Punjab

Ludhiana

CC/20/70

Mohit Sharma - Complainant(s)

Versus

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

Complainant in person

27 Apr 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 70 dated 18.02.2020.                                                Date of decision: 27.04.2022. 

Mohit Sharma S/o. Late Sh. L.K. Sharma, R/o.#7357/A, St. No.4, B/s. Harkrishan School, Daba Road, Daba Colony, Ludhiana-141003. Ph.7059170594.                                                                                                                                                                                     ..…Complainant

                                                Versus

BranchManager, Reliance General Insurance Company Ltd., # 7^th Floor, Surya Tower, 108, The Mall, Ludhiana-141001.                                                                                                                                       …..Opposite party 

          Complaint Under Section 12 of the Consumer Protection Act.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

COUNSEL FOR THE PARTIES:

For complainant             :         Complainant Sh. Mohit Sharma in person.

For OP                           :         Sh. G.S. Kalyan, Advocate.

 

ORDER

PER K.K. KAREER, PRESIDENT

1.                Shorn of the unnecessary details, the case of the complainant is that he bought one medical policy from the OP in August 2015 which was renewed from time to time. The wife and minor son of the complainant are also covered under the said policy. On 12.12.2019, the complainant was hospitalized with SPS Hospital, Ludhiana due to major heart attack. The complainant remained admitted till 14.12.2019. There was no cashless facility. The complainant spent an amount of about Rs.2,00,000/- on his treatment. After having been discharged from the hospital, the complainant applied for the reimbursement of the claim and submitted all the necessary documents on 28.12.2019. However, the claim was rejected by the OP and the policy was also cancelled on the ground that  the complainant had not disclosed in the proposal form that he was suffering from diabetes. The complainant asked the OP to provide him the proposal form and the other documents, but he refused to do so. Hence the complaint whereby it has been requested that the OP be directed to reimburse the total bill of Rs.2.02 Lac and further the OP be made to pay compensation of Rs.5 Lac.

2.                The complaint has been resisted by OP. In the written statement filed on behalf of OP, it has been, inter alia, pleaded that the complaint is false and frivolous and is premature as the complainant has not approached the grievance cell of the OP. According to the OP, the claim was not payable as the complainant was a known case of diabetes mellitus since 2011 and he has been taking regular treatment for the said disease but this fact was not disclosed by the complainant in the proposal form at the time of policy inception. Therefore, as per clause 5.1 of the policy terms and conditions, the policy has been rendered null and void nor any claim is payable to the complainant. There has been no deficiency of service on the part of the OP. The rest of the allegations made in the complaint have been denied as incorrect and a prayer for dismissal of the complaint has also been made.

3.                The complainant filed rejoinder to the written statement reiterating the averments made in the complaint and controverted those mentioned in the written statement.

4.                In evidence, complainant has submitted his affidavit as Ex. CA along with documents Ex. C1 to Ex. C15 and closed the evidence.

5.                On the other hand, learned counsel for the OP tendered affidavit Ex. RA of Sh. Suryadeep Singh Thakur, Manager (Legal) of OP along with documents Ex. R1 and Ex. R21 and closed the evidence.

6.                We have heard the arguments advanced by the complainant and counsel for the OP and have also gone through the record.

7.                Primarily, the claim has been repudiated due to non-disclosure of the fact that the complainant did not disclose in the proposal form at the time of inception of the policy that he was suffering from diabetes mellitus since the year 2011. In this regard, the counsel for the OP has referred to the repudiation letter Ex. RW1. In support of his arguments, the counsel for the OP Has relied upon 2021 (217) AIC 50 in Branch Manager, Bajaj Allianz Life Insurance Company Ltd. and others Vs Dalbir Kaur whereby it has been held by the Hon’ble Supreme Court of India that if the proposer failed to disclose the factum of vomiting of blood which had taken place barely month prior to issuance of policy of insurance and of hospitalization, the claim was not payable. Having considered the contentions raised by the counsel for the OP and after going through the record, we are of the considered view that as per the discharge summary Ex. RW3, the complainant was hospitalized and was diagnosed to be suffering from type-2 diabetes mellitus, coronary artery disease, acute inferior all myocardial infarction, single vessel disease on coronary angiography (12.12.2019), successful primary PCI to right coronary artery (12.12.2019). It is further mentioned in the discharge summary that the complainant was admitted with above mentioned complaints. On admission, ECG was done which showed acute inferior wall myocardial infarction. As a result, urgent coronary angiography was done which revealed single vessel disease. In the same sitting, successful PCI to right coronary was done. Admittedly, the policy for the first time was taken by the complainant in the year 2014. The OP has not placed on record the proposal form whereby the disease of diabetes mellitus was not disclosed. In the complaint, it has been categorically mentioned by the complainant that he asked the OP to provide him a copy of proposal form but it was not supplied to him. At the time of arguments, the complainant has contended that he did disclose the factum of being suffering from diabetes mellitus in the proposal form but the OP has deliberately withheld the proposal form. On this ground, an adverse inference has to be drawn against the OP. Even otherwise, it is a settled proposition of law that diabetes mellitus and hypertension are common diseases and it is not necessary that every person is suffering from hypertension and diabetes mellitus would also suffer from heart attack. Even otherwise, in this case the factum of non-disclosure of pre-existing disease of diabetes mellitus has not been established by the OPs. Under these circumstances and considering the fact that the proposal form has not been placed on record by the OP, it has to be held that the repudiation of the claim by the OP is not justifiable and the same is liable to be set aside. It is ordered accordingly.

8.                As a result of above discussion, the complaint is allowed with an order that the OP shall consider and reimburse the claim in respect of hospitalization of the complainant from 12.12.2019 to 14.12.2019 strictly as per terms and conditions of the policy within 30 days from the date of receipt of copy of the order. The OP shall further pay a composite cost of Rs.7,000/- (Rupees Seven Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

9.                Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:27.04.2022.

Gobind Ram.

Mohit Sharma Vs Reliance GIC                            CC/20/70   

Present:       Complainant Sh. Mohit Sharma in person.  

                   Sh. G.S. Kalyan, Advocate for the OP.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is allowed with an order that the OP shall consider and reimburse the claim in respect of hospitalization of the complainant from 12.12.2019 to 14.12.2019 strictly as per terms and conditions of the policy within 30 days from the date of receipt of copy of the order. The OP shall further pay a composite cost of Rs.7,000/- (Rupees Seven Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

 

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:27.04.2022.

Gobind Ram.