Complaint No: 159 of 2020.
Date of Institution: 07.12.2020.
Date of order: 03.10.2023.
Surinder Sharma S/o Chaman Lal R/o H.No.BXX1356, Pandhian Mohalla, Batala, Tehsil Batala and District Gurdaspur (Punjab). Pin Code - 143505.
….......Complainant.
VERSUS
Care Health Insurance Co. Ltd, (Formerly known as Religare Health Insurance Company Ltd.) Regd. Office 5th Floor, 19 Chawla House, Nehru Place, New Delhi, through its Manager. Pin Code - 110019.
Alternative Address
Care Health Insurance Co. Ltd, (Formerly known as Religare Health Insurance Company Ltd.), Corporate Office Unit No.604-607, 6th Floor, Tower-C, Unitech Cyber Park, Sector 39, Gurgaon-122001,(Haryana), through its Manager.
….Opposite parties.
Complaint U/s 35 of the Consumer Protection Act, 2019.
Present: For the Complainant: Sh.P.C.Sharmal, Advocate.
For the Opposite Party: Sh.Sandeep Ohri, Advocate.
QUORUM: Sh.Lalit Mohan Dogra, President, Sh.Bhagwan Singh Matharu, Member.
ORDER
Lalit Mohan Dogra, President.
Surinder Sharma, Complainant (here-in-after referred to as complainant) has filed this complaint under section 35 of the Consumer Protection Act, (here-in-after referred to as 'Act') against Care Health Insurance Co. Ltd. etc. (here-in-after referred to as 'opposite party).
2. Briefly stated, the case of the complainant is that the complainant purchased private medi claim Health Insurance Policy from the opposite party for himself and his other family members. He got insured vide Policy No.11437035 along with his wife namely Prem Sharma vide Policy No.12683711, his son Rahul Sharma vide Policy No.11437113 and daughter-in-law Rajni Sharma under Policy No.17672359 on 15.07.2017 after fulfilling all the formalities. It is further pleaded that he purchased this policy online from the opposite party and they all covered under the sum insured of Rs.4.00 Lakh against the said policies. It is further pleaded that premium under the policies in question was paid to the OP’s through On-line transaction through his credit card. It is further pleaded that complainant as well as his above family members were possessing good health and not suffering from any ailment at the time of getting the policies and he had been renewing the above mentioned insurance policies for himself and his family member’s continuously by completing all the formalities. It is further pleaded that on 05.09.2020 the complainant fell ill and he was admitted in M.G. Hospital, Batala and remain admitted up to 11.09.2020. It is further pleaded that complainant has spent money on his treatment from his own pocket and he was discharged against the medical advice from the hospital on 11.09.2020 and amount of Rs.45,988/- were incurred on the treatment of the complainant as well as on the medicines. It is further pleaded that timely intimation has been given to the OP regarding admission of complainant in the hospital under Policy No.11437035 and the claim has been duly lodged vide Claim No. 91425398 with the OP’s for reimbursement of amount spent on his treatment, supported with all medical bills and medical reports etc. It is further pleaded that OP’s repudiated the claim of the complainant vide Letter No. CL No.91425398 dated 09.10.2020 on false and flimsy grounds and fake observations “Rejected Non- Disclosure of Diabetes, Hypertension and CAD”. It is further pleaded that this fact is totally wrong. It is further alleged that at the time of obtaining policy he and his family members were got medically examined by the representative of the OP’s before issuance of insurance policy and they were insured by the OP’s when they found fit from all corners. It is further pleaded that the complainant is making payment of premiums continuously for the last 3 years since the date of purchasing the policies. It is further pleaded that due to this illegal act and conduct of the opposite party the complainant has suffered great loss and also suffered mental agony, Physical harassment and inconvenience. It is further pleaded that there is a clear cut deficiency in services on the part of the opposite party.
On this backdrop of facts, the complainant has alleged deficiency and negligence in services and unfair trade practice on the part of the opposite party and prayed that the opposite party be directed to pay Rs.45,988/- spent on his treatment alongwith interest @18% P.A. From the date of discharge of the complainant from the hospital, till its realization and the OP may also be burdened with compensatory costs to tune of Rs.50,000/- on account of harassment, mentally and deficiency in services along with Rs.20,000/- as litigation expenses in the interest of justice. It is further pleaded that opposite party may also be directed to refund Rs.36,484/- i.e. the premium amount of four policies deposited by the complainant and further directed to cancel the aforesaid four policies, in the interest of justice and fair play to the complainant.
3. Upon notice, the opposite party appeared through counsel and contested the complaint and filing their written reply by taking the preliminary objections that the replying opponents state that the policy under dispute has been issued by replying opponents with its name as "Religare Health Insurance Co. Ltd." however the replying opponent had now changed its name from “Religare Health Insurance Co. Ltd.” to "Care Health Insurance Ltd." as per certificate of Registrar of Companies, Delhi. It is pleaded that the complainant has no cause of action and locus standi to file the present complaint and complaint is bad for non-joinder of the necessary party and the insurance is a contract between two parties and both the party are bound with the terms and conditions of the policy and there is no deficiency in services on the part of the insurance co. It is further pleaded that the matter of fact is that the policy having No. 11437035 covering the complainant with period from 12.07.2017 till 11.7.2018 for a sum of Rs.5 Lakh subject to policy terms and conditions was issued and the policy was renewed annually till 11.7.2021 and thereafter the complainant filed a reimbursement claim and approached the respondent company with respect to his hospitalization for a period from 5.9.2020 till 11.9.2020 at M.G. Hospital Batala. It is further pleaded that the complainant was diagnosed with DM, HTN, PUCO, and Conservative management. It is further pleaded that company raised query letter dated 25 September, 2020 to seek the following documents; 1).Exact duration and past history of present ailment with first consultation paper and all past treatment records, 2). Original cash paid receipt against final bill, 3).Treating doctor's certificate justifying the need of hospitalization, 4). Complete Indoor case papers with admission notes, history sheets etc. It is further pleaded that after going through the documents, it has come out that the complainant is none case of HTM, DA and CAD since 4 years and was on regular treatment and same was not disclosed to the company prior to policy inception. It is further pleaded that the claim has been rejected vide letter dated 9.10.2020 due to non dis-closure of material facts regarding his health. It is further pleaded that there is no liability of the insurance co. and the claim has rightly been repudiated.
On merits, the opposite party has reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in services on the part of the opposite party. In the end, the opposite party prayed for dismissal of complaint with costs.
4. The complainant has tendered self declaration of Surinder Sharma, (Complainant) alongwith other documents as Ex.C-1 to Ex.C-7.
5. Learned counsel for the opposite party has tendered into evidence affidavit of Sh. Ravi Boolchandani, (Manager - Legal, Care Health Insurance Co. Ltd.) as Ex.OPW-1/A alongwith other documents as Ex.OP-1 to Ex.OP-12.
6. Rejoinder not filed by the complainant.
7. Written arguments filed by the complainant but not filed by the opposite party.
8. Counsel for the complainant has argued that during the continuation of the health policy complainant fell ill on 05.09.2020 and remained admitted at M.G. Hospital Batala and had spent Rs.45,988/- on his treatment. It is further argued that on claim being lodged the claim was repudiated by the opposite party vide letter dated 09.10.2020 with the observations “Rejected Non- Disclosure of Diabetes, Hypertension and CAD” and repudiation of claim amounts to deficiency in service on the part of the opposite party.
9. On the other hand counsel for the opposite party has argued that complainant had concealed his previous treatment of diseases Hypertension, DA and CAD since 4 years and as such the claim was rightly repudiated on account of "Non-Disclosure of Previous Ailments" and as such there is no deficiency in service on the part of the opposite party.
10. We have heard the Ld. counsels for the parties and gone through the record. It is admitted fact that the complainant had purchased policy of insurance from the opposite party. It is further admitted fact that complainant remained admitted at M.G. Hospital Batala upto 11.09.2020 and had spent Rs.45,988/- on is treatment. It is further admitted fact that claim lodged by the complainant was repudiated vide letter dated 09.10.2020 with the observations “Rejected Non- Disclosure of Diabetes, Hypertension and CAD”. The only disputed point for adjudication before this Commission is that whether the opposite party was justified in repudiating the claim due to non disclosure of Diabetes, Hypertension and CAD. To prove the case complainant has placed on record policy document Ex.C1, statement of account Ex.C2, application details Ex.C3, clam denial letter Ex.C4, copy of legal notice Ex.C5, postal receipt Ex.C6 and copy of E-mail Ex.C7 whereas opposite party has placed on record affidavit/self declaration of Ravi Boolchandani, Manager Legal Ex.OPW-1/A, Policy document Ex.OP1, copy of proposal form Ex.OP-2, copy of claim form signed by doctor Ex.OP3, copy of deficiency letter Ex.OP4, copy of claim denial letter Ex.OP5, copy of questioner for doctor Ex.OP-7, copy of check list Ex.OP8, copy of legal notice Ex.OP-9 and copy of prescription slip Ex.OP10. We have gone through record i.e. questioner for doctor Ex.OP7 as per which the disease in respect of which complainant took treatment is fever body ache, vomiting and in the end there is reference of previous history hypertension, D.M., CAD since 4 years. We are of the view that the complainant took treatment in respect of totally different disease from the previously mentioned diseases of hypertension, D.M. and CAD and there is no relation of disease in respect of which complainant took treatment with the previous ailments and the opposite party has not proved on record that the alleged previous ailments HTN, DM and CAD was responsible for the fever, body ache and vomiting for which complainant took treatment.
11. We have placed reliance upon the judgment of Hon'ble Supreme Court of India in case titled as Om Parkash Ahuja Vs. Reliance General Insurance Co. Ltd. etc. reported in Law Herald (SC) 2023(2) Page 1560 wherein in it has held as under:-
"Insurance Health Insurance Complainant had taken health insurance for his family which was renewed time to time His wife suffered from cancer of ovary and took treatment Claim for reimbursement of medical expenses was repudiated on the ground that wife of complainant was suffering from heart disease and it was not disclosed at the initial time of taking policy Medical Certificate establishes that rheumatic heart disease and carcinoma ovary are not related to each other Thus, non-mentioning of disease from which the wife of appellant suffered at the time of purchasing the policy was not material, as the death was cause from a different disease all together Both had no relation with each other Insurance Company directed to pay the claim amount with interest".
12. As per this judgment it was held by the Hon'ble Supreme Court of India that non mentioning of disease from which wife of the applicant was suffering at the time purchasing policy is not material and the death was caused from different disease all together.
13. The ground of repudiation taken by the opposite parties regarding non settlement of the claim is previous history of hypertension but this Commission is of the view that hypertension is a common disease and it is not necessary that person suffering from hypertension would always suffer from some other disease and this Commission has placed reliance an order of Hon'ble Punjab State Consumer Dispute Redressal Commission, Chandigarh reported in 2017(3) CLT 140 wherein it was held as under:-
"Hypertension is a common disease and it can be controlled by medication".
14. We are of the view that the opposite parties cannot refuse to settle the claim of the complainant with the excuse of previous ailments with which there is no nexus of the present disease. Moreover, the opposite parties have renewed the policy of insurance from time to time receiving premium. As such having renewed the policy of insurance from time to time without having availed medical examination of the complainant prior to renewal of the policy amounts to waiver and as such opposite parties cannot refuse to settle the clam by referring to and repeatedly making reference of previous ailment with which the present case has no concern..
15. We also placed reliance upon judgment of Hon'ble Punjab State Consumer Dispute Redressal Commission, Chandigarh reported in 2014(3) C.P.J. 13 : 2014(87) R.C.R.(Civil) 264 wherein it was held as under:-
"Insurance Company failed to produce any evidence to show that appellant was suffering from said disease at the time of taking policy No affidavit of any doctor or person who recorded history of patient".
16. Moreover, this Commission is of the view that opposite party has although placed on record questioner for doctor which is signed by doctor Dr.Gurpal Singh to prove the previous ailments and treatment undertaken by the complainant but the opposite party has not placed on record affidavit of Dr.Gurpal Singh or any other doctor who allegedly treated the complainant for the alleged HTN, D.M. and CAD since 4 years.
17. Accordingly, by relying upon the above referred record, case laws and evidence on record it is proved on record that complainant took treatment for totally different disease from the alleged previous ailments and as such act of opposite party of having repudiated the claim lodged by the complainant amount to deficiency in service.
18. Accordingly, present complaint is partly allowed and opposite party is directed to pay Rs.45,988/- to the complainant alongwith interest @ 9% P.A. from the date of filing of complaint till realization. Opposite party is further directed to pay Rs.5,000/- for mental tension, harassment and cost of litigation to the complainant. Entire exercise shall be completed within 30 days from the date of receipt of copy of this order.
19. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.
20. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record room.
(Lalit Mohan Dogra)
President
Announced: (B.S.Matharu)
Oct. 03, 2023 Member
*YP*
