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UNION TERRITORY STATE CONSUMER DISPUTES REDRESSAL COMMISSION, CHANDIGARH
Sham Sunder, President, Dev Raj , Padma Pandey, Members
Sushil Mittal - Appellant
Versus
Aegon Religare Life Insurance Co. Ltd. & Anr. - Respondents
First Appeal No. 17 of 2015
Decided On : 06-04-2015
Advocate Appeared:
For the Appellant :Mr. Rakesh Aggarwal, Advocate.
For the Respondent:Mr. J.S. Mann, Advocate.
The duty of the insured to disclose every material fact before the contract was made, and the significant non-disclosure by the appellant justified the rejection of his claim.
Headnote:
Insurance - Health Plan Policy - Consumer Protection Act, 1986 - Section 12 - [Insurance] - [Health Plan Policy] - [Consumer Protection Act, 1986, Section 12]
Fact of the Case:
The appellant purchased a health plan policy and underwent knee replacement surgery, incurring expenses of Rs.3,49,779. His claim for cashless treatment was denied, and his reimbursement claim was rejected by the insurance company. He filed a complaint under Section 12 of the Consumer Protection Act, 1986, seeking payment and compensation.
Finding of the Court:
The court found that the appellant had failed to disclose his pre-existing knee ailment and surgical history in the proposal form, which led to the rejection of his claim. The court upheld the rejection of the claim based on significant non-disclosure by the appellant.
Issues: Non-disclosure of pre-existing medical history, rejection of claim for cashless treatment, and reimbursement claim under the health plan policy.
Ratio Decidendi: The court held that the appellant's non-disclosure of his pre-existing knee ailment and surgical history in the proposal form constituted significant non-disclosure, justifying the rejection of his claim.
Final Decision: The appeal was dismissed, and the order of the District Forum was upheld.
JUDGEMNT :
Dev Raj, Member
This appeal is directed against the order dated 12.12.2014 rendered by th Consumer Disputes Redressal Forum-I, UT, Chandigarh (hereinafter to be called as the District Forum only) vide which, it dismissed the complaint of the complainant (now appellant).
2. The facts, in brief, are that in the last week of October 2010, the representative Opposite Party No.1 visited the office of the complainant and offered him a health plan Policy alongwith many incentives. It was stated that the complainant was informed that in case of any type of medical emergency, he would be entitled to the free treatment including surgery etc. to the tune of Rs.4 Lacs. It was further stated that taking the words to be true, the complainant issued a premium cheque dated 29.10.2010 of Rs.14,037/- and he was got medically and clinically examined. It was further stated that after satisfying itself of the health of the complainant, Opposite Party No.1 issued the policy AEGON Religare Health Plan-Regular Premium, which commenced w.e.f. 23.11.2010 almost after one month of the issuance of the cheque dated 29.10.2010 against the premium. It was further stated that the complainant got the Policy renewed for the years 2011 and 2012 by issuing the cheques of the premium amount.
3. It was further stated that around March 2013, the complainant felt pain in his when the pain increased and became unbearable, he visited the Fortis Hospital, Mohali on 9.7.2013. It was further stated that after x-ray and examination, Dr. Harsimran Singh advised the complainant for total knee replacement surgery involving expenditure of about Rs.4 Lacs. It was further stated that since the complainant was having the health Policy, he contacted the Corporate Office of Fortis Hospital for forwarding the case for cashless treatment. It was further stated that the requisite documents including card, prescription slip, x-ray report and the driving licence were sent by the hospital to Opposite Party No.2 for getting the authorisation for cashless treatment. I was further stated that the complainant was informed that the process would take 2-3 days and he should get himself admitted on July 11 so that the surgery could be performed on July 12. It was further stated that the complainant was informed by way of SMS that the case was under process but subsequently he was told through SMS that there were some additional requirements and queries, in compliance whereof, he sent the scanned copies of his driving licence and PAN card to Opposite Party No.2 vide emails (Annexures C-4 and C-5). It was further stated that, subsequently, one person namely Sh. Gulab Singh, claiming himself to be from Health India, Surveyors on behalf the Opposite Parties, visited the complainant and made certain enquiries and also took the copies of documents.
4. It was further stated that as the pain of the complainant had increased very mu could not sleep, he lodged online complaint on the website of Opposite Party No.1 on July 19, and also sent an email (Annexure C-7) on the said date. It was further stated that to the utter surprise of the complainant he received a reply (Annexure C-8) within 40 minutes informing that his case had been denied vide letter (Annexure C-9). It was further stated that the claim of the complainant was denied on totally irrelevant ground that he was suffering from hypertension and Coronary Artery Disease. It was further stated that the complainant vide emails (Annexures C-10 and C-11) requested the Opposite Parties for providing him with the documents on the basis of which they came to such conclusion, but to no avail. It was further stated that, as the condition of the complainant deteriorated, he got himself admitted in the Fortis Hospital on 29.7.2013, underwent surgery on 30.7.2013 and was discharged on 5.8.2013. It was further stated that, subsequently, the complainant lodged claim for reimbursement of Rs.3,49,779/- with Opposite Party No.2 vide letter dated 22.8.2013 (
