant was admitted to Fortis Escorts Hospital, Verka Majitha Bye-Pass, Amritsar and spent Rs. 79081/- for his treatment to the said hospital. The only ground for the repudiation of the claim of the complainant is that on scrutiny of claim documents, it was found that the complainant was a known case of CAD post CABG post 2005, Type 2 DM for last 4 years and HTN from 2005. The contract of insurance is based on utmost good faith, but the complainant has concealed the material information and has intentionally mislead the Opposite Parties to get a false claim and in this way, the complainant has violated the basic terms and conditions of the policy in question. As per the 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 in force continuously. In the present case, 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. So, the Opposite Parties repudiated the claim vide letter dated 12.8.2016 and intimated the same to the complainant. It is further in evidence that the complainant incurred an expenses of Rs.79081/-, copies of treatment pertaining to Fortis Escorts Hospital, Verka Majitha Bye-Pass, Amritsar accounts for Ex.C19. The ground on which the claim of the complainant has been repudiated has been that the complainant was suffering from hypertension and diabetes prior to the issue of the insurance cover in dispute. But hypertension and diabetes 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 Parties 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 Parties have wrongly repudiated the genuine claim of the complainant. Opposite Parties are directed to make the payment of insurance claim of the complainant to the tune of Rs. 79081/-. 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
