DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

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Complaint  Case  No : 102 of 2011

Date of Institution :  23.12.2011

Date of  Decision   :  05.09.2011

Kamlesh Gupta w/o S. Sham Sunder Gupta, r/o #315, Sector 15, Panchkula, presently R/o # 593-A, Sector 10, Panchkula.

.…Complainant

V E R S U S

M/s Reliance General Insurance Company Ltd., SCO No. 212-214, Sector 34, Chandigarh.

.…..Opposite Party

CORAM:   Sh.P.D. GOEL                    PRESIDENT

SH.RAJINDER SINGH GILL          MEMBER

DR.[MRS]MADANJIT KAUR SAHOTA    MEMBER

Argued by: Sh. Rakesh Kumar Sharma, Counsel for Complainant.

Sh. Kapil Gupta, Counsel for OP.

PER DR.[MRS]MADANJIT KAUR SAHOTA, MEMBER

         Succinctly put, the Complainant took a Health Insurance Policy from the OP, with cashless facility, valid from 17.03.2009 to 16.03.2010. During the currency of the said policy, on 09.10.2009, she was taken to Dr. R.K. Sood of M/s Sood Medical Centre with a complaint of severe abdomen pain with vomiting. On diagnosing presence of multiple stones in the gall bladder, the said Physician, referred the Complainant to Surgical Specialist. After undergoing several tests, the Complainant got admitted in the Fortis Hospital, Mohali on 27.10.2009, for the General Surgery to remove gall bladder, which was successfully removed. On 28.10.2009, she was discharged from the hospital after removal of gall bladder. On account of the aforesaid treatment, the Complainant incurred a sum of Rs.39,873/- from her pocket. Accordingly, she lodged a claim with the OP, along with all the requisite papers. The OP initially raised certain objections, which were duly met with by the Complainant. But to her utter surprise and dismay, OP denied cashless facility by taking plea that the Complainant had been suffering from the ailment for the past few years and prior to the inception of the Policy. Hence this complaint, alleging that the aforesaid acts of the OP amount to deficiency in service and unfair trade practice.

2]       Notice of the complaint was sent to OP seeking their version of the case.

3]       OP in its reply, while admitting the fundamental facts of the case, pleaded that the Complainant purchased Health Policy from the OP through TPA on 17.3.2008 to 16.3.2009 and the same was subsequently renewed with effect from 17.3.2009 to 16.3.2010. It was submitted that the Complainant got admitted in Fortis Hospital Mohali for the surgery to remove gall bladder on 27.10.2009 and discharged on 28.10.2009. The Complainant filled the claim form. After scrutiny of the claim form and other supporting papers supplied by the Complainant, an Investigator was appointed to investigate the matter. During investigation, it was found that the Complainant was admitted for the treatment of Cholelithiasis and this disease was pre-existing illness suffered by the Complainant prior to the inception of the Policy. Hence, the claim submitted by the Complainant was repudiated on the ground of pre-existing disease as per Clause 1 of the terms and conditions of the Policy. All other material contentions of the complaint were controverted. Pleading that there was no deficiency in service on their part, a prayer has been made for dismissal of the complaint.

4]       Parties led evidence in support of their contentions.

5]       We have heard the learned counsel for the parties and have also perused the record, with utmost care and circumspection.

6]       The grouse of the Complainant in this complaint is that during the subsistence of the policy, inspite of the fact that all requisite formalities/ clarifications were provided, well in time to the OP, it has repudiated her claim, which is totally uncalled for and baseless. The Complainant even gave number of reminders regarding settlement of the claim vide email Annexure C-6 and C-7. The ground of repudiation was primarily of pre-existing disease, alleged to have been suffered by the Complainant for the past few years i.e. prior to the inception of the policy in question.

7]       On the other hand, the OP admitted the factual matrix of the case that the Complainant has purchased the Reliance Healthwise Gold Plan Policy, with cashless facility [R-1 & R-2]. It is argued that while filling up the proposal form, the Complainant has categorically stated that she is not suffering from any illness [R-3].

8]       Admittedly, the Complainant got admitted in Fortis Hospital, Mohali for the surgery to remove gall bladder and remained in the hospital from 27.10.2009 to 28.10.2009. It is the case of the Complainant that the Complainant filled the claim form, but without certain documents, which was complied with later on. Furthermore, after scrutiny of the claim form by an investigatory, it was found that the Complainant was admitted for the treatment of “cholelithiasis”, which is a pre-existing illness suffered by the Complainant, prior to the inception of the policy.  

9]       It is the allegation of the OP that the Complainant has a history of abdomen pain for the last few years [R-4 to R-6]. As such, the claim was rightly repudiated qua Annexure R-7, on the ground of pre-existing disease, as per clause 1 of the terms and conditions of the Policy. Hence, the claim lodged by the Complainant is not tenable under the policy.

10]      After perusal of the documents placed on file, it is an admitted fact that the Complainant purchased the Reliance Healthwise Gold Plan Policy, with cashless facility from the OP – Insurance Company, which was subsequently renewed. It is also an admitted fact that during the subsistence of the policy, valid from 17.3.2009 to 16.3.2010, the insured suffered abdomen pain and got admitted in the Fortis Hospital, Mohali for the general surgery to remove gall bladder and in the process had spent an amount of Rs.39,873.70P, from her own pocket. Immediately, after that, when the claim form was submitted, the OP initially delayed the settlement of the claim and finally, rejected the same altogether, on the ground of pre-existing disease.

11]      Even, during the course of arguments, the learned counsel for the OP put reliance on discharge summary [R-5] and submitted that the Complainant was suffering from abdomen pain for the last few years and prior to the inception of the policy. In the said discharge summary, under the heading “Present Illness”, it has been stated that “Patient admitted with c/o pain abdomen x few yrs.”. Similarly, a perusal of repudiation letter [R-7] shows that the primary ground on the basis of which the claim of the Complainant was repudiated is that she is suffering from the ailment for the past few years. However, for the sake of convenience, the relevant extract of the said letter is reproduced hereinbelow:-

“Further, as per the investigation performed and the discharge summary it is evident that the claimant is suffering from the ailment for the past few years & prior to the inception of the policy and going beyond the coverage of present policy.”      

12]      A close scrutiny of Annexure R-7 shows that the ailment, on the basis of which, the claim was repudiated by the OP-Insurance Company, has not been specifically mentioned. Further, to our mind, the ground of repudiation is not available to the OP, as suffering from the ailment for the past few years indicates no ground just for the repudiation of the said claim. Annexure C-9 is letter written by Dr. Atul S. Joshi, Associate Consultant – General & Minimal Acess Surgery, Fortis Hospital, Mohali (Punjab), clearly stating that chronic cholescystites is a clinical diagnosis and cannot be ascribed any time interval. Accordingly to the Complainant, a copy of the said writing has already been sent to the TPA. However, for the sake of convenience, the relevant extract of the same is reproduced below:-

“It is clinically impossible to quantify time limit or as to define the time definition of chronicity. Chronic cholescystites is a clinical diagnosis and cannot be ascribed any time interval. This may please be corroborated from available medical literature.”

13]      In the given situation, it cannot be assumed by any stretch of imagination that the Complainant has been suffering from the ailment for the past few years and prior to the inception of the policy. As such, the inaction of the OP Insurance Company in repudiating the well founded claim of the Complainant, surely and definitely, tantamounts to gross deficiency in service and indulgence in unfair trade practice on the part of the OP-Insurance Company.

14]      As a result of the above discussion, this complaint is accepted and OP is directed to pay an amount of Rs.39,873.70/- to the Complainant, along with interest @12% from the date of repudiation of the claim i.e. 02.03.2010. The OP is also directed to pay to the complainant a sum of Rs.10,000/- towards costs of litigation.  This order be complied with by the OP, within one month, from the date of receipt of its copy.

15]      The certified copies of this order be sent to the parties free of charge. The file be consigned.