State Consumer Disputes Redressal Commission
Care Health Insurance Co.Ltd. & Ors. vs Ravinder Nath Gupta on 7 November, 2024
STATE CONSUMER DISPUTES REDRESSAL COMMISSION
PUNJAB, DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
First Appeal No.1097 of 2022
Date of Institution : 13.12.2022
Reserved on : 16.10.2024
Date of Decision : 07.11.2024
1. Care Health Insurance Limited (Earlier known as Religare
Health Insurance Company Limited) Registered office at 5th
Floor, 19 Chawla House, Nehru Place, New Delhi-110019,
through its Managing Director.
2. Care Health Insurance Limited (Earlier known as Religare
Health Insurance Company Limited), 1st Floor, Golden Plaza
Mall, The Mall Road, Near Fountain Chowk, Ludhiana, through
its Manager.
........Appellants/Opposite Party No.1 & 2
Versus
Ravinder Nath Gupta, R/o H.No.28-C, Moti Nagar, Ludhiana.
.....Respondent/Complainant
Appeal under Section 41 of Consumer
Protection Act, 2019 to challenge the
orders dated 15.09.2022 passed in
RBT/CC No.79 of 2018 by the District
Consumer Disputes Redressal
Commission, Ropar Camp Court at
Ludhiana.
Quorum:-
Hon'ble Mrs. Justice Daya Chaudhary, President
Ms. Simarjot Kaur, Member
Mr. Vishav Kant Garg, Member Present:-
For the Appellants : Ms. Niharika Goel, Advocate for Sh. P.M. Goyal, Advocate For the Respondent : Sh. Ramesh Goyal, Advocate 2 First Appeal No.1097 of 2022
1) Whether Reporters of the Newspapers may be allowed to see the Judgment? Yes/No
2) To be referred to the Reporters or not? Yes/No
3) Whether judgment should be reported in the Digest? Yes/No JUSTICE DAYA CHAUDHARY, PRESIDENT:-
The Appellants/OPs No.1 and 2 i.e. Care Health Insurance Limited & another have filed the present Appeal under Section 41 of the Consumer Protection Act, 2019 (in short the 'Act') to set aside the impugned order dated 15.09.2022 passed in RBT/CC No.79 of 2018 by the District Consumer Disputes Redressal Commission, Ropar Camp Court at Ludhiana (in short the "District Commission") whereby the CC had been allowed.
2. Briefly, the facts of the case of the Complainant as made out by the Complainant Ravinder Nath Gupta in the Complaint filed before the District Commission are that the Complainant had purchased Star Health & Allied Insurance Company Limited for the period w.e.f. 27.07.2011 to 26.07.2013 by disclosing the facts regarding his pre-existing ailment and recoveries including paralysis problem i.e. Cv3. Thereafter, he ported his policy from the said Company to OP Company and he had also disclosed all the old details to the representatives of the OPs. At the time of portability of the Policy from Star Health to OP Company, OP Company had taken into possession the entire old record of the Complainant and OPs were well aware about the same. The team of doctors of the OPs had 3 First Appeal No.1097 of 2022 also medically examined the Complainant during the time of portability and prior to grant of Policy. The Complainant had suffered heart problem and he had taken the treatment from DMC Hero Health Institute, Ludhiana for the period w.e.f. 16.03.2017 to 27.03.2017 and had incurred expenses to the tune of Rs.3,04,600/-. The Complainant had lodged the Claim with the OPs but it was denied on the ground of pre-existing disease. The Complaint was filed by the Complainant before the District Commission with the following prayers :-
i) To pay the claim amount of Rs.3,04,600/-;
ii) To pay Rs.1,00,000/- on account of mental tension,
harassment and pain; and
iii) To pay Rs.20,000/- as litigation expenses.
3. Notice in the Complaint was issued to the OPs and in response thereof, the OPs had appeared before the District Commission and filed their written response wherein certain preliminary objections were raised. Other averments made in the Complaint were also denied. It was also mentioned in the reply that the Complainant had not approached the District Commission with clean hands and certain material facts were misrepresented and concealed from the Court. Further it was mentioned that the Complaint was not maintainable and it was filed with false and frivolous allegations whereas no cause of action had arisen to file the Complaint. By mentioning wrong facts, the Complainant had made efforts to mislead the Court just to extract money. Further it was also 4 First Appeal No.1097 of 2022 mentioned that the terms and conditions of the policy were not explained to the Complainant.
4. By considering the averments made in the Complaint and reply thereof filed by the OPs as well as by considering the oral arguments and evidence/documents produced by both the parties, the Complaint filed by the Complainant was allowed vide order dated 15.09.2022. The relevant part i.e. para No.8 is reproduced as under:-
"8. Consequently, the Complaint of the Complainant is decided in his favour and the Complainant is awarded Rs.2,00,000/- as insurance amount (sum assured amount of policy) along with interest @7.5% per annum from the date of repudiation of the claim of the Complainant. He is also entitled to Rs.20,000/- as compensation with Rs.11,000/- as litigation expenses payable from the date of order till payment. The OPs are further directed to comply with the said order within 30 days from the date of receipt of certified copy of this order. Free certified copies of this order be sent to the parties, as per rules. The file be sent back to the District Commission Ludhiana, for consigning the same to the Record Room"
5. Aggrieved by the said order dated 15.09.2022 passed by the District Commission, the Appellants/OPs have filed the present Appeal before this Commission.
6. Ms. Niharika Goel Advocate appearing on behalf of Advocate Mr. P.M. Goyal for the Appellants has submitted that the District Commission had failed to take note of the material facts that the Respondent/Complainant had filed the claim to pay the incurred expenses on the treatment of the Complainant for CAD with Acute 5 First Appeal No.1097 of 2022 Coronary Syndrome, NSTEMI, OLD CVA, Left Main Disease with Triple Vessel Disease, Mild TR Mild LV Systolic Dysfunction. Learned Counsel has further submitted that the claim was rejected by the Appellants on the ground of non-disclosure of CVA (Cerebrovascular Accident) which occurred 10 years back. Learned Counsel has further submitted that the Appellant Company had conducted the medical examination but still the District Commission had recorded the wrong findings mentioning that it was the duty of the Company to conduct the medical examination. Further it has been submitted that the District Commission had not taken cognizance to the Pre Authorisation Form and Discharge Summary where the history of CVA was recorded. Learned counsel has also submitted that the District Commission had ignored certain material facts as well as the law whereas the policy holder was required and duty bound to disclose all the ailments to enable the insurer to assess the correct risk factor. Further it has been submitted that the District Commission had taken cognizance of the document dated 30.07.2013 whereas it was never provided to the Insurance Company and the Appellant- Insurance Company was not having any knowledge of said documents. The District Commission had also ignored the guidelines of the Company. The Policy was issued for the period w.e.f. 30.07.2013 to 29.07.2014 and it was renewed w.e.f 30.07.2015 to 29.07.2016 and further w.e.f. 30.07.2016 to 29.07.2017 subject to the Policy terms and conditions. Learned Counsel has further submitted that during the period of hospitalization 6 First Appeal No.1097 of 2022 of the Complainant at Christian Medical College & Hospital, Ludhiana, the Respondent/Complainant was diagnosed with Acute Coronary Syndrome, NSTEMI (NON-ST-ELVATION MYOCARDIAL INFARCTION) which is a term used for Heart Attack, Pulmonary Edema (abnormal accumulation of fluids in certain tissues within the body). Further, the District Commission had not also considered a material fact that the Appellant Company had rejected the cashless claim of the Complainant vide letter dated 11.03.2017 on the ground of non-disclosure, as per the provisions of Clause 6.1 of the policy terms and conditions. The Complainant had not disclosed the history of CVA (Cerebrovascular Accident) which occurred 10 years back whereas it was a case of sudden death of some brain cells due to lack of oxygen as the blood had flown to the brain due to which it was impaired because of blockage or rupture of an artery to the brain and as such it was a case of brain stroke. At the end, it has been submitted that as per Clause 6.11 where a free look period was provided and the policy holder was at liberty to return the policy in case he was not satisfied with the policy or any terms and conditions. The Complainant could have requested for refund of the premium as he was entitled during said free look period after deducting the proportionate risk premium for said period. Learned Counsel has also relied upon judgments of cases "Satwant Kaur Sandhu Vs. New India Assurance Company Limited" 2009(8)SCC-316, "Life Insurance Corporation of India Vs. Smt. Neelam Sharma' decided on 30.09.2014 (NC), "Religare Health Insurance Vs. 7 First Appeal No.1097 of 2022 Jatinder Singh" (State Commission Chandigarh), "LIC of India & others Vs. Ramamani Patra & another" Revision Petition No.1061 of 2011, decided on 3.08.2015 (NC) in support of her averments.
7. Mr. Ramesh Goyal Advocate, learned Counsel for the Respondent/Complainant has submitted that the order passed by the District Commission has been passed by considering the contents of the Complaint, reply thereof and also on hearing the oral arguments raised by Counsel representing both the parties and also by relying upon the other relevant facts/evidence/judgments in support of their contentions. The order passed by the District Commission is detailed one. The relief has been granted to the Complainant by the District as per the terms and conditions of the Policy. Learned Counsel has also relied upon the judgments of cases "Oriental Insurance Company Vs. Mohinder Singh (DR)", Appeal No.307 of 2008, decided on 19.05.2008 (Delhi State Commission), "National Insurance Co. Vs. Krishna Avtar Aggarwal" (Delhi State Commission, Appeal No.2049 of 2000, decided on 21.02.2005, "Oriental Insurance Co. Ltd. Vs. Yogesh Kapoor"
F.A. No.233 of 1999, decided on 14.12.2006 (Delhi State Commission, "Oriental Insurance Co. Ltd. & others Vs. Hans Raj Khurana" Appeal No.162 of 2004, decided on 22.11.2007 (Delhi State Commission), "New India Assurance Co. Ltd. & others Vs. Sant Kumar Puri", F.A. No.605 of 2007 (this Commission), decided on 09.05.2007, in support of his contentions. 8 First Appeal No.1097 of 2022
8. Admitted facts of the case of both the parties are that the Complainant had initially obtained Health Policy from Star Health & Allied Insurance Company Limited for the period w.e.f. 27.07.2011 to 26.07.2013. Said policy was ported from Star Health & Allied Insurance Company Limited to OP Company vide policy No.10029841 w.e.f. 30.07.2013 to 29.07.2014. As per the version of the Respondent/Complainant, he had disclosed the facts regarding his pre-existing ailment and recoveries including the paralysis problem i.e. Cv3 at the time of taking the Health Policy from Star Health & Allied Insurance Company Limited and thereafter, the Complainant had ported his policy from said Company to OP Company and the Complainant had also disclosed all the old details to the representatives of the OPs. Further, it was averred by the Complainant that at the time of portability of the Policy from Star Health to OP Company, the OP Company had taken into possession the entire old record of the Complainant and OPs were well conversant about this fact. As per version of the Appellants/OPs, the Complainant was having history of CVA (10 years back) and due to non-disclosure of pre-existing ailment, the Appellants/OPs had denied the cashless facility vide letter dated 11.03.2017 as per Clause 6.1 of policy terms and conditions.
9. The Complainant had submitted in the Complaint before the District Commission that he had disclosed about his pre existing ailment and recoveries including the paralysis problem i.e. CV3, which was cured prior to the purchase of the Policy. This fact was in 9 First Appeal No.1097 of 2022 the knowledge of the earlier Insurance Company i.e. Start Health & Allied Insurance Company as it was duly mentioned in their Proposal Form. Thereafter, the policy was ported from said Insurance Company to OP Company and as per the version of the Complainant, the OP Company had also taken into possession all the old record of the Complainant. The onus was upon the Appellants/OPs to disprove the version of the Respondent/Complainant. It is admitted fact that the said Policy was got ported by the Complainant from said Insurance Company to OP Insurance Company. Meaning thereby, that the Appellants/OPs were having all the record of previous policy. The Appellants/OPs had not produced on record any Proposal Form filled up by the Complainant at the time of taking the Policy from Star Health & Allied Insurance Company. No documents were made available from the side of the Appellants that the Complainant had taken the treatment of CVA/CAD at the time of taking the Health Insurance Policy from OP. Moreover, the documents regarding diseases i.e. CV3, paralysis attack were in the knowledge of the OPs as per the version of the Complainant and the Appellants/OPs had failed to rebut the version of the Complainant by way of producing cogent evidence. The Hon'ble National Commission in case Reliance Life Insurance Co. Ltd. &Anr. Vs. MarriSujata, 2020 DNJ 5 (NC) has held that the petitioner had failed to establish that deceased had undergone treatment and it was also held that the petitioners were not justified in repudiating the claim. 10 First Appeal No.1097 of 2022
10. In another case New India Assurance Co. Ltd. Vs. ArunKrishanPuri, 2009 (3) CPJ 6 (NC), the Hon'ble National Commission had held that "Insurer is under onus to prove pre- existing disease at the time of taking of policy. Failure was there on part of Insurer to produce any evidence in support of concealment of pre-existing disease."
11. The Hon'ble Supreme Court in case titled as "Satwant Kaur Sandhu Vs. New India Assurance Company Liited, Civil Appeal No.2776 of 2022, decided on 10.07.2009 has held that "The respondents have failed to discharge the burden of proving willful concealment of material information by the DLA at the time of obtaining the policy and have failed to bring on record any evidence of the treating doctor byway of evidence or affidavit."
12. It is pertinent to mention here that the Complainant had taken the Health Insurance Policy from the OPs in the year 2013. It is an admitted fact that prior to issuance of the Policy the Appellants/OPs had conducted the medical examination of the Complainant. The Complainant had lodged the claim in the year 2017. The Hon'ble Supreme Court in case titled as, Manmohan Nanda v. United India Assurance Co. Ltd., (2022) 4 SCC 582, has observed that the duty of disclosure by the insured regarding any material fact at the time of making the proposal is well- established. The insurance company must seek details regarding the medical condition of the proposer and assess the 11 First Appeal No.1097 of 2022 risks before issuing the policy. Once the policy is issued after assessing the medical condition of the insured, the insurer cannot later repudiate the claim based on a disclosed existing medical condition which led to the claim. In para 55.4 of this judgment, Hon'ble Supreme Court has observed that "55.4. 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 that, any column is left blank, the Insurance Company has accepted the premium and had issued the policy, it cannot be said at a later stage, when a claim is made under the policy, that there was a suppression or non-disclosure of a material fact, and to repudiate the claim."
In the present case the Complainant was medically examined by the doctors of Appellants/OPs and the Health Policy was obtained in the year 2013 and the Complainant had suffered from the present ailment in the year 2017. When the insurer was satisfied by the result of medical tests at the time of issuing policy, the claim cannot be rejected later on the ground of non-disclosure of past history.
13. Accordingly, for the reasons and detailed discussions as above, we find no merit in the contention raised by learned Counsel for the Appellants and the Appeal filed by the Appellant is dismissed being devoid of merits.
14. The Appellants had deposited an amount of Rs.1,58,815/- at the time of filing of the Appeal with this Commission. Said amount, 12 First Appeal No.1097 of 2022 alongwith interest which has accrued thereon, if any, shall be remitted by the Registry to the District Commission forthwith. The Respondent/Complainant may approach the District Commission for the release of the same and the District Commission may pass appropriate order in this regard in accordance with law.
15. Since the main case is decided, the pending applications, if any, are also disposed of.
16. The Appeal could not be decided within the stipulated period due to heavy pendency of Court cases.
(JUSTICE DAYA CHAUDHARY) PRESIDENT (SIMARJOT KAUR) MEMBER (VISHAV KANT GARG) MEMBER November 07, 2024 (MM)