Chandigarh

DF-II

CC/747/2022

SUDESH CHOUDHRY - Complainant(s)

Versus

CARE HEALTH INSURANCE LIMITED - Opp.Party(s)

22 Jul 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	747 of 2022
Date of Institution	:	30.10.2022
Date of Decision	:	22.07.2024

 

                     

            

 

Sudesh Choudhry, aged 66 years, wife of Late Sh.Sunil Choudhry, resident of # 449, Sector 37-A, Chandigarh 160036

...Complainant

VERSUS

1]  Care Health Insurance Limited, having its registred office at 5^th Floor, 19 Chawla House, Nehru Place, New Delhi 110 019

 

2]  Fortis Hospital, Fortis Healthcare Limited, Jail Road, Sector 62, Mohali 160062, Punjab

…. Opposite Parties

 

BEFORE:  MR.AMRINDER SINGH SIDHU,       PRESIDENT

        MR.B.M.SHARMA,                MEMBER

                               

Argued by:-       Sh.Sanyam Malhotra, Counsel for the complainant (Through V.C.)

                  Ms.Niharika Goel, Adv. proxy for Sh.Mohit Garg, Counsel for OP No.1

                  Sh.Munish kapila, Counsel for OP No.2 (through V.C.)

 

 

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

 

1]      The complainant has filed the present complaint pleading that she and her husband late Sh.Sunil Choudhry were getting their health insurance done jointly since Feb., 2014 without any break through their bankers Punjab National bank, acting as an intermediary and from the year 2014 to 2021, they were medically insured with Oriental Insurance Company Ltd. and in the year 2022 were insured by Care Health Insurance Ltd., as advised by their banker Punjab National Bank, for sum insured of Rs.5 lacs each under the Punjab National Bank Group Care 360 (PNB Platinum) Plan (Ann.C-2).  It is stated that on 29.8.2022 in the morning, the complainant found her husband lying motion-less on the bed, so he was admitted to Fortis Hospital, Mohali/OP No.2 where he was diagnosed with having suffered a brain stroke and after treatment, he was discharged on 1.09.2022.  It is stated that OP No.2 has taken the details of insurance from the complainant and forwarded the same to Op No.1 Insurance Company for approval but the same was denied by it on the ground that there was non-disclosure of a pre-existing heart ailment at the time of purchase of the policy (Ann.C-3). 

         It is submitted that there was no pre-existing heart ailment suffered by the complainant’s husband as he had undergone a bypass surgery of heart in Fortis Hospital on 27.12.2013 and the same cannot be terms as an ailment or disease and it was treated, dealt with and over many year ago.  It is also submitted that even as per policy, the pre-existing disease means any condition, ailment, injury or treatment which is within 48 months prior to the date of the policy, but the policy obtained by the complainant and her husband is more than 8 years old.  It is submitted that the complainant’s husband was again hospitalized on 17.9.2022 as he was not feeling well and remained in Fortis Hospital for treatment till his last breath on 06.10.2022.  It is pleaded that the complainant had paid Rs.15,32,645/- for treatment, medicines, tests etc. for her late husband/life assured from 17.9.2022 to 06.10.2022 in addition to earlier payment of Rs.1,60,203/- paid on 01.09.2022 (Ann.C-6).  The complainant also sent legal notice to the OP Insurance Company for paying sum insured under the policy but to no avail (Ann.C-5). Hence, this complaint has been filed alleging the said act & conduct of the OP No.1 as deficiency in service and unfair trade practice with a prayer to direct OP No.1 to pay sum insured under the policy along with compensation for harassment as well as litigation cost etc. 

 

2]       After service of notice, OP No.1 appeared before this Commission and filed their written version stating that answering OP Company had issued a Group Health Insurance Policy to group policyholder i.e. Punjab National Bank vide Group Policy No.17499225 namely Punjab National Bank Group Care 360 PNB Platinum Plan thereby covering its customer including complainant Ms.sudesh Coudhary and her husband Sunil Choudhry effective from 26.2.2022 to 25.2.2023 for a sum insured upto Rs.5 lacs subject to policy terms. It is stated that the policy was ported from Oriental Health Insurance Policy wherein the date of First Enrolment was 26.2.2014.  It is submitted that the cashless request received in respect of the deceased life assured was rejected because as per the Discharge Summary of the Fortis Hospital dated 01.09.2022, the insured is a known case of hypertension and hypothyroidism; known case of CABG since 2013 and having past medical history of CABG since 2013 and he suffered heart attack in the year 2013.  It is also submitted that at the time of proposing for the health insured policy in question, the life assured has not disclosed the true & complete facts about his pre-existing disease of heart ailment and as such, the claim  was rightly repudiated as per terms & conditions of the policy.  The remaining allegations have been denied and pleading no deficiency in service or unfair trade practice, the OP No.1 has prayed for dismissal of the complaint.

 

3]      The OP No.2 – Fortis Hospital has also filed written version stating that the complainant has no grievance qua OP No.2 and has claimed no relief qua it.  It is admitted that patient Sunil Chudhary was admitted in OP Hospital on 29.8.2022 and discharged on 01.09.2022 and again admitted on 17.9.2022 till 07.10.2022.  It is stated that when for the first time the patient Sunil Choudhry was admitted in the hospital, a cashless request of the patient was forwarded by the Hospital to OP No.1, which was denied on 01.09.2022 and the complainant had to pay Rs.1,58,103/-.  It is submitted that total bill for second admission of the said patient for the period from 17.9.2022 to 07.10.2022 came to Rs.15,32,645/-.  It is also submitted that both the said bills were paid by the complainant.  It is admitted that the patient had undergone bypass surgery at OP No.2 Hospital on 27.12.2013.  Denying other allegations being not related to, the OP NO.2 has prayed for dismissal of the complaint qua OP No.2.

4]       Replication has also been filed by the complainant controverting the assertions made by OP No.1 in its written version.          

5]       The parties led evidence in support of their contentions.

6]      We have heard the Counsel for the contesting parties and have gone through the documents on record including written submission.

 

7]       The perusal of the record reveals that it is an admitted fact that the complainant and her husband late Sh.Sunil Choudhry were medically insured through Punjab National Bank earlier with Oriental Insurance Company and now with OP No.1 Company continuously since the year 2014 to 2022.  It is also admitted that late Sh.Sunil Choudhry, Life Assured got treatment at OP No.2 Hospital twice during the policy period in the year 2022 and the claim was lodged with OP No.1 Insurance Company. However, the OP No.1 Company admittedly rejected the claim on the ground that there was a non-disclosure of a pre-existing heart ailment at the time of purchase of the policy.

 

8]       It is observed that as per IRDA Circular No.IRDAI/HLT/REG/CIR/193/07/2020, dated 22.07.2020 on Health Insurance Products (Ann.C-4), the clause of pre-existing disease covers any ailment, injury, disease or treatment applicable for 48 months period prior to the date of policy issued by the insurer.  It is also observed that in the present case, admittedly the policy was taken in the year 2014 and treatment was taken by the insured only in August, 2022 i.e. after 8 years from the inception of the policy.  Moreover there is no nexus between the heart treatment taken by the insured in the year 2013 and the treatment given to him in 2022.  It is therefore observed that the OP No.1 Insurance Company has wrongly & illegally rejected the genuine claim in respect of the deceased life assured Sh.Sunil Choudhry by wrongly taking the shelter of pre-existing disease, which is not applicable in the present case.  

 

9]      In such a situation, the repudiation made by the OP No.1-Insurance Company regarding genuine claim of the complainant has been made without application of mind. It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.  It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

    “It seems 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.  The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

10]     In view of the above discussion, it can be safely concluded that OP No.1-Insurance Company has committed deficiency in service by wrongly and illegally rejecting the claim of the complainant.

 

11]      Consequently, the present complaint deserves to be partly allowed and the same is accordingly allowed qua OP No.1. The OP No.1-Insurance Company is directed to pay the sum assured i.e. Rs.5,00,000/- to the complainant along with interest @6% per annum from the date of filing of present complaint till the date of actual realisation of the amount.

         This order be complied with by OP No.1 within 60 days from the date of receipt of its certified copy.

12]      The complaint qua OPs No.2 stands dismissed.

13]     The pending application(s) if any, stands disposed of accordingly.

        The Office is directed to send certified copy of this order to the parties, free of cost, as per rules & law under The Consumer Protection Rules & Act accordingly. After compliance file be consigned to record room.

Announced                                    Sd/-

22.07.2024                                                                                       

 (AMRINDER SINGH SIDHU)

PRESIDENT

 

 

Sd/-

 (B.M.SHARMA)

MEMBER