Chandigarh

StateCommission

A/228/2019

Religare Health Insurance Company Ltd. - Complainant(s)

Versus

Davinder Singh Jaaj - Opp.Party(s)

Ramdeep Partap Singh & Shiv Charan Bhola Adv.

29 Nov 2019

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

 

 

Appeal No.	:	228 of 2019
Date of Institution	:	07.10.2019
Date of Decision	:	29.11.2019

 

Religare Health Insurance Company Ltd. having its Service Branch at Vipul Tech Square, Tower C, 3^rd Floor, Sector 43, Golf Course Road, Gurugram, Haryana – 1222009 through its Manager Legal Shreya Chansoria.

…..Appellant/Opposite Party.

Versus

Davinder Singh Jaaj resident of H.no.1053, Sector 27-B, Chandigarh.

…Respondent/Complainant.

Appeal under Section 15 of the Consumer Protection Act, 1986.

 

BEFORE:   JUSTICE RAJ SHEKHAR ATTRI (RETD.), PRESIDENT.

                MRS. PADMA PANDEY, MEMBER.

                MR. RAJESH K. ARYA, MEMBER.

 

Argued by:

 

Sh. Prince, Advocate, proxy for Sh. Ramdeep Partap Singh, Advocate for the appellant.

 

PER  RAJESH  K.  ARYA, MEMBER

                This appeal has been filed by the opposite party against order dated 11.07.2019 passed by District Consumer Disputes Redressal Forum-I, U.T., Chandigarh (in short ‘the Forum’), vide which, consumer complaint bearing No.834 of 2017 filed by the complainant was partly allowed and the opposite party was directed to pay the claim amount of Rs.4,69,998/- to the complainant alongwith interest @9% p.a. from the date of repudiation i.e. 2.9.2016 till realization. Besides above directions, amounts of Rs.20,000/- & Rs.10,000/- were also awarded as compensation and costs of litigation by the Forum. The impugned order was to be complied with by the opposite party within a period of 30 days failing which, the claim amount and compensation awarded were to entail interest @12% .a. from the date of order till realization.

2.             The admitted facts, in brief are, that while getting renewed the health policy from the opposite party, for the period from 29.3.2016 to 28.3.2017 and had duly disclosed about having pre-existing disease of hypertension at the inception of the policy, for which, extra premium was paid by him as per terms and conditions of the policy. As per the policy, there was a four years waiting period for treatment of pre-existing disease. On 18.7.2016, the complainant was admitted in Fortis Hospital, Mohali for treatment of coronary artery disease (CAD) unstable angina and hypertension and discharged on 19.7.2016.  Bill amounting to Rs.4,69,998/- was paid by the complainant as the opposite party did not agree to the request for the cashless treatment. However, the claim against the said bill was repudiated by the opposite party vide letter dated 2.9.2016 on the ground that four years waiting period not expired for treatment of pre-existing disease and its complications. Accordingly, the claim was cancelled as patient IAK/C/O hypertension and the ailment was a complication of the same.

3.             It may be stated here that when this appeal came up for hearing for the first time before the Commission on 14.10.2019,  Sh. Ramdeep Partap Singh, Advocate, Counsel for the appellant appeared and sought time to place on record certain documents. On his request, the matter was adjourned to 22.10.2019, on which date, proxy Counsel appeared and again sought time to do the needful. On the next date i.e. 05.11.2019, none put in appearance and on written adjournment slip submitted in advance by the Counsel for the appellant, the matter was adjourned to 13.11.2019. On 13.11.2019, again proxy Counsel appeared and made a request for adjournment. Last opportunity was granted to the appellant to address arguments, failing which, it was directed that the appeal shall be disposed of after going through the material available on record. The matter was adjourned to 20.11.2019, on which date, again proxy Counsel appeared and made a request for further adjournment. Seeing the laxity and intention not to pursue the appeal, the request for adjournment was declined by this Commission and the matter was reserved for orders.

4.             Admittedly, there was a four years waiting period for treatment of pre-existing disease as per terms and conditions of the policy, due to which, the claim of the complaint was liable to        fail but the Forum was right in observing that Coronary Artery Disease (CAD) unstable angina was not the result of hypertension, which was pre-existing. It based its finding on an opinion (Annexure C-9) given by Dr. Rakesh Kumar Jaswal, MD (Medicine) DM (Cardiology) of Fortis Hospital, who initially treated the complainant. According to Dr. Jaswal, the hypertension was not the only risk factor for CAD;  patient a 71 years old Asian male, has family history of CAD being the non-modifiable risks factor and as per records available, his blood pressure was adequate controlled. We are one with the detailed findings given by the Forum in Paras 8 and 9 of its order, which were based on true and correct appreciation of material available on record. Paras 8 and 9 of the impugned order, being relevant, are extracted hereunder:-

“8.      Per attending on doctor, his opinion reproduced hereinbefore, CAD is a multi-factorial disease and hypertension is one of the risk factors for coronary artery disease and per his report the patient was aged 71 years old Asian male with family history of CAD being non-modifiable risk factor.  We find logic in his report for the reason that the complainant on the date of treatment was aged 71 years i.e. nearing the autumn of his life and at that juncture due to degenerative changes, there is tendency of termination of life and his further opinion was blood pressure was adequately controlled. It is said that old age is in itself a disease, therefore when hypertension pre-existing disease was under control, it cannot be authentically said that CAD for which the complainant was treated is the result of said hypertension. 

9.       It is true that the OP had also taken the opinion of two doctors from Mumbai and their reports are on record which shows that conclusion of one of the doctors was patient Mr. Devinder Singh Jaaj’s coronary artery disease is attributable to his hypertension and although any hypertension treatment reduces the risk of coronary artery disease, it does not neutralize the risk of CAD. Even per opinion of the doctor from Mumbai, anti hypertensive treatment reduces the risk of CAD but it does not neutralize the risk of CAD.  It is also not the case of the OP, complainant was physically/ clinically examined by the said doctors from Mumbai and, thereafter, on examination of treatment record, they have opined so.  Their opinion is based on record produced. Even on the same record physical examination and treatment of doctor from Fortis Hospital, Dr. Rakesh Kumar  Jaswal had  opined  that hypertension was not the risk in the

 

 

present case.  Keeping in view the fact that attending on doctor had opined hypertension was not the risk and he physically and clinically examined the patient and treated him shows that more weight in comparison to the reports of doctors from Mumbai is to be attached to the report of Dr. Rakesh Kumar Jaswal whose report is logical one, complainant was aged 71 years at the fag end of his life and there was also a genetic history of his family suffering from CAD. From this record, we are of the opinion, report furnished by the doctors from Mumbai is not reliable as the report of Dr. Rakesh Kumar Jaswal appears to be more logical keeping in view the family history of the complainant and his age being 71 years.”

 

5.             As per available record before Dr. Rakesh Kumar Jaswal, the blood pressure of the complainant, a 71 year old person, was adequately controlled and in that case, it could be authentically said that CAD, for which, the complainant was treated, was not the result of hypertension. Therefore, the claim repudiated by the opposite parties was an attempt to deny the genuine claim of the complainant by putting forward a flimsy ground, which was not at all sustainable on facts as well as eyes of law. The appellant/opposite party did not think for a while that the complainant at an age 71 years must be in dire need of financial assistance, when he spent an amount of Rs.4,69,998/- from his pocket for a treatment, which, in our opinion, had nothing to do with the history of hypertension, specially, when Dr. Rakesh Kumar Jaswal, had opined on the basis of record available before him that his blood pressure was adequately controlled.

6.             Thus, in view of above, the appellant/opposite party has failed to make out any case for setting aside the well-reasoned order passed by the Forum.              

7.               For the reasons recorded above, we concur with the findings given by the Forum in its judgment and are of the opinion that the order passed by the Forum, being based on the correct appreciation of evidence and law, on the point, does not suffer from any illegality or perversity.    

8.             For the reasons recorded above, the appeal filed by the appellant/opposite party is dismissed in limine with no order as to costs. The impugned order dated 11.07.2019 passed by District Forum-I, U.T., Chandigarh in Consumer Complaint bearing no.834 of 2017 is upheld. Consequently, the miscellaneous applications bearing Nos.693 of 2019 for condonation of delay in filing the appeal and 694 of 2019 for stay, stands disposed of having become infructuous.

9.             Certified copies of this order, be sent to the parties, free of charge.

10.           The file be consigned to Record Room, after completion.

Pronounced.

29.11.2019.

[RAJ SHEKHAR ATTRI]

PRESIDENT

 

 

(PADMA PANDEY)

        MEMBER

 

 

(RAJESH  K. ARYA)

MEMBER

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