State Consumer Disputes Redressal Commission
Care Health Ins.Co.Ltd vs Krishna Shah on 29 April, 2023
Details DD MM YY
Date of Judgment 29 04 2023
Date of filing 08 08 2022
Duration 21 08
IN THE CONSUMER DISPUTES REDRESSAL COMMISSION
GUJARAT STATE, AHMEDABAD.
First Appeal No.740/2022
Court No. 1
The Oriental Insurance Co. Ltd.
Add. Second Floor,
Amrut Jayanti Bhuvan,
B/H. Gujarat Vidhyapith,
Off. Ashram Road,
Ahmedabad-380014. ...Appellant
Vs
Jigar Hasmukh Soni
Res: 39, Siddheshvar Himes,
Opposite Gandhinagar International
Public School, Randheja,
Gandhinagar-382620. ...Respondent
CORAM : Hon‟ble Mr. Justice V. P. Patel, President
Hon‟ble Ms. A.C.Raval, Member
APPERANCE : S. S. Parekh , Ld. Advocate for the appellant Order by Ms. A. C. Raval, Member
1. Appellant being aggrieved by and dissatisfied with the order dated 24/05/2022 passed by the Ld. District Commission, Vadodara in complaint no. 649/2021 has preferred this appeal, under sec.41 of the Consumer Protection Act 2019.
2. The present appellant is the original opponent and the respondent is the original complainant in the judgment and order passed by the Ld. District Commission, Vadodara in complaint No.649/2021. For the sake of convenience, parties are hereinafter referred to by their original nomenclature/status.
Order Under Challenge
3. The Ld. District Commission by order dated 24/05/2022 directed the appellant to pay amount of Rs.2,06,046/- with interest at 9% Akshay A/740/2022 Page 1 of 7 per annum from date of filing the claim and further to pay the amount of Rs.10,000/- towards mental agony and Rs.5,000/- towards the cost.
Facts of the case
4. It is the case of the complainant that the complainant had taken a mediclaim policy named as "Care Floater Policy" bearing policy no.10707220 for the policy period starting from 03/07/2016 to 02/07/2017, providing policy coverage to the complainant Mrs. Krishna Shah and her husband Mr. Akshar Shah, for the sum insured of Rs.16,00,000/-. The policy was renewed from time to time, lastly from 15/07/2018 to 14/07/2019. During the inception of policy, the insured was admitted in Bhailal Amin General Hospital, Vadodara on 30/10/2018 and discharged on 01/11/2018 and diagnosed with the left PUJ Stone with right renal stone. Again admitted in the same Hospital on 1/12/2018 to 03/12/2018 for removal of the stent inserted in urinary track, the total expense incurred of Rs.2,06,046/-. The complainant preferred the claim before the opponent insurance company which was rejected by letter dated 16/01/2019 on the ground of non- disclosure of pre-existing disease ie. epilepsy at the time of policy inception. The complainant clarified the situation and made it clear to the insurance company that the insured was suffering Epilepsy at the age of 15 years. Therefore it was cured and at the time of treatment taken in the Bhailal Amin Hospital, the insured was of the age 33 years. The insured was possessing Indian pilot license and Philippians pilot license and as a pilot he head passed through various medical fitness tests. Hence the episodes of Epilepsy at the age of 15 years cannot be considered as a per-existing disease. The insurance company did not accepted the clarification and claim of the complainant stood rejected. Hence the complainant preferred CC no.649/2021 before the CDRC, Vadodara which was partly allowed by the Ld. District Commission.
Akshay A/740/2022 Page 2 of 75. Being aggrieved and dissatisfied with the order passed by the Ld. District Commission, Vadodara in CC no.694/2022 dated 24/05/2022, the appellant insurance company has preferred the present appeal.
Arguments of the appellant
6. It is argued by the Adv. appeared for the appellant insurance company that the Ld. District Commission has misread and misconstrued the evidence on record Relied upon the averments made in complaint and affidavit filed by the complainant without any supporting evidence. That the contract of insurance is a contract of good faith, wherein both the parties enters into contract in good faith and relying on the statement by counter party and if any point of time, it is found that other party had suppressed or not disclosed true facts before the other party, such contract is voidable. Even otherwise the order passed by the Ld. District Commission is against the principle of natural justice, against the fact and law and required to be quashed and set aside and this appeal may be admitted and allowed.
Merits of the case
7. For deciding the present case, certain facts are undisputed that the insured had taken the mediclaim policy from the appellant insurance company in 2016. The policy was renewed from time to time. The sum insured was Rs.3,00,000/-. Lastly, the policy was renewed for the period 15/07/2018 to 14/07/2019. During the policy period the insured suffered with the kidney stone and was admitted in Bhailal Amin General Hospital, Vadodara for the period 30/10/2018 to 01/11/2018 and 01/12/2018 to 03/12/2018 and incurred total expense of Rs.2,06,046/-. The insured lodged the claim before the appellant insurance company which was rejected by letter dated 16/11/2019 on the ground of non-disclosure of Epilepsy at the time of policy inception.
Akshay A/740/2022 Page 3 of 78. The appellant insurance company has repudiated the claim of the complainant vide letter dated 16/01/2019. The claim denial letter is produced at page no.233 and 273 which reads as under:
"Dear Sir/Madam, We have reviewed the claim filed by you pertaining to Health Insurance Policy (10707220) and hereby inform you that the claim is not payable as per policy terms and conditions listed below:
Non disclosure of Epilepsy at the time of policy inception Non disclosure of material facts/pre-existing ailments at time of proposal."
The claim of the insured was rejected on the ground of non- disclosure of Epilepsy at the time of policy inception, non- disclosure of material facts/pre-existing illness at the time of proposal.
9. To justify the ground of repudiation the appellant insurance company has produced the consultation papers dated 24/08/2003 of Dr. Kanta H. Patel page no.477. The type copy of consultation papers is produced at page no.478 which reads as under:
"Fever low grade - 15 days Headache severe-frontal Common Cold Rx Taken with and relief H/o. Epilepsy- % 5 1/2 year back 2 Capsules + Responded to Rx- Rx taken for 2 1/2 years History- slab allergy+ O/E BP 116/76 Throat congestion + R/s Clear L/E bilateral frontal and Max Sinus tenderness + URTI with Paranasal sinusitis"
10. Looking to the perused documents which transpires that on 24/08/2003 hospital of Epilepsy is mentioned 5 and ½ year back. The first policy taken on 03/07/2016 that means the treatment paper is about 13 years old and the episode of Epilepsy was pre- existing before 5 and ½ years back means before 18.5 years. The Akshay A/740/2022 Page 4 of 7 treatment was taken for sinus on 24/08/2003 and not for epilepsy. Epilepsy was shown as history only. The appellant insurance company has not produced any other documents to show that the insured had taken treatment for Epilepsy between 2003 to 2016.
11. The appellant insurance company has produced the copy of policy along with terms and conditions at page no.93. the part of definition referring „pre-existing disease‟ is not produced. As per the guidelines issued by the IRDAI in conection with the pre- existing disease, "the pre-existing disease means any condition for which diagnosed by physician within 48 months to the effective date of the policy issued by the insurer or its reinstatement or for which medical advice or treatment was recommended by, or received for, from a physician within the 48 months prior to the effective date of the policy issued by the insurer or its reinstatement."
12. If any disease or illness suffered by the insured within 48 months from the inception of the policy then and then only it can be consider as a pre-existing disease. Any illness or disease suffered prior to 48 months from the inception of the policy cannot be considered as a pre-existing disease. Hence the repudiation by the insurance company is illegal and bad in law. The exclusion clause is produced at page no.98, the clause 4 is for the exclusion in the policy terms and conditions 4.1 is regarding waiting period. 4.1 (iii) reads as under:
"Pre-existing Disease: claim will not be admissible for any Medical Expenses incurred for Hospitalization in respect of diagnosis/treatment of any pre-existing disease until 48 months of continuous coverage has elapsed, since the inception of the first policy with the company."
13. From the reading of above clauses, it becomes clear that even the pre-existing disease is not completely excluded from the Akshay A/740/2022 Page 5 of 7 indemnification. Even after the 48 months the risk of pre-existing disease gets coverage under the policy. In such circumstances when the insured has not taken any treatment for so called pre- existing disease i.e. epilepsy within 48 months from the date of policy inception, the claim of the complainant cannot be denied. Even otherwise, there is no nexus or relevance between the epilepsy and the treatment taken by the insured at Bhailal Amin Hospital. The decision of the appellant insurance company is not correct and required to be quashed and set aside.
14. We have considered the ground stated in memo of appeal, reasons stated in the impugned judgment and order passed by the Ld. District Commission, documentary evidence produced on record, argument by the appellant and facts and circumstances of the case. We are of the opinion that order passed by the Ld. District Commission is just, proper and correct in the eye of law and does not required any interference. Hence, appeal is required to be dismissed. In the interest of justice following order is passed.
ORDER
1. The Appeal No.740/2022 is dismissed at admission stage.
2. The order passed by the Ld. District Commission, Vadodara dated 24/05/2022 in Complaint 649/2021 is hereby confirmed.
3. No order as to cost.
4. Registry is directed to verify the amount deposited by the applicant in appeal no. 740/2022 and if found deposited, refund the same with interest, if any, accrued on the deposit to the appellant by RTGS after following due procedure and verification. For this purpose the appellant has to file an application with details to the account branch of this commission.
Akshay A/740/2022 Page 6 of 75. Registry is directed to send certified copy of this judgment to the parties free of cost. Registry is further directed to send copy of this judgment to the District Commission Vadodara through E-mail in PDF format for taking necessary action.
Pronounced in open court today on 29/04/2023.
[Ms. A.C. Raval] [Justice Mr. V.P.Patel]
Member President
Akshay A/740/2022 Page 7 of 7