Chandigarh

DF-I

CC/378/2020

Raghbir Singh - Complainant(s)

Versus

Care Health Insurance Limited - Opp.Party(s)

Vishal Ahuja

14 Feb 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/378/2020
Date of Institution	:	18/09/2020
Date of Decision	:	14/02/2023

 

Raghbir Singh S/o Late Sh. Attar Singh, aged 62 years, R/o House No.2806, Sector 40-C, Chandigarh.

… Complainant

V E R S U S

Care Health Insurance Ltd. (Formerly Religare Health Insurance Co. Ltd.), having its registered office at 5^th Floor, 19 Chawla House, Nehru Place, New Delhi 110019 through its Authorized Signatory/Representative.

2^nd Address: Unit No.606, 6^th Floor, Tower-C, Unitech Cyber Park, Sector 39, Gurugram 122001.

… Opposite Party

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR	MEMBER
	SURESH KUMAR SARDANA	MEMBER

 

                                                

ARGUED BY	:	Sh.Vishal Ahuja, Counsel for Complainant.
	:	Ms.Niharika Goel, Counsel for OP.

 

Per Suresh Kumar Sardana, Member

1.      Averments are the complainant obtained health insurance policy from the OP for a period of 19.01.2020 to 18.01.2021. The complainant and his family members were also insured for a sum of Rs.5,00,000/- each, under the insurance policy. The complainant paid an amount of premium Rs.15,391/-. As per policy, pre-hospitalization, hospital expenses, in patient care and post hospitalization medical expenses incurred by the complainant to the extent of period mentioned in the cover note were admissible (Annexure C-1). As per complainant, on 03.02.2020, the wife of the complainant suffered from sudden onset of severe headache and the same was followed by vomiting. The wife of the complainant was immediately taken to PGIMER, Chandigarh and was admitted in the emergency ward. The wife of the complainant was diagnosed with ‘Right Hemiplegia, Spont Sah with Left Ruptured PCOM Aneurysm’ and remained admitted in the PGIMER, Chandigarh and was operated on 05.02.2020 (Annexure C-2). The complainant spent a sum of Rs.1,59,855/- for treatment of his wife and accordingly submitted the claim form with the OP for reimbursement of the medical expenses on 29.06.2020 (Annexure C-3). Despite being provided with all the necessary documents well in time, the OP kept on delaying the matter by raising one query or the other (Annexure C-4). The OP finally rejected the claim of the complainant on 26.08.2020 on the ground that the 30 days waiting period had not elapsed (Annexure C-5). The claim of the complainant was fully covered under the insurance policy as the medical expenses incurred for treatment of illness was a result of an injury. The act of the OP in declining genuine claim of the complainant amounts to deficiency in service and unfair trade practice on its part. Hence, this present complaint.
2.     OP contested the consumer complaint, filed its written reply and stated that as per the terms and conditions, the claim for any medical expenses incurred for treatment of any illness during the first 30 days of the cover start date shall not be admissible. The policy coverage began on 19.01.2020 and the complainant was hospitalized on 05.02.2020 i.e., within 30 days from policy inception. Therefore, the claim of the insured was rejected. It is also submitted that the company sent a query letter dated 07.05.2020 to the complainant and asked for certain documents. As no documents were received, therefore, the company sent a reminder letter dated 17.05.2020 (Annexure OP-3) Colly. It is further submitted that a query reply to these letters was received from the complainant, but the reply does not consist of the complete documents thereby the company raised another query on dated 21.07.2020 and sent to the complainant and he was asked to provide certain documents (Annexure OP-4). On these lines, the case is sought to be defended by the OP.
3.     Rejoinder was filed and averments made in the consumer complaint were reiterated.
4.     Parties led evidence by way of affidavits and documents.
5.     We have heard the learned counsel for the parties and gone through the record of the case. After perusal of record, our findings are as under:-
6.     The main grievance of the complainant is that inspite of having proper cover of health insurance policy his genuine claim was not passed by the OP’s.
7.     The stand of OP is that detailed terms & conditions were dispatched to the complainant and as per detailed terms and conditions; he was not eligible for the reimbursement of the claim. During arguments the counsel of the complainant argued that detailed terms and conditions were neither supplied, nor explained in detail, however, the policy document supplied to the complainant was annexed as Annexure C-1. On perusal of the policy placed at Anneuxre C-1, there is a wait period of 30 days and “Claim for any Medical expenses incurred for treatment of any illness during the first 30 days of the Cover Start Date shall not be admissible, except those Medical Expenses incurred as a result of an injury.”

         In the absence of any proof of dispatch of any terms & conditions, we have gone through the definition of “Hemiplegia” suffered from the disease from which the complainant suffered searching from the Google engine.

         “Hemiplegia is caused by injury to parts of the brain that control movements of the limbs, body, face, etc. This injury may happen before, during or soon after birth (up to two years of age approximately), when it is known as congenital hemiplegia (or unilateral cerebral palsy). If this happens later in life as a result of injury or illness, it is called acquired hemiplegia.”

         Hence, “Hemiplegia”, is also caused by injury, hence there is no necessity of wait period of 30 days for the insurance cover as “Hemiplegia” included injury.

8.     As per the judgment cited as 2019(2) Law Herald (SC) page No.1225 Bharat Watch Co. through its Partner Vs. National Insurance Co. through regional Manager, the Hon’ble Supreme Court had held when the insurance Co. fails to furnish terms and conditions of the exclusion clause the same would not be binding upon the policy holder.
9.     Further, regarding non-explaining of the exclusion clause, the Hon’ble State Consumer Disputes Redressal Commission, Haryana in Star Health and Allied Insurance Co. Ltd. Vs. Asha and Ors., has held:-

         “Consumer Protection Act, 1986 Section 2(1)(g) Mediclaim-Insurance policy- Terms and Conditions of policy containing exclusion clause- Held that, it is the duty of the insurer to prove that such terms and conditions with exclusion clause were explained to the insured when cover note was issued- It was no where mentioned that the insured was explained about the exclusion- The alleged exclusion clauses, warranties, endorsement, etc. are mentioned in very small letters- Insurance policy is issued by the company much later after accepting proposal and issuing only cover note- It is well settled that the company, who is taking specific plea about repudiation of any claim, has to prove that the exclusion clause was explained to the consumers- Once the insurer failed to prove this fact, it cannot take any benefit from such an exclusion clause- Appeal of insurer against the order of District for a accepting the complaint of consumer, dismissed.”

10.     In case New India Assurance Co. Ltd. Vs. Smt. Usha Yadav & Ors. 2008(3) R.C.R. (Civil) 111, the Hon’ble Punjab & Haryana High Court expressed its anguish and observed as follows:-

         “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.” 

11.     In view of the above discussion, the OP is deficient providing service to the complainant and present consumer complaint succeeds and the same is accordingly partly allowed. OP is directed as under :-

1. to pay an amount of ₹1,59,855/- to the complainant alongwith interest @ 9% per annum from the date of filing of this complaint till realization.
2. to pay an amount of ₹10,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹7,000/- to the complainant as costs of litigation.

12.     This order be complied with by the OP within thirty days from the date of receipt of its certified copy, failing which, it 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.
13.     Certified copies of this order be sent to the parties free of charge. The file be consigned.

			Sd/-
14/02/2023			[Pawanjit Singh]
Ls			President
			Sd/-
			[Surjeet Kaur]
			Member
			Sd/-
			[Suresh Kumar Sardana]
			Member