IN THE CONSUMER DISPUTES REDRESSAL COMMISSION, KOTTAYAM
Dated, the 30th day of November 2022.
Present: Sri. Manulal V.S. President
Smt. Bindhu R. Member
C C No. 203/2019 (Filed on 18-11-2019)
Petitioner : Amala Justin,
W/o. Justin Wilfred.
Anuvilla House,
Muttathuppady,
Kurishummoodu Post,
Changanacherry – 686104
(Adv. Swarna Jose)
Vs.
Respondents : (1) Insurance Agent,
Vipin Soman,
ICICI Lombard General Insurance
Company Ltd. First Floor,
Trade Centre, Near Sastri Road,
Kottayam – 680001
(2) The Manager,
ICICI Lombard General Insurance
Company Ltd. First Floor,
Trade CEnture, Near Sastri Road,
Kottayam - 680001
(Adv. Agi Joseph)
O R D E R
Sri. Manulal V.S. President
Case of the complainant is as follows:
The complainant has taken a medical insurance policy with the second opposite party for the period from10-4-2019 to 9-4-2019. The first opposite party approached the complainant introducing as an insurance agent and with good faith and believing the first opposite party the complainant and her family took the health insurance policy which was described as full cover medical insurance policy with the first opposite party vide policy number 4128i/iH/168983334/00/000 by paying Rs.12,428/- as premium.
The complainant had been admitted at Pushpagiri Medical Society from 15-7-2019 to 8-7-2019 due to high fever. For the said treatment the complainant was billed for an amount of Rs.18,800/.As she was having the insurance policy it was given to the hospital authority for adjusting the bill amount. The in charge of the hospital authority declined the complainant’s request stating that the complainant is a diabetic patient and such patients are not eligible to receive any claim . It is averred in the complaint that complainant was a diabetic patient even
before taking the policy and the same was conveyed to the first opposite party , he never told it is a criteria ,if so the complainant would not join the policy. The opposite parties thus misrepresented and by fraud canvassed the complainant and
forced her to take the policy. The acts and omissions of the opposite party in neither providing policy documents at the time of making payment nor briefing the policy terms and conditions to the complainant amounts to deficiency in service and unfair trade practice. Hence this complaint is filed by the complainant
praying for an order directing the opposite parties to pay Rs.18,800 or to repay the premium amount collected from the complainant and to pay compensation of Rs.10,000/- along with Rs.2000/- as cost of this litigation.
Upon notice second opposite party appeared before the commission and filed version. Though the notice was duly served, the first opposite party neither cared to appear before the Commission nor to file version. Hence first opposite party declared as ex-party .
Version of the second opposite party is as follows:
The liability of the insurance company is only as per the terms and conditions and exception of the policy. Complainant had taken the policy without disclosing her illness. Hence said fact is a material concealment of fact and the opposite party is not liable to pay his claim. The complainant has not disclosed her history in the proposal form for taking the policy. The averment in paragraph 5 and 6 of the complaint are not true. There is no deficiency in service on the part of the second opposite party.
Complainant filed proof affidavit in lieu of chief examination and exhibits A1 to A4 were marked from the side of the complainant. Geetha G Nair who is the manager –legal of the second opposite party filed proof affidavit and got marked exhibit B1.
Point for consideration.
Whether the complainant has succeeded to prove any deficiency in service or unfair trade practice on the part of the opposite parties and to be entitle for any reliefs?
There is no dispute on the fact that the complainant had availed the service of the second opposite party taking a health insurance policy for the period from 10-4-2019 to 9-4-2020.Exhibit A2 policy certificate proves that the complainant had paid Rs.12428 as premium for the said policy and the sum assured was Rs.5,00,000/-. Exhibit A3 is the health card issued by the second opposite party in respect of the policy no.4128i/iH/168983334/00/000. On a mere reading of exhibit A3we can see the second opposite party offered a cashless access to the net work hospital with an authorization letter issued by the second opposite party. It is proved by exhibit A4 that the complainant had treated at Pushpagiri medical Collage hospital as inpatient from 15-7-2019 to 18-7-2019 and complaint had spent Rs.18,800/- for the treatment.
The complaint is resisted by the second opposite party stating that the complainant has not disclosed her history in the proposal form for taking the policy and she obtained the policy by suppressing the material fact that she is diabetic patient. Though the second opposite party contended that there is a suppression of material fact from the complainant they did not produce the proposal form to substantiate their contention. Moreover the second opposite party did not produce any evidence to prove that there was direct nexus between the diabetics and the ailment for which the complainant had undergone for the treatment.
It is now the settled law that pre-existing disease does not automatically follow a valid repudiation of claim. There should be an independent application of mind and recording of satisfaction that the infringement was induced by a motive to misrepresentation of fact or created a possibility of dishonesty in fraudulent manner. Diabetes and Hypertension are common lifestyle diseases; these cannot be treated as pre-existing diseases.
In this context, we rely upon the decisions of the judgment of the Hon’ble Delhi State Consumer Disputes Redressal Commission and two judgments of the Hon’ble National Consumer Disputes Redressal Commission respectively as
follows :-
Oriental Insurance Co. Ltd. – Vs. – Kaushalya Verma &Another [Appeal No.412/2016, 05.05.2021] – which justifies, even though there were pre-existing disease, it will not completely disentitle the respondent from indemnification of the claim from the Insurance Company for such common lifestyle diseases.
Neelam Chopra – Vs. – Life Insurance Company of India [Revision Petition No.4461 of 2012] – which clarifies, the disease of “Cardio Respiratory Arrest” was existing for only five months prior to the death of the deceased therefore, it is clear that the disease was not prevailing when the proposal form was filled.
Although the disease of “Diabetes” existed for some time but was under control at the time of filling up of the proposal form. Moreover, the non disclosure of information in respect of this lifestyle disease of diabetes, will not totally disentitle the complainant for indemnification of the claim.
If the disease was not active at the time of filing of the proposal form and if the disease of “LL Hansen” has no relationship with the actual cause of death i.e. “Cardio Respiratory Arrest”, its suppression would not lead to total denial of the claim. So, even if any information was suppressed in the proposal form, it
cannot be treated as material information. Therefore, the petitioner/complainant would be entitled to the insurance claim.
The National Consumer Disputes Redressal Commission (NCDRC) observed during rejecting the revision plea filed by the Reliance Life Insurance Co. Ltd. against the Maharashtra State Commission’s order dismissing its appeal challenging the District Commission’s direction to pay Rs.1,12,500.00 to the
husband of one of its policy holders who died of diabetic ketoacidosis; even if the insured person was suffering from a disease and did not know about it nor was taking any treatment for the same, the claim cannot be denied by an insurance
company. Diabetes was a lifestyle disease in India and the whole insurance claim cannot be rejected only based on this ground.
In the instant case, the Complainant never had any such complications prior to inception of policy or prior to his ailment on 02.03.2018, even though if the disease of Hypertension and Diabetes were pre-existing, it will not completely disentitle the Complainant from indemnification of the claim from the Insurance Company for such common lifestyle diseases. If the disease of “Hypertension” and “Diabetes” were existed for some time but it may be under control at the time of filling up of the proposal form. Moreover, the non disclosure of information in respect of this lifestyle disease of “Hypertension” and “Diabetes”, will not totally disentitle the complainant for indemnification of the claim.
Therefore, it clearly transpires that, there are not only elements of negligence, unfair trade practice and gross deficiency in service but also forced the Complainant to suffer a severe economic loss, harassment and mental pain by the whimsical and illegal act of the second opposite party.
Now, coming to the matter of reliefs, we find that the second opposite party can’t get absolved from the mischief of negligence, unfair trade practice, harassment and deficiency in service. Accordingly, complaint is allowed and
- we hereby direct the second opposite party to reimburse the hospital expenses for Rs.18,800/- along with simple interest @9% per annum from the date of filing of this complaint till the date of payment.
- Compensation of Rs.5,000.00 and litigation costs of Rs.1500.00 from the second opposite party.
Order shall be complied within 30 days from the date of receipt of copy of this Order. If not complied as directed, the compensation amount will carry 9% interest from the date of Order till realization.
Pronounced in the Open Commission on this the 30th day of November, 2022
Sri. Manulal V.S. President Sd/-
Smt. Bindhu R. Member Sd/-
Appendix
Exhibits marked from the side of complainant
A1 – Risk Assumption letter issued by opposite party
A2- Policy certificate 4128i/iH/168983334/00/000
A3 –Card No.115366802 issued by opposite party
A4 – Copy of medical bills issued by Pushpagiri Medical College
Exhibit marked from the side of opposite party
B1 – Copy of policy with terms and conditions
By Order
Sd/-
Assistant Registrar
