Punjab

Ludhiana

CC/20/90

Surjit Singh - Complainant(s)

Versus

Oriental Insurance Co.Ltd - Opp.Party(s)

Ripon Chadha Adv.

17 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:90 dated 18.03.2020.                                                 Date of decision: 17.10.2023.

 

Surjit Singh aged 80 years, r/o. 271-R, Model Town, Ludhiana.                                                                                                                  ..…Complainant

                                                Versus

1. The Oriental Insurance Company Limited, Regd. & Head Office: 25/27, Asaf Ali Road, New Delhi, through its Managing Director.
2. The Oriental Insurance Company Limited, BO-IV, Opp. Chhabra Hospital, above Fine Furniture, Bus Stand Road, Ludhiana, through its Senior Branch Manager.
3. M/s. Raksha TPA (P) Ltd., SCO-122, 5^th Floor, Feroze Gandhi Market, Ludhiana.                                                                                                                                                                            …..Opposite parties 

Complaint Under section 12 of the Consumer Protection Act, 1986.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Ripon Chadha, Advocate.

For OPs                          :         Sh. B.S. Rampal, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant purchased health insurance policies from opposite parties No.1 and 2 vide policy No.233902/48/2015/4963 w.e.f. 04.03.2015 to 03.03.2016, policy No.233902/48/2016/5662 w.e.f. 04.03.2016 to 03.03.2017, policy No.233902/48/2017/6315 w.e.f. 04.03.2017 to 03.03.2018 and policy No.233902/48/2018/6417 w.e.f 04.03.2018 to 03.03.2019 having coverage of Rs.5,00,000/- each covering himself and his wife Santosh Kaur. The opposite parties gave assurance for paying hospitalization expenses for medical/surgical treatment at any nursing home/hospital in India as an in-patient as defined in the policy. At the time of taking first policy, the complainant and his wife were medically examined. The complainant stated that his wife Santosh Kaur fell down while washing the clothes and lost her senses due to which she was taken to hospital and treated by Dr. Chan Bir Singh, M.D. Medicine, Consultant Physician in RG Stone & Super Specialty Hospital, Model Town, Ludhiana and remained admitted from 20.01.2018 to 25.01.2018. The said hospital issued certificate No.RG73/18 dated 30.04.2018 certifying that Smt. Santosh Kaur has H/o HTN, Diabetes, Parkinsonism, Diabetes Neuropathy since 6-8 months and hypothyroidism since 2 years. The complainant lodged insurance claim with opposite parties but the same was repudiated vide letter dated 01.08.2019 as ‘No Claim’ on the ground of non-disclosure, concealment or misrepresentation of material facts or making false statement in the proposal form. The complainant further stated that in the insured questionnaire dated 13.12.2018, signed by his wife, complete details were mentioned including hospitalization in RG Stone Hospital and medical treatment provided by Dr. Chan Bir Singh as well as eye operation at Dr. Dhami Hospital, Ludhiana and also submitted all the medical record etc. As such, they never concealed any facts from the opposite parties. According to the complainant, the opposite parties have wrongfully repudiated his insurance claim as the complainant. Moreover, the complainant or his wife were not suffering from any disease at the time of Ist policy except the details mentioned in the proposal form and they were enjoying good health. Even they were got medically checked up before issuance of the policy. Moreover, the coverage was increased by the opposite parties which shows that the opposite parties were aware that the complainant or his wife are not suffering from any disease. As such, the complainant is fully entitled to get the amount claimed by him on account of hospitalization of his wife. The opposite parties have repudiated the claim on false and frivolous grounds which amounts to deficiency in service and unfair trade practice on the part of the opposite parties. In the end, the complainant prayed for  issuing direction to the opposite parties to pay claim of Rs.1,00,000/- including Rs.40,000/- of medical expenses etc. along with interest and also to pay Rs.60,000/- as compensation.

2.                Upon notice, opposite parties No.1 and 2 filed written statement and by taking preliminary objections, assailed the complaint on the ground of maintainability of the complaint; lack of jurisdiction; the complaint being time barred; concealment of facts; bad for non-joinder and mis-joinder of necessary parties etc. Opposite parties No.1 and 2 stated that the claim intimation was received from the complainant regarding hospitalization claim under OBC-Oriental Royal Mediclaim Policy no.233902/48/2017/6315 for insurance policy from 04.03.2017 to 03.03.2018 at RG Stone and Super Specialty Hospital, Ludhiana. The diagnosis was prolapsed inter-vertebral disc. DM, Diabetic Neuropathy, HTN, Parkinsonism, Hypothyroidism, Depression and Lumber-Spondolytic disease. Opposite parties No.1 and 2 immediately entertained, registered and processed and handed over the claim fie to its service provider M/s. Raksha Insurance TPA Private Limited who processed the claim and returned the file vide letter dated 24.08.2018 with recommendations, which are reproduced as under:-

“(a) Patient is. These are chronic disorder. Policy is in 3^rd year. Pre-existing disease are payable after three years. Under these circumstances the claim is recommended to be non payable as per clause 4.1.

(b) Discrepancy in the information provided- As per the letter received in query reply it is mentioned that the patient is a K/C/O DM, HTN, Parkinsonism since 6-8 months but as per prescription provided patient is taking medicine related to DM, HTN, Parkinsonism in2016 also. So the claim is recommended to be non payable as per clause 5.7.”

Opposite parties No.1 and 2 further stated that as per exclusion clause 4.1 & 5.7 of Mediclaim Insurance policy terms and conditions, the claim was not payable and was duly informed to the complainant vide pre-repudiation letter dated 15.05.2019 and repudiation letter dated 01.08.2019.

                   On merits, opposite parties No.1 and 2 reiterated the crux of averments made in the preliminary objections and facts of the case. However, opposite parties No.1 and 2 admitted the factum of issuance of the insurance policies in favour of the complainant. The complainant himself signed declaration given in the proposal form dated 25.02.2015. According to opposite parties No.1 and 2, the diagnosed ailment is a complication developed due to the pre-existing disease. The health condition of the insured for which treatment has been done existed earlier to the commencement of the fourth year policy. The claim was repudiated under exclusion clause 4.1 and 5.7 of the policy, which are reproduced as under:-

“4.1  Pre-existing health condition or disease or ailment/injuries: any ailment/disease/injuries/health condition which are pre-existing (treated/untreated, declared/not declared in the proposal form), in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person up to 3 years of this policy being in force continuously. For the purpose of applying this condition, the date of inception of the first indemnity based health policy taken shall be considered, provided the renewals have been continuous and without any break in period, subject to portability condition. This exclusion will also apply to any complications arising from pre-existing ailments/diseases/injuries. Such complications shall be considered as a part of the pre-existing heath condition or disease.

5.7     Disclosure to information norm

          The Policy shall be void and all premium paid hereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or non-disclosure of any material fact.”

Opposite parties No.1 and 2 further stated that as the ailments of the patient can be directly correlated with the aforesaid illness and the complainant concealed the information related to ailments/disease being suffered at the time of taking the policy, the claim was denied in accordance with the above said policy terms and conditions and intimation was given to the complainant vide letters dated 15.05.2019 and 01.08.2019.  Opposite parties No.1 and 2 have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

3.                Opposite party No.3 filed separate written statement and by taking preliminary objections, assailed the complaint on the ground of maintainability of the complaint; lack of jurisdiction; the complaint being time barred; concealment of facts; bad for non-joinder and mis-joinder of necessary parties etc. Opposite party No.3 stated that on receipt of the claim, it was duly registered, processed by it. The complainant sent documents of his treatment and other relevant documents. The diagnosed ailment is a complication developed due to pre-existing disease. As the insurance was inception w.e.f. 04.03.2015 and the condition of insured for which treatment has been taken existed earlier to the commencement of the policy and as such, the claim was repudiated under exclusion clause 4.1 and 5.20 of the policy.

                   On merits, opposite party No.3 reiterated the crux of averments made in the preliminary objections. Opposite party No.3 has denied that there is any deficiency of service and has also prayed for dismissal of the complaint.  

4.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of insurance policy w.e.f. 04.03.2017 to 03.03.2018, Ex. C2 is the copy of treatment record/discharge summary etc., Ex. C3 is the copy of claim closure letter dated 01.08.2019, Ex. C4 is the copy of pre-repudiation letter dated 15.05.2019, Ex. C5 is the copy of letter dated 06.03.2019 of the complainant, Ex. C6 is the copy of insurance policy 04.03.2015 to 03.03.2016, Ex. C7 is the copy of insurance policy w.e.f. 04.03.2016 to 03.03.2017, Ex. C8 to Ex. C10, Ex. C12 to Ex. C24 are the copies of bills/invoices,  Ex. C11 is the copy of claim form dated 06.03.2018, Ex. C25 is the copy of investigation report and closed the evidence.

5.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RA of Sh. Sukhwinder Singh, Sr. Divisional Manager, Oriental Insurance Co. Ltd., D.O.2, Miller Ganj Branch, Ludhiana along with documents Ex. R1 is the copy of insurance policy w.e.f. 04.03.2017 to 03.03.2018, Ex. R2 is the copy of proposal form, Ex. R3 is the copy of email, Ex. R4 is the copy of reply to query dated 23.01.2018, Ex. R5 is the copy of ultrasound report, Ex. R6 to Ex. R8, Ex. R11 to Ex. R16 are the copies of prescription slips, Ex. R9 is the copy of test/investigation report, Ex. R10 is the copy of x-ray report, Ex. R17 is the copy of pre-repudiation letter dated 15.05.2019, Ex. R18 is the copy of claim closure letter dated 01.08.2019, Ex. R19 is the copy of certificate dated 30.04.2018 issued by Dr. Chan Bir Singh of RG Stone and Super Specialty Hospital, Ex. R20 is the copy of query letter dated 26.03.2018, Ex. R21 is the copy of first reminder dated 10.04.2018, Ex. R22 is the copy of final reminder dated 25.04.2018, Ex. R23 is the copy of query letter dated 16.05.2018, Ex. R24 is the copy of first reminder dated 02.07.20178, Ex. R25 is the copy of final reminder dated 17.07.2018, Ex. R26 is the copy of report of TPA, Ex. R27 is the copy of insured questionnaire, Ex. R28 is the copy of policy terms and conditions and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.

7.                It is an admitted case of the complainant having obtained insurance policies from opposite party No.1 and 2 w.e.f. 04.03.2015 to 03.03.2016, 04.03.2016 to 03.03.2017, 04.03.2017 to 03.03.2018 and 04.03.2018 to 03.03.2019 for himself and his wife Smt. Santosh Kaur. During the third policy year, Smt. Santosh Kumar was admitted in RG Stone & Super Specialty Hospital, Ludhiana from 02.01.2018 to 25.02.2018 under the treatment of Dr. Chan Bir Singh, M.D. Medicines. As per discharge summary Ex. C2, Smt. Santosh Kaur, a 74 years female was admitted with complaint of generalized weakness in lower limbs and slurring of speech, unable to walk/stand with history of fell on floor (washroom & bed) as per attendant last 3-4 days. She was a known case of DM, Diabetic Neuropathy, HTN, Hypothyroidism, Parkinsonism, Depression and Lumber-Spondolytic disease. The complainant lodged claim with the opposite parties which was repudiated vide letter dated 01.08.2019 Ex. C3 = Ex. R18 as per exclusion clause 4.1 and 5.7 of the policy terms and conditions, which reads as under:-

          “4.1   Pre-existing health condition or disease or ailment/injuries: any ailment/disease/injuries/health condition which are pre-existing (treated/untreated, declared/not declared in the proposal form), in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person up to 3 years of this policy being in force continuously. For the purpose of applying this condition, the date of inception of the first indemnity based health policy taken shall be considered, provided the renewals have been continuous and without any break in period, subject to portability condition. This exclusion will also apply to any complications arising from pre-existing ailments/diseases/injuries. Such complications shall be considered as a part of the pre-existing heath condition or disease.

5.7     Disclosure to information norm

          The Policy shall be void and all premium paid hereon shall be forfeited to the Company, in the event of misrepresentation, mis-description or non-disclosure of any material fact.”

8.                The repudiation of the claim is based upon the findings of investigation report Ex. R26 Raksha TPA i.e. opposite party No.3 and made the following observations:-

                   “Observation and opinion

1. Patient is a K/C/O/ DM, HTN, Parkinsonism. These are chronic disorder. Policy is in 3^rd year. PED are payable after 3 years. So the claim is recommended to be non payable as per clause 4.1
2. Discrepancy in the information provided- As per the letter received in query reply it is mentioned that patient is a K/C/O/ DM, Parkinsonism since 6-8 months but as per prescription provided patient is taking medicine related to DM, HTN, Parkinsonism in 2016 also. So the claim is recommended to be non payable as per clause 5.7.”

9.                It appears that on the basis of discharge summary Ex. C2 as well as certificate Ex. R19 of treating Dr. Chan Bir Singh, MD (Medicine) of RG Stone and Super Specialty Hospital, the patient was declared to have been suffering from history of HTN, Diabetes, Parkinsonism, Diabetic Neuropathy since 6-8 months and Hypothyroidism since 2 years as per patient. The opposite parties got filled insured questionnaire form dated 13.12.2018 Ex. R27 from the insured in which the insured patient admitted the factum of having suffering from DM since 3 years, HTN since 4 years, joint pain since 1½ year and thyroid since 1½ years. However, the opposite parties have taken the ground of repudiation of the claim that in the proposal form no such pre-existing disease was disclosed. Perusal of proposal form Ex. R2 shows that no such questions were put to the insured at that time and only as per column No.3 the following query was put to the insured:-

“3. Please answer the following in Yes/No

	Proposer	Spouse
Are all the persons proposed for insurance in good health and free from physical and mental disease or infirmity or major complaints?	Yes	Yes

 

Except the above said query, no other query was put before the complainant regarding his health conditions. Had any additional information sought from the insured regarding their pre-existing conditions at the time of issuance of the policy then the insured have answered the same either positive or negative. In that case, it can be said that the insured have concealed the factum regarding their pre-existing ailments. Even assuming that at the time of inception of the insurance policy, Smt. Santosh Kaur was a known case of DM, HTN, Parkinsonism and hypothyroidism, still the claim cannot be repudiated treating these to be preexisting diseases. It is well settled that on account of non-disclosure of such general diseases, the genuine claim cannot be rejected.

10.              In this regard, reference can be made to Religare Health Insurance Company Ltd. Vs Subhash Chander Aggarwal in 2017(3) CLT 140 whereby it has been held by Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh that hypertension is a common disease and can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack. Further reference can be made to Tarlok Chand Khanna Vs United India Insurance Co. Ltd. 2012(1) C.P.J. 84 whereby it has been held by Hon’ble National Consumer Disputes Redressal Commission, New Delhi  that the onus to prove that the insured was suffering from pre-existing disease was on the insurer and if the insurer has not produced the expert opinion, the reasons for repudiation of the claim were held to be unjustified. A reference can be further made to Lakhwinder Singh and another Vs United India Insurance Company etc.  decided in Appeal No.29 of 2009 whereby it has been held by Hon’ble State Consumer Disputes Redressal Commission, U.T, Chandigarh that the maladies like diabetes, hypertension being normal wear and tear of the life cannot be treated as pre-existing diseases.

11.              Further in a case titled as Manmohan Nanda Vs United India Assurance Co. Ltd. and others 2022(I) CPJ 20 (SC) wherein the Hon’ble Supreme Court of India has observed as under:-

“(6)   The appellant’s argument that there is no hard and fast rule that every person with DM-II will necessarily have a cardiac disease merely because it is a risk factor holds water. A person who does not suffer from DM-II can also suffer from a cardiac ailment. He had disclosed his DM-II status for which he was under treatment. The ECG report and other tests also indicated normal parameters. Further, statins were a preventive prescription to prevent development of cardiac issues as DM-II is a risk factor, not because he had a cardiac ailment or hyperlipidaemia. Further, the examining physician was informed of the same before the policy was taken. Accordingly, there was no suppression of any material fact by the appellant to the insurer.

(7)     It was for the insurer to gauge related complications based on the information provided. The insurance company did not think that the medical and health condition of the appellant was such which did not warrant issuance of a medical policy. The insurance company therefore did not decline the proposal of the assured as a prudent insurer.”

Therefore, in our considered view, the repudiation of the claim on the basis of non-disclosure of pre-existing diseases such as DM, HTN, Parkinsonism and hypothyroidism  could not have been made a ground to reject the claim.  The insurance companies are required to be more liberal in their approach without being too technical. In the given set of above said facts and circumstances, it would be just and appropriate if the repudiation letter 01.08.2019 Ex. C3 = Ex. R18 issued by the opposite parties is set aside and the opposite parties are directed to settle and reimburse claim lodged by the complainant in respect of treatment of Smt. Santosh Kaur at along with composite costs of Rs.10,000/-.

12.              As a result of above discussion, the complaint is partly allowed with an order that the repudiation letter 01.08.2019 Ex. C3 = Ex. R18 issued by the opposite parties is set aside and the opposite parties are directed to settle and reimburse claim lodged by the complainant in respect of treatment of Smt. Santosh Kaur as per terms and conditions of the policy within period of 30 days from the date of receipt of copy of the order failing which the opposite parties shall pay interest @8% per annum on the settled amount to the complainant from the date of order till its actual payment. The opposite parties shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Payment of costs shall be made within a period of 30 days from the date of the receipt of the copy of this order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.             

 

 

 

13.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)             (Sanjeev Batra)

Member                         Member                              President        

 

Announced in Open Commission.

Dated:17.10.2023.

Gobind Ram.