Punjab

Rupnagar

CC/22/107

Narinder Singh - Complainant(s)

Versus

Care Health Insurance Ltd - Opp.Party(s)

Rajiv Kumar Rana

24 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, ROOPNAGAR

 

Consumer Complaint No. 107 of 2022

Date of Institution:          : 12.07.2022

             Date of Decision            :  24.3.2023

 

Narinder Singh son of Late Sh. Shiv Singh, resident of Village Hambewal, P.O Nangal Nikku, P.O & Tehsil Nangal, District Rupnagar Punjab, Pin Code 140124.

….. Complainant

Versus

 

1.       Care Health Insurance Limited, Unit No. 604-607, 6^th Floor, Tower C, Unitech Cyber Park, Sector 39, Gurugram, 122001 (Haryana), through its Managing Director/Concerned Authority

2.       Care Health Insurance Ltd , SCO 56-58, Top Floor, Above Dr. Batra Clinic, Madhya Marg, Sector 9-D, Chandigarh 160017 through its Sr. Agency Manager Vishal Singh.

           

                                                                         …..Opposite parties

 

(Complaint under the provision of Consumer Protection Act)

QUORUM:

SH.KULJIT SINGH, PRESIDENT

SH.RAMESH KUMAR GUPTA, MEMBER

 

COUNSEL FOR THE PARTIES

For complainant                       :         Sh.Rajiv Kumar Rana, Adv.

For OPs                                   :         Sh.Amit Gupta, Advocate

                            

Per : KULJIT SINGH, PRESIDENT

 

1. Brief facts of the case are that  the complainant got care health insurance policy from OPs bearing no. 143791478 i.e. from 01.07.2021 to 30.06.2022 for sum insured of Rs.3,00,000/-  He got operated two stents in his body from IVY Hospital Sector 71, Mohali  and paid medical bill amounting to Rs.2,53,153/- . Thereafter, the complainant applied for the claim of Rs.2,53,153/-  but OPs rejected  the claim of the complainant with wrong and vague excuse.  He approached OPs many times but all in vain. He also served a legal notice dated 28.06.2022 upon OPs but OPs failed to give any reply of the said notice.  Due to act and conduct of OPs, the complainant has filed the instant complaint and prayed that the OPs be directed to pay Rs.2,00,000/- as compensation  and Rs.25,000/- as litigation charges
2. Upon notice, OPs appeared and filed written reply and contested the claim of the complainant by averring that  OP issued a health insurance policy bearing no. 14379148 to the complainant Narinder Singh thereby covering himself  and his wife w.e.f. from 10.07.2019 till 30.06.2020  for a sum insured of Rs.3,00,000/-  subject to policy terms and conditions The policy was renewed annually till 30.06.2023.  The complainant had disclosed Hypertension since Oct. 2017 and his wife had disclosed Cholecystectomy as  pre-existing disease.  The complainant filed a cashless request through treating hospital  i.e. Ivy Hospital  Mohali for his hospitalization. As per the pre auth form, he was hospitalized w.e.f. 15.05.2022 and was diagnosed with Acute Coronary Syndrome an unstable angina. The OP scrutinized the claim and rejected the claim of the complainant vide letter dated 15.05.2022 with the following observations : Cashless rejected as 4 years waiting period is applicable for pre-existing disease and related complications, 4 years waiting period.  The policy was in the third year and treatment related to pre-existing disease are only covered after 4 years since policy inception.  Thereafter the complainant filed reimbursement claim his hospitalization , OPs processed the claim and denied vide letter dated 30.05.2022 in view terms and conditions of the policy. Rest of the averments made by the complainant were denied by  OPs and they prayed for dismissal of the complaint.
3. The complainant tendered in evidence his affidavit Ex.CW-1/A along with copies of documents Ex.C-1 to Ex.C-9 and closed the evidence.  On the other hand, OPs tendered in evidence affidavit of Ravibool Chandani Manger as Ex.OP-A along with copies of documents Ex.OP-1 to Ex.OP-12 and closed the evidence.      
4. We have heard learned counsel for the parties and have also gone through the record very carefully
5. It is an admitted fact that the complainant got operated two stents in his body from IVY Hospital Sector 71, Mohali and paid medical bill amounting to Rs.2,53,153/- , this fact is clear from perusal of final bill issued by IVY Hospital Sector 71, Mohali vide Ex.C-2/A on the record.  In this bill, the date of admission of the complainant as 15.05.2022 and discharged on 17.05.2022 , as indoor patient.  We have also perused the payment receipts Ex.C-2/B to Ex.C-2/F of different dates for different amounts.  We have also perused the certificate issued by IVY Hospital Mohali. In this certificate Dr. Rakesh Sharma MD Medicine (PGI Chandigarh) specifically mentioned that  complainant Narinder Singh had acute coronary syndrome – Unstable Angina & TMT was positive for inducible ischema. There was denial from your side for his treatment, reason mentioned was Hypertension as preexisting disease. But the OPs repudiated the claim of the complainant vide repudiation letter Ex.OP-5 on the record on the ground that cashless rejected as 4 years waiting period is applicable for pre-existing diseases and its related complications. 4 years waiting period.  We are of the view that insured /Narinder Singh is k/c/o Hypertension, as disclosed while taking the policy, and it has direct cause effect relation with coronary artery disease and acute coronary syndrome, insured’s acute coronary syndrome and subsequent DVD with the subsequent procedure-PTCA is attributed  to his Hypertension history
6. The defence which has been taken by the insurance companies/OPs was having no legs to stand.  We are of the view that the burden was on the OPs to prove that the insured had concealed the material fact of his pre-existing disease at the time of taking the policy. The OPs have failed to produce on record any document to show that insured/complainant was suffering from above said disease. The National Consumer Disputes Redressal Commission (NCDRC) said even if the insured person was suffering from a disease (Hypertension) and did not know about it nor was taking any treatment for the same, the claim cannot be denied by an insurance company.

• NCDRC said the onus to prove the pre-existing disease lies on the insurance company
• The commission said Hypertension was a lifestyle disease and the whole insurance claim cannot be rejected only based on this ground
•  

8. In the light of our above discussion, we allow the complaint of the complainant and OPs are directed to pay the amount of Rs.2,53,153/- to complainant which has spent on his treatment vide bill Ex.C-2/A on the record. OPs are further directed to pay Rs.10,000/- as compensation for mental harassment and Rs.5,000/- as litigation expenses.

9.       The compliance of the order be made within 45 days from receipt of copy of this order. This complaint could not be decided within stipulated period due to heavy pendency of the cases. Copies of the order be supplied to the parties free of costs. File be indexed and consigned to the record room.

 

Dated         :24.3.2023                               (Kuljit Singh)

                                                                    President

         

 

                  ( Rakesh Kumar Gupta)                                                

                                                                        Member