BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

Complaint No.020 of 2022

      Date of Instt. 24.01.2022

      Date of Decision: 31.05.2023

Sh. Parmod Kumar S/o Sh. Shadi Lal R/o Mohalla Sant Nagar, Nurmahal, Distt. Jalandhar-144039.

..........Complainant

Versus

Care Health Insurance Co. Ltd. formerly known as Religare Health Insurance Co. Ltd. RHICL, Second Floor, SCO-44, PUDA Complex, Opposite District Administrative Complex, Jalandhar-144001 through its Branch Manager.

….….. Opposite Party

Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Smt. Jyotsna                            (Member)

                   Sh. Jaswant Singh Dhillon       (Member)                                

Present:       Sh. A. K. Arora, Adv. Counsel for the Complainant.

                   Sh. R. K. Sharma, Adv. Counsel for OP.

Order

Dr. Harveen Bhardwaj (President)

1.                The instant complaint has been filed by the complainant, wherein it is alleged that the complainant has taken Mediclaim Insurance Policy from OP for the period 31 03 2019 to 30.03.2021, covering the risk of complainant up to Rs.5,00,000.00 for the reimbursement of medical expenses for the treatment of complainant during the period of Insurance Prior to taking the present policy of insurance from the OP, the complainant was taking mediclaim insurance policies from Star Health Insurance Co. Ltd. The complainant was issued only policy schedule by the OP and no terms and conditions of policy of insurance were supplied to complainant by OP. The complainant was feeling difficulty in breathing besides having fever, cough and cold and as such the complainant consulted Mahal Multi Speciality Hospital, Ludhiana on 11.09.2020 The complainant was advised HRCT Chest The complainant got his HRCT of Chest done from Arora Neuro Centre Pvt. Ltd. at the advice of the concerned doctor of Mahal Multi Speciality Hospital. The complainant got himself admitted in Mahal Multi Speciality Hospital on 12.09.2020 for treatment of his ailment qua breathing difficulty, fever, cough & cold and was discharged on 18.09.2020. Mahal Multi Speciality Hospital charged an amount of Rs.1,71,000.00 from the complainant for his treatment. The complainant also incurred other expenses on his treatment in respect of medicines, scan and laboratory test etc. After his discharge from hospital, the complainant lodged a claim for Rs.2,01.972 00 with OP and submitted all relevant papers i.e. discharge summary etc. including bills with OP. The OP kept mum over the matter for a period of six months and did not settle the claim of the complainant. When the complainant asked the OP to settle the claim of the complainant qua the reimbursement of medical expenses incurred by him for his treatment from Mahal Multi Speciality Hospital, the OP rejected the claim of complainant and write letter dated 24 03.2021 to this effect to complainant alleging therein that the claim of complainant is not payable as per terms and conditions i.e. Deficiency not replied, hence rejected. No deficiency was pointed by the opposite party to the complainant in the letter under reference. The said rejection of claim of complainant on Flimsy Ground i.e. as per terms and conditions of policy of insurance as detailed in letter dated 24.03.2011 is patently wrong. The said rejection of lawful claim of complainant without any reason on the ground of alleged deficiency without giving any detail, constitutes deficiency of service on the part of the OP and opposite party are indulging in unfair trade practices. The complainant has submitted all the documents i.e. discharge summary, lab reports and bills etc with OP for reimbursement of his medical expenses incurred on his treatment. No letter whatsoever was written by opposite party to complainant, pointing out deficiency of any document in the claim of the complainant. No terms and conditions of policy of insurance were supplied to complainant by OP and as such it is not clear to which policy condition and deficiency, the opposite party are referring in Ex. C-36. The OP has wrongly and illegally withheld the genuine and bonafide claim of the complainant and has not paid the claim amount to the complainant for the expenses incurred by complainant on his treatment by wrongly rejecting the claim of the complainant on flimsy ground and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to make payment of Rs.201972/- being the expenses incurred by complainant on his treatment during the period of insurance along with interest @12% p.a. from the date of lodging of claim by the complainant with OP till the date of payment. Further, OPs be directed to pay a compensation of Rs.1,00,000/- for causing mental tension and harassment to the complainant and Rs.22,000/- as litigation expenses.

2.                Notice of the complaint was given to the OP, who filed written reply and contested the complaint by taking preliminary objections that  the complaint is pre-matured as the claim has been rejected on account no response from the complaint to letters with regard to fulfilling of requirement for processing and settling the claim. The complainant cannot take advantage of his own wrongs as the complainant has failed comply with the requirement of the OP to process and settle the claim. During the continuation of the policy complainant filed a reimbursement claim bearing No:-91438758 with the respondent company for the hospitalization from 12.09.20 to 18.09.20 at M/s Mahal Multi-speciality hospital, Ludhiana for the chief complaints of Difficulty in breathing since 2-3 days, fever on and off, cough and cough for last 4-5 days and was diagnosed with Covid-19 Pneumonitis. After the registration of the claim, respondent company trigged a claim examination to check the veracity of the claim. Upon careful examination of the claims documents made available to the respondent company, the following observation was made :-

•        That as per the discharge summary issued by M/s Mahal Multi-speciality hospital, Ludhiana dated 18.09.20 insured was finally  diagnosed with Covid-19.

•          That as per the Initial assessment sheet & history sheet of M/s Mahal Multi-specialty hospital, dated 12.09.20 insured was difficulty in breathing since 2-3 days, fever on and off, cough and cough for last 4-5 days and was a known case of diabetes and was under treatment.

          In reference to the above mentioned facts, it was clearly observed by the respondent company that insured was a known case of diabetes.

          Accordingly a query letter dated 29.10.20 was sent to provide:

          “Exact duration and past history of the present ailment with 1st consultation paper and all past treatment records related to diabetes and Complete indoor case papers with admission notes, history sheet, doctor's notes, nursing notes and vital chart”.

                   It is worthy to specify here that since no reply was provided by the complainant and a reminder letter dated 18.11.20 was sent to provide “Exact duration and past history of the present ailment with 1st consultation paper and all past treatment records related to diabetes and Complete indoor case papers with admission notes, history sheet, doctor's notes, nursing notes and vital chart”.

                   Since no reply was provided by the complainant in regards to the query raised. The claim of the complainant was rejected on the grounds of Deficiency not replied as per the policy terms and conditions.

          As per Clause 6.1-Pre-requisite for admissibility of a Claim:

          Any claim being made by an Insured Person or attendant of Insured Person during Hospitalization on behalf of the Insured person, should comply with the following conditions:

(i)      …

(ii)     …     

(iii)    …

(iv)    All the required and supportive Claim related documents are to be furnished within the stipulated timelines. The Company may call for additional documents wherever required.

As per Clause 6.3-Duties of a Claimant/ Insured Person in the event of Claim

(iv)    Intimation of the Claim, notification of the Claim and submission or provision of all information and documentation shall be made promptly and in any event in accordance with the procedures and within the timeframes specified in Clause 6 (Claims Procedure and Management) of the Policy.

As Per Clause 6.5:Documents to be submitted for filing a valid Claim

(i)      The following information and documentation shall be submitted in accordance with the procedures and within the timeframes specified in Clause 6 in respect of all Claims:

1.       Duly filled and signed Claim form by the Insured Person;

2.       Copy of Photo ID of Insured Person;

3.       Medical Practitioner's referral letter advising Hospitalization;

4.       Medical Practitioner's prescription advising drugs or diagnostic          tests or consultations;

5.       Original bills, receipts and discharge summary from the Hospital/Medical Practitioner;

6.       Original bills from pharmacy/chemists;

7.       Original pathological/diagnostic test reports/radiology reports   and payment receipts;

8.       Operation Theatre Notes;

9.       Indoor case papers;

10.     Original investigation test reports and payment receipts supported      by Doctor's reference slip;

11.     Ambulance Receipt;

12.     MLC/FIR report, Post Mortem Report if applicable and conducted;

13.     Any other document as required by the Company to assess the           Claim.

                   As the complainant did not responded to the query letter dated 29-10- 2020 and reminder letter dated 18-11-2020, the claim of the complaint was rejected vide letter dated 24-03-2021 as per terms and conditions of the insurance policy on the ground that the Deficiency not replied hence rejected. On merits, the factum with regard to purchasing of the health insurance policy by the complainant is admitted

3.                Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement. 

4.                In order to prove their respective versions, both the parties have produced on the file their respective evidence.

5.                We have heard the learned counsel for the respective parties and have also gone through the case file as well as written arguments submitted by counsel for the complainant very minutely.

6.                The complainant has proved that he took the mediclaim insurance policy for the period from 31.03.2019 to 30.03.2021 for a sum insured of Rs.5,00,000/-. The complainant has proved on record the insurance policy schedule Ex.C-1 and the card issued to the complainant Ex.C-2. He has alleged that on 11.09.2020, he found difficulty in breathing besides having fever, cough and cold and consulted Mahal Multi Speciality Hospital, Ludhiana. He was advised HRCT test of chest and he got the same done from Arora Neuro Centre Pvt. Ltd. Ludhiana. He has proved on record the prescription slip Ex.C-3 and the report Ex.C-4. He got admitted in Mahal Multi Speciality Hospital, Ludhiana on 12.09.2020 and was discharged on 18.09.2020. He has proved on record the discharge summary. He has also proved on record the total bills spent by him for the treatment which was for the amount of Rs.1,71,000/-. The bills have been proved as Ex.C-7 to Ex.C35. The claim was lodged alongwith bills, the list of the bills sent has been proved as Ex.C-6 and repudiation letter has been proved as Ex.C-36.

7.                The contention of the OP is that as per the discharge summary, the complainant was diagnosed with Covid-19 and he was a known case of diabetes and was under treatment. It has been alleged by the OP that query was put to the complainant, but no reply was ever sent by the complainant to the OP, therefore the claim was rejected on the ground of deficiency not replied as per policy terms and conditions. He has proved on record the reminder letters, query letters Ex.O-1 to Ex.O-3. The OP has relied upon the clauses 6.1, 6.3 and 6.5 of the insurance policy.

8.                The factum of the mediclaim policy is not denied. The only reasons on which the claim of the complainant was repudiated are that there was a deficiency on the part of the complainant in not supplying the documents to the OP and non-disclosure of his pre-existing disease of diabetes. The complainant has alleged that he was never supplied with the terms and conditions, therefore he was never in the knowledge of the policy conditions and the deficiency. Ex.C-36 is the rejection letter which shows that as per the terms and conditions deficiency not replied, hence rejected. The letter Ex.O-2 shows that the duration and past history of diabetes was called for by the OPs and the complete indoor case papers with admission note, history sheet was sought by the OP vide Ex.O-2 and Ex.O-3 dated 29.10.2020 and 18.11.2020 respectively. The complainant has relied upon Ex.C-6 which is the list of the bills, which were allegedly attached by the complainant with the claim form. The OP has produced on record Ex.O-1, the record of Mahal Multi Speciality Hospital, Ludhiana for breathing difficulty, fever and cough and Ex.O-5 is the letter showing that the deficiency was not replied, so the claim was rejected. No proposal form has been produced on record to show that alongwith claim form he has not attached the alleged documents sought for by the OP. No specific documents have been asked by the OP for the settlement of the claim or the previous history of the complainant with the present ailment with first consultation paper and all past treatment records. The OP himself has alleged in the written statement that he was found covid positive, once a person is found covid positive, he cannot have a past history of the ailment of covid. The covid came into existence only in the month of March, 2020. As per discharge summary Ex.C-5, he was considered likely of Covid-19 (Severity Sacore 22/25). In this discharge summary, no past history of the complainant was mentioned and he was provide urgent hospital care, high grade fever, severe headache, breathing difficulty. So, all these ailments cannot be said to be subsisting for the past so many years as alleged by the OP. As per this discharge summary, he was admitted on 12.09.2016 and was discharged on 18.09.2016.

9.                So, far as the past ailment of diabetes is concerned. It has been decided by the Hon’ble National Commission in various judgments that Hypertension and Diabetes are not a disease, it is a general wear and tear of the life which occurred due to the pressure of the present life style and even otherwise the disease of Hypertension and Diabetes can be cured by taking medicine. It has been held by the Hon'ble National Commission in a case titled as ‘Neelam Chopra Vs. LIC (2018)’ that ‘common life style disease cannot be a ground to repudiate insurance claims.  It has further been held that ‘the non-disclosure of information regarding common life style disease such as diabetes will not disentitle the insured from claiming the policy amount’. Similar view was taken by the Hon'ble National Commission in a case titled as ‘Reliance Life Insurance Co. Ltd. Vs. Tarun Kumar Sudhir Halder (2019)’ that ‘diabetes is a life style disease in India and the entire of insurance claim cannot be rejected only based on its non-disclosure.’

                    No terms and conditions have been filed on record by the OP to show that these terms and conditions were well within the knowledge of the complainant, whereas the complainant has alleged that he was never supplied with any terms and conditions. It has been held in a case titled as “Bajaj Allianz General Insurance Co. Ltd. Vs. Rajwant Kaur and Other”, 2021 (3) CLT 540 (CHD) that the onus is on the appellant insurance company to prove that it provided the terms and conditions of the policy to the complainant and the same were in her knowledge. It has been held in a case titled as “National Insurance Co. Ltd. & Ors Vs. M/s Saraya Industries Ltd”, 2020 (1) CLT 278 (NC) that it is the duty of the insurance company to supply all the terms and conditions of an insurance policy to the policy holder-there cannot be any presumption under law on the terms and conditions. It has been held by the Hon’ble Punjab & Haryana High Court, in Civil Revision No.2318 of 2008, decided on 22.04.2008, titled as “New India Assurance Company Limited Vs. Smt. Usha Yadav & Others”, that ‘the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy’. And accordingly, we are of the opinion        that the claim of the complainant has been wrongly and illegally repudiated by the OP and the same is hereby set-aside and further, find that the complainant is entitled for the relief as claimed.

10.              In view of the above detailed discussion, the complaint of the complainant is partly allowed and OP is directed to pay Rs.2,01,972/- i.e. the expenses incurred by the complainant on his treatment with interest @ 6% per annum from the date of lodging of claim by the complainant. Further, OP is directed to pay a compensation including litigation expenses of Rs.20,000/- for causing mental tension and harassment to the complainant. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.

11.               Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.

Dated          Jaswant Singh Dhillon    Jyotsna               Dr. Harveen Bhardwaj     

31.05.2023         Member                          Member           President