DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

 

Complaint Case No : CC/175/2021

Date of Institution   : 18.08.2021

Date of Decision    : 03.05.2023

Naresh Kumar son of Sh. Prem Kumar resident of H.No. B-XIV/1192, Sekha Road, Street No. 3, Barnala, Tehsil and District Barnala. (M. 90565-49075).   

                          …Complainant Versus

1. Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited), SCO 56-57-58, 2nd floor, Sector 9D, Chandigarh 160017 through its Manager/Authorized Signatory.

2. Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited), 5th floor, 19 Chawla House, Nehru Place, New Delhi-110019 through its Manager/Authorized Signatory.

3. Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited), Unit No. 604-607, 6th floor, Tower C, Unitech Cyber Park, Sector 39, Gurugram-122001 (Haryana) through its Manager/Authorized Signatory.   

                       …Opposite Parties

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

Present: Sh. Varun Singla counsel for complainant.

Sh. Dhiraj Kumar counsel for opposite parties.

Quorum:-

1. Sh. Jot Naranjan Singh Gill : President

2.Sh. Navdeep Kumar Garg : Member

 

(ORDER BY JOT NARANJAN SINGH GILL, PRESIDENT):

The complainant namely Naresh Kumar has filed the present complaint under Section 35 of the Consumer Protection Act 2019, (amended upto date) against Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited) and others (hereinafter referred as opposite parties).  

2. The facts leading to the present complaint are that the complainant submitted a proposal form for obtaining the policy plan of CareFreedom- Comprehensive Health Insurance Policy and the proposal form was accepted and policy bearing No. 18605802 was issued to the complainant for the policy period from 22nd  October 2020 to 21st October 2021. In the above said policy Neena wife of the complainant was insured and pre existing disease of Permanent Exclusion for Brain Hemorrhage and Aneurysm & Two year and Hypertension was disclosed to the complainant at the time of submitting the proposal form and the same was accepted. It is further alleged that a sum of Rs. 5,00,000/- was insured under the said policy. It is further alleged that during the policy, the wife of the complainant suffered some health issues and the complainant took her wife to Dr. Naresh Hospital & Health Centre for her medical checkup and different tests were done at Dr. Lal Path Lab, Barnala from 10.2.2021 to 13.2.2021. It is alleged that Dr. Naresh told the complainant to get the treatment from some Neprology doctor. As such, the complainant took her wife at Dayal Kidney Hospital, Bathinda and scans were done and medicines were given but then also not able to get cured. Thereafter, a test was done at Dr. Path Lab Barnala dated 25.2.2021 and samples were collected and result was received on 27.2.2021. The complainant spent Rs. 3,020/- on the treatment of her wife but did not get any affirmative result. It is further alleged that thereafter the complainant took her wife to Dayanand Medical College and Hospital, Ludhiana for her treatment dated 28.2.2021, 1.3.2021 & 2.3.2021 and the wife of complainant admitted on 3.3.2021 at Dayanand Medical College and Hospital, Ludhiana and was discharged on 4.3.2021 and an expenditure of Rs. 28,952/- has been spent on the treatment of complainant's wife. It is further alleged that the complainant approached opposite party No. 1 for the medical claim which is covered under the policy and the complainant submitted the claim form for Rs. 31,972/- with all the required details and documents alongwith a cancelled cheque bearing No. 962046 of Indian Overseas Bank and the opposite party assured the complainant that they will give the claim amount within a week. It is further alleged that the opposite parties repudiated the claim and sent claim denial letter dated 4th April 2021 to the complainant where the reason for rejection was of Diabetes. The complainant again made request for getting claim and the same was repudiated by the opposite parties and a mail was received by the complainant which stated the reason of rejection as Hypertension dated 18th May 2021. It is further alleged that the opposite parties did not pay even a single penny of claim as assured to the complainant till today. As such, the above stated facts clearly shows the deficiency in service on the part of opposite parties. Hence, the present complaint is filed for seeking the following reliefs.- 

i) To pay the claim amount of Rs. 31,972/-. 

ii) Further, to pay the amount of Rs. 50,000/- due to mental torture agony and harassment suffered by the complainant and Rs. 10,000/- as litigation expenses.  

3. Upon notice of this complaint, the opposite parties appeared and filed written version taking preliminary objections interalia on the grounds that the present complaint is not maintainable and the complaint is frivolous and vexatious in nature. The claim of the complainant does not fall within the ambit of insurance. Further, the complainant breach the terms and conditions of the policy and as such claim of the complainant stands declined on the ground of two years waiting period of diabetes mellitus and its complications etc.  

4. On merits, it is submitted that the complainant paid premium under the policy subject to terms and conditions of the policy and the opposite parties issued a health insurance policy under name Care Freedom Plan-1 vide policy No. 18605802 to the complainant with providing coverage to Mrs. Neena Goyal starting from 22.10.2020 till 21.10.2021. Permanent exclusion for Brain Hemorrhage and aneurysm and two year waiting period was applied on Hypertension and Hypothyroidism. It is further submitted that the opposite parties received the Reimbursement Claim vide Claim No 91647379-00-01 for Insured admitted to Dayanand Medical College and Hospital, Ludhiana from 3.4.2021 till 4.4.2021 for being diagnosed with Adult onset Nephrotic Syndrome. It is further submitted that the claim was rejected vide claim denial letter dated 4.4.2021 on the grounds of 2 year waiting period for treatment related to DM and its complications. Since, hypertension was already disclosed and 2 year waiting period was applied at the time of inception and diabetes will also be marked as a pre existing disease. All the claims are processed as per the terms and conditions of the policy and not on an arbitrary basis and the complainant is not entitled for any claim in the given circumstances. Therefore, there is no deficiency in service on the part of opposite parties and prayed for the dismissal of complaint. 

5. The complainant filed rejoinder to the written version filed by the opposite parties vide which the complainant reiterated the averments as mentioned in the complaint. 

6. To prove his case the complainant tendered into evidence his own affidavit Ex.C-1, copy of policy Ex.C-2, copy of prescription slip dated 9.2.2021 Ex.C-3, copy of bill dated 10.2.2021 Ex.C-4, copy of technical analysis report Ex.C-5, copies of receipts Ex.C-6 to Ex.C-9, copy of patient record book of Dayal Kidney Hospital Ex.C-10, copy of bills Ex.C-13 & Ex.C-14, copy of report dated 27.2.2021 Ex.C-15, copies of receipts Ex.C-16 to Ex.C-18, copy of ultrasound report Ex.C-19, copies of report Ex.C-20 & Ex.C-21, copies of bills Ex.C-22 to Ex.C-24, copy of test report Ex.C-25, copy of discharge summary Ex.C-26, copies of receipts Ex.C-27 to Ex.C-29, copy of report dated 3.3.2021 Ex.C-30, copy of receipt dated 3.3.2021 Ex.C-31, copy of pathology report Ex.C-32, copies of receipts Ex.C-33 to Ex.C-35, copy of Biochemistry report Ex.C-36, copies of receipts Ex.C-37 & Ex.C-38, copy of claim denial letter Ex.C-39, copy of Emails Ex.C-40, copy of Adhaar Card Ex.C-41 and closed the evidence. 

7. To rebut the case of the complainant the opposite parties tendered into evidence affidavit of Ravi Boolchandani Ex.O.Ps-1, copy of letter dated 28.10.2020 Ex.O.Ps-2, copy of letter dated 2.10.2021 Ex.O.Ps-3, copy of E mail Ex.O.Ps-4 regarding consent, copy of policy Ex.O.Ps-5, copy of claim form Ex.O.Ps-6, copy of medical record Ex.O.Ps-7, copy of discharge summary Ex.O.Ps-8, copy of bills Ex.O.Ps-9, copy of claim denial letter Ex.O.Ps-10 and closed the evidence. 

8. We have heard the learned counsel for the parties and have gone through the record on file. Written arguments filed by the parties. 

9. Ld. Counsel for the complainant argued that the complainant submitted a proposal form for obtaining the policy plan of CareFreedom- Comprehensive Health Insurance Policy and the proposal form was accepted and policy bearing No. 18605802 was issued to the complainant for the policy period from 22nd  October 2020 to 21st October 2021. It is further argued that in the above said policy Neena wife of the complainant was insured and pre existing disease of Permanent Exclusion for Brain Hemorrhage and Aneurysm & Two year and Hypertension was disclosed to the complainant at the time of submitting the proposal form and the same was accepted. It is further argued that a sum of Rs. 5,00,000/- was insured under the said policy. It is also argued that during the policy, the wife of the complainant suffered some health issues and the complainant took her wife to Dr. Naresh Hospital & Health Centre for her medical checkup and different tests were done at Dr. Lal Path Lab, Barnala from 10.2.2021 to 13.2.2021. It is argued that Dr. Naresh told the complainant to get the treatment from some Neprology doctor, as such the complainant took her wife at Dayal Kidney Hospital, Bathinda and scans were done and medicines were given but then also not able to get cured. Thereafter, a test was done at Dr. Path Lab Barnala dated 25.2.2021 and samples were collected and result was received on 27.2.2021. The complainant spent Rs. 3,020/- on the treatment of her wife but did not get any affirmative result. It is further argued by the Ld. Counsel for complainant that thereafter the complainant took her wife to Dayanand Medical College and Hospital, Ludhiana for her treatment dated 28.2.2021, 1.3.2021 & 2.3.2021 and the wife of complainant admitted on 3.3.2021 at Dayanand Medical College and Hospital, Ludhiana and was discharged on 4.3.2021 and an expenditure of Rs. 28,952/- has been spent on the treatment of complainant's wife. It is further argued that the complainant approached opposite party No. 1 for the medical claim which is covered under the policy and the complainant submitted the claim form for Rs. 31,972/- with all the required details and documents alongwith a cancelled cheque bearing No. 962046 of Indian Overseas Bank and the opposite party assured the complainant that they will give the claim amount within a week. It is further argued that the opposite parties repudiated the claim and sent claim denial letter dated 4th April 2021 Ex.C-39 to the complainant where the reason for rejection was of Diabetes. The complainant again made request for getting claim and the same was repudiated by the opposite parties and a mail was received by the complainant which stated the reason of rejection as Hypertension dated 18th May 2021. It is further argued that the opposite parties did not pay even a single penny of claim as assured to the complainant till today and the above stated facts clearly shows the deficiency in service on the part of opposite parties.

10. Ld. Counsel for the opposite parties argued that the complainant paid premium under the policy subject to terms and conditions of the policy and the opposite parties issued a health insurance policy under name Care Freedom Plan-1 vide policy No. 18605802 to the complainant with providing coverage to Mrs. Neena Goyal starting from 22.10.2020 till 21.10.2021 with Permanent exclusion for Brain Hemorrhage and aneurysm and two year waiting period was applied on Hypertension and Hypothyroidism. It is further argued that the opposite parties received the Reimbursement Claim vide Claim No 91647379-00-01 for Insured admitted to Dayanand Medical College and Hospital, Ludhiana from 3.4.2021 till 4.4.2021 for being diagnosed with Adult onset Nephrotic Syndrome. It is also argued that the claim was rejected vide claim denial letter dated 4.4.2021 on the grounds of 2 year waiting period for treatment related to Diabetes Mellitus and its complications. Since, hypertension was already disclosed and 2 year waiting period was applied at the time of inception and diabetes will also be marked as a pre existing disease and all the claims are processed as per the terms and conditions of the policy and not on an arbitrary basis and the complainant is not entitled for any claim in the given circumstances. So, there is no deficiency in service on the part of opposite parties and prayed for the dismissal of complaint.

11. It is admitted case of the complainant that the complainant obtained the Health Insurance Policy bearing No. 18605802 of the opposite parties which was valid from 22nd  October 2020 to 21st October 2021  and a sum of Rs. 5,00,000/- was insured under the said policy and in the above said policy Neena wife of the complainant was insured. It is further admitted case of the complainant that during the policy, the wife of the complainant suffered some health issues and the complainant spent the total amount of Rs. 31,972/-  on the treatment of her wife. But the claim was rejected by the opposite parties vide claim denial letter dated 4.4.2021 (Ex.C-39 & Ex.O.Ps-10) on the grounds of 2 year waiting period for Diabetes Mellitus and Related Complication. We have perused the policy schedule which was placed on record by both the parties (Ex.C-2 & Ex.O.Ps-2) vide which in the column of Pre-existing disease it is mentioned that “ Permanent Exclusion For Brain Hemorrhage And Aneurysm & Two Year Waiting Period For Hypertension And Hypothyroidism”. We have also perused the Discharge Summary Ex.C-26 vide which Diagnosis mentioned as “Adult Onset Nephrotic Syndrome”. In the Discharge Summary Chief Complaints (Reasons For Admission) mentioned as “Swelling of Face And Other Parts of Body”. It is further mentioned in the Discharge Summary that the patient was admitted with the above complaints, routine urine was suggestive of proteinuria, renal biopsy was planned and under USG guided & with all asepsis precaution 2 core samples taken from left Kidney & sent for Histopathological examination. The procedure was without complications. Now after 24 hours of monitoring, the patient is being discharged. So, there is nothing has been mentioned in the discharge summary about diabetes mellitus and related complication on which ground the claim was rejected by the opposite parties. Moreover, from the perusal of policy schedule it is cleared that two year waiting period is for Hypertension and Hypothyroidism and not for Diabetes Mellitus and Related Complication. 

12. The complainant in support of his case has placed on record the order dated 1.3.2021 of the Hon'ble National Consumer Disputes Redressal Commission, New Delhi in case titled Sunil Kumar Sharma Vs Tata Aig Life Insurance Company & Others in which it is held that “ Insurance claim cannot be denied on the ground of these life style diseases that are so common”. 

13. The complainant has also placed on record the judgment of the Hon'ble Punjab & Haryana High Court, Chandigarh, (2008) 151 PLR 313, decided on 22.4.2008 in case titled New India Assurance Company Vs Usha Yadav And Others in which it is held that “ 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 Company in such case reply upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy”. 

14. The complainant further placed on record the another judgment of the Hon'ble High Court of Punjab and Haryana, Chandigarh, CWP No. 107 of 2020, date of decision January 07, 2020 in case titled Religare Health Insurance Company Limited Vs The Chairman, Permanent Lok Adalat and Another, in which it is held that “ Since the company itself is issuing policies for the tenure of 1 year then the company cannot claim that the company shall not pay any claim before the period of 2 years. There is no explanation as to how this clause justifies the issuance of policy for one year”. 

15. So, we are of the view that the opposite parties have failed to rebut the case of the complainant by producing on record any cogent evidence and there is clear cut deficiency in service on the part of the opposite parties by not giving the genuine claim of the complainant. 

16. As result of the above discussion and law laid down by the Hon'ble National Consumer Commission and the Hon'ble High Court of Punjab & Haryana, Chandigarh, the present complaint is partly allowed and the opposite parties are directed to pay the claim amount of Rs. 31,972/- to the complainant alongwith interest @ 7% per annum from the date of filing the present complaint till realization. The opposite parties are further directed to pay Rs. 5,000/- as compensation on account of mental agony and harassment and Rs. 4,000/- as litigation expenses to the complainant.

17. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order.

18. Copy of this order be supplied to the parties free of costs as per rules. File be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN COMMISSION:

       3rd Day of May, 2023

 

            (Jot Naranjan Singh Gill)

            President

 

(Navdeep Kumar Garg)

Member