Haryana

Karnal

CC/196/2019

Om Kumar - Complainant(s)

Versus

Universal Sompo General Insurance Company Limited - Opp.Party(s)

Ravinder Chaudhay

26 Oct 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL  COMMISSION, KARNAL.

 

                                                          Complaint No. 196 of 2019

                                                          Date of instt.10.04.2019

                                                          Date of Decision 26.10.2021

 

Om Kumar (aged 56 years), son of Shri Hukam Singh, resident of village Padhana, Tehsil Nilokheri, District Karnal.

 

                                                 …….Complainant.

                                              Versus

 

1. Universal Sompo General Insurance Company Limited, having its    registered and office 4^th floor, Sangam Complex, 127, Andheri, Kurla Road, Andheri East, Mumbai (MH)-4000591.

 

2. Branch Manager, Universal Sompo General Insurance Company Limited having its Branch office at 3^rd floor, SCF 55, Sector-6, main market, Urban Estate, Karnal-132001.

       

                                                                      …..Opposite Parties.

 

Complaint Under section 12 of the Consumer Protection Act, 1986 as amended Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

 

Argued by: Shri Ravinder Kumar Chauhan, counsel for  

    complainant.

                    Shri Y.P. Arora, counsel for opposite parties.

 

                    (Jaswant Singh President)

ORDER:   

                

                        The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 as after amendment Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant obtained a Health policy bearing policy no.2825/58446750/00/000 from OPs, valid from 26.03.2018 to 25.03.2019 and paid premium of Rs.10,386/-. The term of policy for one year and limit of coverage of Rs.3,00,000/-. Initially complainant got problem of chest pain, during walk and Numbness of left arm and he went to Amritdhara Hospital, ITI Chowk, Karnal and was checked up by  Dr. Mayank Goyal on 30.08.2018, where various medical test of the complainant were got conducted. At that time, complainant told to the doctor that he is having health policy of Universal Sompo General Insurance Company Ltd. Accordingly, complainant was diagnosed for the disease and he remain admitted in the hospital and discharged on 01.09.2018 with case summary that “This 55 years old male patient brought to us with the complaint of chest pain, during walking alongwith numbness of left arm since 5 days. Patient managed conservatively, angiography done on 30.08.2018, revealed SVD, PTCA stent to RCA done. Now patient is stable and being discharge.” After discharged from the hospital, complainant sent pre authorization form alongwith bills to the OPs mentioning the expenditure of treatment of the complainant to the tune of Rs.1,29,000/- with a request to release and pay the claim amounting to Rs.1,29,000/-. OPs issued a letter dated 01.09.2018, vide which cashless request of complainant was denied on the false and frivolous ground. It is averred that prior to issuing the cashless health policy, the complainant was not suffering from any disease as alleged by the OPs as in the case summary Dr. Mayank has categorically mentioned that the patient brought to us with the complaint of chest pain during walking alongwith numbness of left arm since five days, but while declining the claim of the complainant, this fact has not been taken into consideration by the OPs. In this way there was deficiency in service on the part of the OPs while repudiating the claim of the complainant on the false and frivolous ground. Hence, complainant filed the present complaint.

2.             On notice, OPs appeared and filed their written version raising preliminary objections with regard to maintainability: locus standi and concealment of true and material facts. On merits, it is pleaded that complainant had not given the true facts regarding his health at the time of obtaining insurance policy and concealed the true facts regarding his health. The complainant sent cashless request dated 01.09.2018 and submitted the documents in support of this claim. On perusal of the same the OPs denied the request of the complainant on the following ground which as under:-

        “As per submitted documents patient admitted with c/o recent onset of chest pain with diagnosis HTN/CAD/ACS/USA with H/O HTN since 26 years, since it is first year running policy and the ailment is pre existing disease and as per policy term and condition any pre-existing disease or its complication are payable after continuous coverage of 48 months of policy period, and the HTN was not disclosed during taking policy, hence cashless is denied.”

For the above reason the OPs have rightly repudiated the claim of the complainant. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Complainant tendered into evidence his affidavit Ex.CW1/A, insurance policy Ex.C1, health service card Ex.C2, cashless denied letter Ex.C3, treatment record Ex.C4, discharge summary Ex.C5, medical treatment bills Ex.C6, pre-authorization letter Ex.C7, Aadhar card Ex.C8, bill breakup summary Ex.C9, cashless demand letter Ex.C10, Aadhar card Ex.C11 and closed the evidence on 06.12.2019 by suffering separate statement.

5.             On the other hand, OPs tendered into evidence affidavit of Piyush Shankar Assistant General Ex.O1 and closed the evidence on 18.08.2021 by suffering separate statement.

6.             Learned counsel for the complainant while reiterating the contents of complaint, has vehemently argued complainant obtained a Health policy from OPs. Complainant has problem of chest pain during walk and Numbness of left arm and he went to Amritdhara Hospital, ITI Chowk, Karnal and was checked up by Dr. Mayank Goyal on 30.08.2018, where various medical test of the complainant were got conducted. Complainant was diagnosed for the disease and he remain admitted in the hospital and discharged on 01.09.2018. The complainant had spent an amount of Rs.1,29,000/- on his treatment. The complainant applied for cashless facility for an amount of Rs.1,29,000/-.  OPs did not pay the claim and repudiated the same, vide letter dated 01.09.2018 on the ground complainant is suffering from Hypertension since 26 years, since it is first year running policy and the ailment is pre existing disease and as per policy term and condition any pre-existing disease or its complication are payable after continuous coverage of 48 months of policy period, and the HTN was not disclosed during taking policy.  He further argued that at the time of purchasing of the health policy, the agent of the OPs had assured the complainant that all the diseases will be covered under the policy from the date of purchase of the policy.  OPs never provided/disclosed the terms and conditions of the policy which can aware the complainant that, what diseases are covered and what are not covered under the policy and prayed for allowing the complaint.

7.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that the complainant was admitted in Amritdhara Hospital, ITI Chowk, Karnal for treatment of his chest pain. As per documents, it was observed that complainant was admitted in the hospital on 30.08.2018 and policy is still in its first year of operation. As per terms and conditions of policy, expenses related to Hypertension, Heart Disease and related complications are excluded for first year of cover from the date of commencement of policy. Hence, the claim of the complainant was rightly repudiated and prayed for dismissal of the complaint with heavy cost.

8.             Admittedly, the complainant had purchased a health insurance from the OPs and during subsistence of the insurance policy, complainant was suffering from chest pain and was admitted in the hospital on 30.08.2018 and discharged on 01.09.2018.

9.             The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.C3 on the ground that:-

“As per submitted documents patient admitted with c/o recent onset of chest pain with diagnosis HTN/CAD/ACS/USA with H/O HTN since 26 years, since it is first year running policy and the ailment is pre existing disease and as per policy term and condition any pre-existing disease or its complication are payable after continuous coverage of 48 months of policy period, and the HTN was not disclosed during taking policy, hence cashless is denied.”

10.           The onus to prove that the complainant was having pre-existing disease upon the OPs, but OPs have miserably failed to prove this fact, by leading any cogent and convincing evidence. During the course of evidence OPs have only tendered affidavit of Piyush Shanakar Assistant General Manager and no other evidence as well as documents were placed on record to prove its plea. The OPs have also failed to examine the doctor to ascertain that complainant was having any disease at the time of purchasing the insurance policy. Hence, the plea taken by the OPs is having no force.

11.           The complainant has taken a plea, that at the time of purchasing the health insurance policy, the agent of the OPs assured the complainant that all the diseases will be covered under the policy from the date of its purchased. In this regard OPs have miserably failed to prove that all the terms and conditions of the policy were explained and supplied to the complainant at the time, by leading cogent and convincing evidence.  Moreover, OPs have not placed on file the terms and conditions of the insurance policy to prove its version.  Hence, plea taken by the complainant is having force. In this regard, we relied upon case titled as New India Assurance Co. Ltd Versus Anil Manglunia 2016 (1) CPR 150 (NC),wherein Hon’ble National Commission held that OPs failed to provide policy clause to the complainant and rejected genuine claim of the complainant. Hence, they do not find any merit in the revision petition and the same is hereby dismissed.

12.           Furthermore, if the terms and conditions were not provided to the complainant, then these are not applicable to the complainant. Since, the OPs have failed to prove the facts on record that the terms and conditions of the policy were sent and received by the complainant, therefore, the repudiation of claim of the complainant is not justified in the eyes of law.              

13.           If the version of the OPs believes that Hypertension and related ailments not payable in first year of the policy, in that case also the OPs cannot repudiate the claim of the complainant as, Hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension. In this regard we are placing reliance upon the case of Hon’ble State Commission, New Delhi, titled as Life Insurance Corporation of India Versus Sudha Jain 2007 (2) CLT 423, in which Hon’ble State Commission has drawn conclusion in para 9 of the order and the relevant clause is 9 (iii), is reproduced as under:-

        “9(iii) Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.” Taking into consideration the facts of the present case and law laid down by the Hon’ble Superior Fora in the above referred cases, we are of the view that OPs were not justified in repudiating the claim of the complainant and are thus liable to pay the amount which the complainant had incurred on his treatment.

 

14.           Keeping in view that the ratio of the law laid down in the abovesaid judgment, facts and circumstances of the present case, we are of the considered view that act of the OPs while repudiating the claim of the complainant amounts to deficiency in service, which is otherwise proved genuine one.

15.           The complainant has claimed Rs.1,29,000/- but he has placed on record medical bill Ex.C6 of Rs.1,25,000/- only.  Hence, he is entitled for Rs.1,25,000/- alongwith compensation and litigation expenses.

16.           Thus, as a sequel to above discussion, we allow the present complaint and direct the OPs to pay Rs.1,25,000/- (one lac twenty five thousand only) to the complainant with interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OPs to pay Rs.20,000/- to the complainant on account of mental agony and harassment suffered by him and Rs.5500/- for the litigation expense. This order shall be complied within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 26.10.2021

                                                                       

                                                                      President,

                                                      District Consumer Disputes

                                                      Redressal Commission, Karnal.

 

 

 

 (Vineet Kaushik)              

      Member