Chandigarh

DF-I

CC/794/2021

Brahmjot Singh - Complainant(s)

Versus

Care Health Insurance Co. Ltd. (Formally Known as Religare Health Insurance Co. Ltd. - Opp.Party(s)

Nirmal Singh Jagdeva

26 May 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/794/2021
Date of Institution	:	16.11.2021
Date of Decision	:	26.5.2023

 

Brahmjot Singh S/o Bhupinder Singh R/o flat No.2142-A, Block 9, Sector 63, Chandigarh

2. Navjot Kaur W/o Brahmjot Singh S/o Bhupinder Singh R/o flat No.2142-A, Block-9, Sector 63, Chandigarh.

.

… Complainant

V E R S U S

1.   Care Health Insurance Co. Ltd. (Formally Known as Religare Health Insurance Co. Ltd. through its Managing Director Registered office 5^th floor 19, Chawala House, Nehru Place, New Delhi 110019 & .

2.   Religare Health Insurance Company Ltd. through its Branch Manager, SCO No.56-57-58, Sector 9-D, Chandigarh.

 .  … Opposite Parties

 

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURESH KUMAR SARDANA	MEMBER

                       

ARGUED BY		Sh.  N.S. Jagdeva counsel for complainant.
		Sh. Amarpreet Singh vice counsel for Sh. Ramdeep partap Singh, counsel for OPs.

Per SURESH KUMAR SARDANA, Member

1. Briefly stated on 25.3.2015 the complainants availed medical health insurance policy from OP No.1 which was got renewed from time to time by the complainants.  In the year 2020 the complainant availed plan name Mediclaim and hospitalization benefit policy from OP No.1 valid from 25.4.2020 to 24.4.2021 with annual premium of Rs.15352/-.  The sum insured was Rs.5.00 lakh.  No copy of policy terms and conditions were supplied to the complainants. The complainant No.2 had to undergo emergency medical treatment and she remained admitted from 17.7.2021 to 27.7.2021. The complainants intimated the OPs about the health condition of the complainant No.2 as the previous claim was repudiated by the OPs on the ground of pre-existing condition.  The hospital raised a bill of Rs.4,28,450/-. The complainant submitted his claim alongwith relevant documents with OP No.2. But the OPs vide letter dated 11.9.2021 repudiated the claim of the complainant on the ground of non-disclosure of pre-existing illness. It is alleged that the OPs have wrongly repudiated the claim of the complainants as they were very well aware of the health condition of the complainant as earlier also the  OPs repudiated the claim of complainants in the year 2019 but still they further renewed the policy  without conducting any medical test, thus they subsequently cannot raise the issue of non-disclosure of pre-existing disease condition. Alleging the aforesaid act of Opposite Parties deficiency in service and unfair trade practice on their part, this complaint has been filed
2. The Opposite Parties while admitting the factual matrix of the case stated that on 20.12.2019 a cashless request from Max Super Specialty Hospital Mohali on behalf of insured was received on hospitalization of insured due to abdomen pain. However, the same was denied on account of non-disclosure of material facts/pre-existing ailments at the time of proposal. The complainants again filed a reimbursement claim in the year 2021 and as per documents submitted it was observed that the insured has history of mastectomy (CA breast) done on 2015 at fortis hospital, Mohali. Thus in view of said observation and observations concluded during previous cashless claim investigation the OPs rejected the reimbursement claim vide letter dated 11.9.2021. It is alleged that the complainants had the chance to disclose the pre-existing disease of CA Breast bariatric surgery and hypertension at the time of filing proposal form but the same was not disclosed. It is averred that as IRDAI Regulation 2017 under clause 19(4) enumerating the general principal casts an absolute duty to disclose all material facts to the insurer in order to assess the risk as per its capacity. It is denied that there is any deficiency on the part of the OPs. All other allegations made in the complaint has been  denied being wrong.
3. Rejoinder was filed and averments made in the consumer complaint were reiterated
4. Contesting parties led evidence by way of affidavits and documents.
5. We have heard the learned counsel for the contesting parties and gone through the record of the case.
6. The main grievance of the complainants is that inspite of having proper medical insurance cover, their legitimate medical claim bill was not paid and was rejected by OPs causing them mental agony & harassment.
7. The contentions of learned counsel for the parties seems to be similar to the pleadings, so no need to reiterate the same. The complainant  No.1 has tendered affidavit in support of his contentions placed on the record. He alleged deficiency in service and unfair trade practice on the part of OPs.
8. It is established fact the complainants purchased the Mediclaim policy from OP No.1. The policy in question was valid from 25.04.2020 to 24.04.2021. Admittedly this policy in continuation to the policies issued by the OPs w.e.f. 25.3.2015.  The complainant No.2 admitted in hospital during currency period of policy. The complainant got admitted on 17.07.2021 onwards.  The complainants alleged in their complaint that they submitted the claim of Rs.4,28,450/- to OPs as per the hospitals bills. However, the  OPs repudiated the claim on 11.9.2021 on the ground of non-disclosure of pre-existing illness.
9. The main controversy involved in the present case is that complainant has concealed the fact of pre-existing disease from OPs or not? It is an established fact that due to illness, the complainant No.2 was admitted in the hospital. After getting the treatment, complainants lodged their claim with OPs but OPs repudiated their claim. OPs repudiated the claim of the complainants on the ground that complainant No.2/insured was suffering from pre-existing disease.
10. It has come on record that age of the complainant  No.2 is more than 45 years on the date of issuance of the instant policy. There is nothing on record to show that before current insurance policy was issued to the complainants, the OPs got her medically examined which as per instructions issued by Insurance Regulatory and Development Authority of India (IRDAI) is mandatory. We are fortified by the view taken by UT State Consumer Disputes Redressal Commission, Chandigarh in the case of M/s Max Bupa Health Insurance Co. Ltd Vs Rakesh Walia it Appeal No.191 of 2016 decided on 18.08.2016, wherein “it was also stated that if contrary to instructions issued by Insurance Regulatory and Development Authority of India (IRDAI), an insured above the age of 45 years, was not put to thorough medical examination, claim raised after issuance of Insurance Policy cannot be rejected on account of non-disclosure of the fact of pre-existing when policy was obtained.” A similar view was also taken by UT State Consumer Disputes Redressal Commission, Chandigarh in the case titled as Manish Goyal versus Max Bupa Health Insurance Company Limited reported in 2018(2) CLT 205.
11. Thus, under above circumstances opposite parties themselves failed to adhere to the instructions issued by Insurance Regulatory and Development Authority of India (IRDAI) by not putting the complainant No.2 to thorough medical examination being his age more than 45 years and were interested in collecting premium only from the complainant, as such at this stage, they cannot evade their liability.
12. We are also of the view that insurance company is only interested in collecting hefty premium and then make the insured to run from pillar to post for reimbursement of the claim. This fact is settled by Hon'ble Punjab and Haryana High Court, Chandigarh in case of titled as New India Assurance Company Vs Usha Yadav and other reported in 2008(3) RCR (Civil) page 111 held as under:-

     “It seems that insurance companies are only interested in earning the premium and find ways and means to decline the claims. All conditions which generally are easily understand by a person at the time of buying any policy. The insured companies in such cases rely upon clauses of agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy.” Insurance company was also directed to pay cost of Rs.5000/- in the said case.

 

13.      From perusal of the facts of the present case, we find that it was duty of OPs to get the complainant No.2 (insured) medically examined at the time of filling up the proposal form. Moreover, earlier in the year 2019 also the OPs rejected the claim of complainant No.2 prior to issuance of the instant policy meaning thereby they were very well aware about the health condition of complainant No.2 yet they without medically examining the complainant  No.2 issued the instant policy. The defence which has been taken by the company (OPs) is having no legs to stand in the view of the above discussion and citation. We are of the considered view that the repudiation of the claim of the complainant by OPs is unjustified. By not paying the legitimate claim of the complainant, proves deficiency in service on the part of OPs. 
14. In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed. OPs are directed as under :-

1. to pay the claim amount of Rs.4,28,450/- with interest @9% P.A.from the date of repudiation  Till realization
2. to pay 50,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay Rs.10,000/- to the complainant as costs of litigation.

15.      This order be complied with by the OPs within thirty days 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 this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
16.      Certified copies of this order be sent to the parties free of charge. The file be consigned.

			sd/- [Pawanjit Singh]
			President
			Sd/-
			[Suresh Kumar Sardana]
mp			Member