State Consumer Disputes Redressal Commission
Religare Health Insurance Co. Ltd. vs Jatinder Singh on 17 May, 2017
FIRST ADDITIONAL BENCH
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, SECTOR 37-A, DAKSHIN MARG, CHANDIGARH.
First Appeal No.874 of 2016
Date of Institution: 18.11.2016
Order reserved on:12.05.2017
Date of Decision : 17.05.2017
Religare Health Insurance Company Ltd., Regd. Office D3, P3B,
District Centre, Saket, New Delhi, Branch, through Ms. Ramnique
Sachar, Corporate Legal Manager, Authorized signatory, 3rd floor,
Vipul Tech Square, Tower C, Sector 43, Golf Course road,
Gurgaon, Haryana.
.......Appellant/Opposite Party No.1
Versus
1. Jatinder Singh son of Sh. Rashpal Singh resident of H.
No.17, New Shanti Nagar, near Manav Kender, Chandigarh
Road, Aslamabad, Tehsil and District Hoshiarpur.
.......Respondent/complainant
2. Indusind Bank, Sutehri Road, Hoshiarpur, through its
Branch manager.
........Performa respondent/Opposite Party No.2
Appeal against order dated 21.10.2016
passed by the District Consumer
Disputes Redressal Forum, Hoshiarpur.
Quorum:-
Sh. J.S.Klar, Presiding Judicial Member
Smt.Surinder Pal Kaur, Member Present:-
For the appellants : Sh. Sachin Ohri, Advocate For respondent No.1 : None For respondent No.2 : Sh. Paras Chugh, Advocate ............................................ F.A. No. 874 of 2016 2 SURINDER PAL KAUR, MEMBER :-
Appellant (being Opposite Party No.1 in the complaint) has filed this appeal against order dated 21.10.2016 of District Consumer Disputes Redressal Forum Hoshiarpur (in short the 'District Forum'), accepting the complaint by directing OP No.1 to pay Rs.32,105/-, as treatment amount along with @9% P.A. from the date of filling the claim till realization and further to pay Rs.5,000/- as compensation for harassment and Rs.2,000/- as litigation expenses, within 30 days from the date of receipt of the copy of the order. Respondent No.1 in this appeal is complainant in the original complaint before the District Forum and respondent No.2 of this appeal is OP No.2 in the original complaint. The parties be referred, as such hereinafter, as arrayed in the original complaint.
2. Complainant filed the complaint U/s 12 of the Consumer Protection Act, 1986 (in short, "the Act") against the OPs on the averments, that he purchased one health insurance policy from HDFC Ergo Company from November 2012 to November 2015, by making payment of regular annual premium of abovesaid health insurance policy. During that period, the complainant never fell ill or suffered from any health problem, so there was no occasion to get insurance claim by him. When period of above mentioned policy was about to be expired, the complainant approached OP No. 2 for deposit of premium F.A. No. 874 of 2016 3 amount, but concerned official of OP No.2 advised him to switch over his health insurance policy to Religare Health Insurance Company for better health services. Taken in by rosy pictures, the complainant deposited Rs. 8162/- as premium amount through Indusind Bank Hoshiarpur on 13.11.2015 and policy bearing No. 10463583 was issued by OP No.1 for the period from 29.11.2015 to 28.11.2016 and in December 2015, the complainant got himself medically checked by OP No.1 from an approved hospital of Religare Company and he was found healthy, but all of sudden on 12.01.2016, he suffered black out and fell ill and remained under treatment of IVY hospital till 14.01.2016 and spent Rs.32105/- on his treatment. He submitted his claim with OPs, but the same was repudiated by OP No.1 on the ground of "NON DISCLOSURE OF MATERIAL FACTS/PREEXISTING AILMENT AT THE TIME OF PROPOSAL. PATIENT IS K/C/O OF HTN SINCE JANUARY 2015." OP No.1 repudiated his genuine claim on flimsy grounds, despite the fact that he was medically checked up by OPs and found as fit as a fiddle. The above said act of the OPs amounted to deficiency in service on their part. Hence, complaint was filed before the District Forum by complainant seeking below noted prayers:
i) to pay Rs 32,105/- as claim amount with
interest;
F.A. No. 874 of 2016 4
ii) to pay Rs. 50,000/- as compensation for
harassment, and litigation expenses.
3. Upon notice, OP No.1 filed written reply raising the preliminary objections that claim of the complainant was repudiated, vide letter dated 03.03.2016, as per terms and conditions of the insurance policy. If claim was repudiated after taking due care, then there was no deficiency in service on the part of OPs at all. Complaint is not maintainable and thus deserves to be dismissed on that ground alone. Intricate questions of facts and law are involved in this case and the same requires lengthy and elaborate evidence for its resolution, which is not possible in summary procedures by Consumer Fora, therefore, matter be referred to the competent Civil Court for adjudication. Complainant has not approached the Forum with clean hands and suppressed the material facts from the Forum in the complaint. The OP received a cashless request for treatment of Cerebro Vascular Accident (CVA) and Transient Ischemic Attached (TIA). However, said request was denied under clause 4.1 of the policy for non-disclosure of material information by the complainant to the effect that insured/complainant had been suffering ailment of Hypertension (HTN) since January, 2015 before issuing the policy. The complainant himself disclosed in claim form that he had taken treatment of Hypertension on and off in January 2015 from Dr. Jasbir Singh Bagga. On merits, preliminary objections were F.A. No. 874 of 2016 5 reiterated as averred in the complaint. OP prayed for dismissal of the complainant being without any merit.
4. No one appeared on behalf of OP No.2 inspite of due service therefore, it was proceeded against ex-parte before District Forum on 19.5.2016. Complainant tendered in evidence his affidavit Ex. C1 along with documents Ex.C2 to Ex.C21 and closed his evidence. As against it, OP No.1 tendered in evidence affidavit of Prashant Singh Ex. OP1/14 along with documents Ex. OP1/1 to Ex.OP1/13 and closed its evidence. On conclusion of evidence and arguments, the District Forum allowed the complaint against OP No.1, as detailed therein. Dissatisfied with above order of the District Forum, OP No.1 now appellant has filed this appeal against the same.
5. We have heard the learned counsel for the parties and have carefully gone through the record on the file.
6. It was argued by the counsel for the appellant/OP that District Forum without appreciating the facts, erroneously allowed the complaint. The complainant purchased the insurance policy 29.11.2015 to 28.11.2016 in this case. On 12.01.2016, he suffered blackout and was taken in IVY Hospital Hoshiarpur, where he remained admitted till 14.01.2016 by spending Rs.31,105/- on above treatment. After investigation, it was found that complainant had been suffering from hypertension since January 2015, but this fact was not disclosed at the time of taking the policy by him as insured. The OP rightly repudiated the claim F.A. No. 874 of 2016 6 of insured, as violation of clause 4.1(c) of the policy on the ground of his pre-existing disease of hypertension. As per that clause, "claims will not be admissible for any Medical Expenses incurred as Hospitalization Expenses for diagnosis/treatment of any pre- existing disease until 48 hours of continuous coverage has elapsed, since the inception of the first policy with the company". OP now appellant prayed for acceptance of the appeal by setting aside the impugned order of District Forum.
7. We have carefully considered the above evidence on the record and also heard the respective submissions of the learned counsel for the appellant/OP at considerable length, whereas, no one appeared on behalf of the complainant now respondent in this appeal, at the time of arguments of this appeal. The point for adjudication in this appeal before us is whether it is a case of suppression of material information by the insured knowingly, when he filled in the proposal form. The District Forum has not accepted the argument of OP on this point and recorded the finding that OP failed to prove this fact, that any material information has been concealed by insured in this case. Perusal of record reveals that complainant submitted his claim form Ex.OP1/3, wherein he disclosed in column No.9 of claim form that "I had taken treatment (On/off) for high blood pressure for two days in January 2015 i.e. one year back. Further, in column No.10 of the claim form, it is mentioned that Dr. Jasbir Bagga- Bagga Clinic Hoshiarpur, prescription for the same F.A. No. 874 of 2016 7 not available right now, will provide later as soon as possible. As per the record of the IVY Hospital, Ex.OP1/5 under the head of past medical history, it is recorded that K/C/O HTN on reg rx (record not available), therefore, we cannot say that complainant was not aware of the above ailment of hypertension, when he took the policy. Contract of insurance is based upon the principle of good faith. It is the obligation of complainant/insured to disclose each and every fact to insurer at the time of taking the policy. The decision of the insurer is totally dependent upon this fact, whether to underwrite the risk involved in the policy or not and in case there is suppression of material facts by the insured deliberately and consent of the insurer has been obtained by not disclosing the correct particulars, then the contract of insurance can be avoided on account of exercise on misrepresentation by insured. The insurer might not have issued the policy to insured after knowing his/her pre-existing disease. It is not proved case of the complainant on the record that the facts of the proposal form were not disclosed to him when he filled in the proposal form and hence, he was not aware of the same. Complainant signed the declaration being part of proposal form, wherein he made the statement disclosing true facts of the proposal form. Hon'ble Supreme Court in the case of "Satwant Kaur Sandhu vs. New India Assurance Company Ltd" IV (2009) CPJ 8 (SC) observed as follows:-
F.A. No. 874 of 2016 8
"If the proposer has knowledge of any fact, he is obliged to disclose it particularly while answering questions in the proposal form. Needless to emphasize that any inaccurate answer will entitle the insurer to repudiate his liability, because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a Contract of Insurance".
The District Forum ignored this material aspect of the matter, as pressed before us in this appeal. Consequently, we hold that by not disclosing the pre-existing ailment of hypertension, the insured has violated the terms and condition No.4.1(c) of the insurance policy Ex.OP8 in this case. On account of violation of above condition of the policy by insured, the claim is held not admissible by us. The order of District Forum to the contrary is, thus, unsustainable in the eye of law in our view.
8. In view of our above discussion, the appeal of OP now appellant is hereby accepted and the impugned order of District Forum is set aside in this appeal leading to dismissal of complaint of the complainant.
9. The Appellant/OP had deposited an amount of Rs.25,000/- with this Commission at the time of filing this appeal. This amount with interest, which accrued thereupon, if any, be remitted by the registry to OP No.1 now appellant in this appeal, by way of a crossed cheque/demand draft after the expiry of 45 F.A. No. 874 of 2016 9 days from the date of receipt of copy of the order, subject to stay order, if any.
10. Argument in this appeal was heard on 12.5.2017 and order was reserved. Certified copies of the order be communicated to the parties as per rules.
11. The appeal could not be decided within the statutory period due to heavy pendency of court cases.
(J. S. KLAR) PRESIDING JUDICIAL MEMBER (Surinder Pal Kaur) MEMBER May 17, 2017 DB