Chandigarh

StateCommission

A/186/2016

Religare Health Insurance Company Ltd. - Complainant(s)

Versus

Asha Rani Mehta - Opp.Party(s)

Paras Money Goyal Adv.

25 Jul 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

                                                                 

First Appeal No.	:	186 of 2016
Date of Institution	:	28.06.2016
Date of Decision	:	25.07.2016

 

1. Religare Health Insurance Company Ltd., through its Managing Director,, GYS Global, Plot No.A3, A4, A5, Sector 125, Noida,
   U.P.-201301, through Ramnique Sachar, Manager (Legal) Religare Health Insurance, D-3, District Centre, Saket New Delhi-17.
2. Branch Manager, Religare Health Insurance Company Ltd., SCO No.28, 2^nd Floor, Sector 20-D, Chandigarh.

…..Appellants/Opposite Parties

V e r s u s

1. Asha Rani Mehta wife of Sh. S.C. Mehta, Resident of House No.2647, Sector-47/C, Chandigarh.

                       …..Respondent/Complainant

2. Jai Lakshmi Cooperative Services, Intermediary Code 20005799, Intermediary RM Code HARSWARUP C/o GYS Global, Plot No.A3, A4, A5, Sector-125, Noida, U.P. 201301, having its registered office, Religare Health Insurance, D-3, District Centre, Saket New
   Delhi-17.  

              ....Respondent/Opposite Party No.2

 

Appeal under Section 15 of the Consumer Protection Act, 1986.

 

BEFORE:   MR. DEV RAJ, PRESIDING MEMBER.

                MRS. PADMA PANDEY, MEMBER

 

Argued by:   Sh. Paras Money Goyal, Advocate for the appellants.

 

PER PADMA PANDEY, MEMBER

              This appeal is directed against the order dated 25.05.2016 rendered by the District Consumer Disputes Redressal Forum-I, U.T., Chandigarh (hereinafter to be called as the District Forum only), vide which, it accepted the complaint, filed by the complainant and directed the Opposite Parties, as under:-

“i. To reimburse the medi-claim of the Complainant to the tune of Rs.4,00,000/- being sum assured as per the terms & conditions of the Policy.

ii.  To pay Rs.20,000/- as compensation for mental agony and harassment caused to the complainant;

  iii.   To pay Rs.10,000/- as costs of litigation. 

  This order be complied with by the Opposite Parties within one month from the date of receipt of its certified copy, failing which they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @12% per annum from the date of filing of the present complaint till realization, apart from compliance of direction at Sr.No.(iii) above.”

2.        The facts in brief, are that, the complainant had purchased Health Insurance Policy No.10198938 of Opposite Party i.e. Insurance Company, commencing from 25.01.2015 to 24.01.2016, by paying a premium of Rs.22,775/- (Annexure C-1). It was stated that it was only after thorough examination of the Complainant by the doctors of the Opposite Party-Insurance Company, the policy was issued to her. The Complainant was diagnosed by PGIMER, Chandigarh as “Colon (biopsy) – Adenocarcinoma, moderately differentiated” and was advised Surgery of SigmoidalCA during first week of September 2015. On 31.08.2015 the Complainant was admitted in Fortis Hospital, Mohali for her treatment and was operated upon 01.09.2015. It was further stated that upon intimation, the cashless facility was denied by Opposite Party No.1, on the ground, that the Complainant was a known case of Hypertension since last 7-8 years, which fact she did not disclose, at the time of policy proposal (Annexure C-3). It was further stated that Hypertension has no nexus or relation with the disease, with which she was treated for. It was further stated that the aforesaid acts of the Opposite Parties, amounted to deficiency, in rendering service, as also indulgence into unfair trade practice. When the grievance of the complainant, was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the Act only), was filed, directing the Opposite Parties.
3.        The Opposite Parties have filed joint reply and pleaded that there was non-disclosure, suppression and concealment of material facts regarding the health of the complainant, by her, at the time of obtaining the insurance policy. It was stated that after the receipt of the cashless authorization and other supporting documents and information from Hospital and the complainant and after due application of the mind by the Officials and panel of the Company, the cashless authorization request of the complainant so raised, was declined vide letter dated 03.09.2015, on the ground that the Complainant was a known case of Hypertension for the past 7-8 years, which was not disclosed at the time of policy proposal, therefore cashless claim was rejected. It was further stated that there is no deficiency in service on their part, and the answering Opposite Parties had prayed for dismissal of the complaint.
4.    The complainant, filed rejoinder, to the written statement of the Opposite Parties, wherein she reiterated all the averments, contained in the complaint, and repudiated those, contained in the written version of Opposite Parties.
5.         The Parties led evidence, in support of their case.
6.        After hearing the Counsel for the parties, and, on going through the evidence, and record of the case, the District Forum, accepted the complaint, in the manner, referred to, in the opening para of the instant order. 
7.        Feeling aggrieved, the instant appeal, has been filed by the appellants/Opposite Parties No.1 & 3.
8.        We have heard the Counsel for the appellants, at the preliminary stage and, have gone through the evidence, and record of the case, carefully. 
9.        After giving our thoughtful consideration, to the contentions, advanced by the Counsel for the appellants, and the evidence, on record, we are of the considered opinion, that the appeal is liable to be dismissed at the preliminary stage, for the reasons to be recorded hereinafter.
10.        A careful perusal of the record shows that before issuing the policy, in question, the respondent had undergone thorough medical examination and declared a fit person to avail the policy. Once the respondent presented herself for the thorough medical examination, which is mandatory for issuance of the insurance policy, in question, the question of concealment, non-disclosure, has no relevance. The medical report submitted by the appellants, nowhere reveals that the respondent was suffering from any disease. The doctors who conducted the medical examination of the respondent, were required to take three readings in ten minutes interval, in order to, record the blood pressure of the respondent, but it has been observed that only one reading was taken, which indicates that the doctor was satisfied about the blood pressure checkup of the respondent. The appellants have, therefore, no right to blame that the respondent did not disclose the factum of her status of Hypertension in the proposal form. Moreover, the respondent was diagnosed with “Colon (biopsy) – Adenocarcinoma, moderately differentiated” by PGIMER, Chandigarh and was advised surgery of SigmoidalCA, which was subsequently got done by the respondent in Fortis Hospital, Mohali on 01.09.2015 and claim has been lodged by the respondent for the said surgery, which is nowhere connected with Hypertension. Therefore, we find that the appellants have been grossly deficient in rendering their services, by denying the insurance claim, and accordingly, the said appeal is dismissed with no order as to costs.
11.        No other point, was urged, by the Counsel for the appellants.
12.       In view of the above discussion, it is held that the order passed by the District Forum, being based on the correct appreciation of evidence, and law, on the point, does not suffer from any illegality or perversity, warranting the interference of this Commission.
13.      For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, at the preliminary stage, with no order as to costs. The order of the District Forum is upheld.
14.     Certified copies of this order, be sent to the parties, free of charge.
15.     The file be consigned to Record Room, after completion

 

Pronounced.

25.07.2016

 

 

                                                                          Sd/-

(DEV RAJ)

PRESIDING MEMBER

 

 

 

Sd/-

(PADMA PANDEY)

      MEMBER

 

 

GP

 

 

STATE COMMISSION

(First Appeal No.186 of 2016)

(Religare Health Insurance Company Ltd. & Anr. Vs. Asha Rani Mehta & Anr.)

 

 

Argued by:

Sh. Paras Money Goyal, Advocate for the appellants.

 

Dated the 25^th day of July 2016

 

ORDER

 

              Vide our detailed order of the even date, recorded separately, this appeal has been filed by the appellants/Opposite Parties No.1 & 3, has been dismissed at the preliminary stage, with no order as to cost and the order passed by the District Forum, has been upheld.

 

      

 

 

                      Sd/-                                  Sd/-

(DEV RAJ) PRESIDING MEMBER

(PADMA PANDEY) MEMBER