Chandigarh

DF-I

CC/513/2018

Jyotsna Bali - Complainant(s)

Versus

The Oriental Insurance Company Limited - Opp.Party(s)

R.C. Bali Adv. & Vishal Bali Adv.

26 Sep 2019

ORDER

 DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

                               

Consumer Complaint No.	:	CC/513/2018
Date of Institution	:	15/10/2018
Date of Decision	:	26/09/2019

 

Jyotsna Bali w/o Sh. R.C. Bali (Raghubir Chander Bali), aged about 68 years, r/o H.No.85, Sector 27-A, Chandigarh

 

… Complainant

V E R S U S

1.     The Oriental Insurance Company Limited, D.O.-II, through its Senior Divisional Manager, SCO No.48-49, Sector 17-A, Chandigarh.

2.     Raksha TPA (P) Ltd., through its authorised signatory/Incharge, SCO No.359-360, 1^st Floor, Sector 44-D, Chandigarh, presently at SCO No.39, 1^st Floor, Madhya Marg, Sector 26, Chandigarh.

 … Opposite Parties

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                     

ARGUED BY	:	Sh. Vishal Bali, Counsel for complainant
	:	Sh. J.P. Nahar, Counsel for OPs

 

Per Rattan Singh Thakur, President

1.         The long and short of the allegations are, since 2015, the complainant had been purchasing PNB Oriental Royal medi-claim Policy (with Family Floater) from OP-1 and the latest policy purchased was valid from 28.4.2017 to 27.4.2018.  During the operation of this policy, on 20.2.2018, the complainant felt chest pain and was treated in OJAS Super Specialty Hospital, Sector 26, Panchkula as indoor patient and was discharged on 23.2.2018 and diagnosed and treated for blockage in the main artery for which PTCA and stenting of LAD was done.  The bill of Rs.1,92,285/- was raised by the hospital which was paid and then submitted for reimbursement to OP-2 and OP-1 repudiated it on the ground complainant has been suffering from hypertension for the last 25 years and CAD was a complication of HTN.  The said fact was stated to be wrong and, therefore, there was deficiency in service on the part of the OPs.  Hence, the present consumer complaint for directing the OPs to pay the claim amount of Rs.1,92,285/- alongwith interest, compensation of Rs. two lakhs; Rs. one lakh for deficiency in service, negligence and cost of Rs.50,000/-.
2.         OPs contested the consumer complaint. The crux of their reply is CAD for which the complainant was treated and stenting was done was the outcome of hypertension which she has been suffering for the last 25 years.  The said fact was concealed by the complainant at the time of taking the policy and, therefore, her claim fell in the exclusion clause as with to regard pre-existing health condition, wrong statement was furnished.  On these lines, the cause is sought to be defended.
3.         Rejoinder was filed and averments made in the consumer complaint were reiterated.
4.         Parties led evidence by way of affidavits and documents.
5.         We have heard the learned counsel for the parties and gone through the record of the case. After perusal of record, our findings are as under:-
6.         Per pleadings of the parties, the only ground for repudiation of the claim was the complainant had pre-existing disease of hypertension which was concealed at the time of issuance of the policy on 28.4.2017, therefore, her case fell in the exclusion clause and was rightly repudiated per terms and conditions of the policy. 
7.         Per record, the complainant is aged about 68 years and her husband Sh. R.C. Bali is aged 70 years as on the date of filing the present consumer complaint.  Our attention was drawn to the Insurance Regulatory and Development Authority (for short IRDA) guidelines to the effect, if the person insured above the age of 45 years was not put to thorough examination, claim raised after issuance of insurance cannot be rejected on account of non-disclosure of fact of pre-existing disease when the policy was taken.  To this effect reliance has been placed on case titled as Manish Goyal Vs. Max Bupa Health Insurance Company, Complaint Case No.234 of 2017 decided on 22.3.2018 by our own Hon’ble State Commission whereby it was observed that at the relevant time of obtaining the policy the insured was above 45 years and in that event, as per instructions issued by IRDA, it was the duty of the OP to put the insured to thorough medical examination.  If such breach was done, they are now estopped to deny the claim of the person insured on the ground of concealment of fact.
8.         In the instant case, the complainant was around 67 years on the date of issuance of the policy i.e. 28.4.2017 and was in the autumn of her life alongwith her husband, Sh. R.C. Bali.  In this case, before issuance of the insurance policy, no medical examination was got done despite instructions of IRDA.  Therefore, we are afraid if this defence is available to the OPs to repudiate the claim on the ground of concealment of pre-existing disease. 
9.         The sole ground for repudiation of claim is the complainant, as per reference in record by her husband, had been suffering from hypertension for the last 25 years.  It is not the case nor any medical record produced to say her hypertension was uncontrollable which led to formation of coronary artery disease for which stenting was done.  25 years is a long span of time and hypertension more or less is a common disease and is controllable with proper medication.  Though it is not established beyond doubt that the complainant was suffering from hypertension and it cannot be said with authenticity, her heart problem was due to hypertension.  In case titled as Satish Chander Madan Vs. Bajaj Allianz General Insurance Co. Ltd., I (2016) CPJ 613 (NC), under paragraph No.9 & 10 it was held as under :-

“9.    We do not find merit in the above contention. On perusal of the copy of the medical report of the petitioner dated 4.6.2010 issued by Dr. David P. Lipkin as also the letter of the doctor dated 7.6.2010 addressed to Dr. M. Fertleman of Wellington Hospital would show that as per the observations of Dr. David P. Lipkin, the petitioner had a previous history of hypertension and he was on BP medicine Telmisartan. The above referred reports do not mention that the petitioner disclosed any previous history of heart problem. Therefore, the only fact established by the above reports is that the petitioner prior to obtaining insurance policy was having history of hypertension. This, however, does not lead to conclusion that petitioner was also having previous history of heart problem. Therefore, the insurance claim submitted by the complainant for treatment of his heart problem cannot be termed as a claim in respect of a pre existing disease. Thus, repudiation of insurance claim by the respondent opposite party is not justified.

10.    Learned Counsel for the respondent has contended that it is established on record that the petitioner was having a previous history of hypertension and since hypertension can lead to heart problem, the respondent was justified in repudiating the claim on the ground that the heart problem suffered by the petitioner was caused by pre existing hypertension. There is no merit in this contention. Hypertension is a common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack. Therefore, the argument advanced by respondent is far fetched and is liable to be rejected.”

 

In view of the proposition in hand as well as the precedent of the Hon’ble National Commission, repudiation of the claim on this score is bad in the eyes of law.

10.         Contra, learned counsel for the OP relied on case titled Ram Swaroop Agrawal & Anr. Vs. New India Assurance Co. Ltd., I (2014) CPJ 615 (NC) vide which it was held as discharge summary issued by hospital says that policy holder was known case of diabetes and hypertension for last 15 years, therefore, it is to be considered part of pre-existing condition and repudiation was held justified. This law pertains to the year 2014 while the precedent of Satish Chander Madan (supra), referred in the foregoing paragraph, is of the year 2016 and, therefore, the latest precedent has to be followed. 
11.         The complainant has also produced on record cash memo/bill (Annexure C-7 colly.) which shows total amount deposited with the hospital was Rs.1,92,285/-, therefore, her clam stood verified with this record.  Hence, we hold repudiation of claim of the complainant by the OPs is bad in the eyes of law and the same amounts to deficiency in service. 
12.         In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed. OPs are directed as under :-

1. to pay the claimed amount of Rs.1,92,285/- to the complainant alongwith interest @ 9% per annum from the date of repudiation i.e. 9.5.2018 till realization.
2. to pay an amount of Rs.30,000/- to the complainant as compensation for causing mental agony and harassment to her;
3. to pay Rs.10,000/- to the complainant as costs of litigation.

13.         This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
14.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-	Sd/-
26/09/2019	[Suresh Kumar Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
hg	Member	Member	President