CONSUMER DISPUTES REDRESSAL COMMISSION – X

                           GOVERNMENT OF N.C.T. OF DELHI

UdyogSadan, C – 22 & 23, Institutional Area

                                       (Behind Qutub Hotel)

                                        New Delhi – 110016

  Case No.: 193/21

Sh. Shiv Kumar Tiwari

S/o Late Shri Balkrishan Tiwari

R/o-WZ 1409 NangalRaya.

Behind,DDA Commercial Complex,

New Delhi- 110046                                                       …..COMPLAINANT

Vs.

M/s The Care Health Insurance Limited

(Formerly known as Religare Health Insurance Co. Ltd.)

Through its General Manager

Registered Office at:-

5^th Floor, 19 Chawla House,

Nehru Place, New Delhi 110019     

Correspondence Office at:-

Vipul Tech Square Tower C,

3^rd Floor, Golf Course Road, Sector-4.

Gurugram-122009                                                          …..RESPONDENTS

          Date of Institution- 13.08.2021

          Date of Order-08.11.2024

O R D E R

RITU GARODIA-MEMBER

1. The complaint pertains to deficiency in service on part of OP in rejecting the claim of complainant for his medical treatment.

2. The Complainant had purchased a Mediclaim Insurance Policy bearing number 12090798 after paying a premium of Rs.53,886/- for sum insured ofRs.10,00,000/-.The policy was obtained from OP, TheCare Health Insurance Limited (formerly known as Religare Health Insurance Co. Ltd.).

3. The complainant before purchasing the insurance policy from Religare Insurance Company Ltd, was already insured under Apollo Munich Health Insurance Company from 11.02.2011 onwards for last 7 years. It is stated that the complainant had completed the waiting period under the previous insurance.

4. The policy from the previous insurer was ported to the current policy. The complainant was assured that OP had agreed to adopt all the terms and condition of Apollo Munich Health Insurance Company with added benefits. The complainant and his wife Ms. Renu Tiwari were insured for a period of two years w.e.f. 13.02.2018 till 12.02.2020.

5. In the month of April 2019, the complainant and his wife were in Mumbai to meet their family members.The complainant’s wife Renu Tiwari faced medical issues and had to undergo medical treatment in Sir H.N. Reliance Foundation Hospital, Mumbai.

6. During the medical treatment,intimation was given to OP. A deficiency letter dated 03.05.2019 was sent to the hospital by OP requiring following information:

1. Exact duration and past history of present ailment with first consultation paper and all past treatment records for last one year.
2. Pre-hospitalization OPD treatment records.

7. On 07.05.2019, the wife of the complainant Mrs. Renu Tiwari was admitted to Sir H.N. Reliance Foundation Hospital, Mumbai. She was diagnosed with a rare disease i.e. OPLL. OP insurance denied the cashless claim of the complainant.

8. The Manager Claims,Dr. ShabnamMulani,vide letter dated 21.06.2019,had requested the Superintendent, Medical Record Department of Sir H.N. Reliance Hospital, for furnishing documents in respect of the wife of the complainant, Mrs. Renu Tiwari.On 24.07.2019, a reminder was given to complainant requesting additional information.On 05.11.2019, the complainant had personally visited the correspondence office of OP and submitted a complete set of documents.

9. The complainant was again contacted telephonically and was asked to submit the thyroid reports of his wife.The complainant submitted the reports which were duly acknowledged by OP vide stamp dated 04.02.2020.

10. As no response was received from Religare Insurance Company, the complainantsent a legal notice dated 22.02.2021which was duly replied.

11. The complainant prays for awarding compensation towards medical expenses incurred for treatment of his wife along with interest to the tune of Rs.9,00,000/- with additional 18% interest, Rs.6,00,000/- towards his physical pain and mental agony. Rs.1,00,000/- towards litigation expenses.

12. OP in its reply states that a policy namely Care Floater bearing Policy no. 12090798 was issued providing policy coverage to the complainant and his wife namely Renu Tiwari. The said policy was issued for the period between 13.02.2018 to 12.02.2020 for a sum insured of Rs.10,00,000/-. The policy was further renewed from the period of 13.02.2020 till 12.02.2021. The said policy had been ported from Munich Health Insurance Company Ltd with the date of first enrolment being 11.02.2011.

13. OP submits that a cashless request dated 07.05.2019 was received from the hospital namely HN Reliance Foundation Hospital, Mumbai,pertaining to the wife of the complainant who witnessed pain in neck with radiation to right arm and was provisionally diagnosed with cervical myelopathy on account of ossification of posterior longitudinal ligament.

14. OP vide letter dated 03.05.2019 sought documents from the hospital for exact duration and past history of the present ailment with first consultation paper, records of the past treatment of last one year and pre hospitalization OPD treatment record. OP issued reminder letter dated 04.05.2019 and 05.05.2019 to the hospital.As OP did not receive the documents from the hospital, it denied the cashless request from the hospital vide letter dated 08.05.2019.

15. The complainant filed a claim form dated 06.06.2019. It is submitted that in the discharge summary dated 14.05.2019, the complainant’s wife was found to be suffering from progressive weakness in the right arm for one year. OP sent a letter dated 11.06.2019 seeking exact duration and past history of present ailment with first consultation paper and all past treatment records specifically hypertensionand cervical problem and RT ARM weakness, recent passport size photograph of proposer/nominee, pre-hospitalization OPD treatment record, complete indoor case paper with admission notes, history sheet, doctors notes, nursing note and vital chart.

16. As per the Claim Investigation Report dated 03.07.2019 issued by ICS Assure, it was found that the wife of the complainant had previous history of the hypertension and has been witnessing the pain in the right upper limb since March, 2019. It is alleged that the wife of the complainant had been consulting various doctors for last previous years for the best.

17. OP approached the Complainant vide letters dated 14.07.2019 and 24.07.2019 seeking documents once again. The complainant failed to reply to aforesaid letters. OP rejected the claim vide Claim Denial letter dated 30.09.2019 citing reason “Deficiency not replied”.

18. OP received a legal notice dated 22.02.2021 which was duly replied. It is further stated that as per the terms and conditions of the insurance contract, theinsurance company was not required to reimburse the complainant for expenses incurred by him on pre-existing disease due to non-submission of requisite documents.

19.  The complainant in his rejoinder has reiterated the averments made in the complaint. It is clarified that the complainant was asked by the OP to give an undertaking about the surgery of his wife on 04.05.2019. The complainant provided all the documents to OP at that point of time. The complainant also clarifies that a complete set of documents was provided to OP by the hospital on 03.05.2019.

20. The complainant reiterates that they became aware of the disease OPLL for the first timein Mumbai. The complainant also submits that no investigation report dated 03.07.2019 was received by the complainant.

21. The complainant has filed its evidence by way of affidavit and exhibited the following documents:-

1. Copy of the Aadhar Card is exhibited as EXHIBIT-CW1/1.
2. Copy of the policy no.12090798 is exhibited as EXHIBIT-CW1/2.
3. Photostat copy of policy of Apollo Munich Health Insurance is exhibited as EXHIBIT-CW1/3.
4. Copy of admission receipt is exhibited as EXHIBIT-CW1/4.
5. Copy of letter sent to Reliance Foundation Hospital dated 03.05.2019 is exhibited as EXHIBIT-CW1/5
6. Copy of medical treatments history is exhibited as EXHIBIT-CW1/6.
7. Copy of the letter dated 21.06.2019 is exhibited as EXHIBIT-CW1/7.
8. Copy of reminder letter dated 24.07.2019 is exhibited as EXHIBIT-CW1/8.
9. Copy of documents submitted to OP bearing acknowledgement stamp of the opposite party isexhibited as EXHIBIT-CW1/9.
10. Copy of the reports bearing acknowledgement stamp dated 04.02.2020 of the OP is exhibited as EXHIBIT-CW1/10.
11. Copy of legal demand notice dated 22.02.2021 alongwith original postal receipt is exhibited as EXHIBIT-CW1/11.
12. Copy of the reply dated 19.03.2021 is exhibited as EXHIBIT-CW1/12.
13. Copy of Covid positive report is exhibited as EXHIBIT-CW1/13.

22. OP has filed its evidence by way of affidavit and exhibited the following documents:-

1. Board Resolution dated 28.10.2020 is exhibited as EX-RW1/1.
2. Copy of the Terms and Conditions of the policy is exhibited as EX-RW1/2.
3. Copy of the Proposal Form is exhibited as EX-RW1/3.
4. Copy of the Portability Form is exhibited as EX-RW1/4
5. Copy of the Policy certificate/letter dated 14.02.2018 is exhibited as EX-RW1/5.
6. Copy of the Policy certificate/letter dated 12.02.2020 is exhibited as EX-RW1/6
7. Copy of the Cashless Form is exhibited as EX-RW1/7
8. Copy of the query letter dated 03.05.2019 is exhibited as EX-RW1/8.
9. Copy of the query reply dated 03.05.2019 sent by the OP to Reliance Foundation Hospital is exhibited as EX-RW1/9.
10. Copy of the Reminder letters dated 04.05.2019 and 05.05.2019 sent to the Reliance Foundation Hospital is exhibited as EX-RW1/10
11. Copy of denial letter dated 08.05.2019 sent by OP to Reliance Foundation Hospital is exhibited as EX-RW1/11.
12. Copy of claim form dated 07.06.2019 is exhibited as EX-RW1/12.
13. Copy of the summary dated 14.05.2019 is exhibited as EX-RW1/13.
14. Copy of final bill is exhibited as EX-RW1/14.
15. Copy of the Investigation Report is exhibited as EX-RW1/15.
16. Copy of the Query letter dated 11.06.2019 is exhibited as EX-RW1/16.
17. Copy of the Query letter dated 04.07.2019 is exhibited as EX-RW1/17.
18. Copy of the denial letter dated 30.09.2019 is exhibited as EX-RW1/18.
19. Copy of the Consultant documents is exhibited as EX-RW1/19.
20. Copy of the doctor’s letter is exhibited as EX-RW1/20.
21. Copy of the report submitted by the ICS Assure is exhibited as EX-RW1/21.
22. Copy of the Reminder dated 14.07.2019 and 24.07.2019 is exhibited as EX-RW1/22 & 23.
23. Copy of the legal notice dated 22.2.2021 is exhibited as EX-RW1/24.
24. Copy of the reply dated 19.03.2021 is exhibited as EX-RW1/25.

23The Commission has considered the material and documents on record. The Policy certificate shows that the complainant and his wife were covered for medical treatment from 13.02.2018 to 12.02.2020. The said certificate also shows that the policy was ported from Apollo Munich Health Insurance. The date of inception of the first policy in Apollo Munich Health Insurance was 11.02.2011.OP further renewed the policy from 13.02.2020 to 12.02.2021.

24 The complainant suffered some health problem in April 2019 and went to Sir H N Reliance Foundation Hospital for treatment. A cashless request was sent to OP for treatment. OP sent a deficiency letter dated 03.05.2019 requiring the following information:

1. Exact duration and past history of present ailment with 1^st consultation paper and all past treatment records.

Last 1 year

2)Pre hospitalization opd treatment record.

25. The history and assessment of the complainantby the treating hospital on 07.05.2019 is as follows:

History

Allergies      -        None

Past Medical History

26 The complainant’s wife Renu Tiwari was hospitalized in Sir H.N. Reliance Foundation Hospital.  The discharge summary of the said hospital shows that complainant was admitted on 07.05.2019 and discharged on 14.05.2019. Relevant portion of the discharge summary is as follows:

Presenting complaints & Brief History

Progressive weakness in the right arm since 1 year. Unable to abduct the right arm. Dropping objects from the right had since last year. Numbness. Cannot hold pen since 1 months. Right hand dominant. Left hand okay. Loss of balance while walking one month. But able to walk on her own. Feb 2019, she had a fall and injury to the neck and after that she has noticed more symptoms. Since 6 months she is having nocturia. No incontinence. Sensation of bladder filling. Otherwise no difficulty passing urine.

Hypothyroid on treatment Eltoxin 100mcg daily.

Telma 20mg once a day since last 6 months.

No allergies.

27. The discharge summary also shows diagnosis as Cervical myelopathy due to extensive OPLL from craniovertebral region to the D3 region.

28. The manager, claims, representing ICS Assure Services Pvt. Ltd  and Religare Health Insurance Co. Ltd vide letter dated 21.06.2019 requested the hospital for following documents:

• Duly attested and paginatedcopy of ICPs including (admission notes: details of investigation done – their findings and treatment given, OT Notes, PAC notes, Anesthesia Notes Nursing notes and TPR Chart, final paid receipt of bill).

• Attested copy of Hospital Rate card and indoor case register
• A letter from Dr.Kshitij Chaudhary mentioning the onset of the symptoms, investigations done to arrive at the diagnosis and treatment given for the same.
• Hospital & treating doctor’s registration certificate.
• Estimated bill

29 OP vide letter dated 24.07.2019 requested the following documents:

1. Doctor prescription- provide first consultation paper wherein hypertension was diagnosed for the first time mandatory and all other prescription for the hypertension.
2. Exact duration and past history of present ailment with 1^st consultation paper and all past treatment records.

Including consultation paper of dr. Anup p – whoadvised mri done on 26 dec 2018.

3. Original cash paid receipt against final bill
4. Complete indoor case papers with admission notes, history sheet, doctor’s notes. Nursing notes and vital chart.

Complete set required with pac notes.

30 Dr. Kshitij Chaudhary vide a certificate dated 29.07.2019 answered the queries of OP as follows:

Patient Renu Tiwari was under my treatment for cervical myelopathy due to POLL. A letter to the insurance company was provided by me on 07.05.2019 stating duration of her symptoms & the nature of her problem. I am providing another letter for the same query raised again.

1. Exact duration – 1 year (as stated in the previous report on 07.05.19 as per my first consultation report dated 26.04.19).
2. Past history of present ailment – none. We diagnosed the problem of OPLL on 26.04.19.
3. 1^st consultation paper dated 26.04.19 was attached with the last letter. It is attached again here.

Dr. Kshitij Chaudhary,

Consultant Orthopedic Surgeon

31 The complainant has filed bills of the hospital dated 15.05.2019 that shows that Rs.5,92,388/- and Rs.11,760/- has been charged by the hospital.

32The complainant and OP has filed an MRI report. Relevant portion of the said report is as follows:

Overall features are suggestive of compressive myelopathy.

 33A prescription from Mohanty Surgical Centre & Nursing Home dated 09.04.2019 shows “?? cervical Myelopathy.”

35 OP vide letter dated 30.09.2019 rejected the claim stating deficiency not replied.

36Hon’ble Apex Court in Maha Kali Sujatha vs The Branch Manager Future General India decided on 10.04.2024 has made following observations:

    50. The cardinal principle of burden of proof in the law of evidence is that “he who asserts must prove”, which means that if the respondents herein had asserted that the insured had already taken fifteen more policies, then it was incumbent on them to prove this fact by leading necessary evidence. The onus cannot be shifted on the appellant to deal with issues that have merely been alleged by the respondents, without producing any evidence to support that allegation. …………..A fact has to be duly proved as per the Evidence Act, 1872 and the burden to prove a fact rests upon the person asserting such a fact. Without adequate evidence to prove the fact of previous policies, it was incorrect to expect the appellant to deal with the said fact herself in the complaint or the evidence affidavit, since as per the appellant, there did not exist any previous policy and thus, the onus couldn’t have been put on the appellant to prove what was non-existent according to the appellant.

37Hon’ble National Commission in Reliance Life Insurance Co. Ltd. &Anr. Vs. Tarun Kumar SudhirHalder decided on 31.05.2019 has observed as follows:

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 22.06.2011, 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.  Moreover, in case of diabetes of late, this Commission has been taking a view that diabetes is a life style disease and is so common in India that the whole insurance claim cannot be rejected on this ground.

38  IRDA (Insurance Regulatory and Development Authority) has issued a master circular for Health Insurance Policies vide Ref: IRDAI/HLT/CIR/PRO/84/5/ 2024 Date: 29.05.2024. Relevant portion is as follows:

17) Settlement of Claims:

 a) No claim shall be repudiated without the approval of PMC or a threemember sub-group of PMC called the Claims Review Committee (CRC).

 b) In case, the claim is repudiated or disallowed partially, details shall be conveyed to the claimant along with full details giving reference to the specific terms and conditions of the policy document.

c) Pursuant to intimation of the claim, Insurers and Third Party Administrators (TPAs) shall collect the required documents from the Hospitals. Policyholder shall not be required to submit the documents.

39From the chronology of event, it is clear that the complainant and his wife were insured from 2011 onwards: firstly from Apollo Munich Health Insurance which was subsequently ported to The Care Health Insurance Limited. The complainant was admitted to Sir H. N. Reliance Foundation Hospital on 07.05.2019 and discharged on 14.05.2019. Discharge summary shows that the complainant was suffering from Cervical Myelopathy due to extensive OPLL.

40  OP sent a letter to the hospital on 21.06.2019 requesting indoor case papers and a certificate of the treating doctor along with final paid receipt of bills.

41Thereafter, OP conducted an investigationand gave a questionnaire to the complainant’s wife which was duly filled by her. The investigation report dated 03.07.2019 shows that the investigator visited the hospital. They also went through the treating doctor’s letter, Dr. Mohanti’s letter, and the complainant’s wife letter. The investigator also states that the indoor case papers have been collected from the hospital.

42 The investigator states that the complainant was having pain in right upper limb since March, 2019 and hypertension since July, 2018. The report finally concluded that they are unable to comment on PED (pre-existing disease) as the insured was non-cooperative. No explanations are given as to how the investigator found the complainant’s wife non-cooperative when she has duly filled and sign the questionnaire presented to her. It appears that the investigator was specifically looking for existence of pre-existing disease. Since, he could not find any evidence, he specifically declined to comment on PED while adding a comment of his own: non-cooperation of the insured.

43The said report also annexed a detailed list of question which has been duly answered by the complainant’s wife. The said questionnaire contains the following question and answer:

11. Kindly mention since when patient is suffering from high blood pressure kindly provide first prescription papers.

Ans. Due to death of close relative patient was having B.P. High. So, Dr. Suggested for tablet. No consulting available.

44 Thereafter, OP sent a letter dated 24.07.2019 requesting documents regarding first consultation paper wherein hypertension was diagnosed. The complainant has clearly replied that a doctor had suggested some tabletson the death of her brother and no consultation paper are available. The treating doctor, Dr. Kshitij Chaudhary had also replied to the query raised by OP regarding hypertension stating that the complainant was suffering from hyper tension for past one year. The Apex Court in their judgment Maha Kali Sujata (supra) has clearly stated that the onus to prove an allegation is on the party making the allegation. OP cannot insist on the documents to be given by the complainants which are not in their possession.

45 In the same letter, OP asked for exact duration and past history of present ailment along with first consultation paper. Dr. KshitijChaudhay has replied that there was no past history of present ailment and the first consultation paper has already been submitted. Hon’ble National Commission in Reliance Life Insurance Co. Ltd (supra) has observed that the insurance has to prove any pre-existing disease at the commencement of the policy. OP has not placed any documents on record to show that the complainant’s wife was suffering from the present disease before the inception of the policy in the year 2011.

46. OP asked for indoor case paper which has already been received by the investigator as stated in the investigation report. The said documents were also attached with the reply by the treating doctor. OP also asked for cash paid receipt which had already been received from the hospital as per query letter dated 21.06.2019. OP has also filed a copy of final bill along with its reply.

47. OP repudiated the claim of the complainant vide letter dated 30.09.2019 by merely stating “deficiency not replied”. OP has not clarified as to the deficiency which has not been replied by the complainant. In fact the master circular (supra) clearly lays down that the insurance shall collect the required documents from hospital and not from the policy holders. The master circular further specifies that the repudiation letter should have full details of specific terms and condition relied upon.

48. OP has relied on the terms and condition of the policy. Exclusion clause 4.1.iii. provides that claim will not be admissible for hospitalization of any pre-existing disease until 48 months of continuous coverage. The policy of the complainant commencedon 11.02.2011. The 48 months of continuous coverage was over by 11.02.2015. The policy was ported to OP insurance company in year 2018 with continuity benefitcovering pre and post hospitalization expenses.

49Hence, we find OP guilty of deficiency in service in rejecting the claim of the complainant and direct OP to

1. pay Rs. 6,04,148/- (5,92,388/- and Rs.11,760/-) with 7% interest from date of hospitalization till realization .
2. pay Rs.1,00,000/- as compensation for mental harassment and physical inconveniences.
3.  pay Rs.10,000/- towards litigation expenses.

50Order to be uploaded and complied with within 30 days. File be consigned to Record Room.