Punjab

Ludhiana

CC/19/277

Harvinder Singh - Complainant(s)

Versus

Reliance General Ins.Co.Ltd - Opp.Party(s)

Jaspreet Singh Adv.

16 May 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:277 dated 10.06.2019.                                                         Date of decision: 16.05.2023.

 

Harvinder Singh son of S. Partap Singh, resident of House No.85, New Sant Fateh Singh Nagar, Dugri Road, Ludhiana.                                                                                                                                         ..…Complainant

                                                Versus

1. Reliance General Insurance Company Ltd., Regd. Office: H Block 1^st Floor, Dhirubhai Ambani Knowledge City, Navi Mumbai-400710, through its Director/M.D.
2. Reliance General Insurance Company Ltd., 7^th Floor, Surya Tower, The Mall, Ludhiana, through its Manager.
3. Anuj Bassi s/o. Parmod Kumar Bassi, r/o.B-34-2379, Street No.2, Chander Nagar, Ludhiana.

…..Opposite parties 

Complaint Under section 12 and 14 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Jaspreet Singh, Advocate.

For OP1and OP2           :         Sh. Sunil Goel, Advocate.

For OP3                         :         Complaint against OP3 not admitted vide order                                           dated 20.06.2019.

 

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant along with his wife Mrs. Davinder had gone Australia on 26.04.2028 by booking ticket from New Delhi to Brisbane, Australia from Ludhiana. The complainant stated that he got his aboard trip insured from the opposite parties vide policy No.200121828190000194 dated 13.04.2018 for himself and policyNo.20012182810000193 dated 13.04.2018 for his wife with sum assured of 50,000 USD with coverage of medical expenses including Transportation Evacuation and Repatriation of Moral Remains    which also included USD 12000 for any one illness besides coverage mentioned in the policy. On reaching Australia on 27.04.2018, the complainant fell seriously ill due to dry cough and fever, nausea and vomiting for several days.  After discoveries, the complainant was found suffering from “Right Upper Lobe Pneumonia with SIRS, Acute Kidney Injury” due to which he took treatment from QEII Jubilee Hospital Metro South Health, Australia and incurred $ 23101.10 on his treatment. Thereafter, the complainant lodged cashless and reimbursement claim reference No.M115971.81 which was repudiated by the opposite parties vide letter dated 06.09.2018 due to non-disclosure of his pre-existing disease of “Cardial Ailment”. According to the complainant, the repudiation of his claim due to pre-existing  disease of “Cardial Ailment” is totally illegal, arbitrary and unjust. Even if there existed cardial ailment of the complainant then it has nothing to do with ailment of “Right Upper Lobe Pneumonia with SIRS, Acute Kidney Injury” suffered by the complainant and his claim cannot be repudiated on this account. The complainant further stated that at the time of taking the policy, the form was duly filled by employee of opposite parties who never put any query to the complainant regarding any pre-existing disease. However, it was the duty of the opposite parties to conduct medical examination of the insured person before issuing the policy. The repudiation of the claim of the complainant is totally illegal, arbitrary and capricious which has caused mental pain, agony, harassment to the complainant and which amounts to deficiency in service and unfair trade practice on the part of the opposite parties. The complainant sent a legal notice dated 18.04.2019 upon the opposite parties through Sh. Jaspreet Singh, Advocate but no reply was received. Hence this complaint whereby the complainant has prayed for issuing directions to the opposite parties to pay the claim amount of $ 23,101.10 along with interest along with compensation of Rs.1,00,000/- and litigation expenses of Rs.21,000/-. According to the complainant, the total expenditure was approximately Rs.11,55,050/-.

2.                The complaint was not admitted against opposite party No.3 vide order dated 20.06.2019.

3.                Upon notice, opposite party No.1 and 2 appeared and filed joint written statement and by taking preliminary objections, assailed the complaint on the ground of maintainability of the complaint, lack of cause of action; the complainant is estopped by his own act and conduct; the complainant has no locus standi to file the present complaint. According to opposite party No.1 and 2, the complainant approached them for purchasing Travel Care Policy  for visiting Australia along with his wife and represented having no previous medical history/treatment/hospitalization for any ailment. The complainant also represented to be not on any medication whatsoever and believing the same, they explained about terms/conditions/stipulations/exclusion coverage of the Reliance Travel Care Policy and after understanding the terms of the policy, the complainant filled the proposal from denying to be suffering from any pre-existing illness/injury/conditions.   Accordingly, the opposite parties issued the Reliance Travel Care Policy No.200121828190000194 dated 13.04.2018 w.e.f. 26.04.2018 to 22.10.2018 with policy terms vide which any pre-existing disease or complication was specifically excluded in General Exclusions No.2 of the policy, which is reproduced as under:-

“Without prejudice to anything contained in this Policy, the Company shall not be liable to make any payment of

1. …………
2. Any pre-existing disease or complications thereof.
3. …………”

Further as per policy terms, it is the duty of the insured/complaint to make disclosure of every material facts, which is reproduced as under:-

          “1.    Duty of Disclosure

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.

In the event of untrue or incorrect statements, misrepresentation, mis-description or non-disclosure of any material particular in the proposal form, personal statement, declaration and connected documents, or any material information having been withheld, or a claim being fraudulent or any fraudulent means or device being used by the Policyholder/insured Person or any one acting on his/their behalf to obtain a benefit under this Policy, the Company may cancel this policy at its sole discretion and the premium paid shall be forfeited in its favour.”

Further according to the opposite parties as per policy Schedule clause VIII, it is mentioned as under:

“VIII. I understand that the Policy shall become void at the company’s option, in event of any untrue or incorrect statement, misrepresentation, non-description or non discourse of any material fact in the proposal form/personal statement, declaration and connected documents or any material information having been withheld by me or anyone acting on my behalf.”

Opposite party No.1 and 2 further stated that the complainant moved to the hospital on 22.06.2018 for medical attention to “an episode of dry cough and fever, nausea and vomiting since several days. The clinical physical examination, evaluation, investigation at the hospital provided the complainant, the diagnose of “Right Upper Lobe Pneumonia with SIRS, Acute Kidney Injury” and further provided the complainant with treatment for the same. The overseas records and the medical history from the doctor of the complainant India reveal that the complainant has a background medical history of “Hypertension and Ischemic Heart Disease ‘since 2 years’ with the complainant having undergone Cardiac Stress Test and Coronary Angiography in 2017, diagnosed with triple vessel Coronary Artery Disease and since then is on continuing medicines and treatment for the same. The background history of the “Cardiac Ailment Ischemic Heart Disease/Coronary Artery Disease” in the case of the complainant, is pre-existing to the policy and was not disclosed by the complainant during proposal for insurance from the company. According to the opposite parties, they have rightly denied the claim of the complainant vide repudiation letter dated 06.09.2018 on the ground of nondisclosure of material facts of previous ailment/disease/illness/disorder/hospitalization by the complainant. Moreover, the opposite parties stated that as per the policy terms and conditions, the claimed amount will only be disbursed to the complainant if he submitted the clear due certificate to the company that no outstanding bills are due to the hospital.

                   On merits, opposite party No.1 and 2 reiterated the crux of averments made in the preliminary objections. Opposite party No.1 and 2 have denied that there is any deficiency of service and have 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 i.e. Ex. C1 is the legal notice dated 20.04.2019, Ex. C2 to Ex. C4 are the postal receipts, Ex. C5 is the copy of Aadhar card of the complainant, Ex. C6 is the copy of Aadhar card of Davinder Kaur, EX. C7 is the copy of passport of the complainant, Ex. C8 is the copy of immigration stamp of departure and arrival on the passport, Ex. C9 is the copy of passport of Davinder Kaur, Ex. C10 is the copy of immigration stamp of departure and arrival on the passport, Ex. C11 is the copy of hospital bill dated 02.11.2018, Ex. C12 is the copy of proposer details of the complainant, Ex. C13 is the copy of policy schedule of Reliance Travel Care Policy of the complainant, Ex. C14 is the copy of policy schedule of Reliance Travel Care Policy of Davinder Kaur, Ex. C15 is the copy of proposer details of Davinder Kaur, Ex. C16 is the copy of repudiation letter dated 06.09.2018, Ex. C17 is the copy of hospital bill dated 31.12.2019, Ex. C18 to Ex. C24 are the copies of tax invoices/bills of QEII Jubilee Hospital Metro South Health and closed the evidence.

5.                On the other hand, counsel for opposite party No.1 and 2 tendered affidavit Ex. RA of Sh. Suryadeep Thakur, Area Manager (Legal Claims) of opposite party No.1 and 2 along with documents Ex. R1 is the copy of policy schedule of Reliance Travel Care Policy , Ex. R2 is the copy of claim form, Ex. R3 is the copy of repudiation letter dated 06.09.2018 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.                The complainant availed a Reliance Travel Care Policy No.200121828190000194 dated 13.04.2018 (Ex. R1) w.e.f. 26.04.2018 to 22.10.2018 having a coverage of medical expenses including Transportation Evacuation and Repatriation of Moral Remains when the complainant was due to travel New Delhi to Brisbane, Australia from Ludhiana and accordingly, applicable premium was paid. On reaching Australia, the complainant fell ill and remained hospitalized from 22.06.2018 to 03.07.2018 in QEII Jubilee Hospital Metro South Health, Brisbane, Australia. The complainant lodged cashless and reimbursement claim vide claim form Ex. R1 which was repudiated by the opposite parties vide letter dated 06.09.2018 Ex. R3 due to non-disclosure of pre-existing diseases “Cardiac Ailment”, the operative part of which is reproduced as under:-

“We have now had the opportunity to carefully review the information available on file. We regret to inform you that your claim is not payable due to the following reasons:-

The documents submitted by you, the overseas medical records for the medical attention received overseas from 22-6-2018 to 3-7-2018, the past medical records from India, are carefully reviewed along with the information available on file.

You were moved to the hospital on 22-6-2018 for medical attention to “an episode of dry cough and fever, nausea and vomiting since several days. The clinical physical examination, evaluation, investigation at the hospital provided the complainant, the diagnose of “Right Upper Lobe Pneumonia with SIRS, Acute Kidney Injury” and further provided the complainant with treatment for the same. The overseas records and the medical history from your doctor in India reveal that you have a background medical history of “Hypertension and Ischemic Heart Disease ‘since 2 years’ with you having undergone Cardiac Stress Test and Coronary Angiography in 2017, diagnosed with triple vessel Coronary Artery Disease and are since then on continuing medicines and treatment for the same. The background history of Cardiac Ailment “Ischemic Heart Disease/Coronary Artery Disease” in your case, is pre-existing to the policy and is not disclosed by you during proposal for insurance from the company (refer policy document page 11 Details of Insured Person – where you have declared “no” under pre existing illness/injury/condition if any)

The presence of background history of Cardiac Ailment – “Ischemic Heart Disease/Coronary Artery Disease” in your case, is a “standard exclusion” for the policy, which means that the disclosure of this illness “Ischemic Heart Disease/Coronary Artery Disease” from your side at the time of purchasing the policy would have rejected your proposal for a travel insurance policy and you would not have been issued a travel insurance policy under any circumstances by the company. While the same was not disclosed, the policy was thus issued on basis (1) that you do not have any past history of illness/hospitalization (declaration and warranties that insured has no past history of illness/hospitalization), condition 6 on page 3 of the policy – which states – warranted that insured has no past history of illness/hospitalization) and on the basis (2) that you have no pre existing illness under “standard exclusions”. The non disclosure of your medical history of “Ischemic Heart Disease/Coronary Artery Disease” which is a standard exclusion, renders the policy null and void with insurer having no liability under the policy, and on this basis we regret to inform you that the claim is not admissible.”

8.                While repudiating the claim, the opposite parties have referred to General Exclusion clause No.2 of the policy, the duty to disclose and have also referred to schedule clau9se 8 of the policy which provides that the policy shall become void and the Company office had option in the event of misrepresentation or non-disclosure of any material information.

9.                The counsel for opposite party No.1 and 2 has referred to Ex. R1 of the policy schedule wherein particulars of the complainant being proposer and insured person stated to have been mentioned as under:-

GSTIN/UIN of the Proposer:

Details of the Insured Person:
Name of the Insured Person	Date of Birth	Insured Relationship with the proposer	Passport No.	Pre-existing illness/injury/ condition  if any	Suffering since	Under Medication
Mr. Harvinder Singh	02-Mar-1954	Self	N8768847	No	NA	No

 

The counsel for opposite party No.1 and 2 has further contended that the complainant had said “No” to pre-existing illness/injury/condition so the repudiation was rightly invoked. On one hand, the complainant is very categorically stated that proposal form was filled by the employee of the opposite parties who never put any queries with regard to any pre-existing medical condition. Perusal of Ex. R1 shows that it was not signed by the complainant and it bears the signatures of authorized signatory on the part of opposite parties. It is mentioned therein that policy has been issued on the information of representative. However, the name of such representative has not been mentioned nor any evidence has been brought forth to substantiate that specific queries were put to the complainant with regard to pre-existing disease.

10.              Opposite party No.1 and 2 have not produced any proposal form duly signed and authenticated by the complainant. Even during course of arguments, the opposite parties were asked to provide any such proposal form so that the matter in controversy can be completely and effectively adjudicated upon but no such proposal form was produced before this Commission. The proposal form was material document from which it could have been easily assessed whether there was a concealment on the part of the complainant. Non-production of proposal form leads to inevitable inference that either the proposal form was not got executed before issuing the policy or there are certain anomalies and discrepancies in the proposal form, production of which may prove adverse to the rights of the opposite parties. It was also well within the legitimate rights of the opposite parties to get the complainant medically examined by the empanelled doctors but no such option was exercised.

11.              In this regard, reference can be made to I (2022) CPJ 20 (SC) titled as Manmohan Nanda Vs United India Assurance Co. Ltd. and others wherein the Hon’ble Supreme Court of India has held as under:-

(i) There is a duty or obligation of disclosure by the insured regarding any material fact at the time of making the proposal. What constitutes a material fact would depend upon the nature of the insurance policy to be taken, the risk to be covered, as well as the queries that are raised in the proposal form.

(ii) What may be a material fact in a case would also depend upon the health and medical condition of the proposer.

(iii) If specific queries are made in a proposal form then it is expected that specific answers are given by the insured who is bound by the duty to disclose all material facts.

(iv) If any query or column in a proposal form is left blank then the insurance company must ask the insured to fill it up. If in spite of any column being left blank, the insurance company accepts the premium and issues a policy, it cannot at a later stage, when a claim is made under the policy, say that there was a suppression or non­disclosure of a material fact, and seek to repudiate the claim.

(v) The insurance company has the right to seek details regarding medical condition, if any, of the proposer by getting the proposer examined by one of its empanelled doctors. If, on the consideration of the medical report, the insurance company is satisfied about the medical condition of the proposer and that there is no risk of pre­existing illness, and on such satisfaction it has issued the policy, it cannot thereafter, contend that there was a possible pre­existing illness or sickness which has led to the claim being made by the insured and for that reason repudiate the claim.

(vi) The insurer must be able to assess the likely risks that may arise from the status of health and existing disease, if any, disclosed by the insured in the proposal form before issuing the insurance policy. Once the policy has been issued after assessing the medical condition of the insured, the insurer cannot repudiate the claim by citing an existing medical condition which was disclosed by the insured in the proposal form, which condition has led to a particular risk in respect of which the claim has been made by the insured.

(vii) In other words, a prudent insurer has to gauge the possible risk that the policy would have to cover and accordingly decide to either accept the proposal form and issue a policy or decline to do so. Such an exercise is dependant on the queries made in the proposal form and the answer to the said queries given by the proposer.

12.              Pertinently, the main basis of repudiation of the claim is that the medical history of “Cardiac Ailment Ischemic Heart Disease/Coronary Artery Disease” which was diagnosed and treated in the year 2007 was not disclosed  and its non-disclosure amounts to suppression of material facts. The opposite parties have not produced any evidence of medical record with regard to diagnosis, procedure and treatment of the said pre-existing disease. In fact, there are two histories stated to have been given by the complainant and the opposite parties have firstly relied upon the history given to their representative at the time of issuing the policy and later on, they relied upon the history given to the treating doctor for the purpose of repudiating the claim. In the absence of any other corroborative evidence both are just hearsay evidence and are not sufficient to deprive the complainant from the valuable rights. Further the complainant was diagnosed of “Right Upper Lobe Pneumonia with SIRS, Acute Kidney Injury” in Australia and the opposite parties could not establish that the so diagnosed disease had a direct nexus with the alleged pre-existing disease.

13.              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 the hypertension is a common disease and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack and repudiation on account of pre-existing disease was not justified.

14.              In the light of above said facts and circumstances, opposite party No.1 and 2 were not justified in repudiating the claim of the complainant and as such, there is deficiency in service on the part of the opposite parties. In the given facts and circumstances of the case, if opposite party No.1 and 2 are directed to settle and reimburse the claim of the complainant in terms of policy terms and conditions. Opposite party No.1 and 2 are also burdened with composite costs of Rs.10,000/-.

15.              As a result of above discussion, the complaint is partly allowed with direction to opposite party No.1 and 2 to settle and reimburse the claim to the complainant as per terms and conditions of the policy within 30 days from the date of receipt of copy of order. Opposite party No.1 and 2 shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the complainant within 30 days from the date of receipt of copy of order.  Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

16.              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:16.05.2023.

Gobind Ram.

 

 

Harvinder Singh Vs Reliance General Insurance Co.                 CC/19/277

Present:       Sh. Jaspreet Singh, Advocate for the complainant.

                   Sh.  Sunil Goel, Advocate for the OP1 and OP2.

                   Complaint against OP3 not admitted vide order dated 20.06.2019.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with direction to opposite party No.1 and 2 to settle and reimburse the claim to the complainant as per terms and conditions of the policy within 30 days from the date of receipt of copy of order. Opposite party No.1 and 2 shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the complainant within 30 days from the date of receipt of copy of order.  Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

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

Member                         Member                              President        

 

Announced in Open Commission.

Dated:16.05.2023.

Gobind Ram.