DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

C.C. No. 305/2018                                                                                                                                                           

QUORUM:

Judgment By: Shri S.S. Malhotra (President)

JUDGMENT

By this judgment the Commission would dispose off the present complaint filed by the Complainant against OP alleging deficiency in service for not reimbursing his mediclaim despite having a valid medical policy. 

1. Before coming to the facts of the present complaint it is necessary to mention that complainant is a resident of Bareilly and has filed the present case through his Attorney Sh. Sampoorna Nand. 
2. Brief facts as stated by the complainant in the complaint are that he had a mediclaim policy from the OP under the Platinum enhanced Plan which was valid from 08.05.2017 to 07.05.2018 and had paid a premium of Rs.36,582/- sum insured was of Rs.500000/- and prior to taking the policy the complainant has disclosed his lifestyle habits as well as regarding his pre-existing disease like Diabetes Mallitus and Hypertension and after considering all the details of the complainant and after getting the medical examination of the complainant the OP had issued the above said policy for which there was no waiting period under the Platinum Plan. On 19.09.2017 the complainant suffered brain stroke and paralytic attack and as such he was shifted to Shrinath Medicity Hospital Bareilly, where from he was referred to Sir Ganga Ram Hospital, New Delhi on 20.09.2017 and was admitted in Neurology Department as a case of Cerebrovascular Accident with Pontine Infract which fact was duly informed to the OP on 23.09.2017 with all medical documents. The OP asked certain additional documents on 24.09.2017 w.r.t. treatment given by treating doctor, last alcohol intake, duration and frequency of alcohol intake by complainant which were duly replied by doctor and submitted by brother of the complainant without any delay but the OP in whimsical manner repudiated the cashless claim on 26.09.2017 citing the reason for denial as ‘mis-representation, mis-description and non-disclosure of material facts’ and no specific reason was mentioned in the letter w.r.t. concealment of particular information. However, the complainant then preferred another application for re-considering the cashless claim in view of additional certificate dated 29.09.2017 issued by the Department of Neurology (Unit-II) stating there in that the illness caused is unrelated to the history of Alcohol Consumption and it is a case of Acute Ischemic Cerebrovascular Accident with Pontine Infract but OP without considering the aforesaid certificate issued by the treating doctor rejected the claim again and even sent a letter dated 05.10.2017 for terminating the policy on the ground of non-disclosure of alcoholism in a proposal form. The complainant thereafter sent a legal notice to the OP on 21.10.2017 which was not complied with and he was discharged on 23.10.2017 and spent an amount of Rs.7,73,591/- on his treatment which was paid by him and as such since the amount has not been reimbursed and sum assured of the policy was Rs.500000/-, the complainant had filed the present complaint seeking directions that OP be held liable for deficiency in service and be directed to pay Rs.500000/- along with interest @ 12% p.a., Compensation of Rs.50,000/- and litigation charges of Rs.45,000/-. 
3. Complainant has filed an affidavit in support of the complaint of Sh. Sampoorna Nand.
4. The OP was served and he has filed his written statement.  Thereafter the complainant also filed an application u/s 5 of Limitation Act for condoning of delay in filing the written statement which application was decided on 09.03.2022 thereby condoning the delay in filing the written statement subject to cost of Rs.10,000/- upon OP to be deposited in DLSA Patiala House and it is matter of record that OP has not deposited this cost rather OP stopped appearing and was formally proceeded ex-parte vide order dated 24.08.2022.
5. Complainant has already filed his evidence and written arguments.
6. OP has also filed its evidence and written arguments.
7. Since, the written statement of OP was filed at belated stage and since the application seeking condonation of delay was allowed subject to cost and which OP did not deposit the cost and therefore written statement filed by OP would not be read for the purpose of its defence and as such there is no evidence of the OP even on the record.
8. The Commission has heard the arguments and perused the record.
9. The basic document by which the OP has rejected the claim is the proposal form, but the subsequent query was raised from the complainant w.r.t. the drinking habits and taking alcohol by the complainant. Although OP’s written version is not on record but the repudiation letter is on record and as per the repudiation letter the reason of the denial of the claim is as such:

Section A. PREAMBLE This Policy has been issued on the basis of the Disclosers to information norm, including the formation provided by You in respect of the Insured Persons in the Proposal Form and any other details submitted in relation so the Proposal Form. This Policy is a contract of insurance between You and Us which is subject to the receipts of premium in full and the terms, conditions and exclusions of this Policy.

Definition 19. Disclosure to information norm The Policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of misrepresentation, mis-description or non-disclosure of any material fact

Kindly note the cashless denial is based on the available documents: it is not the complete final denial of the claim However, denial of claim doesn't imply repudiation of the treatment by concerned Doctor. And it doesn't prevent clamant to seek medical assistance or hospitalisation or reimbursement.

The OP in this letter has not mentioned as to what exactly is the concealment however it is matter of record that while admitting the patient in the hospital the fact that complainant has been taking alcohol is not disputed. The contention of OP is that it is a case of critical alcoholism which the complainant has not disclosed whereas the contention of the complainant is that the complainant had not been keeping good health and although he had been taking liquor but he was not an addict to liquor and that fact has been verified and written by the treating doctor thereby specifically mentioning in its letter dated 29.09.2017 i.e. issued by Dr. Anshu Rohtagi MD, DM Neuro in the department of Neurology in Sir Ganga Ram Hospital, certifying that the complainant is a case of Acute Ischemic Cerebrovascular Accident with Pontine Infract and is not related to the history of alcohol consumption. This is a certificate given by the doctor and the Commission is of the opinion that if an expert has given an opinion w.r.t. his patient then such opinion of an expert can only be counted by equally good opinion of another doctor practising in the same field. It has not been done by the OP and the conduct of OP is quite surprising that it initially filed the written statement at a belated stage and when it filed the application seeking condonation of delay in filing its reply and when that application was allowed subject to cost, he did not pay the cost and then he stopped even appearing and was proceeded ex-parte and this conduct of the OP in not assisting the Commission with the equally good opinion of the doctor concerned, proves the deficiency on the part of OP.  Further, there is another aspect i.e. disclosure of a material fact, the complainant in its proposal form although specifically mentioned that he had been suffering from Diabetes Mellitus and Hypertension but once the question w.r.t. alcohol was mentioned where he replied that he is not consuming alcohol. The Commission is of the opinion that consumption of alcohol to a limited extent is not fatal and even been such consumption to the limited extent  is approved under the laws, and the provision of Motor Vehicle Act can be referred in this regard and therefore taking liquor per-se cannot be said to be a cause of concern but not disclosing this fact may amount to certain contributory negligence on the part of complainant. The law in this regard is well settled that the complainant as well as insurance company both have to be honest in their respective disclosures i.e. complainant has to disclose each and every fact to the insurance company before he takes the policy and OP had to inform all such facts pertaining to the policy to the insured before issuing the policy and particularly if the performa of the OP is perused then it has only used the word ‘alcohol’. It has not explained the word as to what is meant by the OP when it writes or seek information w.r.t. alcohol use. The OP should have been specific in its proforma if he is asking about the alcoholic habits of the OP and in absence there of, the general rule would apply.  The proposal form of OP does not convey any such condition that the complainant had to disclose in the proposal form, the last date of consumption of Alcohol or then OP started asking the report of the doctor or report from the  extent of Alcohol  or  intake of the liquor in last 15-30 days.  There is no clause in the proposed form rather the same is too vague. If the OP has to rely on such information then OP had to receive all such information on its own proposal form which is too vague and after receiving the claim then it is the bounden duty of the OP to seek such information from the complainant in the ‘proposal form’ itself and mere writing one clause by writing ‘alcohol’ would not suffice rather the proper proposal form should have been as to whether the complainant is taking alcohol, if so how much per day, or per week or per fortnight or per month. If these information would have been explicitly mentioned in the proposal form the complainant would have been able to reply on such information. Therefore, the proposal form of the OP is quite vague on this clause. Simultaneously, even if the complainant is taking alcohol in a small quantity then he is also not supposed to tick mark the word ‘No’ rather he should have marked it on ‘Yes’ thereby specifying his own consumption. Therefore, there is some vagueness in the proposal form of the complainant and some concealment on the part of complainant in not clearing his own stand. This fact coupled with the unrebutted report of the doctor /expert concerned clarified that the complainant was taking liquor but the ailment which he had underwent was not related with the use of alcohol. Therefore, the Commission is of the opinion that there is some deficiency on the part of OP in not giving proper questionnaire in the shape of proposal form initially and there is some deficiency on the part of complainant in not disclosing complete particulars and accordingly the Commission holds that there was some contributory deficiency on the part of both the parties and therefore it is a fit case where claim of the complainant can be settled on ‘Non standard basis’. The rejection of the entire claim to the extent of sum insured of Rs.500000/- on the basis of vague proposal form is not proper.  Therefore the Commission hereby orders as follows: 

• OP would pay 75% of the sum insured to the complainant with interest @ 9% p.a. from the date of filing the complaint but since it is a case of some concealment on the part of complainant, no compensation and litigation charges are awarded.      

This judgment be complied by OP within 30 days from the date of receipt of the judgment failing which OP would pay enhanced rate of interest i.e. 12% p.a. from the date of filing the complaint till actual realization.

Copy of the order be supplied / sent to the parties free of cost as per rules.  

File be consigned to Record Room. 

Announced on 23.10.2024.