Haryana

StateCommission

A/227/2018

RELIGARE HEALTH INSURANCE CO. LTD. - Complainant(s)

Versus

LALITA RANI - Opp.Party(s)

SACHIN OHRI

30 Jan 2019

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION, HARYANA, PANCHKULA

                                                First Appeal No.           :         227 of 2018

                                                Date of Institution        :         20.02.2018

                                                Date of Decision                   :         30.01.2019

 

Religare Health Insurance Company Limited, GYS Global plot no.A-3, A4, A5, Sector-125 Noida UP, Karnal through Mr. Prashan Singh, Legal Manager, Authorized Signatory at 3^rd Floor, Vipul Tech Square, Tower C, Sector 43, Golf Course Road, Gurgaon Hayana.

          …… Appellant

Versus

 

Smt. Lalita Rani wife of Shri Om Parkash, resident of House No.85-A, Bahadhur Chand Colony, Gali No.1, Hansi Road, Karnal.

……. Respondent

 

CORAM:             Hon’ble Mr. Justice T.P.S. Mann, President

Shri Diwan Singh Chauhan, Member.

 

Present:              Mr. Sachin Ohri, counsel for the appellant.

                             Mr. Vipul Sharma, counsel for respondent.

                            

O R D E R

 

DIWAN SINGH CHAUHAN, MEMBER

 

 

                             This appeal has been preferred against the order dated 15.12.2017 passed by the District Consumer Forum, Karnal (for short ‘District Forum’) whereby complaint filed by complainant against the OPs has been allowed. The observations given by Learned District Forum are under:-                    

Keeping in view the above facts and circumstances of the case, we are of the opinion that OP has failed to prove that the complainant had suppressed the fact of her pre-existing ailment at the time of taking the policy. Hence the OP has wrongly repudiated the claim of the complainant and is deficient in providing services to the complainant.

The complainant alleged that the hospital has charged Rs.80,200/- and she spent Rs.30,000/- on medicines from market. But the complainant has placed on the file, photocopy of bill Ex.C3 for Rs.80,200/- only. Regarding the original bill, the learned counsel for complainant stated at the time of argument that the same (original bill) was given to the OP alongwith the claim. This contention of complainant has force and moreover the same has not been denied by the OP which means admitted by the OP. Hence in our view the complainant is entitled for this amount of Rs.80,200/-.

Thus, as a sequel of above discussions, we allow the complaint and direct the OPs to pay Rs.80,200/- to the complainant.  We further direct the OPs to pay Rs.5500/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied within 30 days from the date of this order failing which the abovesaid amount will carry interest at the rate of 8% per annum from the date of order till its realization.”

                             Brief facts of the case are that complainant purchased policy bearing No.10067973 under Plan no. Care Cover Type Individual by paying the premium amount of Rs.4513. The said policy was valid from January, 2014 to 13^th January, 2015 covering the medical claim of Rs.2,00,000/- and she herself was insured for hospitalization expenses, pre-hospitalization and hospitalization expenses, ambulance cover, organ donor cover, domiciliary hospitalization, health check-up, recharge of sum insured, daily allowance. She was medico legally examined by the OP at the time of issuance of said policy. On 1.8.2014 she all of sudden felt some problem and she was taken to Shri Ram Chand Memorial Hospital, Karnal where she was examined by the doctors and she was found a patient of high blood pressure. On 12.8.2014 she suffered from acute headache and on examination she was found high blood pressure and doctors on examination diagnosed the disease as allergic bronchitis and K/C/O. She being treated as indoor patient and she remained admitted in the abovesaid hospital upto 19.8.2014. She spent Rs.80,200/- on her treatment and she also spent Rs.30,000/- towards medicines purchased from the market. Thereafter, she contacted with the OPs and lodged the claim bearing no.90060234 and at the time of submitting the claim, she submitted all the required documents and treatment record and OPs assured her that the claimed amount would be remitted to him as early as possible. She visited the office of OPs several times and requested for reimbursement of the amount, but OPs did not pay any heed to her request and lastly repudiated her claim, vide letter dated 6.12.2014 on the ground that Vertigo was caused due to change in pressure in ear, hence claim stand denied.  This act and conduct of the Ops clearly amounts to deficiency in service and unfair trade practice.

                             Upon notice OPs filed written statement raising preliminary objections with regard to territorial jurisdiction; locus standi and cause of action; deficiency in service and concealments of true and material facts. On merits, it has been submitted that the OPs issued a policy No.10067973, Plan Name Care, Cover type Individual to the complainant providing a coverage upto Rs.2 lakhs for Hospitalization Expenses (conditions for Medical expenses-upto Rs.2,00,000/- i. Room Rent= 1% of Benefit/ Sum Insured per day, ii ICU charges= 2% of Benefit/Sum Insured per day),  pre-hospitalization & Post-hospitalization Expenses, Ambulance cover, organ Donor Cover, domiciliary hospitalization, health check-up, recharge of sum insured, daily allowance and No Claims Bonus on payment of Rs.4513/- as insurance premium and was valid from 14.1.2014 to 13.1.2015 subject to the Policy Terms and Conditions. Complainant lodged the claim with the OP and submitted required document. The claim of the complainant has been repudiated on the grounds of Non-disclosure of pre-existing ailments at the time of proposal and patient is hypertensive since 10 years on regular treatment as mentioned in the claim denial letters. However, the alleged certificate on the letter head of Shri Ram Chand Memorial Hospital where it is mentioned that Lalita Rani was not suffering from HTN but she is taking medication for HTN but not on regular treatment, which was contradictory. Hence there was no deficiency on the part of the OPs in repudiating the claim of the complainant. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

Both the parties led their evidence in support of their respective claims.

On appraisal of the pleadings of the parties and evidence adduced on record, the District Forum allowed the complaint of the complainant as noticed in the opening para of this order.

Aggrieved with the impugned order, appellant-OPs has come up in appeal.  Hence this appeal.

We have heard the learned counsel for both the parties and perused the case file thoroughly.

                             The counsel of the appellant contended that the order passed by the learned District Forum is patently perverse, devoid of merits and not sustainable in the eyes of law. The learned District Forum failed to appreciate the fact that the insured was suffering from hypertension since 10 years (Annexure A-6) which she had not disclosed in the proposal form which is the very basis of contract.  Thus, there is no deficiency in service on the part of appellant and prayed that appeal of the appellant may be allowed and complaint of the complainant be dismissed.

On the other hand, the counsel for the complainant/respondent contended that the District Forum has rightly allowed the complaint and prayed for dismissal of the appeal of the appellant.

We have gone through the facts and circumstance of the case, evidence adduced on record by both the parties.

Complainant/respondent purchased policy under plan name Care, cover type individual. Appellant produced Annexure A-6 a certificate issued by Shri Ram Chand Memorial Hospital, Karnal wherein it was stated that Lalita Rani is suffering from KKO/HTN and she is taking treatment for this on OPD basis approximately from last 10 years. Whereas as per Ex. C2 produced by the respondent/Complainant same hospital i.e. Shri Ram Chand Memorial Hospital, Karnal had also issued a certificate that Mr. Lalita Rani was not suffering from hypertension from last 10 years but she is taking medicine for hypertension not in a regular manner, which is contradictory. Moreover the appellant has not examined any doctor from the said hospital to prove that complainant/respondent was suffering from pre-existing diseases. Hon’ble National Consumer Disputes Redressal Commission, New Delhi in Revision Petition No. 3619 of 2013 titled “Satish Chander Madan versus M/s Bajaj Allianz General Insurance Co. Ltd.” held that Hypertension is a common ailment and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack-Treatment for heart problem cannot be termed as claim in respect of pre-existing diesease.

In this view of the matter, we are of the considered view that the District Forum has taken the correct view by allowing the complaint and needs no interference.

Finding no merit in this appeal, it is dismissed.

 

The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the appellant against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

 

Announced                            (Diwan Singh Chauhan)                (T.P.S. Mann)

30.01.2019                                    Member                                       President

 

FA No. 227 of 2018

 

Present :              Mr. Sachin Ohri, counsel for the appellant.

                             Mr. Vipul Sharma, counsel for respondent.

                            

                                     

Delay in filing the appeal is condoned for the reasons stated in the application.

 

                                       (Diwan Singh Chauhan)                (T.P.S. Mann)

30.01.2019                                    Member                                       President