State Consumer Disputes Redressal Commission
Mrs. Geeta Negi vs Religare Health Insurance Co. Ltd. on 28 February, 2024
FA NO./238/2018 D.O.D.: 28.02.2024
MRS. GEETA NEGI VS. RELIGARE HEALTH INSURANCE LTD.
IN THE DELHI STATE CONSUMER DISPUTES
REDRESSAL COMMISSION
Date of Institution:11.05.2018
Date of Hearing:09.01.2024
Date of Decision: 28.02.2024
FIRST APPEAL NO.-238/2018
IN THE MATTER OF
MRS. GEETA NEGI,
L-53, 2ND FLOOR, SRI NIWAS PURI,
NEW DELHI - 110065.
(Through: Mr. Amit Yadav, Advocate)
...Appellant
VERSUS
1. RELIGARE HEALTH INSURANCE CO. LTD.,
406, LAXMI BHAWAN, 72, NEHRU PLACE,
NEW DELHI - 110019.
2. RELIGARE HEALTH INSURANCE CO. LTD.,
G - 45, GLOBAL, PLOT NO. A3, A4, A5,
SECTOR - 125, NOIDA, UP - 201301
(Through: Mrs. Suman Bagga & Associates)
...Respondents
ALLOWED PAGE 1 OF 13
FA NO./238/2018 D.O.D.: 28.02.2024
MRS. GEETA NEGI VS. RELIGARE HEALTH INSURANCE LTD.
CORAM:
HON'BLE JUSTICE SANGITA DHINGRA SEHGAL
(PRESIDENT)
HON'BLE MS. PINKI, MEMBER (JUDICIAL)
Present: Mr. Dheeru Nigam, counsel of Appellant.
Mr. Virender Prabhakar and Ms. Suman Bagga counsel
for respondent.
PER: HON'BLE JUSTICE SANGITA DHINGRA SEHGAL,
PRESIDENT
JUDGMENT
1. The facts of the case as per the District Commission record are:
"The case of the complainant is that she had taken a Health Insurance policy bearing no. 10018250 from Religare Health Insurance Company Limited, in March, 2013 and even renewed within time next year by paying renewal premium. On 21st March, 2014, she developed chest pain and had to be admitted to National Heart Institute where she was operated and the hospital bill of Rs. 3,00,000/- was paid but the Insurance company rejected her claim on the ground of "non disclosure of pre-disease (Diabetes)"
The complainant further submitted that she was not suffering from diabetes at the time of taking the policy. But there was a mistake in the form of the Hospital, instead of 2 months, a family member (daughter in law) inadvertently and in a hurry wrote 2 years. Even according to the diabetes test conduct pursuant to issuance of Religare Health Check-up coupon, the report showed Fasting sugar as 116. She further submitted that on her request the OP had reconsidered her case and this time, ALLOWED PAGE 2 OF 13 FA NO./238/2018 D.O.D.: 28.02.2024 MRS. GEETA NEGI VS. RELIGARE HEALTH INSURANCE LTD.
the claim was rejected by referring to a prescription of AlIMS Emergency Department dated 215t March, 2010, submitted by the complainant along with the claim form, on the right side corner whereof, the words "K/C/O-D.M. Type II" was found written, but nowhere in the said form Diabetes range has been mentioned. She submitted that she had gone to Emergency Department of AlIMS on 21st March, 2010 in connection with a gastric problem, and that on enquiry from a doctor, she had told him that she gets diabetes test done. She further submitted that when the insurance policy was taken and also when it was got renewed, reports of both the Blood tests got conducted by the Company showed the Diabetes as -VE Report. The complainant submitted that she is a poor widow and is getting a pension of Rs. 1000/- only her son and daughter in law mortgaged their jewellery and also borrowed some money. She claims Rs.3,00,000/-alongwith interest, medicine expenses, compensation and transportation."
2. The District Commission after taking into consideration the material available on record passed the order dated 20.04.2018, whereby it held as under:
"We have gone through the case file carefully. The only point for consideration is that whether rejection of the claim on the basis of pre existing disease was justified. The case of OP is that the complainant has concealed the fact that she was known case of diabetes. It is further submitted by OP that insurance is a contract of good faith and a person taking policy is supposed to disclose correct facts and ALLOWED PAGE 3 OF 13 FA NO./238/2018 D.O.D.: 28.02.2024 MRS. GEETA NEGI VS. RELIGARE HEALTH INSURANCE LTD.
concealment of any fact tantamount to procuring of contract by fraud.
Now the point for consideration is whether the complainant was suffering from diabetes.
It is significant to note that the complainant was admitted to Moochand Hospital on 21.03.2014 where it was found that her RBS was 185. She left that hospital. Thereafter she came to National Heart Institute and the clinical details on admission given by her shows that when she was asked whether she is diabetic, she answered 'yes' - duration two years - normal below 200. Later on explanation was given on behalf of the complainant that this information was furnished by her daughter-in-law by mistake while filling the form as she was in hurry. Later on it was explained that she was suffering from the diabetes for the last two months.
It is significant to note that on 27.03.2010 she was taken to AIIMS as she was suffering from abdominal pain and there it is mentioned on the emergency medicine slip 'K/C/O DM type 2'. It was evident from the emergency medicine slip that the complainant was known case of diabetes DM type-2. To say that no tests were conducted by AIIMS to know whether she was suffering from diabetes or not is irrelevant because the complainant herself had admitted that she was diabetic. The complainant has submitted that HbA1C test was conducted which shows that her sugar was 5.6% against normal range of 5.0-7.0%. It is further stated that at the time of renewal of the ALLOWED PAGE 4 OF 13 FA NO./238/2018 D.O.D.: 28.02.2024 MRS. GEETA NEGI VS. RELIGARE HEALTH INSURANCE LTD.
policy. Health check-up was done on 19.03.2014 and the report revealed HbA1C-604%.
It is significant to note HbA1C test is conducted for monitoring the long term care of people with diabetes. There is no iota of doubt that the complainant was suffering from diabetes before taking of the policy and she has concealed this fact hence OP was justified in repudiating the claim.
Reference in this regard is placed on case of LIC of India Ors Vs Ramani Batra and Ors. - V (2015) CPJ 529(NC) - wherein it was held that contract between the parties falls in the category of contract uberrimae fidei. It is not for the proposer to determine whether the information sought for is material for the purpose of policy or not. It was duty of the insured to disclose true facts.
Identical view was taken in the cases of Dilraj Singh (Mrs.) Vs LIC and Ors. - IV (2015) CPJ 665 (NC), Shakuntala Vs LIC - III (2014) 517 CPJ (NC) and Birla Sunlife Insurance Company Ltd. and Ors. Vs Asha - III (2014) CPJ 580 (NC)."
3. Aggrieved by the aforesaid order of the District Commission, the Appellant/Complainant has preferred the present appeal contending that the District Commission failed to appreciate the evidence/documents produced before the commission. The Appellant further submitted that the respondent company is not justified in repudiating the claim of the Appellant on the basis of pre-existing disease. Pressing the aforesaid contentions, the Appellant prayed for setting aside the order of the District Commission.
ALLOWED PAGE 5 OF 13 FA NO./238/2018 D.O.D.: 28.02.2024
MRS. GEETA NEGI VS. RELIGARE HEALTH INSURANCE LTD.
4. The Respondents, on the other hand, filed written submission, wherein, respondent denied all the allegations of the Appellant and submitted that the Respondents rightly rejected the claim of the appellant as per clause 6.1 of the said policy for non-disclosure of the pre-existing disease at the time of taking policy.
5. We have perused the material available on record and heard the counsel for the parties.
6. The question for consideration before us is whether the insured i.e., Respondent has deliberately concealed the fact of pre-existing disease i.e., Diabetes at the time of obtaining the policy.
7. On the concept, meaning and import of word disease, pre-existing disease in reference to medical insurance commission has drawn following ten conclusions in a highly extensive, dissecting manner in their decision Pradeep Kumar Garg v. National Insurance Co. Ltd., FA-482/2005 decided on 01.08.2008. These are as:
"a. Disease means a serious derangement of health or chronic deep-seated disease frequently one that is ultimately an insured must have been hospitalized or operated upon in the near proximity of obtaining the mediclaim. b. Such a disease should not only be existing at the time of taking the policy but also should have existed in the insured had been hospitalized or operated upon for the said disease in the near past, say, six months or to disclose the said fact to rule out the failure of his claim on the ground of concealment of information as to.
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MRS. GEETA NEGI VS. RELIGARE HEALTH INSURANCE LTD.
c. Malaise of hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal modern day life which is full of tension at the place of work, in or out of the house and are controllable on standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these other disease. d. If insured had been even otherwise living normal and healthy life and attending to his duties and daily chores person and is not declared as a diseased person as referred above he cannot be held guilty for concealment medical terminology of which is even not known to an educated person unless he is hospitalized and operated particular disease in the near proximity of date of insurance policy say few days or months. e. Disease that can be easily detected by subjecting the insured to basic tests like blood tests, ECG etc. the insured to disclose such disease because of otherwise leading a normal and healthy life and cannot be branded as diseased. f. Insurance company cannot take advantage of its act of omission and commission as it is under obligation to issuing mediclaim policy whether a person is fit to be insured or not. It appears that insurance companies obligation as half of the population is suffering from such malaises and they would be left with no or very little.
ALLOWED PAGE 7 OF 13 FA NO./238/2018 D.O.D.: 28.02.2024
MRS. GEETA NEGI VS. RELIGARE HEALTH INSURANCE LTD.
Thus, any attempt on the part of the insurer to repudiate the claim for such non-disclosure is not permissible, exclusion clause invokable.
a. Claim of any insured should not be cannot be repudiated by taking a clue or remote reference to any so-called discharge summary of the insured had concealed his hospitalisation or operation for the said disease undertaken reasonable near proximity as referred above.
b. Day to day history or history of several years of some or the other physical problem one may face occasionally landed for hospitalisation or operation for the disease cannot be used for repudiating the claim. For instance suffered from a particular disease for which he was hospitalised or operated upon 5, 10 to 20 years ago and living healthy and normal life cannot be accused of concealment of pre-existing disease while taking mediclaim being cured of the disease, he does not suffer from any disease much less the pre-existing disease while taking as after being cured of the disease, he does not suffer from any disease much less the pre-existing disease. c. For instance to pay that insured has concealed the fact that he was having pain in the chest off and on for years diagnosed or operated upon for heart disease but suddenly lands up in the hospital for the said purpose and disentitled for claim bares dubious design of the insurer to defeat the rightful claim of the insured on flimsy are not rare where people suffer a massive ALLOWED PAGE 8 OF 13 FA NO./238/2018 D.O.D.: 28.02.2024 MRS. GEETA NEGI VS. RELIGARE HEALTH INSURANCE LTD.
attack without having even been hospitalised or operated upon years or so.
d. Non-instance of hospitalisation/or operation for disease that too in the reasonable proximity of the date of the only ground on which insured claim can be repudiated and on no other ground."
8. From the above dicta it is clear that unless and until a person is hospitalised or undergoes operation of a particular disease in the near proximity of obtaining insurance policy or any disease for which he has never undergone operation is not a pre-existing disease. If a person conceals the factum of his hospitalisation of an operation undergone by him in the near proximity of obtaining the insurance policy, only then it can be termed factum of disease and doctrine of good faith under Section 45 of the Insurance Act, 1938 can then alone be pressed company and not otherwise. Doctrine of good faith is two-way traffic and not a one-way traffic.
9. The next issue of pre-existing disease of diabetes, we deem it appropriate refer to Revision Petition No. 3557 of 2013 titled as "Sunil Kumar Sharma vs. TATA AIG Life Insurance Company and Ors"
decided on 01.03.2021, wherein the Hon'ble National Commission has dealt the issue of pre-existing disease and held as follows:
"14. Moreover the claim had been repudiated only on the ground that the insured was suffering from diabetes for a long time. So far as life style diseases like diabetes and high blood pressure are concerned, Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., W.P.(C) No. 656 of 2007, decided on 17.09.2007 held as under:
"Insurance-Mediclaim-Reimbursement-Present Petition filed for appropriate directions to respondent to reimburse ALLOWED PAGE 9 OF 13 FA NO./238/2018 D.O.D.: 28.02.2024 MRS. GEETA NEGI VS. RELIGARE HEALTH INSURANCE LTD.
expenses incurred by him for his medical treatment, in accordance with policy of insurance-Held, there is no dispute that diabetes was a condition at time of submission of proposal, so was hyper tension-Petitioner was advised to undergo ECG, which he did-Insurer accepted proposal and issued cover note-It is universally known that hypertension and diabetes can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications depending upon varied factors-That implies that there is probability of such ailments, equally they can arise in non-diabetics or those without hypertension-It would be apparent that giving a textual effect to Clause 4.1 of policy would in most such cases render mediclaim cover meaningless-Policy would be reduced to a contract with no content, in event of happening of contingency-Therefore Clause 4.1 of policy cannot be allowed to override insurer's primary liability-Main purpose rule would have to be pressed into service-Insurer renewed policy after petitioner underwent CABG procedure- Therefore refusal by insurer to process and reimburse petitioner's claim is arbitrary and unreasonable-As a state agency, it has to set standards of model behaviour; its attitude here has displayed a contrary tendency-Therefore direction issued to respondent to process petitioner's claim, and ensure that he is reimbursed for procedure undergone by him according to claim lodged with it, within six weeks and petition allowed."
15. In RP No. 4461 of 2012, Neelam Chopra Vs. Life Insurance Corporation of India & Ors., decided on 08.10.2018, (NC), it was held that:
"11. From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of ALLOWED PAGE 10 OF 13 FA NO./238/2018 D.O.D.: 28.02.2024 MRS. GEETA NEGI VS. RELIGARE HEALTH INSURANCE LTD.
such diseases. The person insured may suffer consequences in terms of the reduced claims.
14. Moreover, the non-disclosure of information in respect of this life style disease of diabetes, will not totally disentitle the complainant for indemnification of the claim in the light of the judgment of Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., (supra)."
16. Based on the above discussion, I am of the opinion that the Insurance Company had not been able to prove beyond doubt that the Complainant was suffering from diabetes before filing of the proposal form. It is also to be noted that the Insurance Company had given Insurance to a person of 66 years of age without any preliminary medical examination which could have definitely revealed whether the proposer was suffering from diabetes or not. It is commonly known that a person of 66 years of age has a high probability of suffering from common lifestyle diseases like diabetes and hypertension. If the company is ready to take the risk at this age of the proposer, without any preliminary medical examination, then the company should be ready to honour the claim also because the chances of death of such persons are more during the currency of the Policy."
10. From the aforesaid settled law, it is clear that the common lifestyle disease like diabetes and hypertension, cannot be treated as pre-existing diseases, therefore, cannot be a ground of repudiation of the claim by Insurance companies. However, the Respondents rejected the claim of the Appellant on the basis common lifestyle disease on the basis she was suffering from diabetes at the time of obtaining said policies.
11. Further, it is well settled law that the Insurance company before issuing the policy should have examined the person through medical tests in ALLOWED PAGE 11 OF 13 FA NO./238/2018 D.O.D.: 28.02.2024 MRS. GEETA NEGI VS. RELIGARE HEALTH INSURANCE LTD.
order to check whether the person is suffering from any pre-existing diseases. In present case, the Respondents also examined the Appellant while obtaining said policy and was declared as healthy. More so, it is clear that the Appellant did not have diabetes from the Respondent's examination at the time of obtaining said policy, which revealed that the Respondent's fasting blood sugar level was 5.6, within the normal range of 5% - 7% (Annexure at pg. 25 of the present appeal).
12. In view of aforesaid discussions done and the legal position as settled, we hold that the Respondents are deficient in providing services to the Respondent by rejecting the claim of the Appellant in the guise of non- disclosure of pre-existing disease.
13. Consequently, we hold that the District Commission erred in dismissing the complaint of the Appellant on the ground that there is no deficiency on part of the Respondents. Therefore, we set aside the order dated 20.04.2018 passed by the District Consumer Disputes Redressal Forum- X, Udyog Sadan, C-22 & 23, New Delhi - 110016.
14. Keeping in view the facts and circumstances of the present case, the Respondents are directed to pay a sum of Rs. 3,00,000/- (Cost of Medical Expenses) to the Appellant along with interest @ 6% p.a. calculated from 19.04.2014 (being the date on which the said claim of the Appellant was repudiated) till 28.02.2024 (being the date of the present judgment).
15. The directions mentioned in para 14 shall be complied by the Respondents within two months from the date of judgment. In case of failure to comply with the same within two months, the entire amount would entail a penalty of 9% p.a. till the actual realization of amount.
16. Application(s) pending, if any, stands disposed of in terms of the aforesaid judgment.
ALLOWED PAGE 12 OF 13 FA NO./238/2018 D.O.D.: 28.02.2024
MRS. GEETA NEGI VS. RELIGARE HEALTH INSURANCE LTD.
17. The judgment be uploaded forthwith on the website of the commission for the perusal of the parties.
18. File be consigned to record room along with a copy of this Judgment.
(JUSTICE SANGITA DHINGRA SEHGAL) PRESIDENT (PINKI) MEMBER (JUDICIAL) Pronounced On:
26.02.2024 LR-ZA ALLOWED PAGE 13 OF 13