Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No. 121/dated 03.05.2017
Harish Dotania s/o Dhanna Ram
r/o 16/496-H, IV Floor, Hardhyan Singh
road, Bapa Nagar, Karol Bagh,
New Delhi-110005 …Complainant
Versus
United India Insurance Co. Ltd.
Divisional Office-IV, 501-503,
5th Floor, Vikarant Tower, 4,
Rajendra Place, New Delhi-110008 ...Opposite Party
Date of filing 03.05.2017
Date of Order: 07.10.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
ORDER
Inder Jeet Singh , President
1.1. (Introduction to case of parties) –The complainant/Insured has grievances against OP/Insurer that despite having medi-care policy valid from 26.02.2016 to 25.02.2017, when was admitted in emergency on 14.05.2016 in Sir Ganga Ram Hospital, Delhi, he was declined cashless facility and later on his valid claim of medical bills/expenses, that is why the complaint was filed. The complainant seeks reimbursement of medical treatment expenses of Rs. 2 lakh, mental agony of Rs. 2 lakh, litigation expenses of Rs. 25,000/-, other medical expenses of Rs. 25,000/- and other relief.
1.2. Whereas, the OP/Insurer opposed the complaint that there was a valid insurance policy, the complainant’s case is that he was admitted in the hospital on 14.05.2016 for treatment of “severe pain in right leg” due to the disease DM & Venous Thrombosis, which was diagnosed after the various laboratory tests in Sir Ganga Ram Hospital. However, it was revealed that actually the complainant was suffering from the said decease for the last four years which was confirmed by the treating doctor. The complainant had not disclosed the said pre-existing decease in the proposal form, the insurance policy was obtained with fraudulent intentions.
2.1. (Case of complainant) –The complainant took family medi-care policy from OP vide policy no. 0404002814P 110264795 and then it was got renewed vide policy no. 0404002815P 114490022 valid from 26.02.2016 to 25.02.2017. On 14.05.2016, during the life of policy, the complainant felt heavy pain in his right leg and he was admitted in emergency of Sir Ganga Ram Hospital, where various tests were conducted and he was advised amputation of lower leg, otherwise there may chances of mis-happening to his life and of major operation.
2.2. The complainant’s son deposited the medical policy but it shocked and surprised that Sir Ganga Ram Hospital was already black listed by the OP for the reasons best known to the hospital. The complainant was advised for deposit of advance for treatment, the complainant’s family could arrange Rs. 30,000/-, his right leg was operated in the Sir Ganga Ram Hospital. The complainant deposited Rs.1,50,819/- despite having insurance policy no. 0404002815P 114490022 and the complainant was discharged on 16.05.2016 after payment of bills.
2.3. After discharge and recovery, the complainant submitted his claim and relevant documents under claim no. HH5811700658 with the OP, the complainant was also ensured that his claim will be settled in short period. There was a query through letter dated 18.06.2016 (CCN:HHB11700658), which Sir Ganga Ram Hospital replied to Heritage Health TPA Pvt. Ltd. that complainant was recently diagnosed with DM, through Dr. Amrish Satwik, Consultant, Department of Peripheral Vascular & Endovascular Surgery, Sir Ganga Ram Hospital. Moreover, the complainant has been visiting the hospital as outdoor patient under the advice of treating doctor, for which he was spending Rs. 500/- trip of tax fare and Rs. 1,000/- of doctor’s fee. The complainant has been pursuing a lot for settlement of his medi-claim but the OP harassed, humiliated and caused mental and physical pain to the complainant. The complainant keeps on visiting the OP, for the last more than one year but no result and finally he had written application dated 20.07.2016 but no response. That is why the present complaint.
2.4. The complaint is accompanied with copies of insurance policy cover, copy of letter dated 18.07.2016, medical bills, letter dated 18.06.2016, clinical reports and lastly written letter dated 20.07.2016.
3.1 (Case of OP)-The OP does not dispute about the insurance policy issued and its tenure, however, the claim is opposed that it has been revealed that complainant was suffering from the disease for the last four years and it was not disclosed in the proposal form, the complainant mis-represented the facts and obtained the family medi-care health insurance policy with fraudulent intension and consequently the exclusion clause 4.1 and 5.8 applies, the policy shall be void and premium stand forfeited to the OP. The complaint is liable to be dismissed because of suppression of such deliberate and intentional material facts. Lastly, the complaint involves complicated question of facts and law, therefore, it is to be determined by the Civil Court.
3.2. The reply is accompanied with copy of insurance policy and proposal form dated 23.02.2015.
4. (Replication of complainant) –The complainant files his replication while further making allegations against the OP that proposal form was filled in by the agent of insurance company, he cannot be blamed for the information therein. The complainant has been cheated by the OP as despite securing the valid insurance policy the claim is being denied in order to safe its own scheme. The claim is maintainable and he deserves the relief claimed.
5. (Evidence)- The complainant led his evidence by filing detailed affidavit with the support of documents filed with the complaint. OP led its evidence by filing compact affidavit of Sh. Jagdish Narang, Deputy Manager, with the support of documents filed with the reply.
6.1 (Final hearing)-The complainant as well as the OP filed their respective written arguments, which is replica of their pleading and evidence. Moreover, the parties were given opportunity to make oral submissions, therefore, Sh. Raju Vijay, Advocate for complainant made the oral submissions and during oral submissions he furnished a sheet of calculation that total medical bill amount is of Rs. 3,13,963/- besides other relief claim in the complaint.
The complainant was enquired that in the complaint as well as in the affidavit of evidence there is mentioning of discharge slip/summary but it was not filed on record.\ However, on 04.10.2023, the complainant had appeared and filed the discharge summary, which was not filed earlier.
6.2. The OP failed to make any oral submissions, therefore, the written arguments filed will be considered.
7.1 (Findings)-The contentions of both the sides appearing from their pleadings, evidence and arguments are analysised, assessed and considered.
7.2 The OP took the objection in the reply that there is complicated questions of fact and law to be determined by the civil court, which was opposed by the complainant. It has not been established by the OP nor circumstances is suggesting as to how the issues involved cannot be determined by summary procedure, when there is documentary record as well as other circumstances on record. Therefore, for want of establishing the circumstances, this contention of OP carries no weight that issue can be determined by the civil court exclusively. The present Commission is competent to determine the issue involved by summary procedure on the basis of facts, features and other documentary record.
7.3 The narrow question is whether the complainant was suffering from any pre-existing decease of central venous thrombosis 4 years ago OR whether the complainant had suppressed this ailment from the OP, besides whether the complainant is entitled for relief claimed. By taking into account totality of circumstances, the following conclusions are drawn:-
(i) The discharge summary is a material document, which depicts the medical complaint, medical history, examination of patient, investigation carried and the treatment given besides appropriate advises to the patient at the time of discharge inclusive of appropriate follow up. It was not proved in evidence but a few days back on 04.10.2023 the copy of discharge summary was filed. However, the complainant has proved other medical documents.
(ii) Sir Ganga Ram Hospital had issued letter dated 18.07.2016 addressed to OP and it was in response to query on cashless facility, it reads as “this is to say that when the patient was diagnosed with central venous thrombosis 4 years ago. And, no arterial symptoms in the lower limb. No evidence of thrombosis in the lower limb”.
(iii) The OP1 also written letter dated 14.07.2016 to the complainant, while that claim is not payable as per clause no. 4.1 because of pre-existing disease by mentioning in the operating part “it has been observed in your case that you had been suffering from Central Venous Thrombosis since 4 years, whereas policy has been taken 1-1/2 year backs and thereafter it is a case of pre-existing disease”.
(iv) OP’s TPA had made an enquiry, it was responded by Sir Ganga Ram Hospital by issuing letter dated 18.06.2016 to OP’s Heritage Health TPA Pvt. Ltd. and in its operating part of paragraph no. 3, it was informed to the TPA “patient was reportedly diagnosed recently with DM (01 month prior to admission) (14-05-2016) and central venous thrombosis 4 years ago.
(v) The OP has proved insurance policy cover and also proposal form dated 23.02.2015, it gives the proposer’s detail in Annexure-A & Annexure-B. The Annexure-A provides a table for appropriate detail of adverse medical history of applicable illness diabetes questionnaire; hypertension questionnaire; chest pain or coronary insufficiency or myocardial infarction questionnaire. The other part/Annexure-B is to be completed by the physician/surgeon.
In all the questionnaire of Annexure-A, the answer mentioned is “No”, however, there is no column pertaining to other specific column of ailment of thrombosis to be filled by the complainant or other general questionnaire.
(vi) As per letter dated 18.06.2016 issued by Sir Ganga Ram Hospital, the diabetes of complainant was diagnosed about 1 month prior to admission on 14.05.2016. Therefore, when proposal form was filled in on 23.02.2015, the complainant was not known case of diabetes nor suffering from such ailment, therefore, it cannot be said that there was concealment of this ailment.
(vii) As per OP’s letter dated 14.05.2016 the claim was declined as complainant was suffering from ailment of central venous thrombosis 4 year ago and it was not disclosed in the claim form. Whereas, neither Annexure A nor Annexure B of the proposal form contains any questionnaire pertaining to inquiry about ailment of central venous thrombosis or thrombosis. Since there was no specific questionnaire about this ailment, therefore, it cannot be said that complainant had concealed this ailment from the proposal form or he had mis-represented it.
(viii) As per OP’s another letter dated 23.09.2016 the claim was repudiated by invoking exclusive clause 4.1 and clause 5.8 that policy is void because of obtaining the policy by misrepresentation. The insurance policy has been proved by the OP and there is exclusion clause 4.1 that when there is pre-existing condition, in that eventuality the insurer will not be liable to pay the amount until 48 months of continuous coverage of such person has elapsed.
The complainant took the first policy insurance coverage from 26.02.2016 to 25.02.2017 and it was got renewed for period 14.05.2016 to 26.02.2017. During the currency of renewed policy, the complainant was admitted in the hospital on 14.05.2016 on complaint of sudden pain in right leg for last 10-12 days. The discharge summary shown by the complainant also reflects so besides that he is known case of central venous thrombosis with seizures. In the letter dated 18.06.2016 it was made clear by the Sir Ganga Ram hospital that he was diagnosed with central venous thrombosis 4 year ago. On the basis of this material on record the clause of 4.1 of insurance policy applies, therefore, the tenure of 48 month is yet to be elapsed to make out claim of the complainant. This, exclusion clause 4.1. does not entitle the complainant for claim.
(ix) The OP had also invoked clause 5.8 of the insurance policy in its written statement, however, this plea of OP does not sustain for the reasons that there was no column in the proposal form to describe the ailment of central venous thrombosis thence, there was no occasion for the complainant to respond questionnaire, it cannot be construed mis-representation, mis-description and non-disclosure and then to treat the policy void-ab-initio.
Thus, OP’s plea that policy shall be void and premium is forfeited is not tenable in view of the aforementioned discussion. The policy is to be treated continued without forfeiting of its premium paid.
7.3. In view of the above, the complaint is partly dismissed to the extent that because of exclusion clause 4.1, the complainant’s claim is not made out and he is not entitled for any medical claim or other relief claimed. However, the complaint is deemed to be partly allowed in terms of sub clause (ix) of paragraph no. 7.2 above, the policy cannot be treated void ab-initio and the premium cannot be treated as forfeited. The policy is to be treated continued without forfeiting of its premium paid. No order as to cost. The complaint is accordingly disposed off.
8: Announced on this 7th October 2023 [अश्विन 15, साका 1945].
9. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for compliances.
[Vyas Muni Rai] [Shahina] [Inder Jeet Singh]
Member Member (Female) President
