Chandigarh

DF-I

CC/752/2021

Dr Vishesh Garg - Complainant(s)

Versus

Care Health Insurance Ltd.(formerly known as Religare Health Insurance Company Ltd.) - Opp.Party(s)

Adv. Diwan Sharma

05 Oct 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/752/2021
Date of Institution	:	28/10/2021
Date of Decision	:	05/10/2023

 

Dr. Vishesh Garg s/o Sh. Dev Raj Garg r/o House No.1112, GF, Sector 29B, Chandigarh 160029.

… Complainant

V E R S U S

1. Care Health Insurance Limited (formerly known as Religare Health Insurance Company Limited), Regd. Office : 5^th Floor, 19 Chawla House, Nehru Place, New Delhi-110019.

Correspondence Address : Unit No.604-607, 6^th Floor, Tower C, Unitech Cyber Park, Sector 39C, Gurugram-122001 (Haryana).

2. Care Health Insurance Limited (formerly known as Religare Health Insurance Company Limited) SCO 56-57-58, 2^nd Floor, 9-D, Chandigarh 160017.

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

 

               

ARGUED BY	:	Sh. Manoj Lakhotia, Advocate for complainant
	:	Ms. Niharika Goel, Advocate for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Dr.Vishesh Garg, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that the complainant had purchased a health insurance policy from the OPs under the plan named “CARE” with cover type floater starting w.e.f. 20.9.2019 to 19.9.2020 (Annexure C-1), covering him and his wife Neetu Rani with sum insured of ₹10.00 lacs.  The said policy was got renewed by the complainant from the OPs w.e.f. 20.9.2020 to 19.9.2021 (Annexure C-2) (hereinafter referred to as “subject policy”).  On 13.12.2020, the complainant felt severe pain in his back and he immediately went to Health Sure Multispecialty Hospital, Gharaun, Mohali, where he was examined as an outdoor patient and he was advised certain tests and was admitted in the Ortho emergency. Copy of prescription and admission slip is Annexure C-3.  Certain tests were conducted in the said hospital and the reports are Annexure C-4 and C-5.  As per the subject policy, the complainant was eligible for cashless hospitalisation and accordingly he made a request to the OPs for pre authorization of cashless hospitalisation, but, the same was turned down by the OPs vide letter dated 23.12.2020 (Annexure C-6) on the ground of non disclosure of material facts/pre-existing ailment at the time of filling of the proposal form.  However, the complainant requested the OP vide email dated 30.12.2020 (Annexure C-7) for reconsideration as the previous injury was suffered by the complainant about six years ago i.e. prior to the subject policy. Thereafter the complainant was discharged from the hospital on 31.12.2020 and the copy of discharge summary is Annexure C-8.  The hospital had raised bill of ₹1,55,000/- (Annexure C-9) which was paid by him. Subsequently, complainant issued notices dated 9.2.2021 & 9.3.2021 (Annexure C-10 & C-11) to the OPs, but, nothing has been done by them. The complainant had further taken domiciliary treatment at home and had purchased medicines worth ₹17,331/- as per summary (Annexure C-12) and has further engaged one Lovepreet Singh as patient caretaker and paid him an amount of ₹44,550/- for 81 days vide receipt (Annexure C-12A) and also got himself re-examined in the OPD at Healing Hospital where he paid ₹500/- vide receipt (Annexure C-13) and had also taken physiotherapy treatment with Dr.Gaganjot Singh Saini, to whom he paid an amount of ₹69,000/- vide receipts (Annexure C-14 colly.). Complainant filed a proper claim (Annexure C-15) of ₹2,86,331/- with the OPs on 25.7.2021. Even after that, complainant issued legal notice dated 28.8.2021 (Annexure C-16) to the OPs, but, nothing has been done by them, rather the OPs vide letter dated 23.9.2021 (Annexure C-17) have intimated the complainant that the policy has been cancelled and the claim has been rejected.  In fact, in the year 2013 the complainant was treated for “CAUDA EQUINA” and the said ailment has no connection with the ailment, which the complainant had suffered in the year 2020, which fact has also been verified by the treating doctor vide his certificate (Annexure C-19).  In this manner, the aforesaid acts of the OPs amounts to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability and cause of action.  However, it is admitted that the complainant purchased the subject policy from the OPs and the same was valid at the relevant time i.e. at the time of treatment given by the treating hospital and also that the cashless request was received from the treating hospital for the hospitalisation of the complainant on 19.12.2020.  It is, however, alleged that in fact the claim of the complainant was repudiated as the complainant had not disclosed about the pre-existing disease from which he was suffering i.e. the history of “CAUDA EQUINA” and was operated in the year 2013 and even in the proposal form, the complainant did not disclose the aforesaid material fact/pre-existing ailment and accordingly the claim of the complainant was repudiated by the OPs as per the terms and conditions of the subject policy. On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including the written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that at the relevant time i.e. 19.12.2020 to 31.12.2020, the complainant was covered under the subject policy, which was valid w.e.f. 20.9.2020 to 19.9.2021 and also that the claim of the complainant was rejected by the OPs on the ground of non-disclosure of material facts qua the pre-existing ailment suffered by the complainant, who was also treated for “CAUDA EQUINA” in the year 2013 and was operated upon in the PGI, the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in repudiating the claim of the complainant on flimsy ground and have cancelled the policy and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs are justified in repudiating the claim of the complainant on account of non-disclosure of pre-existing disease at the time of purchasing the subject policy by the complainant and the same is in violation of the terms and conditions of the subject policy and the consumer complaint of the complainant is liable to be dismissed, as is the defence of the OPs.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, medical record, having been relied upon by both the parties and the repudiation letter, and the same are required to be scanned carefully.
   3. Perusal of the subject policy (Annexure C-2/OP-1) clearly indicates that in case the insured did not disclose about the preexisting disease, having been suffered by him, to the insurer, at the time of purchasing the subject policy, the insurer will not be liable to pay any claim to the insured.  As per the case of the complainant, though he was operated upon for ‘CAUDA EQUINA’ in the year 2013 in PGI, Chandigarh, as is also evident from the report of operation (Annexure OP-6), but, since the said ailment has no connection with the treatment which has been taken up by the complainant in the treating hospital in the month of December 2020 onwards, when he was diagnosed with “PIVD L3-L4/L4-L5/L5-S1 WITH CANAL STENOSIS” and OPs have wrongly repudiated the claim of the complainant by holding that he was having pre-existing disease at the time of purchasing the subject policy.
   4. Perusal of the discharge summary (Annexure C-8) of the treating hospital clearly mentions the previous diagnosis, diagnosis and present complaints as under:-

PREVIOUS DIAGNOSIS	F/U/C Cauda Equina Compression – Post Op Status in 2013.
DIAGNOSIS	PIVD L3-L4/L4-L5/L5-S1 WITH CANAL STENOSIS
PRESENT COMPLAINTS	SEVERE BACKACHE RADIATING TO BEATERAL LOWER LIMBS X 3 DAYS DIFFICULTY WALKING + TINGLING SENSATION IN LEFT FOOT+ H/O LIFTING HEAVY WEIGHT 3 DAYS AGO NO BLADDER/BOWEL INVOLVEMENT

 

5. Similarly, the report of operation dated 29.10.2013 (Annexure OP-6) of PGI further makes it clear that the complainant was operated for ‘CAUDA EQUINA’ in the month of October 2013.  In medical terms, ‘CAUDA EQUINA’ means “a group of nerves shaped like a horses’ tail at the end of spinal cord or nervous tissues extends below the end of spinal cord”. On the other hand, “Canal stenosis” which in medical terms is also called “spinal stenosis” can put pressure on the spinal cord and the nerves within the spine and it commonly occurs in the neck and lower back and the causation of same is age related wear and tear.
6. Moreover, even the treating doctor has also certified in the certificate (Annexure C-19) that the injury operated upon by him on 24.12.2020 is not pre-existing condition or disease and the same has no connection with the previous injury which was operated upon in the year 2013. The relevant portion of the said certificate is reproduced as under :-

        “It is certified that injury operated upon by me on 21.12.2020 is not pre existing condition or disease. The operation dated 21.12.2020 has no connection with the previous injury which was operated upon in the year 2013 related to PIVD Lumber region and the operation on 21.12.2020 relates to New disc ……… Both the operations are independent and have no connection with each other.”

 

7. Thus, one thing is clear on record that there is no suppression of material information of the disease ‘CAUDA EQUINA’ as it has no connection with canal stenosis and the OPs have wrongly repudiated the claim of the complainant vide letter dated 23.9.2021 (Annexure C-17/OP-10), by holding that the complainant did not disclose about the previous ailment/pre-existing disease, especially when even the disease of ‘CAUDA EQUINA’ was treated by the hospital in the year 2013 by performing surgery of the same and in the year 2020 the complainant has been diagnosed with a different disease i.e. canal stenosis for which also treatment was given.   Here we are strengthened by the order passed by the Hon’ble National Commission in Neelam Chopra Vs. Life Insurance Corporation of India & Ors., IV (2018) CPJ 321 (NC) and the operative part of the same reads as under :-

                12. In the present case, clearly the cause of death is cardio respiratory arrest and this disease was not existing when the proposal form was filled. Clearly, there is no suppression of material information in respect of this disease, which is the main cause of death. The other disease of LL Hansen, which was prevailing for five weeks on the date of admission on 1.8.2003 was also not existing when the proposal was filed by the DLA. The fact of DLA having been treated in the year 2002 for LL Hansen is not supported from any direct evidence though PGI Chandigarh in its certificate has mentioned that disease was treated in 2002. Moreover, this disease does not have any correlation with the cause of death in the present case. Hon’ble Supreme Court in Sulbha Prakash Motegaonkar and Ors. v. Life Insurance Corporation of India, Civil Appeal No.8245 of 2015, decided on 5.10.2015 (SC) has held the following:

        “We have heard learned Counsel for the parties.

                It is not the case of the Insurance Company that the ailment that the deceased was suffering from was a life threatening disease which could or did cause the death of the insured. In fact, the clear case is that the deceased died due to ischaemic heart disease and also because of myocardial infarction. The concealment of lumbar spondylitis with PID with sciatica persuaded the respondent not to grant the insurance claim.

                We are of the opinion that National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim by the respondent. The death of the insured due to ischaemic heart disease and myocardial infarction had nothing to do with this lumbar spondylitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified.”

8. In view of the foregoing discussion and the ratio of law laid down above, it is clear that the OPs have not been able to connect the previous ailment with which the complainant was diagnosed in the year 2013 with the present ailment for which he had taken the treatment from the treating hospital and the present consumer complaint deserves to succeed. 
9. Now coming to the quantum of relief to be awarded to the complainant, since the complainant has proved bills/receipts (Annexure C-9 & C-12 to C-14), details of which have also been given in Annexure C-15 totaling to ₹2,86,331/-, it is safe to hold that OPs are liable to pay the said amount to the complainant alongwith interest and compensation etc. for the harassment suffered by him.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹2,86,331/- to the complainant alongwith interest @ 9% per annum from the date of repudiation/rejection of the claim i.e. 23.09.2021 onwards.
2. to pay an amount of ₹15,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 05/10/2023 hg			Sd/- [Pawanjit Singh] President
			Sd/- [Surjeet Kaur] Member