State Consumer Disputes Redressal Commission
Shivani vs Religare Health Insurance Co. on 24 June, 2024
Cause Title/Judgement-Entry STATE CONSUMER DISPUTES REDRESSAL COMMISSION UT CHANDIGARH First Appeal No. A/96/2023 ( Date of Filing : 16 May 2023 ) (Arisen out of Order Dated 02/03/2023 in Case No. CC/671/2021 of District DF-I) 1. SHIVANI 131 WARD NO. 09 NALAGARH ITI ROAD NALAGARH SOLAN HIMACHAL PRADESH ...........Appellant(s) Versus 1. RELIGARE HEALTH INSURANCE CO. SCO 56,57,58 SECTOR 9 CHANDIGARH CHANDIGARH CHANDIGARH ...........Respondent(s) BEFORE: HON'BLE MRS. PADMA PANDEY PRESIDING MEMBER HON'BLE MR. PREETINDER SINGH MEMBER PRESENT: Dated : 24 Jun 2024 Final Order / Judgement STATE CONSUMER DISPUTES REDRESSAL COMMISSION, U.T., CHANDIGARH (Additional Bench) Appeal No. : 96 of 2023 Date of Institution : 16.05.2023 Date of Decision : 24.06.2024 Shivani w/o Late Sh.Amit Swami, R/o 131 ward No.9 Nalagarh, ITI Road, Nalagarh (T) Nalagarh, Solan, Himachal Pradesh-174101. ... Appellant V E R S U S Religare Health Insurance Co. Ltd. SCO 56,57,58 Sector 9 Chandigarh-160017 through its Manager/Authorized Signatory. Email: [email protected]. Religare Health Insurance Co. Correspondence address Vipul tech Square, Tower C, 3rd Floor, Sector 43, Golf Course Road Gurgaon-122009 through its Manager/Authorized Signatory. Email: [email protected]. ..... Respondents Appeal under Section 41 of the Consumer Protection Act, 2019 against order dated 02.03.2023 passed by District Consumer Disputes Redressal Commission-I, U.T. Chandigarh in Consumer Complaint No.671/2021. BEFORE: MRS. PADMA PANDEY, PRESIDING MEMBER
Mr.PREETINDER SINGH,MEMBER Argued by: Sh.Amandeep Singh Nirman, Advocate for the appellant.
Ms.Niharika Goel, Advocate, proxy for Sh. Paras Money Goyal, Advocate for the respondents.
PER PADMA PANDEY, PRESIDING MEMBER This appeal is directed against the order dated 02.03.2023, rendered by the District Consumer Disputes Redressal Commission-I, U.T. Chandigarh (hereinafter to be referred as "the Ld. Lower Commission"), in Consumer Complaint No.671 of 2021,vide which, it dismissed the complaint, being meritless.
2.. Before the Ld. Lower Commission, it was case of the complainant/appellant that husband of the complainant got himself insured with Max Bupa Health Insurance for a cover of Rs.5,00,000/- (Annexure C-1). The complainant's husband got the insurance renewed again for another one year and took a top up medical insurance policy from OPs and got himself insured for a sum of Rs.25,00,000/-. The Complainant's husband paid a premium of Rs.6152/- and validity of the insurance policy was from 18.09.2018 to 17.09.2019 (Annexure C-2). It is averred that Husband of the complainant was diagnosed with Jaundice and Pneumonia in 2017. During the currency period of the insurance policy, husband of the complainant was admitted at Fortis Hospital Mohali on 07.07.2019 and thereafter he was shifted to Max Super specialty Hospital on 19.07.2019. After undergoing treatment for few more days, unfortunately on 26.07.2019, complainant's husband died. The complainant submitted claim for reimbursement of expenses incurred on the treatment of his husband under the insurance policy. Max-Bupa Health Insurance company reimbursed the medical claim of Rs.5,50,000/-. The complainant supplied all the relevant requisite documents to the OPs. The complainant received a letter from OPs on 15.02.2020, wherein it was stated by the OPs that her claim is not payable as per policy terms and conditions. The rejection of the claim was stated to be due to non-disclosure of chronic liver disease. The complainant again approached the OPs vide various emails and requested them time and again to settle the claim. But the OPs did not pay any heed to the requests of complainant and rejected the claim of the complainant (Annexure C-8 colly).Hence, a consumer complaint was filed before the Ld. Lower Commission.
3.. Pursuant to issuance of notice, Opposite parties appeared before the Ld. Lower Commission and contested the complaint. In their written reply it was stated that as per the medical documents and discharge summary, the insured was admitted to the hospital for treatment of chronic liver disease (CLD) Cryptogenic/Nash related with de-compensated Cirrhosis with massive UGI variceal bleed, ischemic hepatitis among other things. The complainant had the opportunity to disclose at the time of proposal that he was having history of chronic liver disease, diabetes and dyslipidemia prior to policy inception date, however, the said pre-existing condition/ailment was deliberately and intentionally not disclosed by the complainant/insured in order to get benefit out of health insurance policy from the OP-company. Therefore, the OP-company has rightly rejected the claim in accordance with Clause 7.1 of the policy terms and conditions. The copy of the terms and conditions is annexed as Annexure OP-11. It is further stated that the complainant had earlier approached the Insurance Ombudsman at Chandigarh where the complaint was dismissed vide order dated 28.08.2020. Denying all other allegations, it was pleaded that there was no deficiency in service on their part and a prayer was made for dismissal of the complaint.
4. On appraisal of the complaint, and the evidence adduced on record by the parties, Ld. Lower Commission came to the conclusion that there was no merit in the complaint and the same was dismissed.
5. Aggrieved against the aforesaid order passed by the Ld. Lower Commission, the instant Appeal has been filed by the Appellant/complainant for setting aside the impugned order and grant of relief as prayed for in the complaint..
6. We have heard Counsel for the parties and have gone through the evidence and record of the case with utmost care and circumspection.
7. The ground taken by the appellant in appeal is that her husband never concealed any fact from the respondents. Her husband was admitted in the hospital in 2017 and diagnosed with jaundice and Pneumonia and this fact was duly mentioned in the proposal form whenever it was asked by the respondents. It is contended on behalf of the appellant that the respondents submitted cyclostyle reply to the complaint before the Ld. Lower Commission without appreciating the record and took up a defence by stating that the husband of the appellant gave answers in negative to the questions asked in the proposal form. The insured (now deceased) gave answer in affirmative to the question "does any person to be insured has any pre-existing disease". Answer to the other question "have any of the above mentioned person(s) to be insured been diagnosed/hospitalized for any illness/injury during the last 48 months" was also given in affirmative. It was further contended that Max Bupa Insurance has reimbursed the claim amount for the same illness whereas the respondents have wrongly denied the claim on the ground that husband of the appellant was a known case of alcohol abuse. Even the Fortis hospital had issued a certificate that the husband of the appellant was not a case of alcohol disorder. On the other hand, it was contended on behalf of the respondents that the Insurance company repudiated the insurance claim on the grounds of non-disclosure of Chronic Liver Disease, Diabetes and Dyslipidemia and as such, order passed by the learned Lower Commission is quite justified and does not call for any interference.
8. There is no denying the fact that husband of the appellant was insured with Max Bupa Insurance with sum insured of Rs.5,00,000/- for the period from 18.9.2017 to 17.9.2018. He again got the policy renewed for the period from 18.9.2018 to 17.9.2019. However, he also availed health insurance top up policy from the respondents for a sum of Rs.25.00 Lakhs. Max Bupa Insurance settled the claim of the appellant at Rs.5,50,000/- however, the respondents rejected the claim of the appellant with regard to top up plan on the ground of non-disclosure of material facts about the health. It is case of the appellant that the insured in the proposal form has given answers in affirmative to the question asked therein. Annexure OP 10 is the proposal form which reads as under ;
Proposal Form: ENHANCE Dear Mr. Amit Swami Reference to your online proposal (1120006328486) for ENHANCE Comprehensive Health Insurance Policy, please find below the details as provided by you Proposer Details Name : Mr. Amit Swami Address House No.95 Ward No.9, Near ITI Nalagarh Nalagarh Nalagarh-174101 Himachal Pradesh Date of Birth : 07/08/74 Landline :
Mobile : 8219920936 E-mail : [email protected] Details of the Persons be Insured Name Date of Birth Relation Pre-existing Diseases Amit Swami 07/08/74 MEMBER FRACTURE OF LEFT ARM Additional Details Does any person(s) to be insured has any pre-existing diseases? Insured Yes B. Have any of the above mentioned person(s) to be insured been diagnosed/hospitalized for any illness/injury during the last 48 months? Insured Yes C. Have any of the person (s) to be insured ever filed a claim with their current/previous insurer? Insured Yes D. Has any proposal for Health insurance been declined, cancelled or charged a higher premium? Insured No E. Is any of the person(s) to be insured, already covered under any other health insurance policy of Religare Health Insurance? Insured No
On the top of the proposal form, it is recited that this proposal form is in reference to online proposal given by the proposer for enhance; comprehensive health insurance policy. Under the heading " Additional details" the proposer has given answers to questions A, B, C in affirmative and answers to questions D and E in negative. Thus, the husband of the appellant has given answers in affirmative to the question asked in proposal form under the heading Additional details that he was suffering from pre-existing diseases ; he was diagnosed/hospitalized for any disease/injury during the last 48 months and he had filed a claim with his current/previous insurer. The said proposal form was considered by the insurance company before the policy was issued to the insured. It was accepted and policy was issued. The insurance company therefore did not think that the medical and health condition of the appellant was such which did not warrant issuance of a mediclaim policy. The insurance company therefore did not decline the proposal of the insured. The Hon'ble Supreme Court in Manmohan Nanda Vs United India Assurance Company Limited and another (2022) 4 Supreme Court cases 582 observed that Principle of uberrimae fidei i.e. principle of utmost good faith imposed meaningful reciprocal duties owed by the insured to the insurer and vice versa. That is to say, just as the insured has a duty to disclose all material facts, the insurer must also inform the insured about the terms and conditions of the policy that is going to be issued to him and must strictly conform to the statements in the proposal form or prospectus, or those made through his agents.
9. It was obligatory on the part of the Insurance company to go through the proposal form before accepting it and issuing insurance policy. Once the proposal form has been accepted and policy issued it cannot take such objection that pre-existing disease was not disclosed. Further, the other insurance company i.e. Max Bupa Insurance has settled the claim of the appellant for the said ailment and released the settled amount under the policy.
10. For the reasons recorded above, the appeal is accepted and the impugned order is set aside. The respondents are directed to indemnify the appellant by settling her claim under the insurance policy regarding the expenses incurred on the treatment of the deceased insured , within a period of 45 days from the receipt of copy of the order, failing which, respondents shall be liable to pay interest @9% from the date of default till payment.
11. Misc. application, if any pending, also stands disposed of
12. Certified copies of this order be sent to the parties free of charge.
13. The file be consigned to Record Room, after completion.
[HON'BLE MRS. PADMA PANDEY] PRESIDING MEMBER [HON'BLE MR. PREETINDER SINGH] MEMBER