STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HARYANA, PANCHKULA
First Appeal No.18 of 2022
Date of Institution: 18.01.2022
Date of Decision: 10.02.2022
1. The Manager/Authorized Signatory/Secretary Care Health Insurance Ltd. Formerly known as Religare Health Insurance Company Limited, Vipul Tech Square, Tower-C, 3rd Floor, Golf Course Road, Sector-43, Gurugram-122009.
2. The Manager/Authorized Signatory Care Health Insurance Ltd. Formerly known as Religare Health Insurance Company Limited, GYS Global, Plot No.A3, A4, A5, Sector 125, Noida, UP-201301.
….Appellants
Versus
Kavita Devi wife of Sh. Sanjay Kumar, resident of Medicine House, Opposite Civil Hospital Gali No.01, Bhiwani at present village Bardu Dhirja, Tehsil Loharu, District Bhiwani.
……Respondent
CORAM: Mr.A S Narang, Judicial Member.
Mr. Suresh Chander Kaushik, Member.
Present:- Mr. Paras Money Goyal, counsel for the appellants.
O R D E R
A.S. NARANG, JUDICIAL MEMBER:
(The matter has been heard through virtual hearing).
Delay of 35 days in filing of the present appeal is hereby condoned for the reasons stated in the application for condonation of delay.
2. The Manager Care Health Insurance Ltd. & another (Appellants) have filed this appeal against the order dated 29.10.2021, whereby the District Consumer Disputes Redressal Commission, Bhiwani (in short “DCDRC”) has allowed the complaint filed by the complainant (Kavita Devi) against them.
3. On 22.03.2019, complainant filed the complaint before the DCDRC, Bhiwani against the appellants with the averments that she had purchased medical health policy bearing No.10738690 from the appellants effective from 14.08.2016 to 13.08.2017. On 07.11.2016, she suffered a spinal fracture. On 11.11.2016, she was operated upon at the Medanta, The Medicity Hospital, Gurugram. She was admitted in the hospital on 07.11.2016 and discharged on 14.11.2016. She spent Rs.3,25,000/- on her treatment as per bill issued by Medanta, The Medicity Hospital, Gurugram. She had lodged a claim regarding this with the appellants. However, they refused to make the payment. Complainant alleged that she also issued a legal notice on 24.01.2018, which was duly served upon the opposite parties (present appellants). However, they did not respond. Complainant alleged that she suffered mental agony, harassment and pecuniary loss due to the act and conduct of appellants. Accordingly, she filed the complaint before the DCDRC, Bhiwani against the appellants, claiming the policy amount of Rs.3,25,926/- with interest alongwith compensation and other relief.
4. Appellants in the written reply admitted that the complainant had purchased the insurance policy. They alleged that upon submission of the cashless policy claim by the complainant, vide letter dated 08.11.2016, they had sought certain documents and clarifications in order to properly assess the loss. However, the hospital concerned did not provide any documents and clarifications. Accordingly, they repudiated the complainant’s cashless facility request stating “as per the documents submitted pre-existing nature of ailment could not be ruled out, hence, liability of insured could not be taken at present juncture and cashless facility is being denied”. This was duly communicated to the complainant on 09.11.2016. On 24.01.2019, they had received a notice from the counsel for the complainant. They duly responded to the same. Appellants alleged that the complainant has filed the complaint by misrepresenting the facts. They requested that the complaint be dismissed.
5. Complainant tendered in evidence her affidavit (Ex.CW-1/A) and affidavit of Sanjay Kumar (Ex.CW-2/A) alongwith documents Annexure C-1 to Annexure C-3.
6. On the other hand, respondents tendered in evidence affidavit of Ms. Shreya Chansoria, Manager (Legal) as (Ex.RW-1/A) and documents Annexure R-1 to Annexure R-6.
7. After hearing the parties and perusing the evidence on the record, vide impugned order dated 29.10.2021, the DCDRC, Bhiwani allowed the complaint and directed the appellants to reimburse Rs.3,25,926/- alongwith interest at the rate of 9% from the date filing of complaint till realization. The DCDRC, Bhiwani also directed the appellants to pay Rs.40,000/- as compensation to the complainant on account of physical harassment and mental agony and Rs.5500/- as litigation expenses.
8. Aggrieved by the order passed by the DCDRC, Bhiwani, appellants have filed this appeal.
9. We have heard Mr. Paras Money Goyal, counsel for the appellants.
10. Assailing the impugned order, Mr. Paras Money Goyal, counsel for the appellants has submitted that the DCDRC, Bhiwani has not appraised the evidence on the record properly. Drawing our attention to the Pre-Authorization Request Form (Annexure A-1), counsel for the appellants submitted that the complainant in her form had stated that she was suffering from back pain. She had suffered spinal fracture of D-12. Counsel for the appellants also drew our attention to their letter dated 09.11.2016 to Medanta, The Medicity Hospital, Gurugram, wherein they alleged that as per the documents submitted to them, the pre-existing nature of ailment could not be ruled out. Accordingly, the cashless facility was denied. Counsel for the appellants submitted that the complainant had not disclosed earlier ailments. In fact, from the material on record, it appears that she was having some ailments prior to purchasing the insurance policy. He further submitted that the law is well settled that the contract of insurance is a contract uberrima-fide. In such like contracts, it is the duty of parties to disclose all the facts in their knowledge. However, in the case in hand, the complainant deliberately concealed the vital information from the appellants. Counsel for the appellants submitted that the appeal be admitted for hearing and notice be issued to the complainant.
11. We have considered the contentions canvassed at the bar by the counsel for appellants. However, we are of the considered view that there is no merit in the same. A reading of the Pre-Authorization Form (Annexure A-1) submitted by the complainant to the appellants would show that she had suffered fracture of D-12 and as per the treatment plan, Posterior Spinal Fixation was to be done. Complainant is a young lady aged 33 years. Had she suffered this injury prior to purchasing the insurance policy, this would have come to the notice of appellants. From the material on the record, it appears that the complainant suffered this injury on 07.11.2016 as alleged by her. She was admitted in Medanta, The Medicity Hospital, Gurugram. We are of the considered view that the DCDRC, Bhiwani has appraised the evidence properly and rightly allowed the complaint. The appellants were not justified in declining the cashless facility to the complainant. They unnecessarily harassed the complainant and made her undergo mental agony. We do not find any merit in the appeal and dismiss the same in limine. A copy of this order be sent to the DCDRF, Bhiwani and to the parties.
12. Statutory amount of Rs.2,26,257/- deposited by the appellants at the time of filing the present appeal be disbursed to the respondent-complainant as per rules, against proper receipt and identification after the expiry of the period of filing of appeal/revision, if any. However, before disbursing the sum of Rs.2,26,257/- to the respondent-complainant, the Registrar of this Commission would ensure that the complainant has not received the decreetal amount from the appellants. The DCDRF, Bhiwani would adjust the sum of Rs.2,26,257/- disbursed to the complainant at the time of execution of the order dated 29.10.2021, passed by DCDRF, Bhiwani.
Pronounced in open court.
Suresh Chander Kaushik A S Narang
February 10th, 2022 Member Judicial Member
Addl. Bench Addl. Bench
R.K
