Haryana

Karnal

CC/317/2021

Ajay Bhatia - Complainant(s)

Versus

Care Health Insurance Limited - Opp.Party(s)

Deepak Kumar Sardana

14 Feb 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 317 of 2021

                                                        Date of instt.08.07.2021

                                                        Date of Decision:14.02.2023

 

Ajay Bhatia son of Shri Raghbir Singh Bhatia, resident of Nirmal Kunj, Jarnailly colony, Karnal aged about 67 years (Aadhar no.4373 6315 3996).

 

                                               …….Complainant.

                                              Versus

 

Care Health Insurance Ltd. (formerly known as Religare Health Insurance Company Limited) Unitech Cyber Park, Tower C, 6^th floor, Unit no.604, 605, 606 and 607, Gurgaon-122001 through its Managing Director.

 

                                                                      …..Opposite Party.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

      Dr. Rekha Chaudhary……Member

          

 Argued by: Shri Deepak Kumar, counsel for the complainant.

                    Shri Ashwani Popli, counsel for the OP.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite party(hereinafter referred to as ‘OP’) on the averments that complainant alongwith his wife Mrs. Deepika Bhatia purchased a Care Freedom Plan-I Health Insurance Policy from the OP by paying a premium of Rs.48522/-, vide insurance policy no.1741225, valid upto 24.05.2021 and sum insured under the said policy was Rs.5.00 lakhs. The OP has also been renewing the same from time to time. Complainant was having fever due to which he was taken to Dr. Gian Bhushan Nursing Home Karnal and there his tests were conducted and he was found patient of Covid-19 and as such he on 20.11.2020 admitted in the said hospital and was discharged on 25.11.2020. The said hospital has charged an amount of Rs.47,700/- and other expenses of tests etc. is of Rs.17,000/-. After the discharge from the hospital, complainant lodged his claim with the OPs on 10.12.2020 and sent all the documents to the OP. Thereafter, complainant visited the office of OP several times and requested to settle the claim but OP did not pay any heed to the request of complainant and lingered the matter on one pretext or the other. On 03.02.2021, complainant received a letter from the OP for requirement of additional information for claim and same was sent on 10.03.2021. After that complainant  sent an email on 20.05.2021 for reimbursement of the mediclaim amount but to no effect. To the utter surprise of the complainant when he received a letter dated 21.06.2021, vide which the claim of the complainant has been rejected/repudiated on the ground that “as per consultation dated 28.05.2015 patient is chronic smoker with history of COPD, CAD Post ANGIO CT, pancreatitis and hypertension prior to policy inception which comes under PED and not disclosed, hence claim cannot be considered”. The said plea taken by the OPs is totally illegal, null and void whereas complainant was suffering from covid-19 pandemic and this ailment has no concern with hypertension as alleged by the OP. The hypertension is not a permanent disease and it sometimes increase and sometime it reduce and if non-mentioning of such type of disease in the declaration form would not amount to mis-statement in real sense, so in the light of abovesaid fact, the repudiation of claim of the complainant by the OP was not justified and pancreatitis was recovered in the year 2015. The OP has taken wrongful view of guidelines/condition of the policy, in fact the abovesaid condition/guidelines are not applicable to the facts of present case. The complainant had good health reached to the age of 67 years and was good in health at the time of getting the policy of OP, then it cannot be taken that he had any pre-existing disease. The repudiation of claim on flimsy ground is deficiency in service and unfair trade practice adopted by the OP in order to avoid their inability to pay the compensation. Hence complainant filed the present complaint.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that complainant was covered under a health insurance policy namely “Care Freedom Plan 1” bearing policy no.17412225 from 20.05.2020 till 24.05.2021 covering the sum insured of Rs.5,00,000/- subject to policy terms and conditions. The policy was renewed from 22.06.2021 to 21.06.2022 the said policy was ported from Oriental Insurance Company Limited from 2016 to 2020. Thereafter, complainant ported his health insurance policy with the OP. The policy certificate alongwith policy terms and conditions was duly delivered to the complainant, vide email and SMS dated 14.06.2020. The renewal policy copy was sent vide email and SMS dated 21.06.2021. It is further pleaded that complainant submitted a reimbursement claim with the OP on 23.01.2021 seeking  hospitalization benefit under the said policy for his hospitalization at Dr. Gian Bhushan Nursing Home, Karnal from 20.11.2020 to 25.11.2020. As per the medical documents and discharge summary received alongwith claim form the complainant was diagnosed with covid-19 infection with Pneumonia. As per the discharge summary the final diagnoses were type II Diabetes Mellitus/HTN, Vovid-19 infection with Pneumnia, Coronary artery disease. Upon perusal of the documents received with the claim form and those additional documents procured the OP came up with the following findings:

The insured has a prolonged history of illness and the same were not disclosed to the OP company at the time of entering into the health insurance policy. during the tele-underwriting call, the insured declared that he and his spouse are suffering from Diabetes Mellitus since 10 years. The complainant also disclosed his history of operation of sinus during childhood.

The following evidences were taken into consideration by the company at the time of execution-

.       As per medical document dated 27.05.2015 from Cardiothoracic and Neurosciences Centre, AIIMS, New Delhi, the complainant is mentioned to be a chronic smoker and suffering from obesity and Chronic Obstructive Pulmonary Disease (COPD). He also has a history of Hypertension, Diabetes Mellitus. He also underwent Pancreatitis treatment in 2007.

.       As per medical document dated 28.05.2015 from Cardiothoracic and Neurosciences Centre, AIIMS, New Delhi, the complainant is mentioned to be a known case of Hypertension, Diabetes Mellitus and Chronic Obstructive Pulmonary Disease (COPD). He also has a history of Hypertension, Diabetes Mellitus. He also underwent Pancreatitis treatment in 2007.

.       As per medical document dated 29.05.2015, the complainant is mentioned to be a case of Coronary Artery Disease-Post Angio CT and had a history of Pancreatitis since 2007. He was also a known case of Type 2 DM since 2007.

.       As per medical document dated 15.10.2015 from Cardiothoracic and Neurosciences Centre, AIIMS, New Delhi, the complainant had a history of Acute Pancreatitis and alcohol consumption in the past. In the same document, the treating doctor had mentioned the insured’s history of smoking. He also had a history of coronary angiography  in 2015 at AIIMS.

.       As per the discharge summary of the current hospitalization, he had past history of DM and HTN

        In view of the aforementioned findings, the OP repudiated the claim, vide Denial letter dated 31.03.2021 on the ground that “As per consultation dated 28.05.2015, patient is chronic smoker with history of COPD, CAD Post Angio CT, Pancreatitis and Hypertension prior to policy inception which comes under PED and not disclosed, hence claim cannot be considered”.  It is further pleaded that the insured had the opportunity to disclose the history of smoking, alcohol consumption, chronic obstructive, pulmonary disease (COPD), hypertension, coronary artery disease (CAD), acute pancreatitis I 2007 at the time of filing online proposal form and tel-underwring; however, the said pre-existing disease/ailment were deliberately not disclosed by the insured in order to get undue benefit of health insurance from the OP. There is no deficiency in service on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policy of Religare Health Insurance of the year 2020-2021 Ex.C1, copy of insurance policy of OP of the year 2021-2022 Ex.C2, copies of medical bills Ex.C4, copy of discharge summary Ex.C5, copy of claim form Ex.C6, copy of demand of certain documents vide letter dated 03.02.2021 Ex.C7, copy of additional information required for claim Ex.C8, copy of email dated 20.05.2021 Ex.C9, copy of rejection of claim letter dated 21.06.2021 Ex.C10 and closed the evidence on 10.02.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Ravi Boolchandani, Manager-Legal at Care Health Insurance Limited Ex.OP1/A, copy of certificate of incorporation Ex.OP1, copy of policy certificate Ex.OP2, copy of policy terms and conditions Ex.OP3, copy of previous policy Ex.OP4, copy of claim form Ex.OP5, copy of discharge summary Ex.OP6, copy of evidences Ex.OP7, copy of denial letter Ex.OP8, copy of online proposal form Ex.OP9, copy of judgment Ex.OP10 and closed the evidence on 20.10.2022 by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant had purchased a health insurance from the OP. On 20.11.2020, complainant admitted in Dr. Gian Bhushan Nursing Home Karnal due to Covid-19 and discharged on 25.11.2020. Complainant spent Rs.64700/- on his treatment. After discharged from the hospital, complainant submitted the claim form with the OP for reimbursement of the said amount and got completed all the formalities. The complainant requested the OP several times for reimbursement of claim amount but OP did not pay the claim amount and repudiated the same, vide letter dated 21.06.2021 on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that the complainant approached the OP for reimbursement of the claim for his hospitalization due to Covid-19. As per medical documents and discharge summary, complainant has a history of hypertension, diabetes Mellitus and was also underwent pancreatitis treatment in 2007. Hence, the claim of the complainant has been repudiated by the OPs, vide letter dated 21.06.2021 and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant has availed the health insurance policy from the OP. It is also admitted that during the subsistence of the insurance policy complainant has taken a treatment in Dr. Gian Bhushan Nursing Home, Karnal.

11.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.C10 dated 21.06.2021 on the ground, which reproduced as under:-

       “As per consultation dated 28.05.2015, patient is chronic smoker with history of COPD,CAD Post Angio CT, Pancreatitis and hypertension prior to policy inception which comes under PED and not disclosed, hence claim cannot be considered”.      

 12.          The onus to prove its case lies upon the OPs, but OP has miserably failed to prove the same by leading any cogent and convincing evidence. The case of the OP is based upon treatment record Ex.OP7 dated 28.05.2015, issued by Cardiothoracic and Neurosciences Centre, AIIMS, New Delhi, and treatment record dated 29.05.2015 issued  by Professor Vineet Ahuja of AIIMS, Hospital New Delhi. Neither the said doctors who have issued the said treatment record were examined nor their affidavits were tendered into evidence by the OP to prove its version. Moreover, said treatment records are only photocopies and same are not admissible in the eyes of law. Furthermore, there is no nexus between the Covid-19 i.e. treatment taken by the complainant and treatment taken by the complainant in alleged treatment record.

13.           Further, for the sake of arguments, if it is presumed that the complainant was suffering from Hypertension and diabetes at the time of obtaining the insurance policy, in that case also the claim of the complainant cannot be repudiated on the said ground, because Hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension. In this regard, we are also fortified from the observations of the Hon’ble State Commission, New Delhi, titled as Life Insurance Corporation of India Versus Sudha Jain 2007 (2) CLT 423, in which Hon’ble State Commission has drawn conclusion in para 9 of the order and the relevant clause is 9 (iii), is reproduced as under:-

“9(iii) Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.” Taking into consideration the facts of the present case and law laid down by the Hon’ble Superior Fora in the above referred cases, we are of the view that OPs were not justified in repudiating the claim of the complainant and are thus liable to pay the amount which the complainant had incurred on his treatment”.

 

Further in United India Insurance Co. Ltd. & Anr. Versus S.K. Gandhi, 2015 (2) CLT 71 (NC)  the insurance company had not placed on record either the discharge summery of the complainant or any medical document signed by the doctors who treated him in Bhatnagar Eye Centre, Karnal and Arpana Hospital, Madhuban to show that the complainant when he was admitted to the said hospital, had himself stated that he was suffering from hypertension from last 8 years. In that case it was held that it is quite possible that the complainant, despite suffering from diabetes was not actually aware of the same and he cannot be accused of mis-statement or concealment. Onus was upon the insurance company to prove that he had made a mis-representation while obtaining the insurance policy and since the insurance policy failed, it was held that it was liable to pay to the complainant to the extent a sum insured by it.

14.  

                It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.

 15.          Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OP while repudiating the claim of the complainant amounts to deficiency, which is otherwise proved genuine one. 

16 .          The complainant has spent Rs.64,700/- on his treatment and in this regard he has placed on record medical bills Ex.C4. The said bills have not been rebutted by the OP. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

17.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.64,600/- (Rs. sixty four thousand six hundred only)) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OP to pay Rs.10,000/- to the complainant on account of mental agony and harassment and Rs.5500/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:14.02.2022                        

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 (Vineet Kaushik)       (Dr. Rekha Chaudhary)

                          Member                           Member