DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

C.C. No. 267/2018

Date of Institution: 16.08.2018

Judgment Reserved on: 22.07.2024

Judgment Passed on: 22.07.2024

QUORUM:

Sh. S.S. Malhotra (President)

Sh. Ravi Kumar (Member)

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

JUDGMENT

1. By this judgment the Commission would dispose off the complaint of the complainant alleging deficiency of service by OP in not reimbursing the medical bill against the valid mediclaim policy.
2. Before coming to the fact,s it is necessary to mention that the complaint case was initially filed against ‘Apollo Munich Health Insurance Co. Ltd.’ and subsequently an application was filed by OP for change of its name from Apollo Munich Health Insurance Co. Ltd. to HDFC ERGO Health Insurance Limited on the ground that the previous OP had been taken over by the HDFC ERGO & that application was allowed and therefore the name of the OP is mentioned as HDFC ERGO Health Insurance Limited in the cause title.  
3. Brief facts as stated by the complainant in the complaint are that complainant purchased a Cashless Floater Insurance Policy in the name of himself and his wife in February 2016 for sum insured of Rs.3 Lakh and paid the premium of Rs.7684.75/- and at the time of taking the policy the complainant had duly apprised each & every disease which the complainant’s wife namely Smt. Paramjeet Kaur had been suffering from, and he was assured that the same shall be covered under the policy by the Respondent/OP, & not only this, the policy was even renewed from time to time and in May 2018 the wife of the complainant had to be admitted in Max Healthcare Hospital, Vaishali and complainant raised a cashless approval from the OP but the same was denied, however, mentioning that the denial of cashless claim in no way indicates the denial of the claim, and accordingly complainant paid the medical bills of Rs.71,342/- and after the discharge of his wife he sent all the documents alongwith claim form with the request to reimburse the amount of Rs.71,342/- but initially OP did not reply and on persistent writing of letters the OP rejected the claim alongwith a notice of termination of health policy by stating that the said disease of Spondyloarthorpathy and HLA B 27 was the pre-existing disease to the wife of the complainant and she had been suffering from this disease ‘Spondyloarthorpathy and HLA B 27’ even prior to getting the policy which fact was not disclosed by the complainant at the time of taking the policy and as such the claim was rejected and even notice for cancellation of policy was also issued & in this circumstances the complainant has approached this Commission thereby seeking directions to the OP to reimburse the medical bills alongiwth compensation of Rs.25,000/- with legal expenses.
4. The OP was served and has filed its reply taking preliminary objections that complaint is not maintainable on various grounds interalia that complainant has concealed the material facts w.r.t. ailment of his wife at the time of taking policy and has taken the policy with ulterior motive and malafide intention as the complainant has been specifically asked in Para-4(B) of the proposal form as to whether the present proposed/insured had ever suffered or had been currently suffering from any of the disease mentioned in the list including Arthiritis Spondylosis or any other disorder of muscles etc or whether the insured is under regular medication etc, to which the complainant/insured declared as ‘no’ and after the ailment of the complainant’s wife when the investigation were made the facts were revealed that the complainant’s wife had been suffering with such disease and had a history of Spondyloarthorpathy and HLA B 27 positive since 2013 and since the complainant has not disclosed this fact, the company issued show cause notice for cancellation of the policy and even repudiated the claim which was in accordance with the law/agreement & therefore there is no cause of action against the OP and complaint is liable to be dismissed & be dismissed. As far as merits are concerned, the gist of the facts as have been taken in the preliminary objections are reiterated & it is prayed that complaint case of the complainant be dismissed.
5. Complainant has filed replication to the this particular facts and had denied the fact that he has not disclosed the facts to the agent of the OP & it is specifically stated that he was assured that this disease would be covered in the policy but at the time of reimbursement, the company has rejected the claim on this very ground, although this fact was duly communicated to the insurance agent at the time of taking the policy & therefore complaint of complainant be allowed.
6. Complainant has filed affidavit of his own as evidence whereas OP has filed evidence of Sh. Aviraj Singh, Assistant Manager-Legal of OP/HDFC ERGO. Both the parties have filed written arguments.
7. Commission has heard the arguments and perused the record. The only issue is as to whether the complainant has disclosed the fact w.r.t. ailment of his wife while taking the policy or not. The Commission has also perused the claim form and it is clear that complainant has not disclosed this fact to the OP in the proposal form although in the pleadings he stated that this fact was orally communicated to the agent of OP. Law w.r.t. oral statement & written document is well settled under the provision of Section 91 & 92 of the Indian Evidence Act which interalia speaks that in the presence of written document, the oral statement in the presence of written document has to be discarded and written document has to prevail over the oral statement. How the agent has communicated to the complainant or how the complainant has understood is only an oral fact which has to be discarded in view of the written document and the written document specifically shows that the complainant did not inform this fact to the insurance company when this query was specifically asked in the proposal form. The OP has mentioned various judgments in its written statement as well as written argument and Commission is in agreement with the contention that it is the duty of the complainant to inform the material facst w.r.t. health of the proposer and thereafter it is the prerogative of the insurance company to issue the policy to the complainant on those facts or may change the terms & conditions by increasing the premium and then issue the policy or even reject the same.
8. In the present case without referring much on the so many judgments relied upon by the OP, the Commission is of the opinion that complainant at the time entering/proposing, has not conveyed in written to the OP that the wife of the complainant had been suffering from the disease of Spondyloarthorpathy and HLA B 27 since 2013 and therefore the OP was within its right while rejecting the claim. Accordingly complainant has not be able to prove any deficiency in rejecting the claim by the OP. Complaint case of the complainant is therefore dismissed.       

Copy of the Order be supplied/sent to the Parties free of cost as per rules.

Announced on 22.07.2024.

File be consigned to Record Room.