Order by:

Smt.Priti Malhotra, President

1.       The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that the complainant availed a Health Insurance Policy no.44530198 in the year 2014 for cashless treatment covering himself, his spouse and one child. During the policy coverage, the complainant was suffering from knee and joint pain and on 16.01.2023, he had

taken the advice of Dr. Mohit Bhandari (Bariatric & Metabolic Surgeon) in Mohak Hi-tech Specialty Hospital, MR-10 Crossing, Indore (M.P). In the meantime, mid of July 2023, the complainant suffered swear pain in his lower back and got treated by Dr. Seemant Garg (MD medicine) in Sham Nursing Home & Heart Care Centre. As per the instructions of the Doctor complainant got his X-ray of chest done on dated 16.07.2023. Thereafter, on dated 29.07.2023 the complainant went to Deep Nursing home & Children Hospital, Model Town, Ludhiana for further treatment as well as to relief of swear pain of kidney and he was discharged on dated 30.07.2023. For this treatment Rs.68000/- were charged by said the hospital and same was paid by the complainant in cash. On dated 11.08.2023 as per instructions of the doctor, the complainant went to Deep Nursing Home and Children Hospital, Model Town, Ludhiana for final treatment/removal of stunt and he was discharged on same day. For this treatment complainant paid Rs.12,000/- to the said hospital. Alleged that the complainant submitted all original bills and other documents with the Opposite Parties for the approval of claim, but request of reimbursement claim was rejected on 06.10.2023 and 09.10.2023 by Opposite Parties due to the reason “Non-disclosure of morbid obesity prior to policy and non-disclosure of material facts/pre-existing ailments at the time of proposal.” Thereafter, on 11.09.2023, the complainant again visited the hospital of Dr. Mohit Bhandari (Bariatric & Metabolic Surgeon) in Mohak Hi-tech Specialty Hospital and the said doctor advised the complainant for Bariatric & Metabolic Surgery. Then the complainant applied for cashless hospitalization for the approval of said treatment, but the request for the approval for cashless treatment was rejected on 28.09.2023 by the Opposite Parties. On dated 27.09.2023, the complainant was admitted in Mohak Hi-tech Specialty Hospital for the Bariatric & Metabolic Surgery and got discharged on dated 03.10.2023. For the said surgery, the complainant has spent Rs.3,50,000/-. Thereafter, the complainant submitted all original bills and other documents with Opposite Parties for reimbursement, but the request for reimbursement was rejected on dated 09.10.2023 due to reason "Non-disclosure of morbid obesity prior to policy and non - Disclosure of material facts/ pre-existing aliments at the time of proposal". Alleged further that the above said act on the part of opposite parties has caused & damage beside mantel tension, trauma great loss and inconvenience and loss of value of the money of complainant. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-

a)       Opposite Parties may be directed to pay an amount of Rs.4,30,000/- .

b)      To pay a sum of Rs.50,000/- as compensation on account of mental tension, and harassment alongwith Rs.20,000/- as travel expenses.

c)       To pay Rs.22,000/- as litigation expenses.

d)      And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.

2.       Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the complainant has attempted to misguide and mislead this Commission; the complaint involves disputed question of facts which cannot be determined in summary jurisdiction of Consumer Commission; the complainant has filed the complaint with malafide intention and has not come this Commission with clean hands; the complaint is false, frivolous and vexatious in nature; the complainant is stopped from filing the present complaint by his own act, conduct, omissions and acquiescence; the complainant has tried to challenge the veracity of decision of the Opposite Parties to repudiate the claim and the complainant should approach the Civil Courts in order to challenge the veracity of the decision of the Opposite Party Company; this Commission has no jurisdiction to entertain the present complaint; there is no deficiency in service rendered by the opposite party in the present case.

          Averred that the replying opposite party company issued a group health Insurance policy to the group policyholder i.e. Punjab National Bank vide Group Policy No. 17499225 namely "Group Care 360° (PNB Platinum)" covering Ashwani Kumar, his spouse and his son from 23.07.2022 till 22.07.2023 for a sum insured up to Rs. 7,00,000/- subject to policy terms and conditions. The said policy was ported from Group Retail Prev Pol Insurer wherein the first date of enrolment was 23.07.2014. The Policy Certificate along with Policy Terms and Conditions was delivered electronically to the complainant on 27.07.2022 at Akshay.Kansal13@gmail.com and no dispute was raised during the free look period as prescribed under policy terms and conditions. Believing the information and details provided by the Proposer including the medical history to be true and correct in all respect, the policy was issued. Submitted that the Policy kit containing all relevant documents was duly delivered to the Complainant from time to time, thereby giving an opportunity to the Complainant to verify and examine the benefits, terms and conditions of the Policy taken by the Complainant. The Complainant never approached the replying Opposite Party Company stating that any information given in the Policy Schedule was incorrect. Averred that the replying opposite party received a reimbursement claim for the hospitalization of the complainant at Deep Hospital, Ludhiana from 29.07.2023 till 30.07.2023 as he was diagnosed with “left upper ureteric calculus”. Upon the receipt of the claim a query dated 06.09.2023 and reminder dated 13.09.2023 was raised and the complainant was asked to provide:

QUERY

1.         INVESTIGATION REPORT SUPPORTING DIAGNOSIS.

2.         DETAIL ORIGINAL DISCHARGE SUMMARY.

3.         COMPLETE INDOOR CASE PAPERS WITH ADMISSION NOTES, HISTORY SHEET, DOCTOR'S NOTES, NURSING NOTES AND VITAL CHART.

          Thereafter upon the receipt of the claim, an investigation was also triggered to check the veracity of the claim. Therefore the opponent sent a denial letter dated 08.10.2023 to the insured wherein the claim was rejected for the following reasons:

NON DISCLOSURE OF- MORBID OBESITY PRIOR TO POLICY.

6.1.1 NON DISCLOSURE OF MATERIAL FACTS/PRE-EXISTING AILMENTS AT TIME OF PROPOSAL

          A reimbursement claim was filed for the day care hospitalization of the Complainant at Deep Hospital, Ludhiana on 11.08.2023 as he was diagnosed with follow up case of Left RIRS + DJS. Upon the receipt of the claim a query dated 08.09.2023 and reminder dated 22.09.2023 was raised and the complainant was asked to provide:

1.         INVESTIGATION REPORT SUPPORTING DIAGNOSIS.

2.         DETAIL ORIGINAL DISCHARGE SUMMARY.

3.         PRE HOSPITALISATION OPD TREATMENT RECORD.

4.         COMPLETE INDOOR CASE PAPERS WITH ADMISSION NOTES, HISTORY SHEET, DOCTOR'S NOTES, NURSING NOTES AND VITAL CHART

          Thereafter upon the receipt of the claim an investigation was also triggered to check the veracity of the claim. Therefore the opponent sent a denial letter dated 06.10.2023 to the insured wherein the claim was rejected for the following reasons:

NON DISCLOSURE OF- MORBID OBESITY PRIOR TO POLICY.

6.1.1 NON DISCLOSURE OF AILMENTS AT TIME OF PROPOSAL MATERIAL FACTS/PRE-EXISTING

          Further, a cashless request was received from Mohak Hi Tech Speciality Hospital, Indore for the hospitalization of the Complainant from 25.09.2023 as he was provisionally diagnosed with Morbid Obesity. Upon the receipt of the claim a query dated 18.09.2023 was raised and the complainant was asked to provide:

1.         DOCUMENTS REQUIRED

2.         HEIGHT AND WEIGHT AT TIME OF POLICY INCEPTION

3.         EXACT DURATION AND PAST HISTORY OF PRESENT AILMENT WITH 1ST CONSULTATION PAPER AND ALL PAST TREATMENT RECORDS.

4.         PRE HOSPITALISATION OPD TREATMENT RECORD.

The cashless request was rejected via claim denial letter dated 28.09.2023 on the grounds of:

          NON DISCLOSURE OF- MORBID OBESITY PRIOR TO POLICY.

6.1.1 NON DISCLOSURE OF MATERIAL FACTS/PRE-EXISTING AILMENTS AT TIME OF PROPOSAL

Then, another reimbursement claim was filed for the hospitalization of the Complainant at Mohak Hi Tech Speciality Hospital, Indore from 27.09.2023 till 03.10.2023 as he was diagnosed with Morbid Obesity, OA, OSA, HTN, T2DM. Upon the receipt of the claim an investigation was also triggered to check the veracity of the claim. Therefore the opponent sent a denial letter dated 24.11.2023 to the insured wherein the claim was rejected for the following reasons:

          NON DISCLOSURE OF- MORBID OBESITY PRIOR TO POLICY.

6.1.1 NON DISCLOSURE OF MATERIAL FACTS/PRE-EXISTING AILMENTS AT TIME OF PROPOSAL

As per the patient statement he is suffering from morbid obesity from 3 to 4 years and his current weight is 132 Kg which has been increased 30-40 kgs due to which he is suffering from knee pain, joint pain and back pain. The Insured had the chance to disclose about his past medical history of Morbid Obesity at the time of filling the proposal form, but the Complainant/Insured failed to disclose the same for the best reasons known to him. Averred further that depending upon the disclosures made by the complainant at the time of Proposal, the Respondent Company decides whether to accept the risk and provide the policy to the customer or not. It is the duty of the Insured to disclose correct and accurate information about his/her current health status at the time of proposal for the accurate assessment of risk. However, the Complainant by not disclosing the correct health status of patient has blatantly violated the principle of Utmost Good Faith i.e., Uberrimae Fides and the Policy Terms and Conditions which is the basis of contract between the Complainant and the Company. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.

3.       In order to prove the case, complainant has placed on record his affidavit as Ex.C1 alongwith copies of documents Ex.C2 to Ex.C16.

4.       On the other hand, Opposite Parties have placed on record copies of documents Ex.OPs/1 to Ex.OPs/17 and affidavit of Sh.Prabhjyot Singh, Authorized Signatory, Care Health Insurance Ltd. as Ex.OPs/18.

5.         We have heard the ld. counsel for both the parties and also gone through the record.

6.       It is admitted and proved on record that the complainant availed health insurance policy vide Group Policy No.17499225 namely ‘Group Care 360 (PNB Platinum)’ covering the complainant self and his spouse Anju Bala and son Aman Kansal for the period 23.07.2023 to 22.07.2024  for a sum insured of Rs.7,00,000/-. It is also admitted and proved on record that the complainant ported his policy in question from the previous company to the company of Opposite Parties and complainant was availing the policy from the previous company since the year 2014. It is evident on record that during the policy coverage, the complainant on three occasions remained admitted in variant hospitals for treatment of his ailments suffered. It is matter of record that the claims lodged for the reimbursement of the said hospitalization periods were repudiated by the Opposite Parties, vide letters dated 06.10.2023, 09.10.2023 (28.09.2023 cashless denial) and 24.11.2023.

7.       The perusal of the record reveals that the Opposite Parties repudiated the aforesaid claims of the complainant vide letters dated 06.10.2023, 09.10.2023 (28.09.2023 cashless denial) and 24.11.2023 on the similar grounds. As the ground taken by the Opposite Parties for the repudiation of the claims of the complainant are same, so we hereby reproduce the contents of only one letter, which is as under:-

          Non Disclosure of Obesity prior to policy.

6.1.1 Non Disclosure of Material facts/Pre-existing ailments at the time of proposal.

8.       The grounds of repudiation as taken by the Opposite Parties does not appear to be genuine for the reasons recorded hereunder. First of all the Application Form (Ex.OPs/17) placed on record by the Opposite Parties reveals that in the Column under the heading “Health and Lifestyle Information” the insured i.e. complainant in questionnaires gave the following answers to the questions mentioned in the proposal form:-

From the above, it is clear that in the said application form, no question regarding the history of Obesity was asked from the insured. Neither there is any record revealing that the complainant ever took the treatment for the said ailment before the issuance of the policy in question. So, in these circumstances, the plea taken by the Opposite Parties regarding ‘non disclosure of obesity prior to insurance policy” is not maintainable.

9.       The plea taken by the Opposite Parties for repudiation of the claim regarding ‘Non disclosure of Material facts/Pre-existing ailments at the time of proposal’ is also not maintainable as per the ‘term’ defining the pre-existing disease under the policy, which is as under:-

“Pre-Existing Disease: Pre-existing Disease means any condition, ailment, injury or disease:

a)      That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinsatement

or

b)      For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement.

Since, there is no denial of the fact that the complainant alongwith his wife and child for the first time obtained the Mediclaim Policy from ‘Oriental Insurance Co. Ltd.’ in the year 2014 and thereafter they ported it out from the said company to present Insurance Company i.e. Care Health Insurance Co. Ltd. without any break. Meaning thereby that insured under the policy are entitled for the benefit of continuation of the policy. So, the repudiation of the claim on the ground of material facts/pre-existing disease is not legal.  For the decision above also, we are guided by ‘Master Circular’ dated 22^nd July, 2020 of IRDAI, wherein under heading Chapter III: Standard Wordings for some of the exclusions in Health Insurance Policies 1 (A) (c), it is mentioned that “If the Insured Person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage”.

10.     From the above discussion, we are of the view that the Opposite Parties wrongly and illegally repudiated the claims of the complainant.

11.     Vide instant complaint, the complainant claimed the amount of Rs.4,30,000/- i.e. Rs.68,000/- spent at Deep Nursing Home, Ludhiana for the period 29.07.2023 to 30.07.2023, Rs.12,000/- again spent at Deep Nursing Home on 11.08.2023 and Rs.3,50,000/- spent at Mohak Hi-Tech Specialiaty Hospital, Indore for the period 27.09.2023 and 03.10.2023, which are duly proved on record vide Ex.C9, Ex.C10 and Ex.C15 respectively.

12.     From the above discussion, we allow the instant complaint in part and direct the Opposite Parties to pay an amount of Rs.4,30,000/- (Rupees Four Lakh Thirty Thousand only) to the complainant. Opposite Parties are also directed to pay compository cost of Rs.15,000/-(Rupees Fifteen Thousand only) as compensation and litigation expenses to the complainant. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Parties within 30 days from the date of receipt of copy of this order, failing which, the Opposite Parties are further burdened with additional cost of Rs.10,000/-(Rupees Ten Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.

Announced on Open Commission