Chandigarh

StateCommission

A/14/2019

Religare Health Insurance through Manager Legal Parshant Singh - Complainant(s)

Versus

Jasmeen Kaur Bedi - Opp.Party(s)

Ramdeep Partap singh & Shiv Charan Bhola Adv.

27 May 2019

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

 

 

Appeal No.	:	14 of 2019
Date of Institution	:	24.01.2019
Date of Decision	:	27.05.2019

Religare Health Insurance through Manager Legal Parshant Singh, aged 27 years son of Sh. Dhirendra Singh, Vipul Tech Square, Tower C, 3^rd Floor, Sector 43, Gold Course Road, Gurugram, Haryana 122009.

…..Appellant/Opposite Party.

Versus

 

Jasmeen Kaur Bedi wife of Guruparkar Singh Bedi, Resident of H.no.2385, Sector 44-C, Chandigarh.

...Respondent/Complainant.

 

Appeal under Section 15 of the Consumer Protection Act, 1986  against  order  dated  12.11.2018 passed by District   Consumer Disputes Redressal Forum-II, U.T. Chandigarh  in Consumer Complaint No.168 of 2018.

 

BEFORE: JUSTICE JASBIR SINGH (RETD.), PRESIDENT.

                MRS. PADMA PANDEY, MEMBER.

                MR. RAJESH K. ARYA, MEMBER.

 

Argued by:

 

Sh. Ramandeep Partap Singh, Advocate for the appellant.

Sh. R. S. Sidhu, Advocate for the respondent.

 

PER  RAJESH  K.  ARYA, MEMBER

                This appeal has been filed by the opposite party against order dated 12.11.2018 passed by District Consumer Disputes Redressal Forum-II, U.T., Chandigarh (in short ‘the Forum’) vide which, her complaint bearing No.168 of 2018 was allowed in the following manner:-

“11]      From the above discussion, it is held that the Opposite Parties have wrongly & illegally rejected the claim of the complainant as well as cancelled the policy in question, which clearly amounts to gross deficiency in service and unfair trade practice on their part.  Therefore, the present complaint is allowed against the Opposite Parties with following directions:-

a.      To reimburse the claim amount of Rs.3,01,268/- to the complainant along with interest @8% p.a. from the date of filing the complaint i.e. 19.3.2018 till realisation;

b.     To restore the policy of insurance in the name of subscriber/insured with upto date benefits and renew the policy with same coverage in favour of the insured so applied by the complainant by paying the requisite premium;

c.      To pay an amount of Rs.15,000/- as compensation for causing harassment & mental agony to the complainant;

d.     To pay an amount of Rs.7000/- towards litigation expenses.

         This order be complied with by the OPs within a period of 30 days from the date of receipt of its certified copy, failing which they shall also be liable to pay additional cost of Rs.15,000/- apart from the above relief.”

2.             Undisputedly, Care Health Insurance Policy, in question, was purchased by the respondent/complainant from the appellant/Opposite Party in the year 2015-2016, covering risk for the period from 28.2.2015 till 27.2.2016. The said Policy was again issued afresh in the year 2016 for the period from 6.3.2016 to 5.3.2017, which was renewed thereafter further for the period from 12.3.2017 to 11.3.2018. On getting diagnosed with Schwannoma (Brain Tumer), the respondent/complainant was treated at Medanta Hospital, Gurugram, Haryana where he remained admitted for the period from 7.9.2017 to 9.9.2017. An amount of Rs.3,01,268/- was incurred by him for treatment undergone. 

3.             However, the claim when lodged with the appellant/opposite party, the same was repudiated vide Claim Rejection Letter dated 10.11.2017 (Annexure R-8) by stating following reason:-

“NON DISCLOSURE OF MATERIAL FACTS/PRE-EXISTING AILMENTS AT THE TIME OF PROPOSAL (AS PER COSULTATION PAPER ON 11-02-2010, PATIENT HAS COMPLAINTS OF DECREASED HEARING SINCE 2 MONTHS WITH TINNITUS, ALSO IN REPLY MAIL OF INSURED, CLEARLY STATED THAT HEARING LOSS BECAUSE OF GOING IN LOUD MUSIC AS PER DR. RAMAN ABROL IN 2010 WHO ALSO SUGGESTED THAT HARING LOSS CAN NOT BE CORRECTED.)

NON DISCLOSURE OF MATERIAL FACTS/PRE-EXISTING AILMENT AT TIME OF PROPOSAL.”

4.               The reason quoted by the appellant/opposite party for denial of the claim was that the respondent/complainant did not disclose the problem of hearing loss suffered in the year 2010 while availing the policy on 28.2.2015 and as such, the Cashless Facility request of the respondent/complainant was denied as per Clause 7.1 of the Policy Terms and Conditions, which was intimated to the respondent/complainant vide letter dated 09.09.2017.

5.             Counsel for the appellant/opposite party argued that the respondent/complainant had the opportunity to disclose the state of health at the time of taking the policy in the proposal form, which he did not. It was also argued that by answering in negative and not disclosing the material information qua his hearing loss problem and Tintus since 2010, he misrepresented to the Insurance Company and fraudulently obtained the policy, in question. It was next argued that the appellant/opposite party has rightly repudiated the claim and is not liable to make payment of any claim to the respondent/complainant.

6.             Rebutting the arguments made by the Counsel for the appellant/opposite party, it was argued by the Counsel for the respondent/complainant that the question posed in the proposal form was qua any illness/injury during the last 48 months or is suffering from any illness/disease and not preceding to the said period of 48 months and as such, the answer to that question was given in the negative. It was argued that the appellant/opposite party miserably failed to prove that the respondent/complainant ever taken any treatment for the so called pre-existing ailment of hearing loss and tinnitus with the period of 48 months prior to inception of the policy in question. It was also argued that the order passed by the Forum is just and proper and the appeal is liable to be dismissed.

7.             The core question before us in this appeal to be decided is as to whether rejection of claim lodged by the respondent/complainant with the appellant/opposite party, for the reasons given in the Claim Rejection Letter was justified. Our answer to this question is in negative as there was no suppression on the part of the respondent/complainant as she was not under obligation or any compulsion to disclose about any illness/injury suffered by her prior to the period of 48 months from the date of inception of the policy, in question. She answered the question in the proposal very specifically as was required of her. Furthermore, the appellant/opposite party miserably failed to establish by leading any documentary evidence, much less cogent and convincing, that the respondent/complainant ever underwent any treatment for the alleged pre-existing disease of hearing loss and tinnitus since 2010, when she was diagnosed for such problem.  Not only above, record also lacks evidence qua the respondent/complainant ever taken any treatment for the same within the period of 48 months prior to inception of the policy in question. The reasons given in the Claim Rejection Letter by the appellant/opposite party were totally unjustified and seemed to be engraved only to deny rightful claim to the respondent/complainant.

8.             It may also be stated here that on one hand, the Insurance Companies want to augment their business by charging the premium and when out of ten, one or two consumers file a claim, they start finding out one excuse or the other, most of which are dubious and feeble to defeat the rightful claim of the party. This is highly unethical and uncouth practice. We have considered this case in its entirety and hold that the appellant/opposite party adopted unfair trade practice by arbitrarily repudiating the genuine mediclaim of the respondent/complainant. In our considered opinion, the Forum has rightly directed the opposite parties to reimburse the claim amount of Rs.3,01,268/- to the respondent/complainant along with interest @8% p.a. It also rightly ordered restoration of the policy of insurance in the name of subscriber/insured with up-to date benefits and renew the policy with same coverage in favour of the insured so applied by the respondent/complainant by paying the requisite premium. It also rightly awarded compensation to the tune of Rs.15,000/- towards harassment & mental agony and Rs.7,000/- towards litigation expenses to the respondent/ complainant.

9.             Hence, we 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.

10.           No other point was raised by the Counsel for the parties.

11.           For the reasons recorded above, this appeal being devoid of any merit, is dismissed, with no order as to costs. The impugned order dated 12.11.2018 passed by District Forum-II, U.T., Chandigarh is upheld.

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

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

Pronounced.

27.05.2019.

[JUSTICE JASBIR SINGH (RETD.)]

PRESIDENT

 

 

(PADMA PANDEY)

        MEMBER

 

 

(RAJESH  K. ARYA)

MEMBER

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