DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

                            Complaint Case No: CC/90/2023

                                                           Date of Institution: 02.08.2023

                            Date of Decision: 07.11.2024

Surinder Kumar, aged about 75 years, son of Brij Lal resident of # B-X/92, Ahata Narain Singh, Barnala, Tehsil and District Barnala, Punjab. 

             ﾅComplainant

                                                   Versus

1. 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, Gurgaon-122001, Haryana, through its Branch Manager/Authorized Person;

2. Care Health Insurance Limited (formerly known as Religare Health Insurance Company Limited), Branch Office CHIL, Ist Floor, Taneja Tower, SCO No. 28, District Shopping Complex, Ranjit Avenue, Amritsar-143001, through its Branch Manager;

3. Punjab National Bank, Main Branch Barnala, through its Branch Manager.  

                                                                                                     ﾅOpposite Parties

Complaint Under Section 35 of the Consumer Protection Act, 2019.

Present: Sh. Chander Shekhar Garg Adv counsel for complainant.

              Sh. Dhiraj Kumar Adv counsel for opposite parties No. 1 & 2.

    Sh. A.K. Jindal Adv counsel for opposite party No. 3.

Quorum.-

1. Sh. Ashish Kumar Grover: President

2. Smt. Urmila Kumari : Member

3. Sh. Navdeep Kumar Garg: Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against 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, Gurgaon-122001, Haryana, through its Branch Manager/Authorized Person & others (in short the opposite parties). 

2. The facts leading to the present complaint are that the complainant obtained a Care Health Insurance Policy for the year 2023-24 valid from 19.02.2023 to 18.02.2024 of the opposite parties through the opposite party No. 3 being account holder in the opposite party No. 3 for Rs. 5,50,000/- and in this regard the opposite parties issued a group policy No. 17499225, certificate of insurance No. 37611012. It is further alleged that the complainant got insured himself and his wife namely Raj Rani through the above said policy. It is further alleged that previously the complainant obtained Care Health Insurance Policy for the year 2022-23 valid from 19.02.2022 to 18.02.2023 of the opposite parties No. 1 and 2 through the opposite party No. 3 being account holder in the OP No. 3 after port from Oriental Insurance Company Limited, which was insisted by opposite party No. 3 to the complainant and in this regard the opposite party No. 2 issued policies and the present policy was obtained in continuation of above said policies. It is further alleged that the complainant feels pain in both knee joint, associated with difficulty in walking or climbing stairs and was admitted in Fortis Hospital, Mohali on 22.05.2023 and his surgery for bilateral total knee replacement done on 23.05.2023 and was discharged from there on 29.05.2023 after his treatment and in this regard before admission cashless preauthorization for treatment was applied by the said hospital, which was denied by the opposite parties No. 1 and 2 vide letter dated 17.05.2023 and payment of treatment amounting to Rs. 4,00,400/- was made by the complainant. It is further alleged that after treatment the complainant again applied for claim of insurance/treatment but the opposite parties declined to pay the same without any reason with malafide intention and several requests were made by the complainant to the opposite parties for payment but the opposite parties declined for payment of treatment amount. The complainant also issued legal notice dated 4.7.2023 through his counsel but opposite parties did not bother to reply the same. Due to the act and conduct of the opposite parties the complainants are suffering from a lot of harassment and mental agony and there is deficiency in services and negligence on the part of the opposite parties. Hence, the present complaint is filed for seeking the following reliefs.-

i. The opposite parties may be directed to make payment of Rs. 4,00,400/- alongwith interest.    

ii. To pay Rs. 50,000/- as compensation of humiliation and harassment.   

iii. Further, to pay Rs. 15,000/- as litigation expenses. 

3. Upon notice of this complaint, the opposite parties No. 1 & 2 appeared and filed written version by taking preliminary objections interalia on the grounds that the complaint filed by the complainant is not maintainable and is liable to be dismissed. The present complaint is not maintainable in the present form as the complaint involves disputed question of facts which cannot be determined in summary jurisdiction of consumer forum. The present complaint filed by the complainant with the mala-fide intention and has not come before this Commission with the clean hands. That intricate questions of law and facts are involved in the matter in issue and parties should have to lead evidence by examining the witnesses and the other party should have to cross examine the witnesses and the matter involved in this case cannot be decided in summary manner and the complainant, if so advised, may approach the Civil Court etc. 

4. On merits, it is submitted that the replying opposite party had issued a group insurance policy namely "Group Care 360 PNB- Platinum" bearing Policy No. 17499225 with Certificate of Insurance number 37611012 was ported from Oriental Insurance by Mr. Surinder Kumar covering himself and his spouse Ms. Raj Rani for the policy period of 19.02.2022 till 18.02.2023 for a sum insured up to Rs. 5,00,000/- subject to policy terms and conditions. It is alleged that the policy was renewed in the year 2023-2024 and the copy of Schedule bearing relevant details of the Policy along with policy bond having terms and conditions were duly sent and delivered to the Proposer. It is further alleged that a cashless request was received from the Fortis Hospital, Mohali for the hospitalization of the complainant on 23.05.2023 till 29.05.2023 for the knee replacement surgery he underwent there. It is further alleged that in the admission note it has been mentioned that the complainant had undergone a Percutaneous Transluminal Coronary Angioplasty (PTCA) in 2013 and given this history was not disclosed in the proposal form, it made ground for rejection of the claim on the basis of Pre-existing ailments at the time of proposal- Coronary Artery Disease vide rejection letter dated 17.05.2023. It is further alleged that at the time of filing of the proposal form, the complainant did not disclose his PED and the medication he is taking for the same. All other allegations of the complaint are denied and prayed for the dismissal of complaint. 

5. The opposite party No. 3 filed separate written version by taking legal objections on the grounds that the complaint of the complainant is bad for mis-joinder and non-joinder of necessary parties. The complainant has got no cause of action and locus-standi to file the present complaint. The opposite party No. 3 is not in the business of insurance nor under law can it carry on the business of insurance and is only doing the business of banking and the opposite party No. 3 was only a facilitator/corporate agent etc.

6. On merits, it is admitted to the extent that the complainant maintains his saving account No. 3471000100054652 with opposite party bank. It is further admitted that the complainant purchased Health Insurance Policy from opposite party No. 1 and 2 and complainant is the account holder of the answering opposite party. All other allegations are denied and prayed for the dismissal of complaint. 

7. Ld. Counsel for complainant filed rejoinder to the written version of opposite parties No. 1, 2 & 3 and denied the averments as mentioned in the written version.    

8. To prove his case the complainant tendered into evidence affidavit of complainant as Ex.C-1, policy as Ex.C-2 (containing 7 pages), previous policy Ex.C-3 (containing 7 pages), copy of denial letter Ex.C-4, discharge summary Ex.C-5 (containing 4 pages), copy of bill Ex.C-6 (containing 2 pages), legal notice Ex.C-7, postal receipts Ex.C-8 to Ex.C-10 and closed the evidence on behalf of complainant.

9. To rebut the case the opposite parties No. 1 & 2 tendered into evidence copy of policy certificate alongwith policy term and conditions as Ex.O.P1.2/2 (9 pages), copy of admission note Ex.O.P1.2/3 (5 pages), copy of reply to legal notice Ex.O.P1.2/4 (2 pages), copy of repudiation letter Ex.O.P1.2/5 and closed the evidence. 

10. The opposite party No. 3 tendered into evidence affidavit of Arjun Vinayak Ex.O.P3/1, copy of statement of account Ex.O.P3/2 (2 pages) and closed the evidence. 

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

12. It is admitted case of the opposite parties No. 1 & 2 that the opposite parties had issued a group insurance policy namely "Group Care 360 PNB- Platinum" bearing Policy No. 17499225 with Certificate of Insurance number 37611012 was ported from Oriental Insurance by Mr. Surinder Kumar covering himself and his spouse Ms. Raj Rani for the policy period of 19.02.2022 till 18.02.2023 for a sum insured up to Rs. 5,00,000/- subject to policy terms and conditions (Ex.C-3). It is further admitted case of the opposite parties that the policy was renewed in the year 2023-2024 (Ex.C-2). It is further admitted that a cashless request was received from the Fortis Hospital, Mohali for the hospitalization of the complainant on 23.05.2023 till 29.05.2023 for the knee replacement surgery he underwent there (Ex.C-5). 

13. Ld. Counsel for the complainant argued that the complainant feels pain in both knee joint, associated with difficulty in walking or climbing stairs and was admitted in Fortis Hospital, Mohali on 22.05.2023 and his surgery for bilateral total knee replacement done on 23.05.2023 and was discharged from there on 29.05.2023 and in this regard before admission cashless preauthorization for treatment was applied by the said hospital, which was denied by the opposite parties No. 1 and 2 vide letter dated 17.05.2023 and payment of treatment amounting to Rs. 4,00,400/- was made by the complainant. It is further argued that after treatment the complainant again applied for claim of insurance/treatment but the opposite parties declined to pay the same without any reason with malafide intention and several requests were made by the complainant to the opposite parties for payment but the opposite parties declined for payment of treatment amount. It is further argued that the complainant also issued legal notice dated 4.7.2023 Ex.C-7 through his counsel but opposite parties did not bother to reply the same.

14. On the other hand, Ld. Counsel for the opposite parties No. 1 & 2 argued that in the admission note it has been mentioned that the complainant had undergone a Percutaneous Transluminal Coronary Angioplasty (PTCA) in 2013 and this history was not disclosed in the proposal form, it made ground for rejection of the claim on the basis of Pre-existing ailments at the time of proposal- Coronary Artery Disease vide rejection letter dated 17.05.2023 Ex.O.P1.2/5. It is further argued that at the time of filing of the proposal form the complainant did not disclose his PED and the medication he is taking for the same.

15. Ld. Counsel for the opposite party No. 3 argued that the opposite party No. 3 is not in the business of insurance nor under law can it carry on the business of insurance and is only doing the business of banking and the opposite party No. 3 was only a facilitator/corporate agent. It is further argued that the complainant maintains his saving account No. 3471000100054652 with opposite party bank. It is further argued that the complainant purchased Health Insurance Policy from opposite party No. 1 and 2 and complainant is the account holder of the opposite party No. 3.

16. It is the specific case of the opposite parties No. 1 & 2 that the insured had pre-existing disease and this fact has not been disclosed by the insured/complainant at the time of filing the proposal form or at the time of purchasing the policy or at the time of renewing the policy in question which amounts to misrepresentation/non-disclosure of material facts. It is further argued that as per terms and conditions of the policy issued to the insured, if there is any misrepresentation/non-disclosure of material facts whether by the insured person or any other person acting on his behalf, the Company is not liable to make any payment in respect of any claim, hence the claim was rejected and the same was informed to the insured vide letter dated 17.05.2023 Ex.O.P1.2/5. We have gone through the denial letter dated 17.5.2023 Ex.O.P1.2/5 vide which it is mentioned that "Non Disclosure of Material Facts/Pre Existing Ailments at time of proposal-Coronary Artery Disease Prior to Policy, 6.1.1 Non Disclosure of Material Facts/Pre Existing Ailments at time of Proposal" On the other hand, Ld. Counsel for the complainant argued that the complainant feels pain in both knee joint, associated with difficulty in walking or climbing stairs and was admitted in Fortis Hospital, Mohali on 22.5.2023 and his surgery for bilateral total knee replacement done on 23.5.2023 and he was discharged on 29.5.2023 after his treatment and to prove this fact the complainant has placed on record Discharge Summary i.e. Ex.C-5. Further, in Ex.C-5 it is nowhere mentioned in the history that the patient had the above said disease since 2013 as alleged by the opposite parties. Further, the opposite parties (insurance company) have failed to place on record any cogent evidence to prove that they have medically examined the insured at the time of porting/issuing the policy in question or filling the proposal form or at the time of renewing the policy. Moreover, the opposite parties have failed to place on record any medical record of the complainant to prove the fact that the complainant had undergone a Percutaneous Transluminal Coronary Angioplasty (PTCA) in 2013. The opposite parties have also failed to place on record the proposal form. So, at this stage how the opposite parties (insurance company) could have raised the objection that the insured had pre-existing disease prior to the policy inception date. The complainant to prove his case has placed on record copy of Care Health Insurance policy Ex.C-2 which was valid from 19.2.2023 to 18.2.2024. The complainant also placed on record copy of previous insurance policy of opposite parties which was valid from 19.2.2022 to 18.2.2023. So, the plea of the opposite parties that the complainant has the above said disease (since 2013) prior to policy inception date is not tenable. We are of the view that it was in the hands of insurance company to see and not to port the policy or renew the policy in question where person is not entitled to claim on account of treatment of Pre-existing disease. So, we are of the view that at this stage the opposite parties cannot be escaped from their liabilities by raising these types of unreasonable and unjustified grounds. The learned counsel for the complainant also relied upon the judgment of the Hon'ble Punjab and Haryana High Court (DB) 2012 (1) RCR (Civil)-901 in which the Hon'ble High Court held that "Claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the policy. Single judge allowed the claim on the ground that it was for Insurance Company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. No interference called for in the order of Single Judge. Held the pre-existing condition existed in the year 2002 which was five years prior to acquiring Insurance Policy. Claim cannot be denied".

17. In the present case the insurance policy was initially commenced in the year 2016 and the opposite parties alleged that the complainant has suffered from the disease Percutaneous Transluminal Coronary Angioplasty (PTCA) in the year 2013 which is prior to 3 years of issues the policy. The opposite parties specifically relied upon the proposal but despite ample opportunities of evidence the opposite parties failed to produce the proposal form to support their version. 

18. The policy in question is continued from 2016 without any hurdle, this fact is also proved from policy produced by complainant and opposite parties No. 1 & 2 as Ex.C-2 & Ex.O.P1.2/1 respectively. 

19. From the above discussion, it is proved that the claim of the complainant/insured was repudiated/rejected by the opposite parties (insurance company) on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties. 

20. The complainant to prove his claim has placed on record copy of Inpatient Detail Bill Ex.C-6 which shows that Rs. 4,00,400/- has been spent on the treatment of complainant in the above said hospital. 

21. In view of the above discussion, the present complaint is partly allowed against the opposite parties No. 1 & 2 and the opposite parties No. 1 & 2 are directed to pay an amount of Rs. 4,00,400/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties No. 1 & 2 are further directed to pay Rs. 5,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN COMMISSION:

7th Day of November, 2024

 

                                              (Ashish Kumar Grover)

                                               President

         

                (Urmila Kumari)

                                               Member

 

                                              (Navdeep Kumar Garg)

                                               Member