DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, LUDHIANA. Consumer Complaint No. 552 of 17.09.2015 Date of Decision : 01.08.2017 Pardeep Kumar s/o Shri Gurbachan Lal, House No.9412, St. No.23, Near Shiv Mandir, Kot Mangal Singh, Ludhiana, Punjab-141003. .. Complainant Versus 1.Religare Health Insurance Co.Ltd, Regd. House D-3, District Centre, Saket, New Delhi-110017, through its Managing Director/Chairman. 2.Bajaj Capital Insurance Broking Limited, Feroze Gandhi Market, Ludhiana through its Branch Manager. Opposite parties (Complaint U/s 12 of the Consumer Protection Act, 1986) QUORUM: SH.G.K.DHIR, PRESIDENT SH.PARAM JIT SINGH BEWLI, MEMBER COUNSEL FOR THE PARTIES: For complainant : Sh.G.S.Sikka, Advocate For OP1 : Sh.G.S.Kalyan, Advocate For OP2 : Sh.S.S.Rai, Advocate. PER G.K.DHIR, PRESIDENT
1. On allurement of Ops that the policy in question is best in the market and lodged claim will be settled at once, complainant purchased Floater Health Insurance policy and subsequently the same was got renewed. Policy No.10016476 with validity up to 18.03.2016 was purchased for complainant and whole of his family. Complainant is a hale and hearty person and enjoying good family life. Complainant is in business for the last 15-20 years and earning good income as well as reputation. Suddenly on 20.6.2015, the complainant felt uneasiness and was taken to nearby Grewal Hospital. Doctor incharge of that hospital informed the complainant that their hospital is not approved for cashless health insurance policy of Ops. So, complainant decided to shift to Satguru Partap Singh Apollo Hospital, Ludhiana. Since after 20.6.2015, complainant was not feeling well and as such, he decided to get his medical condition re-checked from Apollo Hospital. Dr.Pawan K.Suri medically diagnosed complainant and advised for getting a stent inserted because of problem of blockage in the veins. Relatives of complainant approached that hospital for availing cashless treatment. Notice to OP1 regarding the cashless treatment was given, but the same vide letter dated 23.6.2015 disallowed the claim of complainant and as such, relatives of complainant compelled to make payment of Rs.1,82,797/- for the treatment got by the complainant from hospital during period from 20.6.2015 to 23.6.2015. Complainant after getting discharge from the hospital, could not approach Ops immediately, but he gave telephonic call to Ops and thereafter, by way of personal meeting through relatives. No satisfactory reply was got by the complainant and as such, he sent emails dated 9.7.2015, 20.7.2015 and 29.7.2015. Claim of the complainant was refused//repudiated vide letter dated 10.8.2015 and thereafter, complainant sent letters dated 1.9.2015 and 8.9.2015 and even the emails. Legal notice through counsel even served, but no reply received from Ops. Repudiation of claim has caused pressure on mind of complainant, due to which, he underwent depression and his whole family physically and mentally suffered. Claim No.90115802 was submitted with OP1 on 23.6.2015. By pleading deficiency in service on the part of Ops and by claiming that repudiation of claim is improper, prayer made for directing Ops to reimburse hospitalization expenses of Rs.1,82,797/- and pay Rs.50,000/- as compensation for mental pain and agony with interest @18% per annum w.e.f.23.6.2015 till payment. Litigation expenses of Rs.11,000/- more claimed.
2. In written statement filed by OP1, it is pleaded interalia as if complaint is not maintainable because no cause of action available to the complainant; claim of the complainant was duly repudiated after entertaining and processing as per clause 4.3(A)(XXIV) of the terms and conditions of the policy; complainant has not approached this Forum with clean hands because he has suppressed the material facts and that there is no deficiency in service on the part of OP1. Admittedly, the complainant availed the health insurance policy after understanding the terms and conditions of the policy on being explained by OP1 and on submitting the proposal form dated 8.3.2013. The information provided through proposal form was declared as true and correct by the complainant and after believing the same, the policy was issued by supply of complete policy kit along with policy No.10016476 for period from 19.3.2013 to 18.3.2014. That policy was further renewed from 19.3.2014 to 18.3.2015 and subsequently from 19.3.2015 to 18.3.2016. During policy period, complainant was admitted in Satguru Partap Singh Apollo Hospital, Ludhiana for treatment of Coronary Artery Disease, acute inferior wall myocardial infarction, single vessel disease. Percutaneous coronary intervention to right coronary artery was done along with angiography. Normal LV systolic function was 60%. Pre-authorization request was received, but from the indoor case papers, it was noticed that the complainant had past history of smoking for the last 25 years. A clear cut link between tobacco intake and cardiovascular disease was found and that is why claim of the complainant was repudiated. On request of complainant, review was done, but the claim was not payable as per clause 4.3(A)(xxiv) of the terms and conditions of the policy because the illness, for which, treatment got was related to abuse of tobacco. Tobacco smoking was found a major contributing factor for coronary artery disease. Ops sent letters dated 20.7.2015 and 29.7.2015 for supply of documents, but those were not supplied and as such, Ops closed the claim of the complainant vide letter dated 10.8.2015. Ops also deputed J.D.Health Care Service, Corporate Office, Sector 11, Garden Colony, Kharar, District Mohali on 10.7.2015 to collect the indoor case record. The said investigator submitted report dated 1.8.2015 to the effect that after visit to the hospital, he found case of the complainant to be a case of chronic smoker for the last 25 years as per ICP notes. Even the hospital sheet and nutritional assessment form issued by Satguru Partap Singh Apollo Hospital, Ludhiana clearly mentioned that the complainant was a chronic smoker for the last 25 years. After receipt of documents and application of mind and review, claim was duly repudiated. Clause 4.3(A)(xxiv) clearly provides that any act of self-destruction and self-inflicted injury attributable to the misuse or abuse of tobacco is a permanent exclusion and not payable. Complainant despite being well educated person failed to disclose the material fact of his life style of smoking. Cashless facility even was rightly declined as per terms and conditions of the policy. Each and every other averment of the complaint denied by claiming that complainant is not entitled to any claim amount.
3. OP2 filed separate written statement by claiming that sole aim of the complainant is to recover the insurance claim amount, despite the fact that amount is not claimable from OP2 and complaint against it not maintainable because of the fact that OP2 just acted as broking agent and has independent entity. Contract of insurance was arrived at between the complainant and OP1 on submission of proposal form and execution of documents. Op2 is a stranger to that contract. Complainant himself voluntarily and willingly deposited the annual insurance premium directly in the account of OP1. No amount or fee or consideration was charged by OP2 from the complainant and as such, complainant is not a consumer of OP2 as defined in Section 2(d) of the Consumer Protection Act (hereinafter in short referred to as Act). It is the sole prerogative of OP1 to release or not to release the claim amount as insurer to the complainant and OP2 is nothing to do in that respect. Complaint alleged to be bad due to mis-joinder of parties because OP2 has been unnecessarily impleaded as party. Besides, complaint alleged to be false, frivolous and vexatious. Complainant for availing mediclaim insurance policy himself visited the Ludhiana Office of OP2 on 9.3.2013 and he himself voluntarily availed the policy after going through and understanding the terms of policy. On request and instruction of the complainant, OP2 without delay duly transmitted/forwarded the submitted documents to OP1, who sent the policy certificate, premium acknowledgment receipt etc to the complainant. Complainant approached OP2 in August 2015 for getting assistance in obtaining status report of insurance claim from OP1. On the basis of that request, OP2 duly coordinated through emails with OP1 and obtained reply of insurance company on 11.8.2015. Through that email, it was disclosed that there is waiting period of 2 years and that MRI suggested about chronic changes and no traumatic lesion. Present ailment was disclosed to be due to degenerative spinal disorder causing disc bulge and nerve compression. That information was shared with the complainant by OP2 and thereafter, complainant never visited/contacted/approached OP2 or its office. Role and responsibility of OP2 is duly expressed/mentioned on acknowledgment receipt dated 9.3.2013 itself, which was issued by OP2 in favour of complainant. Clauses 1 to 5, 9 and 10 are quoted in the written statement for claiming that responsibility of OP2 as broker is limited. Each and every other averment of the complaint denied, but by claiming that OP2 has its branch/legal office at Ludhiana, whereas OP1 has its office at New Delhi.
4. Complainant to prove his case tendered in evidence his affidavit Ex.CA along with documents Ex.C1 to Ex.C12 and even tendered affidavit Ex.CW2 of Sh.Parkash Chand(elder brother of complainant), but Ex.CW3 of Smt.Priya Rani(wife of complainant) and Ex.CW4 of Dr.Sushil Jaiswal and thereafter, evidence was closed by the complainant.
5. On the other hand, counsel for OP1 tendered in evidence affidavits Ex.RA and Ex.RB of Sh.Ramnique Sachar, Manager(Legal) of OP1 and of Dr.S.B.Jain, M.B.B.S., Head Clinical Audit along with documents Ex.R1 to Ex.R17 and thereafter, closed the evidence.
6. Counsel for OP2 tendered in evidence affidavit Ex.RA2 of Mr.Vivek Kumar Singh, Authorized signatory of OP2 along with documents Ex.RW2/A to Ex.RW2/F and then closed the evidence.
7. Written arguments in this case submitted not only by the complainant, but by both the Ops also. Oral arguments even heard and records gone through carefully.
8. Ex.RW2-A is the authority letter in favour of Mr.Vivek Kumar Singh issued by OP2, whereas Ex.R2/B is the authority letter in favour of Mr.Vishwas Sethi. It is vehemently contended by counsel for OP2 that OP2 while acting as a broker of OP1 just collected the premium amount and documents from the complainant and thereafter, forwarded the same to OP1 and contract of insurance arrived at between the complainant and OP1 only and as such, OP2 is not liable in any respect because the matter of payment of insurance claim is between the complainant and OP1. Besides, it is contended that OP2, on being approached by the complainant, for ascertaining the status of insurance policy, duly entered into correspondence with OP1 and as such, there is no deficiency in service on the part of OP2 at all. Complaint against broker also contended to be not maintainable. Status report Ex.RW2/C was obtained by Op2 from Op1 regarding the claim processing detail and reason of rejection and as such, same shows that OP2 even provided services to the complainant for assisting him for collecting the information qua status of his policy from OP1.
9. Document Ex.RW2/D shows that OP2 concerned has got a certificate of incorporation from Ministry of Corporate Affairs, Government of India in its own name for working as broker, facilitator and regulator. Coy of certificate of renewal license of OP2 is produced on record as Ex.RW2/E. So, this documentary evidence establishes that OP2 is a company duly incorporated under the Companies Act and carrying on business as a broker. Receipt Ex.RW2/F of premium acceptance from the complainant by OP2 was duly issued showing as if premium of Rs.9360.98P was collected from the complainant.
10. Perusal of clause 1 endorsed on this receipt Ex.RW2/F itself reveals that premium was collected from complainant by OP2 for onward transmission to the concerned insurer. Further, perusal of clause 4 of Ex.RW2/F establishes that OP2 undertook to have no responsibility for the acts of the insurer, which the said insurer may undertake in its discretion in connection with the proposal form submitted by the complainant and documents forwarded by complainant through OP2. As per clause 5 of Ex.RW2/F, liability of OP2 was limited to forwarding the proposal form and the premium to the concerned insurer. Acceptance of the proposal form and the payment of the benefits thereunder or any modification, exclusion, variation of such payments or benefits, were entirely in the discretion of the insurer as per clause 5 of Ex.RW2/F. Further, as per clause-7 of Ex.RW2/F, the receipt issued by OP2 is neither a cover note and nor any acknowledgement of commencement of the insurance policy because the cover note etc., to be issued by the insurer (OP1), on processing and after acceptance of proposal. As per clause 9 of Ex.RW2/F, no inducement or incentive of any manner has been offered or made by OP2 or received or accepted by it from the proposer in connection with the proposal being submitted for onward transmission to the insurer. Further as per clause 10 of Ex.RW2/F, proposal submitted by the proposer entirely on its own accord after being satisfied about the responsibility and soundness of the concerned insurer. So, from the entire reading of Ex.RW2/F, the only inference drawable is that OP2 acted as a broker/agent of OP1 for acceptance of premium, forwarding the proposal form and documents by clearly divulging complainant in detail that liability of paying benefits will be of the insurer. Besides, no consideration was accepted from the complainant by OP2 while acting as agent of OP1 for accepting the premium and forwarding the documents. In view of these circumstances, certainly submissions advanced by counsel for OP2 has force that there was no privity of contract between the complainant and OP2 because the contract of insurance was arrived at between the complainant and OP1 after acceptance of proposal submitted by the complainant to OP1 through OP2. As claim in this case put forth for the reimbursement of medical claim insurance benefits and as such, certainly the same is payable by the insurer as per the terms and conditions of the insurance policy. Op2 has no role in processing, entertaining and paying the insurance claim amount and as such, certainly complaint against OP2 is not maintainable, particularly when as per law laid down in cases titled as Director General of Police, Chandigarh and another vs. Jeevan Lata-II(2006)CPJ-119(N.C); Manager, Golden Trust Financial Services vs. Abdul Mannan Khan- bearing Appeal No.FA/08/192 of 2008, decided by the Honble State Consumer Disputes Redressal Commission, West Bengal; The New India Assurance Company Limited vs. Soma Kandu and another,- bearing No.FA/2008/341 decided on 12.1.2009 by the Honble State Consumer Disputes Redressal Commission, West Bengal; S.K.Mobarshare Ali vs. The Senior Divisional Manager & another- bearing No.FA/08/240, decided on 21.11.2008 by Honble State Consumer Disputes Redressal Commission, West Bengal; Golden Trust Financial Services and another vs. Smt. Malwa Devi-I(2009)CPJ-264(Jharkhand State Consumer Disputes Redressal Commission, Ranchi); P.M.Systems and Financial Services (P) Limited vs. Narayan Ch.Mitra and others-IV(2007)CPJ-407(West Bengal State Consumer Disputes Redressal Commission, Kolkata) and Golden Trust Financial Services vs. Madhuri if aSingh-III(2006)CPJ-409(Bihar State Consumer Disputes Redressal Commission, Patna), broker/agent of insurance company after accepting premium and the proposal form, forwards the same to insurance company, then liability of paying the insurance claim remains of insurer alone and not of the broker/agent. So, certainly complaint against OP2 is not maintainable because of its being broker and the privity of contract of insurance was between the complainant and OP1 only. Insurer in this case admittedly is OP1 and as such liability, if any for payment of insurance claim, to remain of OP1 and not of OP2.
11. Ex.CW1 is the policy cover note showing that complainant along with his wife and issues were covered by the insurance policy issued by OP1 for the period from 19.3.2015 to 18.3.2016. This cover note Ex.CW1 in fact issued on renewal of policy as revealed by copy of welcome letter annexed there with submitted by the complainant. After going through that welcome letter dated 19.3.2015, it is made out that Ops forwarded the policy certificate and premium acknowledgement certificate documents to the complainant by clearly disclosing that for any clarifications, he may contact through email or on phone, details of which given in that letter itself. The membership card number also was issued to the complainant and he was disclosed through the welcome letter, as if the renewed policy is on the same terms and conditions of care, as was earlier issued policy. So, from this documentary evidence produced on record by the complainant himself, it is made out that he was duly made aware about the terms and conditions of the policy by disclosing that he can avail the assistance/help through email as well as telephonic conversation even. Admittedly, complainant got treatment from Satguru Partap Singh Apollo Hospital, Ludhiana for period from 20.6.2015 to 23.6.2015 and cash final bill of amount of Rs.1,82,797/- is produced on record as Ex.CW2 along with discharge summary as Ex.CW3. Complainant remained under treatment of Dr.Pawan K.Suri, Senior Consultant as disclosed by Ex.CW3. Ex.CW4 disclosed about Single view x-ray chest report and enclosed coronary artery disease, acute inferior wall myocardial infarction. Same also shows that successful PTCA+Stent to RCA was done for diagnosed coronary artery disease, acute inferior wall myocardial infarction. Further, 2D Echo Imaging in Plax, Sax and apical views revealed LV normal in size and there was no LV regional wall motion abnormality. Even RV was found normal in size as per record produced by the complainant of Satguru Partap Singh Apollo Hospital, Ludhiana. Request for pre-authorization of cashless hospitalization of the complainant was rejected vide letter dated 23.6.2015 in view of clause 4.3(A)(xxiv) of the terms and conditions of the policy by holding that complainant is a known case of smoking since for the last 25 years and illness related to abuse of tobacco is not payable. Through this letter, it was found that tobacco is a major contributing factor for coronary artery disease. Request for review was submitted through letter Ex.CW5 by the complainant on ground that complainant is not a chain smoker and that Apollo hospital, Ludhiana in their discharge memo dated 23.6.2015 has not mentioned the reason of heart attack due to the smoking. Rather, in this letter Ex.CW5, it is mentioned as if complainant is not a habitual smoker and he takes wine once or twice in a year in a function, but smokes only in family function once or twice in a year. However, contents of affidavit Ex.CW2 of Sh.Parkash Chand are to the effect that the complainant never smokes or drinks because as per traditions of the family, smoking and drinking is strictly prohibited in the family of the complainant. As per affidavit Ex.CW2, deponent is real brother of the complainant and he has never seen any matchbox/lighter in the pocket of the complainant and nor he has seen cigarette in the pocket of the complainant. As per affidavit Ex.CW2, brother of the complainant never smelled any smell of smoking or wine from the complainants mouth. Affidavit Ex.CW3 of Mrs.Priya Rani, the wife of the complainant is also on the same lines as are the contents of affidavit Ex.CW2 of younger brother of the complainant. So, it is obvious that contents of affidavits Ex.CW2 and Ex.CW3 are not true that the complainant never smokes or drinks. It is so because complainant himself through review letter Ex.CW5 disclosed as if he takes wine once or a twice in a year in a function and smokes only in family functions once or twice in a year. Younger brother and wife of the complainant definitely bound to have correct information, but despite that both of them denied the fact that the complainant drinks or smoke during family functions even. However, an admission suffered by the complainant through registered notice Ex.CW5 sent to Ops as referred above and as such, in view of contradiction stands taken in Ex.CW5 and Ex.CW2 as well as in Ex.CW3, there is no escape from conclusion that the complainant and his family members deliberately suppressing the facts regarding smoking and drinking habits of complainant. Only that person will suppress such facts, who has to disclose lie for getting some undue benefit. This aspect of the matter has to be taken into consideration while appreciating the other material produced on record.
12. EX.CW7 and Ex.CW8 are the emails, through which, request for early remitting of the claim of the complainant was made. Ex.CW6 is the letter sent by the complainant for reviewing of the alleged wrong rejection of the claim. Through Ex.CW6, complainant claimed that in case, his claim not settled, then he will take legal action through counsel. Thereafter, notice EX.CW9 through postal receipts Ex.CW10 to Ex.CW12 was sent to Ops before filing of this complaint and as repudiation of claim contended to be unjustified and as such, prayer made for allowing the complaint. These submissions advanced by counsel for complainant has no force because the complainant has suppressed the material facts qua his being smoker or drinker at the time of submission of the proposal form and direct connection of smoking with ailment, for which, treatment got by the complainant from Satguru Partap Singh Apollo Hospital, Ludhiana, is there.
13. Even affidavit of Dr.Sushil Jaiswal, family doctor of the complainant is tendered for proving that he has no knowledge about smoking habit of the complainant or of non finding of any connection of the coronary artery disease with the smoking, but despite that on appraisal of overall material, it is made out that the complainant actually had been smoking and drinking earlier, but he through submitted affidavits Ex.CW2 to Ex.CW4 projected the claim as if he is not smoker or drinker at all. Besides, the connection of coronary artery disease in question with smoking certainly is there as discussed hereinafter.
14. Ex.RW1 is Welcome letter dated 13.3.2013. Perusal of same reveals that when the policy for the first time was got by the complainant from OP1, then the policy certificate, premium acknowledgement, key policy information, policy terms and conditions and claim process documents were duly sent to the complainant. However, from perusal of subsequent welcome letter annexed with Ex.CW1 referred above, it is made out that the terms and conditions of renewed policy are unchanged. In view of sending of the terms and conditions of the policy to complainant on March 13, 2013, it is obvious that the complainant was made aware about the terms and conditions of the policy not only at the time of first purchase of the policy in 2013, but by subsequently notifying him that earlier sent terms and conditions remained unchanged. So, complainant now cannot claim that he was not made aware about the terms and conditions of the policy. Similar welcome letter of 21.3.2014 Ex.R2 is produced on record by Ops and the same is in identical wordings as is of the welcome letter of 19.3.2015, copy of which is produced on record by the complainant (as annexed with Ex.CW1). Ex.R3 is the welcome letter of 19.3.2015 produced by Ops. All this documentary evidence establishes that actually the policies got renewed by the complainant on some terms and conditions right in 2013/2014/2015 and 2016. Besides, terms and conditions of these policies were duly made known to the complainant by sending those at the time of first purchase and conveying subsequently that terms and conditions already sent are unchanged.
15. Ex.R4 is the proposal form, which was submitted by the complainant at the time of purchase of the policy in March 2013. This proposal form Ex.R4 is of date 8.3.2013. Through this proposal form, complainant disclosed himself to have not suffered from any ailment or disease earlier at all. Through this proposal form Ex.R4, complainant has not disclosed about his smoking or drinking habits because information in that respect has not been sought through this proposal form Ex.R4 at all and as such, it is contended by counsel for complainant that there was no withholding of information by the complainant at the time of submission of the proposal form Ex.R4. Even if withholding of this information qua smoking and drinking habits of the complainant not there, while submitting the proposal form Ex.R4, but even then the terms and conditions of the insurance policy in question, copy of which is produced on record as Ex.R5 is binding on the parties because contract of insurance is a contract of utmost good faith. Terms and conditions of the insurance contract are binding on the parties and nothing can be added or subtracted thereto is the settled proposition of law laid down in cases of Ind Swift Limited vs. New India Assurance Co.ltd and others-IV(2012)CPJ-148(N.C.); Usha Sharma and others vs. New India Assurance Co.Ltd and others-I(2012)CPJ-488(N.C.); United India Insurance co.Ltd. vs. Harchand Rai Chandan Lal-IV(2004)CPJ-15(S.C.) and Deokar Exports So, it has to be seen as toPrivate Limited vs. New India Assurance co.Ltd-I(2009)CPJ-6(S.C.). whether repudiation of claim is as per Ex.R5 or not?
16. After going through clause 4.3(a)(xxiv) of ex.r5, it is made out that any claim in respect of any insured person arising out of or directly or indirectly due to act of self-destruction or self-inflicted injury, attempted suicide or suicide, while sane or insane or illness or injury attributable to consumption, use, misuse or abuse of tobacco, intoxicating drugs and alcohol or hallucinogenic is not payable by the insurance company due to permanent exclusion clause. Repudiation of insurance claim in question took place by invoking this clause.
17. Ex.R6 is the portability form, whereas Ex.R7 is X-claim form consisting of report issued by Dr.S.B.Jain, MBBS, Head-Clinical Audit. Affidavit of Dr.S.B.Jain produced on record as Ex.RB by Op1 and he claims that this report Ex.R7 is correctly submitted by him. This report Ex.R7 duly takes into consideration the observations recorded in the discharge summary qua diagnosis, the observations qua the procedure and kind of treatment provided along with medical literature qua affect of smoking on the coronary heart disease. This report absolutely is correct, particularly when an over view of smokes effect on heart and blood vessels as extracted from internet has the same wording as is incorporated at page no.2 of Ex.R7 itself. The chemicals in tobacco smoke harm the blood cells and they can damage the function of heart as well as structure and function of the blood vessels. This damage increases the risk of arthrosclerosis. Said arthrosclerosis is a disease in which, a waxy substance called plaque builds up in the arteries. Overtime, plaque hardens and narrows the arteries, resulting in limiting the flow of oxygen-rich blood to organs and other parts of the body. Further as per internet search, coronary heart disease occurs, if plaque builds up in the coronary(heart) arteries. Over time, coronary heart disease can lead to chest pain, heart attack, heart failure, arrhythmias or even death. So, smoking is a major risk factor for heart disease as per this internet search. When such is the medical position qua effects of smoking on coronary heart disease, then certainly submissions advanced by counsel for OP1 has force that smoking habit of the complainant for the last 25 years contributed mainly to the ailment of coronary heart disease. Even if finding regarding smoking and drinking habits of the complainant for the last 25 years challenged by the complainant, but despite that proof in that respect has been adduced by OP1 by producing on record readings taken by Sh.Rajbir Singh at Satguru Partap Singh Apollo Hospital, Ludhiana on 23.6.2015. That record of readings produced on record as Ex.R11 and Ex.R13. Perusal of Ex.R11=Ex.R13 establishes that complainant is smoker since for the last 25 years and he consumed alcohol occasionally. In the acute coronary syndrome sheet of Satguru Partap Singh Apollo Hospital, Ludhiana produced on record as Ex.R12 also, it is specifically mentioned that smoking is an aggravating factor for complained of chest pain and that smoking habit of the complainant is for the last 25 years. Even in social and economic history of the complainant, mention of habit of the complainant of smoking and of alcoholic occasionally is made. Ex.R13 is the same thing as is Ex.R11. So, the produced record of Satguru Partap Singh Apollo Hospital, Ludhiana by Ops enough to establish that the complainant or his relatives themselves disclosed the doctors or attendant, as if complainant is habitual smoker for the last 25 years. That habit augmented the chest pain, owing to problem of coronary heart disease and as such, it is obvious that smoking habit of the complainant contributed much to the ailment for which, he got treatment, for submitting the insurance claim in question. As the affect of smoking is made known to each and every one by way of record of warning on cigarette packets since from long and as such, certainly complainant by indulging in habit of smoking for the last 25 years invited trouble of coronary heart disease itself. Being so, it is a case, in which, illness suffered by the complainant mainly due to consumption, use, misuse or abuse of tobacco habit. That itself was self-destructive and as such, due to smoking habit of the complainant for the last 25 years, he has self-inflicted injury resulting in ailment of coronary heart disease. So, repudiation of claim is certainly as per clause 4.3(A)(xxiv) of Ex.R5. Even repudiation of cashless hospitalization request through letter Ex.R9 in such circumstances is quite proper. Ex.R10 is copy of discharge summary of treatment of complainant got from Satguru Partap Singh Apollo Hospital, Ludhiana, whereas, Ex.R14 is the letter of repudiation of claim submitted by the complainant, but Ex.R16 is reply sent by OP1 to the complainant in response to the notice Ex.R15 got issued by him through counsel Sh.G.S.Sikka, Advocate.
18. Though, it is contended by Sh.G.S.Sikka, Advocate representing complainant that OP1 failed to produce any independent witness for proving that the complainant is habitual smoker, but despite that record of Satguru Partap Singh Apollo Hospital, Ludhiana Ex.R11 = Ex.C13 referred above itself establishes that the complainant or his attendant at the time of admission of complainant in that hospital disclosed about smoking habit of the complainant for the last 25 years and as such, it is not a case, in which, reliance placed by the OP1 exclusively on the opinion given by Dr.S.D.Jain through Ex.R7. Rather, it is a case, in which, material collected by OP1 before repudiating the claim.
19. It is also contended by Sh.G.S.Sikka, Advocate representing complainant that even a person not smoking sometime suffers from coronary artery disease and as such, repudiation of claim is improper. That submission of counsel for complainant has no force because the contents of Ex.R12 as already referred above, establishes that smoking habit of the complainant for the last
25 years was found as an aggravating factor by treating hospital for coronary heart disease of the complainant, due to which, putting of stent because of problem of blockage in the veins took place. So, overall material produced on record as well as affidavit of Dr.S.D.Jain and record of treatment of complainant establishes that major factor qua ailment suffered by the complainant was his smoking habit. Even if the coronary artery disease came to be suffered to the knowledge of the complainant in 2015, but despite that his old habit of smoking for the last 25 years was the major contributing factor to the ailment and as such, repudiation of claim is quite proper, even if complainant may have no knowledge of suffering from pre-existing disease. Present is not a case of repudiation of claim on account of suppression of material facts qua pre-existing disease, but it is a case, in which, repudiation took place due to smoking habit of the complainant for the last 25 years resulting in coronary artery disease in question and as such, knowledge or no knowledge of the complainant qua pre-existing disease is not much material at all. Being so, benefit from ratio of cases titled as New India Assurance Co.Ltd vs. Vasanto Rao-S.C. & National Commission Consumer Law cases(2005-2008)-509; New India Assurance Co.Ltd and others vs. Raj Kumar Chuchra- S.C. & National Commission Consumer Law cases(2005-2008)-442 and cant beNational Insurance Co.Ltd and another vs. Girin R.Shah-III(2012)CPJ-322(N.C.) availed by the counsel for complainant. Present is not a case, in which, claim repudiated on the ground of fraud, but it is a case, in which, claim repudiated due to self suffered ailment due to smoking habit and as such, the produced internet search by the complainant pertaining to repudiation of claim on ground of fraud, is not material.
20. As repudiation of claim and rejection of review request is quite in consonance with the terms and conditions of the insurance contract as held above and as such, there is no deficiency in service on the part of OP1, particularly when repudiation is quite legal and justified.
21. As a sequel of the above discussion, complaint dismissed with no order as to costs. Copies of order be supplied to parties free of costs as per rules.
22. File be indexed and consigned to record room. (Param Jit Singh Bewli) (G.K. Dhir) Member President Announced in Open Forum Dated:01.08.2017 Gurpreet Sharma. -10-