ORDER
Complaint under Sec.12 of the CPA 1986 as amended upto date
Ms. Nipur Chandna, Member
The Complainant is the medicalim policy holder of the OP company vide policy no. 040700/48/12/06/00001697 w.e.f. 12.9.2012 to 11.09.2013.
It is alleged by the complainant that he was admitted in Metro Hospital and Cancer Institute, Preet Vihar, Delhi on 5.3.2013 with the complaint of severe chest pain and was discharged on 8.3.2013.
It is further alleged by the complainant that after discharge from the hospital he submitted all the treatment records and medical bill of Rs.2,11,038/- and bill of Rs.3,533/- of medicine to the OP company on 13.3.2013 for reimbursement. Complainant also wrote letter dated 7.5.2013 to the OP company for the reimbursement of his claim, but no response was given by the OP .
It is further alleged by the complainant that vide letter dated 20.5.2013, OP company repudiated/rejected his claim under clause 5.9.2 (a) of the policy, on false and flimsy grounds.
The complainant, therefore, approached this Forum for the redressal of his grievance.
Complaint has been contested by the OP . OP company has filed its reply to the complaint. Para Nos. 3 & 4 of the W.S. are relevant and the same are reproduced as under:
3. That the contract of the insurance is a contract of utmost good faith and he insurance is required and expected to disclose the true facts and information without concealing any material facts. That complainant had failed to disclose the material facts rather concealed the same with the opposite party by not disclosing the fact that the insured was suffer from and a known case of systemic hypertension since 6 months as mentioned in the indoor case papers which fact was concealed by the insured as well as the treating doctor.
4. That the present claim is not maintainable. As per the policy conditions this claim comes under exclusion 5.9 (2a) so this claim is not payable therefore the claim was repudiated and intimation to the said effect was given vide letter dated 2.5.2013.
The exclusion clause 5.9 2a of Family Medical Policy :- Any fraud, misrepresentation or suppression by the insured or on his behalf is found either in obtaining insurance or subsequently in relation thereof.
Both the parties have filed their evidence by way of affidavits.
The counsel for the complainant has also placed a record additional affidavit alongwith the copies of medical bills dated 14.5.2013, 3.8.2013, 9.11.2013, 12.2.2014, 13.5.2014 and 17.8.2014. The perusal of the above bills clearly shows that all these bills are for the period beyond 60 days of the hospitalization and as such the same are not payable as per clause 1.2 of the policy term and condition.
We have heard arguments advanced at the bar and have perused the record.
The counsel for the OP has contended that the investigation had revealed that the patient was suffering from systemic hypertension since six months, as mentioned in the Indoor case papers and had thus obtained the insurance policy by supposing vital facts. He has contended that the claim of the complainant falls under exclusion clause no. 5.9 (2a) of the policy term and conditions and was not payable.
It is further contended by the counsel for the OP company that the OP company had rightly repudiated the claim of the complainant and prayed for the dismissal of the compliant.
We however, are not in agreement with the contention of the counsel for the OP .
In the case of C.P. Mathur v/s New India Assurance Company v/s Hon’ble State Commission has held that :
As regards concealment of the disease of hypertension and diabetes, we have taken a view that these are not such diseases which are to be disclosed as these are controllable on day to day basis unless a consumer is hospitalized or undergone an operation for a particular disease and is otherwise leading a normal healthy life. The non-disclosure of such type of diseases which in the modern day life are normal wear and tear of life cannot disentitle the consumer as to the claim under medicalim policy.
Even otherwise the insurance company cannot be allowed to take advantage of its own acts of omissions and commissions. While issuing medicalim policy the minimum expectation from the insurance company is to subject a consumer to basic tests like ECG, blood sugar, blood pressure to rule out such type of diseases. Hypertension and diabetes of such a magnitude that may disentitle the consumer to obtain a medicalim policy can be easily detected by these tests. It is also our view that unless and until a consumer in the near proximity of obtaining the policy is hospitalized or is operated upon cannot be disallowed to reap benefit to the policy.
Further, the OP insurance company has not placed on record the proposal form executed by the complainant at the time of purchase of the policy. There is, therefore, no evidence that the complainant had made a misstatement about the state of his health at the time of purchase of the policy.
Even otherwise the complainant was admitted in emergency and was diagnosed as a case of CAD (CVD). There is no evidence on record that this ailment had occurred only because of hypertension. The OP has ignored a certificate issued by Metro Hospital and Cancer institute dated 4.5.2013 which states that the patient has no history of CAD in past.
In view, of the above discussion we are of the considered opinion that the repudiation of the claim lodged by the complainant was not justified.
We, therefore, hold OP guilty of deficiency in service and direct it as under:-
- Pay to the complainant a sum of Rs.2,14,571/- (Two Lac Fourteen Thousand Five Hundred Seventy One Only ) alongwith interest @ 10% from the date of filing of complaint till payment.
- Pay to the complainant a sum of Rs.25,000/-(Rupees Twenty Five Thousand only ) for pain and mental agony suffered by him.
- Pay to the Complainant a sum of Rs.5,000/- (Rupees Five thousand only ) as a cost of litigation.
The OP shall pay this amount within a period of 30 days from the date of this order failing which they shall be liable to pay interest on the entire awarded amount @ 10% per annum. If the OP fails to comply with this order, the complainant may approach this Forum for execution of the order under Section 25/27 of the Consumer Protection Act.
Copy of the order be made available to the parties as per rule.
File be consigned to record room.
Announced in open sitting of the Forum on ___________
