Haryana

Karnal

CC/190/2022

Dheer Singh - Complainant(s)

Versus

Care Health Insurance Limited - Opp.Party(s)

Balraj Pal

22 May 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 190 of 2022

                                                        Date of instt.01.04.2022

                                                        Date of Decision:22.05.2024

 

Dheer Singh son of Shri Karam Chand, resident of village Mangalpur P.O. Tikri, near Government Senior Secondary School, Karnal.

 

                                                                        …….Complainant.

                                              Versus

 

Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited), SCO no.354, Mugal Canal, Karnal.

IInd Address:-Registered Office: 5^th floor, 19 Chawla House, Nehru Palace, New Delhi-1100019 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.  Suman Singh…..Member

 

 Argued by: Shri Balraj Pal, 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 the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant purchased a mediclaim policy bearing no.30139171, valid from 11.02.2021 to 10.02.2022 and the said policy covered the complainant, his wife Pramila and daughter Mannat. The complainant paid the premium of Rs.19,590/ to the OP. On 26.09.2021, the complainant started suffering from left side chest pain with sweating and uneasiness. The complainant went to Life Care Hospital, Karnal. The complainant remained admitted in the said hospital from 26.09.2021 to 28.09.2021. Complainant spent an amount of Rs.40,986/- on his treatment. The abovesaid policy was a cashless policy but complainant paid the said amount from his own pocket. After discharge from the hospital, complainant lodged the claim with the OP and submitted all the required documents for reimbursement of the claim but OP did not pay the claim  and repudiated the same on the false and frivolous ground. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence complainant filed the present complaint.

 2.            On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action; locus standi; jurisdiction and concealment of true and material facts. On merits, it is pleaded that OP issued a health insurance policy under the Plan namely “Care” bearing policy no.12083709 in favour of complainant  for providing policy coverage to the complainant, his spouse and daughter. The policy was issued w.e.f. 07.02.2018 till 06.02.2019 for a sum insured of Rs.4,00,000/- subject to policy terms and conditions. The said policy was further renewed on annual basis, however, due to cheque bounce, the policy could not be renewed in time for the policy period 2021-2022. Thereafter, the policy was later self-ported with a new policy bearing no.30139171 for the period from 11.02.2021 till 10.02.2022. The said policy has been further renewed w.e.f.11.02.2022 till 10.02.2023. It is further pleaded that complainant approached the OP with a Reimbursement Claim as he was admitted to Life Care Hospital, Karnal from 26.09.2021 till 28.09.2021. As per the medical documents and discharge summary, the insured was diagnosed with ACS-Ubstable Angina with PSVT in K/c/o CAD (Post PCI) with Type 2 DM. An investigation was also triggered by the OP in order to check the veracity of claim. Upon receipt of Reimbursement Claim, the OP perused the medical documents and observed that:-

.       As per Discharge Summary dated 15.01.2018 of previous hospitalization, the insured has been mentioned with past history of DM-2 and HTN since 4 years. Also, the insured was diagnosed with ACS, CAG-DVD and underwent PTCA (Stenting) on 16.01.2018 and TIA i.e. prior to policy inception.

.       As per Insured’s statement procured during investigation, the insured has stated that he has history of hypertension since 1.5 years, (Tab. Telema), Diabetes since 3 years. He had also stated that he underwent operation of Heart on 15.01.2018 a Max Hospital, Mohali where I stent in his heart.

.       As per treating doctor statement procured during investigation, he stated that the insured had undergone PCI in 2018 at Max Hospital, Mohali and has history of heart disease since 3 years.

.       As per in-patient history and physical record dated 26.09.2021 of Life Care Hospital, the insured is marked with past medical history of K/c/o Type 2 DM and CAD post PCI 3 years.

                In view of the above findings, the OP repudiated the claim vide Denial Letter dated 09.12.2021 on the following grounds:

.       Claim Repudiated; for non-disclosure of Diabetes, Hypertension, Heart Disease and TA prior to the Policy Inception.

        The Policyholder/complainant had the opportunity to disclose the History of DM, HTN, Heart Disease and TIA since January 2018 at the time of proposal i.e. since prior to policy inception; however, the said pre-existing disease was deliberately not disclosed by the complainant for the reasons best known to him. Thus, the claim of complainant has rightly been repudiated by the OP. There is no deficiency in service and unfair trade practice 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 policy certificate Ex.C1, copy of liability details of insured Ex.C2, copy of letter dated 16.02.2021 Ex.C3, copy of claim denial letter dated 09.12.2021 Ex.C4, copy of letter of Grievance Redressal Procedure Ex.C5, copy of medical bills Ex.C6 to Ex.C11, copy of discharge summary Ex.C12 and closed the evidence on 11.01.2023 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Lakshay Juneja, Manager Ex.OP1/A, copy of policy certificate Ex.OP1, copy of terms and conditions of the policy Ex.OP2, copy of discharge summary Ex.OP3, copy of claim form Ex.OP4, copy of final bill Ex.OP5, copy of investigation report Ex.OP6, copy of claim denial letter dated 09.12.2021 Ex.OP7, copy of statement of patient during verification and investigations Ex.OP8, copy of doctor statement Ex.OP9, copy of investigation flow chart Ex.OP10 and closed the evidence on 11.05.2023 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  purchased a health insurance from the OP. On 26.09.2021, complainant admitted in Life Care Hospital, near Community Centre, Main Market, Sector-7, Karnal due to chest pain and discharged on 28.09.2021. Complainant spent Rs.40,986/- on his treatment. After discharged from the hospital, complainant submitted the claim alongwith relevant documents with the OP for reimbursement of the said amount. 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 09.12.2021 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 chest pain. As per medical documents and discharge summary, complainant has a history of hypertension since 1.5 years, diabetes since 3 years and was also underwent operation of heart on 15.01.2018 at Max Hospital, Mohali. Thus, the claim of complainant has rightly been repudiated by the OP and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, complainant availed the health insurance policy from the OP. It is also admitted that during the subsistence of the insurance policy complainant was hospitalized in Life Care Hospital, Karnal. It is also admitted that the policy in question is continuing since 2018.

11.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.C4/OP7 dated 09.12.2021 on the ground, which is reproduced as under:-

“We have reviewed the claim filed by you pertaining to Health Insurance Policy and hereby inform you that the claim is not payable as per policy terms and conditions listed below:

.               Claim Repudiated; for non-disclosure of Diabetes,    Hypertension, Heart Disease and TA prior to the Policy Inception.

.               Non Disclosure.

12.           The claim of the complainant has been repudiated by the OP on the abovesaid ground. The onus to prove its version was relied upon the OP, but OP has miserably failed to prove the same by leading any cogent and convincing evidence. The case of the OP is based upon discharge summary of Life Care Hospital, Karnal Ex.OP3 and doctor statement Ex.OP9, the complainant admitted in the said hospital on 26.09.2021 and discharge on 28.09.2021 and diagnoses for ACS-Unstable Angina with PSVT in k/c/o CAD (Post PCI) with Type 2 DM.  In the said discharge summary, it is nowhere mentioned that complainant was having pre-existing illness. There is no previous treatment record placed on file by the OP to prove its version. OP neither examined the Doctor nor tendered his affidavit, who has suffered the statement Ex.OP9. In this regard we are relying upon the case law titled as SBI Life Insurance Co. Ltd. Vs. Lakshiben Naginbhai Chauhan and others 2020 CJ 110 (NC) and Authorised Signatory, Hon’ble National Commission has held that Insurance-SBI Home Loan Master Policy-Repudiation of death claim on ground of concealment of pre-existing disease-Complaint allowed by fora below-Both District Forum and State Commission had reached to conclusion after going through all documents that medical papers have not been properly proved since neither doctor has been duly examined nor his affidavit has been furnished-National Commission is not expected and required to re-appreciate and re-assess evidences-where on the basis of evidences Fora below have reached to a conclusion which is a possible conclusion, then such conclusion need not be disturbed in Revision Petition-Revision petition dismissed. Further in case titled as Bajaj Allianz Life Insurance Co. Ltd. and 2 others Versus Kanduru Gangadhara Rao in Revision Petition no.1054 of 2020, decided on 07.10.2021 Hon’ble National Commission held that Insurance Law-concealment of disease-Death claim repudiated by insurer on ground that life assured suppressed her health condition of her taking treatment for  placed reliance on the treatment record, ‘Chronic non-specific cervicitis’ prior to obtaining the policy-Hence this complaint-Held, insurance company placed reliance on treatment record, which was a mere photocopy and not certified. The Doctor who treated the Life Assured was also not examined nor was his affidavit filed by the insurance company. Also, insurance company failed to satisfy this Commission that there was any co-relation between death of the Life Assured and the suppression of ailment "Chronic non-specific cervicitis". Complaint allowed.

                Keeping in view the ratio of law laid down in the aforesaid judgments, facts and circumstances of the case, it is proved on record that OP has wrongly and illegally repudiated the claim of complainant. Hence, plea taken by the OP, complainant was having pre-existing disease has no force.

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.           Furthermore, the OP on the basis of above medical record which pertains to the period after issuance of the policy presumed that complainant has longstanding heart disease prior to inception of medical insurance policy. However, it is settled proposition of law that merely on the basis of presumption without any cogent and convincing evidence, it cannot be concluded that complainant was suffering from any disease prior to taking the insurance policy. In this regard, we are also fortified from the observations of the Hon’ble National Commission made in judgment dated 31.05.2019 rendered in Rivision Petition No.2097 of 2017 case titled as Reliance Life Insurance Company Ltd. & Anr. Vs. Tarun Kumar Sudhir Halder in which it is observed as under:-

“12. From the above entry, it seems that either the doctor filling up this form has not clearly given the date or somebody has made cutting after the word ‘since’. Thus, no conclusion can be drawn in respect of the period since when the DLA was suffering from diabetes. From the entries in the Medical Attendant Certificate it is clear that the DLA first complained about illness only on 22.06.2021. This entry clearly denies pre existing disease of Diabetic Ketoacidosis. The insurance company has not filed any evidence to show that the DLA was taking treatment for the disease prior to filling up of the proposal form. Even if there was disease inside the body, but the life insured did not know about the disease and was not taking any treatment for the same, the insurance claim cannot be denied on mere presumption that the life assured might be suffering from pre-existing disease. Thus, on merits, I am convinced on the basis of the entries in the Medical Attendant Certificate that the disease was complained for the first time by the DLA on 22.06.2021, which is much after the date of the proposal form. The onus to prove the pre-existing disease lies on the Insurance Company and no supporting documents have been filed by the Insurance Company in support of their assertion.”

15.  

“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.

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

17.           The complainant has spent Rs.40,986/- on his treatment and in this regard he has placed on record medical bills Ex.C6 to Ex.C11. The said bills neither denied nor rebutted by the OP. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental pain, agony and harassment and litigation expenses etc.

18.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.40,986/- (Forty thousand nine hundred eighty six only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 09.12.2021 till its realization. We further direct the OP to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- 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:22.05.2024 

  President,       

District Consumer Disputes

Redressal Commission, Karnal.

 

                  (Vineet Kaushik)              (Dr. Suman Singh) 

                         Member                             Member