District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 394/2022.
Date of Institution: 26.07.2022.
Date of Order:11.08.2023.
Girraj Rohella S/o Roop Chand, R/o House No. 1263A, Sector-23A, Faridabad – 121005.
…….Complainant……..
Versus
Care Health Insurance Limited, R/Office 5th Floor, 19 Chawla House, Nehru Place, New Delhi – 110 019.
Second address:-
Care Health Insurance Limited, Corp. Office Unit NO. 604, 6th floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram-122001.
…Opposite party.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
PRESENT: Sh. Gourav Sharma , counsel for the complainant.
Sh. N.K.Garg , counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the opposite party
gave mediclaim policy to the complainant “Group Health Insurance Product Policy for bank account holders of OBC only) UIN: OICHLGP18075V011718. The complainant’s policy had been running from their company since 2012. During the treatment of said policy, the complainant was operated due to Acute Exacerbation of Chronic Obstructive Pulmonary disease Hyperkalaemia (corrected) at Fortis Escorts Hospital, Neelam Bata Road, Faridabad , on 06.02.2021 and he remain admitted as indoor patient from 06.02.2021 to 11.02.2021 and he was treated there. The complainant was discharged on 11.02.2021 from the said hospital. The bill for rs.94,906/- was revised against the complainant. At the time of admission of opposite party into the said hospital the intimation regarding the medical treatment of complainant fill the claim form and sent to the opposite party and opposite party’s surveyor visited the said hospital and inspect the same. But after that the opposite party did not approved the claim amount to complainant and opposite party issued a “claim payment denial letter dated 07.02.2021” with the reason of “Non discloser the fact for complainant’s disease” and complainant pay all the amount of treatment from his own pocket. On the basis of above said policy, the complainant submitted all information/intimation regarding the treatment and hospitalization and apply the claim with all bills, discharge summary & necessary documents, after discussing the opposite party’s agent Mr. Kunal. The opposite party’s agent advice to the complainant to reimbursement the claim payment. The complainant claimed the reimbursement amount 94,606/-. But the opposite party again not paid/released the claim amount of Rs.94,606/- and the opposite party had again issued “claim payment denial letter dated 01.05.2021” to the name of the complainant, stating therein that “Rs.94,606/- with the reason of “Non Discloser the fact for their disease.” The complainant was not suffering from this type of disease at the time
of policy renewal and also the opposite party and opposite party’s agent Mr. Kunal did not require any medical examination in any manner regarding the medical status of complainant and the opposite party and opposite party’s agent Mr. Kunal told the complainant at the time of policy renewal they need not any type of medical examination because their medical policy continuously with from previous policy and they would track his medical status from the previous policy from last 2 years. The complainant submitted the said letter to the opposite party and requested to settle the claim of the complainant but despite going through all the documents on record, facts and circumstances of the case, if complainant had not make the payment of the claimed amount of Rs.94,606/- or mediclaim as declared under the policy to the complainant. The complainant sent a legal notice dated 05.03.2022 to the opposite party but all in vain.The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) pay the treatment charges of Rs.94,606/- to the complainant alongwith interest to the complainant, jointly & severally.
b) pay Rs.1,50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 15,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the complainant had taken a Health Insurance Policy No. 17499225 with certificate of insurance No. 18676485 under the Plan “Group Care 360 (PNB- Platinum)” was issued to the complainant Mr. Girraj Rohella (herein after referred
to as insured”) w.e.f.4.11.220 till 3.11.2021 providing policy coverage to himself and his spouse for a sum insured of Rs.2,00,000/- subject to policy terms and conditions. The policy had been further renewed with the latest policy effective from 4.11.2021 till 3.11.2022.
First Cashless request (Claim No. AL-80476080-00)
a) The opposite party company received cashless facility request from the hospital on behalf of the insured as he was admitted to Fortis Escorts Hospital, Faridabad on 06.02.2021 for complaints of difficulty in breathing and was stated to had been provisionally diagnosed with COPD with AE i.e. Chronic Obstructive Pulmonary Disease Exacerbation).
b) An investigation was triggered by the opposite party Company to check the veracity of the cashless request.
c) A query was raised to the treating hospital vide deficiency letter dated 07.02.2021 seeking information/documents as under:
i. Exact duration and past history of present ailment with first consultation paper and al the past treatment records, COPD.
ii. Investigation report supporting diagnoses.
iii. Pre-hospitalization, OPD treatment record.
A query reply was received from the treatment hospital submitting for medical documents. Upon perusing the medical documents received alongwith cashless form in query reply an additional document procured during investigation, the opposite party came up forefront with the following findings:
i. As per insured’s statement (question No. 16) dated 07.02.2021, the insured had history of Asthma/Rspiratory disease since 2 years. His son in the
statement had submitted that his father was having respiratory issues since 2 years.
ii. As per the insured’s statement, the insured was having history of smoking since 10 Years (1 packet/day but had stopped since 2/3 years.
iii. As per the critical care initial assessment form dated 6.2.2021 of Fortis Hospital, the insured was stated to be having history of K/c/o COPD on inhaler therapy on and off.
In view of the above findings, the opposite party company rejected the cashless request of the insured vide denial letter dated 07.02.021 on the grounds of claim paid and discharge following grounds:
Non Disclosure of material facts/pre-existing ailments at the time of proposal-COPD.
Reimbursement Claim (91678555-00)
Upon rejection of cashless request, the complainant filed a re-imbursement claim (received on 20.04.2021) with the opposite party company for the hospitalization at Fortis Hospital, Faridabad form 6.2.2021 till 11.2.2021. As per the discharge summary and other medical documents received alongwith claim form, the insured was stated to have been diagnosed with Acute Exacerbation of chronic obstructive pulmonary disease with hyperkalemia (in corrected). The opposite party company in view of the findings concluded in cashless investigation repudiated the re-imbursement claim and the same was intimated to the complainant vide denial letter dated 1.5.2021 on the following grounds:
Non disclosure of material facts/pre-existing ailments t the time of proposal- COPD.
The policy holder/complainant had the opportunity to disclose at the time of proposal that he had history of CPD since two years i.e prior to policy inceptions date, however, the said pre-existing disease/ailment was deliberately not disclosed by the complainant in order to get benefit out of health insurance policy from the opposite party company. The following questions were asked while filing the proposal where mis-declarations had been made under the head “health and life style information”.
Question: has the insured members ever got hospitalized due to any reason apart from common cough/cold/fever or ever undergone any surgery?
Answer marked by insured No.1 : Yes
It is pertinent to mention here that the complainant/insured had only disclosed his history of hearing loss and gastric problem during the proposal of policy and the said ailments were duly noted by the opposite party company. However, he failed to disclose any history of COPD or Asthma problems. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party–Care Health Insurance Limited with the prayer to: a) pay the treatment charges of Rs.94,606/- to the complainant alongwith interest to the complainant, jointly & severally. b) pay Rs.1,50,000/- as compensation for
causing mental agony and harassment . c) pay Rs. 15,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Girraj Rohella, Ex.C-1 – postal receipt, Ex.C-2 – reply to legal notice, Ex.C-3 - reply to legal notice, Ex.C-4 – legal notice reply dated 20.04.2022,, Ex.C-5 , Ex.C-5 – Adhaar card, Ex.C-6 – letter dated 15.12.2021,Ex.C-7 - certificate of insurance, Ex.C-8 – denial letter dated 07.02.2021, Ex.C-9 – Claim denial letter dated 01.05.2021, Ex.C-10 – certificate of insurance, Ex.C-11 – Claim form, Ex.C-12 – consent letter, Ex.C-13 – Inpatient summary bill,, Ex.C-14 – cancelled cheque, Ex.C-15 – discharge summary, Ex.C-16 – GST invoice, Ex.C-17 – prescription, Ex.C-18 – GST invoice,, Ex.C-19 – outpatient bill, Ex.c-20 – prescription,, Ex.C-21 – GST invoice,, Ex.C-22 – outpatient bill, Ex.C-23 – prescription, Ex.C-24 – GST invoice, Ex.C-25 – discharge summary, Ex.C-26 – summary bill,, Ex.C-27 – discharge summary,, Ex.C-28 – IPD bill.
On the other hand counsel for the opposite party strongly agitated and opposed. As per the evidence of the opposite party Ex.RW-1/A – affidavit of Lakshay Juneja of Care Health Insurance Ltd. Ex.R-1 – policy with terms and conditions, Ex.R-2 – Request for cashless hospitalization for medical insurance policy, Ex.R-3 – Deficiency letter dated 07.02.2021, Ex.R-4 – Claim verification form/Questionnaire, Ex.R-5 – statement of Harichand Rohella son of Girraj Rohella,Ex.R-6 – claim verification form/questionnaire,, Ex.R-7 Assessment sheet,, Ex.R-8 – denial letter, Ex.R-9 – discharge summary draft, Ex.R-10 - Claim denial letter dated 01.05.2021 , Ex.R-11 – application form, Ex.R-12 – legal notice,, Ex.R-13 – reply to legal notice.
6. In this case, the opposite party gave mediclaim policy to the
complainant “Group Health Insurance Product Policy for bank account holders of OBC only) UIN: OICHLGP18075V011718. During the treatment of said policy, the complainant was operated due to Acute Exacerbation of Chronic Obstructive Pulmonary disease Hyperkalaemia (corrected) at Fortis Escorts Hospital, Neelam Bata Road, Faridabad, on 06.02.2021 and he remain admitted as indoor patient from 06.02.2021 to 11.02.2021 and he was treated there. The complainant was discharged on 11.02.2021 from the said hospital. The bill for Rs.94,906/- was raised against the complainant As per Ex.R-8 opposite party issued a “claim payment denial letter dated 07.02.2021” with the reason of “Non discloser the fact for complainant’s disease” and complainant pay all the amount of treatment from his own pocket. On the basis of above said policy, the complainant submitted all information/intimation regarding the treatment and hospitalization and apply the claim with all bills, discharge summary & necessary documents, after discussing the opposite party’s agent Mr. Kunal. The opposite party’s agent advice to the complainant to reimbursement the claim payment. The complainant claimed the reimbursement amount 94,606/-. But the opposite party again not paid/released the claim amount of Rs.94,606/- and the opposite party had again issued “claim payment denial letter dated 01.05.2021” to the name of the complainant, stating therein that “Rs.94,606/- with the reason of “Non Discloser the fact for their disease.”
7. During the course of arguments, the counsel for the complainant has placed on reliance Medical Insurance – Once Insurer Accepts that concealment of disease was not material, reimbursement & renewal can’t be refused passed by the Hon’ble Supreme Court of India on 6th July 2023.
Ratio of this authority is applicable to the facts of the present case
8. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite party is directed to process
the claim of the complainant within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite party is also directed to pay Rs.2200/- as compensation for causing mental agony & harassment alognwith Rs.2200/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 11.8.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
