State Consumer Disputes Redressal Commission
Care Health Insurance Ltd. vs Kulbir Singh on 27 October, 2023
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH.
First Appeal No.847 of 2022
Date of institution : 04.10.2022
Reserved On : 10.10.2023
Date of decision : 27.10.2023
Care Health Insurance Ltd., formerly known as Religare Health
Insurance Co. Ltd., having its Local Branch Office at SCO 28, Taneja
Towers, B-Block, Ranjit Avenue, Amritsar, through its Branch
Manager/Person Overall Incharge.
....Appellant/OP
Versus
Kulbir Singh son of Sh. Onkar Singh, aged about 42 years, resident of
46/14, Gali No.2, opposite White Avenue, near Green Field, Amritsar.
....Respondent/Complainant
First Appeal under Section 41 of the
Consumer Protection Act, 2019 against the
order dated 27.07.2022 passed by the
District Consumer Disputes Redressal
Commission, Amritsar.
Quorum:-
Hon'ble Mrs. Justice Daya Chaudhary, President
Ms. Simarjot Kaur, Member
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 Present:-
For the appellant : Ms. Niharika Goel, Advocate for Sh. P.M. Goyal, Advocate For the respondent : Mrs. Rashmi Singh, Advocate.First Appeal No.847 of 2022 2
JUSTICE DAYA CHAUDHARY, PRESIDENT Appellant/OP i.e. Care Health Insurance Ltd. (earlier known as Religare Health Insurance Co. Ltd.) through its Branch Manager has filed the present appeal under Section 41 of the Consumer Protection Act, 2019 to challenge the impugned order dated 27.07.2022 passed by the District Consumer Disputes Redressal Commission, Amritsar (in short, "the District Commission"), whereby the complaint filed by the respondent/complainant was allowed.
2. It would be apposite to mention here that hereinafter the parties will be referred, as have been arrayed before the District Commission.
3. Briefly, the facts of the case as made out by the respondent/complainant in the complaint filed by him before the District Commission are that he had been obtaining the Mediclaim Insurance Policies from the appellant/OP from time to time and had also obtained the Mediclaim Insurance Policy bearing No.13305643, which was valid w.e.f. 16.11.2018 to 15.11.2019 for the sum assured of ₹5 lac by paying the requisite premium. It was further mentioned that during the currency of the said policy, the complainant had suffered severe pain in his chest on 19.04.2019 and for that purpose, he got himself admitted in Baba Deep Singh Hospital, Amritsar, where the concerned treating Doctor had issued a Certificate dated 01.08.2019 (Ex.C-2), wherein it was mentioned that "it has been First Appeal No.847 of 2022 3 wrongly interpreted as ten years", as the patient had never taken treatment in the Hospital for Hypertension or any other problem/ailment. Thereafter, the complainant was shifted to Anand Hospital, Amritsar, where he was diagnosed for Myocardial Infarction and remained admitted in the said hospital w.e.f. 19.04.2019 to 25.04.2019. A Certificate to this effect was also issued by the said Hospital as Ex.C-2/A and the total bill for the said period was ₹45,000/-. It was a cashless policy and the OP was required to pay the entire amount towards the medical expenses incurred on the treatment of the complainant but it was not paid and as such the complainant was compelled to pay the said amount of ₹45,000/- from his own pocket.
4. It was further mentioned that a request was made to the OP by the complainant to release the said amount spent on his treatment but still the amount was not released in-spite of seeing the Certificate issued by the Hospital Authorities. As per the version of the complainant, there was no past history of Hypertension, DM and CAD.
5. Stating to be a case of 'deficiency in service' and 'unfair trade practice' on the part of the OP, the complaint was filed with the prayer for issuance of directions to the OP to pay the claim amount of ₹45,000/- along with interest at the rate of 12% per annum and also to pay compensation of ₹50,000/- for causing mental agony and First Appeal No.847 of 2022 4 harassment to the complainant as well as ₹11,000/- towards litigation expenses.
6. Upon issuing notice to the OP, written version was filed, wherein certain preliminary objections were raised. The other averments/allegations as made in the complaint were also denied.
7. By considering the contents of the complaint and reply thereof filed by the OP, the complaint was allowed by the District Commission vide impugned order dated 27.07.2022. The relevant portion of said order as mentioned in Para-9 is reproduced as under:
"9. In view of the above discussion, we allow the complaint with costs and the opposite party is directed to pay the impugned claim of Rs. 45000/- alongwith interest @ 9% p.a. from the date of filing of the complaint till realization. Opposite party is also directed to pay compensation to the tune of Rs. 10000/- and litigation expenses of Rs.5000/- to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order; failing which complainant shall be entitled to get the order executed through the indulgence of this commission. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this commission."
8. Said order dated 27.07.2022 passed by the District Commission has been challenged by the appellant/OP by way of filing the present appeal by raising a number of arguments.
9. There was a delay of 15 days in filing of the appeal. Misc. Application No.1341 of 2022 was filed for condonation of delay, which was supported by an affidavit. Said application was allowed vide order dated 24.11.2022 and the delay in filing of the appeal was condoned.
10. Ms. Niharika Goel proxy for Mr. P.M. Goyal, learned counsel for the appellant/OP has submitted that the District First Appeal No.847 of 2022 5 Commission while allowing the complaint had not considered the controversy in hand, as admittedly the complainant was treated for AMWI (Anterior Wall Myocardial Infarction) in the hospital. However, certain material facts were not disclosed by him at the time of taking the policy. The claim of the complainant was repudiated by taking into consideration the actual and factual position and by considering Clause 7.1 of the terms and conditions of the policy. The complainant was suffering from Hypertension but this fact was not disclosed by him while filling up the Proposal Form and as such the contract had become void. Had this fact been disclosed at the time of filling up the Proposal Form, the policy could not have been issued to the complainant. Learned counsel has further submitted that the District Commission had wrongly held that the insurer had failed to examine the insured prior to the inception of the policy and necessary tests should have been conducted. It was a case of breach of the terms of the conditions of the policy and concealment of material facts. The complainant was required to disclose each and every aspect with regard to his health at the time of filling up the Proposal Form but he did not do so intentionally. There was no 'deficiency in service' on the part of the appellant and the impugned order is liable to be set aside. Learned counsel has also relied upon the following judgments in support of her contentions:
i) SGS India v. Dolphin International Ltd. LL 2021 SC 544 (SC);First Appeal No.847 of 2022 6
ii) Indigo Airlines v. Kalpana Rani Debbarma (2020) 9 SCC 424 (SC);
iii) Reliance Life Insurance Co. Ltd. v. Rekhaben Nareshbhai Rathore Civil Appeal No.4261 of 2019 decided on 24.04.2019 (SC);
iv) Satwant Kaur Sandhu v. New India Assurance Co. Ltd.
(2009) 8 SCC 316 (SC);
v) P.C. Chacko & Anr. v. Chairman, LIC of India & Ors. (2008) 1 SCC 321 (SC);
vii) Ravneet Singh Bagga v. KLM Royal Dutch Airlines (2000) 1 SCC 66 (SC);
vii) Life Insurance Corporation of India v. Smt. G.M. Channabasamma (1992) 1 SCC 357 (SC); and
viii) LIC of India v. Smt. Neelam Sharma decided on 30.09.2014 (NC).
11. Mrs. Rashmi Singh, learned counsel for the respondent/complainant has submitted that the order passed by the District Commission is well reasoned and the same was passed by considering the averments made in the complaint, reply and also the ratio of judgments passed in a number of cases as mentioned therein. Learned counsel has further submitted that the treating Doctor of the hospital had issued a Certificate dated 01.08.2019 (Ex.C-2), wherein it was mentioned that in the treatment record it was wrongly mentioned that the patient was taking the treatment in the Hospital for the last 10 years. The patient had never got himself treated earlier with the problem of Hypertension or any other connected ailment. By taking undue advantage of that clerical mistake, the OP had wrongly First Appeal No.847 of 2022 7 repudiated the genuine claim of the complainant vide letter dated 02.09.2019, which is contrary to the terms and conditions of the policy and the law. Learned counsel has relied upon the following judgments in support of her contentions:
i) New India Assurance Co. Ltd. v. Paresh Mohanlal Parmar 2020 (1) RCR (Civil) 1006 (SC);
ii) P. Vankat Naidu v. LIC of India & Anr. 2011 (3) CPC 350 (SC);
iii) ICICI Prudential Life Ins. Co. Ltd. v. Dattatrey Bhivsan Gujar RP No.3858 of 2017 decided on 14.6.2019 (NC);
iv) LIC of India & Anr. v. Naseem Bano RP Nos.3739 & 3740 of 2007 decided on 23.05.2012 (NC);
v) New India Assurance Co. Ltd. v. Murari Lal Bhusri 2011 (III) CPJ 198 (NC);
vi) LIC of India & Ors. v. Kunari Devi RP No.2733 of 2008 decided on 31.07.2008 (NC);
vii) LIC of India & Anr. v. Murti Devi FA No.1037 of 2007 decided on 16.08.2012 (Punjab State Commission);
viii) LIC of India v. Sushma Sharma FA No.980 of 2006 decided on 14.02.2008 (Punjab State Commission); and
ix) LIC of India v. Sudha Jain FA No.A-651 of 2006 decided on 31.10.2006 (Delhi State Commission).
12. Heard the arguments raised by learned counsel for the parties. We have also carefully perused the impugned order passed by the District Commission and all other documents available on the file with the able assistance of the learned counsel for the parties.
13. Facts regarding filing of the complaint by the complainant before the District Commission, reply thereto filed by the appellant/OP, First Appeal No.847 of 2022 8 allowing of said complaint and thereafter filing of the present appeal by the appellant/OP before this Commission are not in dispute.
14. Admittedly, the complainant had purchased the Health Insurance Policy from the OP for the sum assured of ₹5 lac, which was valid for the period w.e.f. 16.11.2018 to 15.11.2019. The complainant had suffered chest pain on 19.04.2019, for which he was admitted in Baba Deep Singh Hospital, Amritsar and thereafter he was shifted to Anand Hospital, Amritsar and was discharged on 25.04.2019. As per the version of the complainant, an amount of ₹45,000/- was spent on the treatment of the complainant in the Hospital. However, the claim lodged by the complainant was repudiated by the appellant/OP vide letter dated 02.09.2019 as per Clause 7.1 (Non-Disclosure of Hypertension at the time of Policy Inception) of the terms and conditions of the policy.
15. It is not in dispute that the complainant had taken treatment for AMWI (Anterior Wall Myocardial Infarction) from the Hospital. The OP had taken the defence that as per OPD notes of the Hospital, the complainant was a known case of HTN for the last 10 years. However, the concerned treating Doctor had issued a Certificate dated 01.08.2019 (Ex.C-2), wherein it was mentioned that "it has been wrongly interpreted as ten years", as the patient had never taken treatment in the said hospital for Hypertension or any other problem. In view of this Certificate, the version of the OP cannot First Appeal No.847 of 2022 9 be relied upon. OP had failed to produce any evidence on record to prove that the complainant had taken any treatment for Hypertension prior to the issuance of the policy.
16. The Hon'ble National Commission in the case titled as Neelam Chopra Vs. Life Insurance Corporation of India & Ors. R.P. No.4461 of 2012 decided on 08.10.2018 has held that the claim cannot be denied on the ground of life style diseases such as Diabetes and Hypertension etc. The relevant portion of said judgment is reproduced as under:
"So far as the life style diseases like diabetes and high blood pressure are concerned, Hon'ble High Court of Delhi has taken the following view in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., W.P.(C) No.656 of 2007, decided on 17.09.2007:
"Insurance- Mediclaim-Reimbursement- Present Petition filed for appropriate directions to respondent to reimburse 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 First Appeal No.847 of 2022 10 reimbursed for procedure undergone by him according to claim lodged with it, within six weeks and petition allowed."
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. "
17. In another case titled as Satish Chander Madan Vs. Bajaj Allianz General Insurance Co. Ltd. I (2016) CPJ 613 (NC), the Hon'ble National Commission has held that hypertension is common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack. In paras No.8 to 10 it was held as follows:
"8. Learned Counsel for the respondent has contended that as per the terms and conditions of the insurance contract, the Insurance Company was not required to reimburse the petitioner complainant for expenses incurred by him on pre-existing disease. Learned Counsel has argued that from the medical report of the petitioner, it is clear that the petitioner was suffering from hypertension prior to the purchase of the insurance policy and since hypertension has a direct nexus with heart ailment, the respondent Insurance Company was justified in repudiating the insurance claim in view of the exclusion clause which excluded the expenses incurred on pre-existing disease.
9. We do not find merit in the above contention. On perusal of the copy of the medical report of the petitioner dated 4.6.2010 issued by Dr. David P. Lipkin as also the letter of the doctor dated 7.6.2010 addressed to Dr. M. Fertleman of Wellington Hospital would show that as per the observations of Dr. David P. Lipkin, the petitioner had a previous history of hypertension and he was on BP medicine Telmisartan. The above referred reports do not mention that the petitioner disclosed any previous history of heart problem. Therefore, the only fact established by the above reports is that the petitioner prior to obtaining insurance policy was having history of hypertension. This, however, does not lead to conclusion that petitioner was also having previous history of heart problem. Therefore, the insurance claim submitted by the complainant for treatment of his heart problem cannot be termed as a claim in respect of a pre existing disease. Thus, repudiation of insurance claim by the respondent opposite party is not justified.
10. Learned Counsel for the respondent has contended that it is established on record that the petitioner was having a previous history of hypertension and since hypertension can lead to heart problem, the respondent was justified in repudiating the claim on the ground that the First Appeal No.847 of 2022 11 heart problem suffered by the petitioner was caused by pre existing hypertension. There is no merit in this contention. Hypertension is a common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack. Therefore, the argument advanced by respondent is far fetched and is liable to be rejected."
18. Further in case Bajaj Allianz Life Insurance Co. Ltd. & Ors. Vs. Raj Kumar III (2014) CPJ 221 (NC), it was held by the Hon'ble National Commission that usually the authorized doctors of the Insurance Company examine the insured to assess the fitness and after complete satisfaction, the policy is issued. Later on, the Insurance Company cannot allege that any disease was concealed. It was held that the Insurance Company had wrongly repudiated the claim of the complainant.
19. In the case of New India Assurance Company Limited Vs Smt. Usha Yadav & Ors.", 2008(3)RCR(Civil)-111(P&H), the Hon'ble Punjab & Haryana High Court held as under:-
"6. Before parting, I wish to express anguish over the method and mode adopted by Insurance Companies in somehow declining the claim of claimants, be it under such type of policy or other life insurance claims or those arising out of insurance of vehicles etc. It seems that the Insurance Companies are only interested in earning the premiums, which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance Companies make the effected people to fight for getting their genuine claims. The insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus, pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy."
20. As far as the stand of the appellant that as per Clause 4.1
(iii) of the policy, mediclaim for any pre-existing disease was not First Appeal No.847 of 2022 12 payable until 48 months continuous coverage had elapsed is concerned, it is relevant to mention that first of all, the complainant has specifically mentioned in Para-1 of the complaint that he had been taking the mediclaim policies from the OP continuously. This fact had not been denied by the OP in its reply. Secondly, the appellant had failed to prove that the complainant was suffering from any pre-existing disease, as no past history of the complainant has been produced on record. So, Clause 4.1 (iii)of the policy is not attracted.
21. The stand of the OP is also that the complainant had failed to provide the relevant documents as sought vide letters dated 24.05.2019, 02.06.2019 and 12.06.2019 but the OP has failed to prove as to through which mode those letters were sent to the complainant.
22. In view of the above discussion as well as facts and circumstances and also the ratio of law as laid down in the aforesaid judgments, the claim of the complainant was wrongly repudiated. The impugned order passed by the District Commission is based on proper appreciation of the evidence available on the record as well as the applicable law and no interference is required. The judgments relied upon by learned counsel for the appellant/OP are distinguishable and are not applicable to the facts and circumstances of the present case.
23. Accordingly, finding no force in the arguments raised by learned counsel for the appellant, the present appeal is hereby First Appeal No.847 of 2022 13 dismissed and the impugned order dated 27.07.2022 passed by the District Commission is upheld.
24. Since the main case has been disposed of, so all the pending Miscellaneous Applications, if any, are accordingly disposed of.
25. The appellant had deposited a sum of ₹35,886.37/- at the time of filing of the appeal. Said amount, along with 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.
26. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(JUSTICE DAYA CHAUDHARY) PRESIDENT (SIMARJOT KAUR) MEMBER October 27, 2023.
(Gurmeet S)