Chandigarh

StateCommission

A/317/2018

Religare Health Insurance Company Ltd. - Complainant(s)

Versus

Vipul Jain - Opp.Party(s)

Sachin Ohri, Adv.

03 Dec 2018

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

 

 

Appeal No.	:	317 of 2018
Date of Institution	:	23.10.2018
Date of Decision	:	03.12.2018

 

Religare Health Insurance Company Ltd., SCO No.56-58, Sector 9-D, Chandigarh – 160017 through Authorized Signatory, Mr. Ankit Shanker Bhardwaj, Manager Legal, Religare Health Insurance, 3^rd Floor, Vipul Tech Square, Tower C, Sector 43, Golf Course Road, Gurgaon, Haryana.

…….Appellant/Opposite Party.

 

Versus

 

Vipul Jain R/o House No.A-901, Vrindavan Garden Society, Zirakpur, District Mohali (Punjab).

 

...Respondent/Complainant.

 

Appeal under Section 15 of the Consumer Protection   Act, 1986 against   order dated 31.08.2018 passed by District   Consumer Disputes Redressal Forum-II, U.T. Chandigarh  in Consumer Complaint No.631 of 2017.

 

BEFORE: JUSTICE JASBIR SINGH (RETD.), PRESIDENT.

                MRS. PADMA PANDEY, MEMBER.

                MR. RAJESH K. ARYA, MEMBER.

 

Argued by:

 

Sh. Sachin Ohri, Advocate for the appellant.

 

PER  RAJESH  K.  ARYA, MEMBER

                   The appellant has filed this appeal against order dated 31.08.2018 passed by District Consumer Disputes Redressal Forum-II, U.T., Chandigarh (in short ‘the Forum’ only), vide which, complaint bearing No.631 of 2017 filed by the respondent/complainant was  allowed in the following manner:-

“13]  Keeping into consideration the facts & circumstances of the case, as discussed in the preceding paragraphs, the present complaint is allowed with directions to the Opposite Parties to repay an amount of Rs.76,709/- to the complainant along with interest @9% per annum from the date of filing this complaint i.e. 22.8.2017. The Opposite Parties are also directed to pay a compensatory cost of Rs.10,000/- and litigation cost of Rs.5000/- to the complainant.

         This order shall be complied with by the Opposite Parties within a period of 30 days from the date of receipt of copy of this order, failing which they shall be liable to pay additional compensatory cost of Rs.5,000/- to the complainant apart from the above relief.”

2.              Before the Forum, it was case of the complainant that he subscribed a cashless Health Insurance Policy of the opposite parties in November 2015 and got it renewed from 16.11.2016 to 15.11.2017 vide Policy No.10423735.  Under the said policy, the wife and son of the complainant were also covered with sum insured of Rs.5 lacs.  The complainant suddenly felt pain in abdomen and on check-up and endoscopy test on 7.1.2017, stone of 4.4 mm was found in his gall bladder. The matter was reported to the opposite parties, whose representative visited the complainant and noted down that the complainant was suffering from bronchial asthma since his childhood and had been taking inhaler for the same.  However, the representative assured the complainant that he would be entitled for claim benefits but despite that the pre-approval was rejected by the opposite parties.  Ultimately, the complainant was admitted in Alchemist Hospital on 24.1.2017 for surgery of removal of stone and discharged on 25.1.2017 after paying all the expenses. Thereafter, a claim was lodged with the opposite parties but the same was rejected on the ground of non-disclosure of material facts/pre-existing ailments at the time of proposal.  It was stated that bronchial asthma was not a persistent problem with the complainant and he rarely used the inhaler specially once or twice in a year, but the representative of the opposite parties misguided the complainant and pressurized him to give in writing that the same had been using the inhaler since his childhood.  It was further stated that bronchial asthma & the use of inhaler and surgery of gall bladder had no co-relation in any manner nor bronchial asthma was the reason of development of stone in gall bladder.  Alleging repudiation of claim as illegal and an act of deficiency in service on the part of the opposite parties, a consumer complaint was filed before the Forum. 

3.             The opposite parties, in their reply, while admitting the factual matrix of the case, stated that the cashless facility request of the complainant for the treatment undertaken by him was denied on 22.1.2017 for non-disclosure of pre-existing ailment while proposing for the policy as per terms & conditions thereof.  It was stated that the hospitalization of complainant at Alchemist Hospital from 24.1.2017 to 25.1.2017 was for the treatment of Gall Intestine Stone disease and Chronic Gastritis and after perusal of medical documents submitted by the complainant & investigation, it was observed that the complainant had a history of Bronchial Asthma since childhood and use inhaler for the same and was suffering from Cholelithiasis since May, 2015, which was not disclosed by the complainant while proposing for the policy and as such, breached the principle of utmost good faith.  It was further stated that the claim of the complainant was rightly rejected for non-disclosure of pre-existing ailment at the time of taking the policy. It was further stated that neither there was any deficiency, in rendering service, on the part of the opposite parties nor they indulged into any unfair trade practice. The remaining averments, were denied, being wrong.

4.             The complainant filed replication wherein he reiterated all the averments contained in the complaint and repudiated those contained in the written version of opposite parties.

5.            The parties led evidence. The Forum, on analysis of pleadings of the parties, documents on record, and the arguments addressed, allowed the complaint. When forming above opinion, the Forum, in Paras 9 to 11, observed as under;

“9]       The complainant has stated that he does not suffer from any disease of bronchial asthma.  He has stated to have used inhaler very occasionally only when he feels little suffocated on account of seasonal change.  Dr.Vinay Verma, MBBS, MD (Medicine) Consultant physical & Cardiologist vide certificate Ann.C-13 has certified as under:-

“Sh.Vipula Jain does not suffer from Bronchial Asthma at this time. His PFT is normal.  He however gives history that he occasionally gets some seasonal allergy once or twice a year from which he takes/uses inhaler on his own. It is further certified that Bronchial asthma does not lead to Gall Bladder stones & the two problem are not related to each other in any way.”   

10]      The Opposite Parties have not produced any cogent, reliable defense in rebuttal to the opinion of Dr.Vinay Verma. 

11]      The contentions raised by the OPs in their written statement regarding concealment of pre-existing disease of Cholelithiasis since May, 2015 by the complainant, are vague and hypothetical too.  The CT Scan abdomen and pelvis dated 20.5.2016 (Ann.R-4) only indicate impression:-

1. Diffuse Fatty change in the Liver.
2. Cholelithiasis

         The term Cholelithiasis may refer to the presence of gall stones.  The gall stones tend to be asymptomatic.  People though having stones in their body, did not have an iota of feeling of presence of such stones in their body till the same is detected by way of medical investigations/X-ray/scan etc. The mere impression of Cholelithiasis on 20.5.2016 in CT Scan Report (Ann.R-4) does not indicate the same within the knowledge of the complainant till that time. There is no intentional or willful suppression of any fact by the complainant, prejudicial to the terms & conditions of the policy. The complainant has taken the Health Insurance Policy from Opposite Parties w.e.f. 14.11.2015 much prior to CT Scan dated 20.5.2016.”

6.             After going through the evidence on record and submissions of the Counsel for the appellant, we are of the opinion that the appeal is liable to be dismissed at the preliminary stage for the reasons to be recorded hereinafter.

7.             Challenge to order dated 31.08.2018 has been laid on the ground that the Forum failed to appreciate the outpatient record of the complainant, which clearly mentioned that he was suffering from Cholelithiasis since May, 2015 i.e. before taking the policy,    in question, on 15.11.2015. To say so, reliance was placed on CT Scam Report dated 20.05.2016 (Annexure R-4). It was argued that the factum of taking treatment for the said disease was not disclosed in the proposal form. It was further stated that the complainant was well aware with the fact that he was suffering from Cholelithiasis before taking of the policy. It was further stated that the Forum also failed to appreciate Clause 19(4) of IRDA (Protection of Policyholder’ interests) Regulations, 2017, as per which, the complainant was to furnish all information sought from him by the insurer. Reliance was placed on Satwant Kaur Sandhu Vs. New India Assurance Company Ltd., (2009) 8 SCC 316, to say that material fact is to be understood to mean as any fact which would influence the judgment of a prudent insurer, in deciding whether to accept the risk or not. Lastly, prayer for setting aside the impugned order has been made.

8.                   A careful perusal of the record shows that the policy, in question, was issued for the period w.e.f. 15.11.2014 to 14.11.2015 and was subsequently renewed up-to 15.11.2017.  No doubt, the Policy, in question, was cancelled and the claim of the respondent/complainant was repudiated by the appellant-Insurance Company vide letter dated 12.10.2017 (Annexure R-8 at Page 149 of District Forum record), on the ground that there was misrepresentation of material information at the time of proposal. In our opinion, the plea of the appellant that the respondent/complainant did not disclose the fact qua suffering Bronchial Asthma while filling up the proposal form, is not well based as the Policy, in question, was issued by the appellant Insurance Company after following proper procedure and norms as per the standards governing the said Policy. Moreover, as per established norms of Insurance, Policy is only issued after thoroughly examining the life assured by doctor at the panel of the Insurance Company. However, for the sake of arguments, if it is accepted that the respondent/complainant was suffering from Bronchial Asthma, which fact he allegedly did not disclose in the proposal form, still there is no nexus between suffering from Bronchial Asthma and Gall Bladder Stone, for which the respondent/complainant underwent treatment from 24.01.2017 to 25.01.2017 as an indoor patient. This observation is also corroborated by Dr. Vinay Verma, MBBS, MD (Medicine) Consultant Physical & Cardiologist who had placed on record of Forum a Certificate (Annexure C-13), wherein he specifically certified that the complainant does not suffer from Bronchial Asthma at this stage and further, it does not lead to Gall Bladder Stones & the two problems are not related to each other in any way. The appellant has, therefore, no right to blame that the respondent/complainant did not disclose the factum of his suffering from Bronchial Asthma in the proposal form. Therefore, we find that the appellant has been grossly deficient in rendering services, by denying the genuine insurance claim of the respondent/complainant. Hence, we are of the opinion that the order passed by the Forum, being based on the correct appreciation of evidence and law, on the point, does not suffer from any illegality or perversity.

9.             No other point was raised by the Counsel for the appellant.

10.           For the reasons recorded above, this appeal being devoid of any merit, is dismissed in limine with no order as to costs. The impugned order passed by the District Forum is upheld. Consequently, the application for placing on record of appeal, copies of repudiation letter dated 22.01.2017 and Policy Cancellation letter dated 12.10.2017 as Annexures A-9 & A-10 stands disposed of having become infructuous. It may be stated here that the aforesaid two documents are already available in the complaint file as Annexures R-5 & R-8 respectively.

11.           Certified copies of the order be sent to the parties free of charge.

12.           File be consigned to the Record Room after completion.

Pronounced

03.12.2018.

[JUSTICE JASBIR SINGH (RETD.)]

PRESIDENT

 

 

 

(PADMA PANDEY)

MEMBER

 

 

(RAJESH K. ARYA)

MEMBER

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STATE COMMISSION

 

(Appeal No.317 of 2018)

 

Argued by:  Sh. Sachin Ohri, Advocate for the appellant.

 

Dated the 3^rd day of December, 2018.

ORDER

            Vide our detailed order of the even date, recorded separately, this appeal has been dismissed in limine with no order as to costs. The impugned order passed by the District Forum has been upheld.

 

 

(RAJESH  K.  ARYA) MEMBER

(JUSTICE JASBIR SINGH (RETD.)) PRESIDENT

(PADMA PANDEY) MEMBER

 

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