Punjab

Sangrur

CC/677/2020

Inder Pal Singla - Complainant(s)

Versus

Care Health Insurance Limited (Formerly Known as Religare Health Insurance Comapany Limited) - Opp.Party(s)

Sh. Sandip Kumar Goyal

30 Jul 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

 

                                                                        Complaint No. 677

 Instituted on:   16.12.2020

                                                                        Decided on:     30.07.2024

 

 

Inder Pal Singla son of Dharampal Singla, resident of #274, Delha Road, Ward No.10, Moonak, Tehsil Moonak, District Sangrur.

                                                         …. Complainant.     

                                                 Versus

1.             Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited) Regd. Office: 5^th Floor, 19, Chawla House, Nehru Place, New Delhi-110019.

2.             Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited) Corp. Office: Unit No.604-607, 6^th Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram 122001.

                                                        ..Opposite parties.

 

For the complainant    :       Shri Sandip Kumar Goyal, Adv.

For Opp.parties          :       Shri Jatinder Verma, Adv.

 

Quorum                                           

1. Jot Naranjan Singh Gill    : President
2. Sarita Garg                        : Membe
3. Kanwaljeet Singh              : Member

ORDER

JOT NARANJAN SINGH GILL, PRESIDENT

1.             Complainant has preferred the present complaint against the opposite parties  on the ground that complainant obtained a health insurance  policy bearing number 16153104 from the OPs for an amount of Rs.5,00,000/- by paying the requisite premium of Rs.11,768/- on 05.11.2019 and the policy in question was valid for the period from 05.11.2019 to 04.11.2020. The policy in question was cashless one.  Further case of complainant is that on 26.09.2020 the complainant became ill and was admitted in Vardhman Hospital at Patiala, which is authorised hospital of OPs for cashless treatment. The grievance of the complainant is that employees of Vardhman Hospital Patiala intimated the complainant that the OPs have denied for the cashless claim and suggested the complainant to get reimbursement after paying the bill without mentioning any reason. Further case of complainant is that thereafter complainant was discharged on 30.09.2020 and after arranging the treatment expenses the complainant paid an amount of Rs.74,357/- to the hospital authorities. Thereafter the complainant submitted the claim with the OPs including all the necessary documents on 06.10.2020 for reimbursement of the claim amount, but the claim was not approved/paid despite serving of legal notice dated 02.11.2020 through his counsel Shri Sandip Kumar Goyal, Advocate.  Thereafter the OPs issued a letter dated 03.11.2020 whereby it was intimated the complainant that the claim is not payable due to non disclosure of Diabetes. Further it is mentioned in the complaint that the complainant was hale and hearty at the time of submission of proposal form. Moreover, the patient was admitted in the hospital for the treatment of chest pneumonia which has no nexus with Diabetes.  As such, the repudiation of claim is said to be illegal one.  Thus, alleging deficiency in service on the part of the Ops, the complainant has prayed that the Ops be directed to pay to the complainant the claim amount of Rs.74,357/- alongwith with interest and further claimed compensation and litigation expenses.

2.             In reply filed by OPs, preliminary objections are taken up on the grounds that the complaint is not maintainable in the present form, that the complainant has filed the present complaint with malafide intention and has not come to this Commission with clean hands, that the complaint is false, frivolous and vexatious in nature and that there is no case made out in favour of the complainant. On merits,  it is admitted that the complainant obtained the insurance policy in question for the period from 05.11.2019 to 04.11.2020 for a sum of Rs.5,00,000/- Product : Care (Floater) for himself, his wife and his son. It is further averred that the claim was denied for on the  discrepancy regarding h/o diabetes noted, kindly file claim in reimbursement with all past treatment records vide letter dated 29.09.2020. It is admitted that the insured was hospitalized w.e.f. 26.09.2020 till 30.09.2020 at Vardhman Mahaveer Health Care and as per the discharge summary, the complainant had complaints of fever, cough and breathlessness for 5-6 days. He was finally diagnosed with bilateral pneumonitis/covid-19 negative.  As per the discharge summary, he had past history of Type 2 Diabetes Mellitus. It is further averred that after receipt of the documents alongwith claim form, the OPs came to know that he is a known case of Type 2 DM, hence the company raised a query letter dated 15.10.2020 to seek further documents and it is stated that the complainant concealed his earlier disease, as such the claim is said to has rightly been repudiated. The other allegations levelled in the complaint have been denied and prayed for dismissal of the complaint with costs.

3.             The learned counsel for the complainant has produced Ex.C-1 to Ex.C-18 copies of documents and affidavit and closed evidence. On the other hand, the learned counsel for the OPs has produced Ex.OPs/1 to Ex.OPs/12 copies of documents and affidavit and closed evidence.

4.             We have gone through the pleadings put in by the parties along with their supporting documents with their valuable assistance. 

5.             It is an admitted fact between the parties that complainant  with his wife and son was insured with the OPs under the medical insurance policy in question. The contention of the complainant is that during the subsistence of the insurance policy on 26.09.2020 the complainant became ill and was admitted in Vardhman Hospital at Patiala, which is authorised hospital of OPs for cashless treatment. It is further contended that the employees of Vardhman Hospital Patiala intimated the complainant that the OPs have denied for the cashless claim and suggested the complainant to get reimbursement after paying the bill without mentioning any reason. Further it is contended by the learned counsel for the complainant that thereafter complainant was discharged on 30.09.2020 and after arranging the treatment expenses the complainant paid an amount of Rs.74,357/- to the hospital authorities from his own pocket. Thereafter the complainant submitted the claim with the OPs including all the necessary documents on 06.10.2020 for reimbursement of the claim amount, but the claim was not approved/paid despite serving of legal notice dated 02.11.2020 through his counsel Shri Sandip Kumar Goyal, Advocate.  Thereafter the OPs issued a letter dated 03.11.2020 whereby it was intimated the complainant that the claim is not payable due to non disclosure of Diabetes, which is said to be illegal one. Lastly, the learned counsel for complainant has prayed for acceptance of the complaint.  

6.             On the other hand,  the learned counsel for the OPs  has admitted that the complainant obtained the insurance policy in question for the period from 05.11.2019 to 04.11.2020 for a sum of Rs.5,00,000/- on floater basis for himself, wife and his son. It is further contended that the claim was denied on the ground that the complainant was having the past history of diabetes, as such the complainant was requested to produce all past treatment records vide letter dated 29.09.2020. It is further admitted by the OPs that the insured was hospitalized w.e.f. 26.09.2020 till 30.09.2020 at Vardhman Mahaveer Health Care and as per the discharge summary, the complainant had complaints of fever, cough and breathlessness for 5-6 days. He was finally diagnosed with bilateral pneumonitis/covid-19 negative.  As per the discharge summary, he had past history of Type 2 Diabetes Mellitus. It is further contended that after receipt of the documents alongwith claim form, the OPs came to know that he is a known case of Type 2 DM, hence the company raised a query letter dated 15.10.2020 to seek further documents and it is stated that the complainant concealed his earlier disease, as such the claim is said to has rightly been repudiated. Lastly the Ops have prayed for dismissal of the complaint.

7.             It is an admitted fact that the complainant obtained the insurance policy in question from the Ops, a copy of which on record is Ex.C-4 and during the subsistence of the insurance policy the complainant suffered illness and as such was admitted at Vardhman Mahaveer Hospital, Patiala on 26.09.2020 where he remained admitted upto 30.09.2020 and spent an amount of Rs.74,357/-. But the grievance of complainant is that the claim was wrongly repudiated by the OPs vide letter dated 03.11.2020, Ex.C-5 on the ground of non disclosure of Diabetes.  Ex.C-6 to Ex.C-18 are the copies of various bills and documents issued by Hospital authorities. Ex.C-9 is the discharge summary vide which in the column final diagnosis it is mentioned Bilateral Pneumonitis/Covid-19 Negative. It is further mentioned in the column of Brief History and Physical Examination on Admission – Patient presented in ER of VMHC with complains of fever, cough, breathlessness for 5-6 days and in the column Past History (Medical and Surgical) it is mentioned known case of T2DM.    

8.             On the other hand, the learned counsel for the OPs has contended that the claim has rightly been repudiated as the complainant was suffering from diabetes which disease was not disclosed by him during the process of purchasing the insurance policy.  Now, the only question for determination before this Commission is whether the OPs have rightly repudiated the claim of the complainant on the ground of Diabetes or not. Further a bare perusal of para 3 of the affidavit filed by Ms. Shruti Saxena, authorised signatory of the Ops, it is clearly mentioned that as per the discharge summary, he had complaints of fever, cough and breathelessness for 5-6 days and was finally diagnosed with bilateral pneumonitis/covid 19 negative and was having past history of type 2 Diabetes Mellitus. But we are unable to go with the contention of the learned counsel for the OPs that the claim can be rejected on the ground of disease of diabetes. In Life Insurance Corporation of India versus Sushma Sharma 2008(2) CPJ 213 (Punjab State Commission),  wherein the case was that insured was suffering from hypertension and diabetes for last 10 years before death and it was not disclosed. Repudiation of claim under section 45 of Insurance Act. It is not concealed fact of every fact that gives right of repudiation of claim. Hypertension and diabetes are not material diseases. If these diseases had been material insured would not have survived for 10 years. Complaint allowed by Forum. Payment of insurance claim with interest was directed and the appeal of the opposite parties/insurance company was dismissed. In the circumstances of the case, we find that the OPs have wrongly and illegally repudiated the rightful claim of the complainant on the ground that complainant was suffering from diabetes. Moreover, the alleged pre-existing disease i.e. diabetes of the insured is not co-related with the treated disease i.e. Bilateral Pneumonitis.  Hon’ble National Commission in Revision Petition No.54 of 2018: Life Insurance Corporation of India versus Sunita and others reported in 2020(3) CPR 301 (NC),  the death of the life assured was due to cardiac arrest and the deceased-assured was suffering from diabetes mellitus and chronic liver disease, when he was brought to hospital. It was held by the Hon’ble National Commission  that cause of death of the life assured was nowhere connected to his pre-existing disease.

9.             Now, coming to the quantum of compensation payable to the complainant. Admittedly, the insurance policy is for the sum insured of Rs.5,00,000/-.  The complainant has  claimed an amount of Rs.74,357/- which is also corroborated by producing the bills/invoice on record as Ex.C-6 to Ex.C-18. As  such, we find that the OPs are liable to pay to the complainant an amount of Rs.74,357/- which were illegally and wrongly withheld by the Ops. 

10.            The insurance companies are in the habit to take these type of projections to save themselves from paying the insurance claim. The insurance companies are only interested in earning the premiums and find ways and means to decline claims. The above said view was taken by the Hon’ble Justice Ranjit Singh of Punjab and Haryana High Court in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others 2008(3) R.C.R. 9 Civil) 111.

11.            Accordingly, in view of our above discussion, we allow the complaint and direct OPs to pay to the complainant the claim amount of Rs.74,357/- alongwith interest @ 7% per annum from the date of filing of the present complaint i.e. 16.12.2020 till realisation. Further OPs are directed to pay to the complainant an amount of Rs.5000/- as compensation for mental tension, agony and harassment and further an amount of Rs.5000/- on account of litigation expenses. This order be complied with within a period of sixty days of receipt of copy of this order.

12.            The complaint could not be decided within the statutory time period due to heavy pendency of cases.

13.            Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance. 

                        Pronounced.

 

                July 30, 2024.

 

           (Kanwaljeet Singh)  (Sarita Garg) (Jot Naranjan Singh Gill)

                  Member               Member                   President