State Consumer Disputes Redressal Commission
Care Health Insurance Ltd. vs Baljeet Singh on 30 April, 2024
STATE CONSUMER DISPUTES REDRESSAL COMMISSION
PUNJAB, DAKSHIN MARG, SECTOR 37-A, CHANDIGARH
First Appeal No.651 of 2022
Date of Institution : 03.08.2022
Reserved on : 19.04.2024
Date of Decision : 30.04.2024
Care Health Insurance Ltd. (Earlier known as Religare Health
Insurance Co. Ltd.,) through its Chairman/Managing Director/
Principal Officer, through its Branch Office at District Shopping
Complex, Ranjit Avenue, Amritsr, through its Branch Manager.
........Appellant/ Opposite Party
Versus
Baljeet Singh son of Santokh Singh, resident of H.No.1139, Gali
Hansali Wali Kucha Madho Shah Bhatia, Amritsar.
.....Respondent/ Complainant
Appeal under Section 41 of Consumer
Protection Act, 2019 to challenge the
order dated 15.06.2022 passed by the
District Consumer Disputes Redressal
Commission, Amritsar in C.C. No.701 of
2019.
Quorum:-
Hon'ble Mrs. Justice Daya Chaudhary, President
Ms. Simarjot Kaur, Member
Present:-
For the Appellant : Ms. Niharika Goel, Advocate for Sh. P.M. Goyal, Advocate For the Respondent : Sh. Sukhandeep Singh, Advocate
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 2 First Appeal No.651 of 2022 JUSTICE DAYA CHAUDHARY, PRESIDENT:-
The Appellant/OP i.e. Care Health Insurance Ltd.
(earlier known as Religare Health Insurance Co. Ltd.,), through its Branch Manager has approached this Commission by way of filing the present Appeal under Section 41 of the Consumer Protection Act, 2019 (in short the 'Act') being aggrieved by the impugned order dated 15.06.2022 passed by the District Consumer Disputes Redressal Commission, Amritsar (herein after referred as the "District Commission") in C.C. No.701 of 2019.
2. Briefly, the facts of the case as made out by the Complainant in the Complaint filed before the District Commission are that the Complainant had got Health Benefit Mediclaim Insurance Policy for himself and his wife which was for the period w.e.f. 20.03.2018 to 19.03.2019. The Complainant fell ill during the first year of the policy and remained admitted in the hospital at Randhawa Hospital, Amritsar on 20.07.2018 and again for the period w.e.f. 27.07.2018 to 29.07.2018. Thereafter, he was shifted to IVY Hospital, Amritsar and remained admitted there w.e.f. 29.07.2018 to 08.08.2018. The total expenses for hospitalization was Rs.2,82,300/-. The claim was submitted by the insured with the Insurance Company but it was repudiated vide letter dated 28.12.2018 on the ground that it was a case of pre-existing disease as insured was diabetic.
3. Respondent/Complainant being not satisfied with the repudiation of the claim filed Complaint before the District 3 First Appeal No.651 of 2022 Commission to which reply was filed by OP and thereafter on hearing the arguments raised from both the sides and also by considering the evidence adduced and arguments raised by both the parties, the Complaint filed by the Complainant was allowed vide order dated 15.06.2022. The relevant portion of said order as mentioned in para No.9 is re-produced as under:-
"9. In view of the above discussion, we allow the Complaint with costs and the opposite party is directed to pay the amount of Rs.2,75,048/- 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."
4. The Appellant/OP Insurance Company has challenged the order passed by the District Commission before this Commission by way of filing the Appeal.
5. Ms. Niharika Goel Advocate appearing on behalf of Mr. P.M. Goyal Advocate for the Appellant has submitted that the District Commission has not taken into consideration the documents filed/produced before the District Commission to prove that the Respondent/Complainant was a known case of Diabetes Mellitus for 4 First Appeal No.651 of 2022 the last 4 years. This objection raised in the reply has not been taken into consideration. Learned Counsel has further submitted that the claim of the Respondent/Complainant was rejected by considering the terms and conditions of the policy and it was within its right to reject. There was concealment on the part of the Respondent/Complainant but still claim was decided in favour of the Complainant. Further it has been submitted that the District Commission has ignored the medico legal opinion given by Dr. C.H. Asrani as he had opined that coronary artery disease was attributable because of complications of diabetes mellitus as per the opinion given by the doctor. Further it has been submitted that the District Commission has also not considered a number of judgments cited by the Appellant/OP Company. The order passed by the District Commission was not passed by considering the objections raised by the Appellant/OP. Further, it has been submitted that the policy holder had not disclosed the factum of ailment/chronic condition as the Complainant was suffering from said ailment and it should have been brought to the notice of the Appellant-Insurance Company. Further, it has been submitted that the evidence adduced on record by the Appellant/OP Company was not taken into consideration as it was clear from the Discharge Summary of Randhawa Hospital, Amritsar that the Complainant was specified to have Type II Diabetes Mellitus for the past four years as it was clear from the progress note dated 20.07.2018 prepared by Doctor of Randhawa Hospital. Further, it has been submitted that the claim was rejected by the Appellant 5 First Appeal No.651 of 2022 Company in view of Clause 7.1 of the policy's terms and conditions for non-disclosure of material information. At the end, learned proxy Counsel for the Appellant has relied upon judgments of cases i.e. "Export Credit Guarantee Corp. of India Limited Vs. M/s Garg Sons International" (SC), "Oriental Insurance Co. Ltd. Versus Sony Cheriyan" AIR 1999 SC 3252, "SGS India Vs. Dolphin International Limited " LL 2021 SC 544, "Reliance Life Insurance Company & others Vs. Rekha Ben Naresh Bai Rahore" CA No.4261/2019, "Satwant Kaur Sandhu Vs. New India Assurance Company Limited " (2009) 8 SCC 316, "Life Insurance Corporation of India Vs. Smt. Neelam Sharma" and others judgments in support of her contention.
6. Mr. Sukhandeep Singh Advocate, learned representing Counsel of the Respondent/OP has opposed the submissions made by learned Counsel for the Appellant stating that the order has been passed by the District Commission by considering the stand taken in the Complaint, reply thereto and also by considering the terms and conditions of the policy. Detailed findings have been recorded by taking into consideration the version of both the parties and as such no interference is required by this Commission. Learned Counsel has further submitted that the District Commission has rightly observed that the Appellant had failed to produce any evidence relating to past medical record of the Complainant. Neither any evidence was produced on record about any ailment in the past or while remained admitted in the hospital nor any affidavit of any Doctor has been 6 First Appeal No.651 of 2022 placed on record. Learned Counsel has further submitted that the Appellant had failed to produce any cogent evidence/proof that the Complainant had taken any treatment for his alleged pre-existing disease from any hospital and as such the order passed by the District Commission is based on proper appreciation of evidence adduced by both the sides. Further it has been submitted that the District Commission while allowing the Complaint filed by the Respondent/Complainant had also relied upon the judgment of Hon'ble National Commission of case "New India Assurance Co. Limited & another Vs. Murari Lal Bhusri" 2011 (III) CPJ 198 (NC) and no interference is required. Learned Counsel has also relied upon judgments i.e. "PNB Metlife Insurance Company Limited Vs. Vinita Devi" 2019(1) C.P.J. 441 (NC), "Sushil Kumar Jain Vs. United India Insurance Co. Ltd." 2012(1) C.P.J. 204, "Life Insurance Corporation of India Vs. Sushma Sharma" 2008(2) CPJ 213, "Care Health Insurance Limited Vs. Pushpa Kumari & another" FA No.845 of 2022, decided on 20.10.2023, decided by this Commission in support of his contentions.
7. We have heard the arguments raised by learned Counsel for the Appellant/OP as well as learned Counsel for the Respondent/Complainant. We have also carefully perused the order passed by the District Commission and also relevant documents and evidence as available on the file.
7First Appeal No.651 of 2022
8. Facts relating to filing of the Complaint filed by the Complainant before the District Commission, reply thereof filed by the Appellant/OP and thereafter passing of impugned order dated 15.06.2022 by the District Commission and thereafter being aggrieved by the said order, filing of Appeal by the OP before this Commission are not in dispute.
9. Admittedly, the Complainant was having Health Benefit Mediclaim Insurance Policy which was w.e.f. 20.03.2018 to 19.03.2019. The Complainant fell ill during the first year of the policy and remained hospitalized at Randhawa Hospital Amritsar on two occasions and thereafter shifted to IVY Hospital Amritsar and had also remained admitted w.e.f. 29.07.2018 to 08.08.2018 and total expenses of hospitalization was Rs.2,82,300/-. The claim was repudiated vide letter dated 28.12.2018 on the ground of pre-existing disease being a case of Diabetes Mellitus.
10. It is pertinent to mention here that under the similar facts and circumstances, this Commission had earlier decided F.A. No.845 of 2022 titled as Care Health Insurance Limited (Supra), decided on 20.10.2023 and by relying of upon judgments of Hon'ble Supreme Court of India, Hon'ble National Commission and Hon'ble High Court of Delhi had dismissed the Appeal filed by the Insurance Company. The relevant portion of the said order as mentioned in para Nos.13 to 16 are reproduced as under:-
8First Appeal No.651 of 2022
"13. Ms. Niharika Goel Advocate, learned proxy counsel for the appellant has submitted that there was expert opinion/Certificate issued by Dr. C.H. Asrani to contend that the complainant's coronary artery disease was attributable to her pre-existing disease of Diabetes Mellitus and the independent risk factor for the heart disease was there. It is pertinent to mention here that Dr. C.H. Asrani is only M.B.B.S., DNB (Family Medicine), having Advance Diploma in Forensic Medicine & Toxicology. He was not a Cardiologist and, as such, he cannot be said to be an expert to give such opinion and the opinion given by him was not acceptable. It is also a matter of common knowledge that some ailments remain for decades, lurking in the body of an individual, until they suddenly spring- up in life. Many persons are have diseases but they are not aware about such problems. Some diseases remain dormant in the body for years together. Some illnesses have incubation period of anywhere from years to even decades. Some diseases wait in the body for decades before striking. Heart disease can also remain dormant for number of months/years. At any time or at any age, they can strike without warning, changing life forever. However, it has not been proved that the insured-Pushpa Kumari was taking treatment for heart ailment from any specific doctor or Hospital prior to inception of the Insurance Policy.
14. Section 19 of the General Insurance Business (Nationalization) Act, 1972 is relevant, which is reproduced as under:-
19. Functions of acquiring companies.--(1) Subject to the rules, if any, made by the Central Government in this behalf and to its memorandum and articles of association, it shall be the duty of every acquiring company to carry on general insurance business.9 First Appeal No.651 of 2022
(2) Each acquiring company shall so function under this Act as to secure that general insurance business is developed to the best advantage of the community.
(3) In the discharge of any of its functions, each acquiring company shall act so far as may be on business principles and where any directions have been issued by the 3[Central Government or the Insurance Regulatory and Development Authority established under sub-section (1) of section 3 of the Insurance Regulatory and Development Authority Act, 1999 (41 of 1999)], shall be guided by such directions.
(4) For the removal of doubts it is hereby declared that the Corporation and any acquiring company may, subject to the rules, if any, made by the Central Government in this behalf, enter into such contracts of reinsurance or reinsurance treaties as it may think fit for the protection of its interests It is pertinent to mention here that Section 19 of the General Insurance Business (Nationalization) Act, 1972 reflects that it shall be the duty of every Insurance Company to carry on general insurance business so as to develop it to the best advantage of the community. The denial of medical expenses reimbursement is totally arbitrary on the ground that disease in question was pre-existing disease. It is mere an excuse to escape liability and is not bona fide intention of the Insurance Company. Fairness and non-arbitrariness are considered as two immutable pillars supporting the equity principle, an unshakable threshold of State and public behavior. Any policy in the realm of Insurance Company should be informed, fair and non-arbitrary.
15. However, the appellant has failed to produce any cogent and convincing evidence that the said ailments suffered by the complainant had any direct/close nexus with the disease of Diabetes Mellitus. The Hon'ble National Commission in the 10 First Appeal No.651 of 2022 case titled as Life Insurance Corporation of India Vs. Sunita & Others 2020 SCC OnLine NCDRC 710 has held in Para-9 to 11 as under:
"8. In the present case, the deceased assured was suffering from diabetes mellitus and chronic liver disease when bought to the hospital. But, the death was due to cardiac arrest. In our view the cause of death is nowhere connected to his preexisting disease. Our view dovetails from the decision of Hon'ble Supreme Court in the Civil Appeal No. 8245 of 2015 titled Sulbha Prakash Motegaoneker v. Life Insurance Corporation of India, decided on 05.10.2015, wherein it was observed that suppression of information regarding any pre- existing disease, if it has not resulted in death or has no connection to cause of death, would not disentitle the claimant for the claim.
10. We find the Orders of the District Forum and the State Commission to be well appraised and well-reasoned. The State Commission concurred with the findings of the District Forum. We note in particular the extracts of the respective observations made by the two fora, quoted in paras 4 and 5 above. Within the meaning and scope of section 21(b), we find no grave error in appreciating the evidence by the two for a below, as may necessitate re- appreciation of the evidence in revision. We find the award made by the District Forum (quoted in para 4 above), and as affirmed by the State Commission, to be just and appropriate. We find no jurisdictional error, or a legal principle ignored, or miscarriage of justice, as may necessitate interference in the exercise of the revisional jurisdiction of this Commission.
11. The revision petition, being misconceived and devoid of merit, is dismissed."11 First Appeal No.651 of 2022
16. In another case titled as Neelam Chopra Vs. Life Insurance Corporation of India & Ors. R.P. No.4461 of 2012 decided on 08.10.2018, the Hon'ble National Commission has held that the claim cannot be denied on the ground of life style diseases such as diabetes. 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 12 First Appeal No.651 of 2022 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."
11. In above said judgment, this Commission has held that the coronary artery disease, sepsis, UTI can also arise to non- diabetic patient. In the present case, there is no affidavit on record of treating doctor to prove the nexus of above said ailment to diabetes. The Hon'ble National Commission in case PNB Metlife Insurance Company (Supra) had held that "burden to prove that the life assured was suffering from any pre-existing disease lies with the Insurance Company". In the present case, the Appellant has failed to produce on record any medical history of said ailments suffered by the life assured at the time of taking the policy before the District Commission as well as before this Commission. The District Commission has rightly appreciated the matter and the order passed by the District Commission is based on proper appreciation of facts and evidence available on the record.
12. In view of above detailed discussion, we do not find any merit in the contentions raised by learned Counsel for the Appellant/OP, the Appeal filed the Appellant/OPs is hereby dismissed being devoid of merits.
13. The Appellant had deposited an amount of Rs.1,80,121/- at the time of filing of the Appeal with this Commission. Said amount, 13 First Appeal No.651 of 2022 alongwith 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 an appropriate order in this regard in accordance with law.
14. Since the main case is decided, the pending applications, if any, are also disposed of.
15. The appeal could not be decided within the stipulated period due to heavy pendency of Court cases and due to pandemic of Covid-19.
(JUSTICE DAYA CHAUDHARY) PRESIDENT (SIMARJOT KAUR) MEMBER April 30, 2024 (MM)