Delhi

East Delhi

CC/133/2021

DEVENDER KR. - Complainant(s)

Versus

M/S RELIGARE HEALTH INS. - Opp.Party(s)

03 Aug 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. No.133/2021

	Mr. Devender Kumar S/o Shri Rohtas Singh R/o 61-L, Street No.5, Sai Baba Mandir, East Laxmi Market, New Delhi – 110092.	….Complainant
Versus
	M/s. Religare Health Insurance Co. Ltd. Office at:- 5th Floor, 19, Chawla House, Nehru Place, New Delhi – 110019. HAVING ITS OFFICE AT:- Unit No. 604-607, 6th Floor, Tower – C, Unitech Cyber Park, Sector – 39, Gurugram – 122001, Haryana   Now:   Care Health Insurance Ltd. 3rd Floor, Vipul Tech Square Tower-C Sector-43, Golf Course Road, Gurugram, Haryana (As per affidavit of Opposite party)	……OP

Date of Institution: 04.03.2021

Judgment Reserved on: 26.07.2023

Judgment Passed on: 03.08.2023

CORUM:

Sh. S.S. Malhotra (President)

Ms. Rashmi Bansal (Member)

Sh. Ravi Kumar (Member)

 

Order By: Ms. Rashmi Bansal (Member)

 

JUDGMENT

The present case is filed by the complainant against OP for repudiating his insurance claim alleging deficiency in service and unfair trade practice.

1. It is the case of the complainant that he has taken a policy dated 19.03.2020 for his family members from OP, valid from 20.03.2020 to 19.03.2021. The son of complainant, aged 2.4 year suffered from typhoid and was admitted in hospital on 24.08.2020.  Complainant Submits that before admission to the hospital his request for cashless hospitalization was not approved by OP and vide bill dated 24.08.2020, he has paid a sum of Rs. 1,04,458/- & vide bill dated  19.08.2020 paid a sum of Rs.20,000/-  to the hospital.
2. The claim of the complainant was rejected by OP vide rejection letter dated 23.08.2020 on the ground that there is concealment of the fact about the kidney problem of his son. Complainant submits that his son was not suffering from any kidney problem at any point of time rather was diagnosed typhoid only for which he was admitted in the hospital. The legal notice dated 06.11.2020 was replied by OP dated 03.12.2020, whereby OP agreed to settle all the disputes with the complainant and instructed the complainant to submit all original relevant documents for resolving the dispute which were handed over to the OP, but thereafter OP did not clear the claim of the complainant. Complainant submits that OP is deficient in its service in not passing the claim of the complainant because of which he has suffered irreparable loss, harassment and mental agony and prays for clearance his claim amount of Rs.1,24,450/- along with compensation and litigation charges.
3. OP has filed its reply and admitted the issuance of the policy to the complainant. OP has also filed the documents showing that the name of the company changed from Religare Health Insurance Co. Ltd. to Care Health Insurance Co Ltd, vide certificate of incorporation dated 19.08.2020, hence the complaint in the name of Religare Health Insurance company is liable to be rejected.
4. OP also submits that in the cashless claim request, received with pre-authorization form, it was mentioned in the past history as “DTPA scan, showing RT small kidney”. A query letter dated 19.08.2020, was sent to the hospital and was asked to provide certain documents, but no reply was received from the hospital. Reminder letters dated 20.08.2020 and 21.08 2020 were sent to the complainant also. The OP has also filed a consultation paper dated 13.08.2019 where in it was mentioned that insured was diagnosed with a small right kidney & after perusal of the documents sent by the hospital that were procured during investigation to check the veracity of the claim, OP rejected the cashless request of the complainant vide denial letter dated 22.08.2020 on the ground of non-disclosure of right small kidney of the insured which was diagnosed in January 2020. A re-consideration request received from the hospital, OP again reviewed the documents and rejected the claim vide letter dated 23.08.2020. OP also submits that they have received an intimation from the hospital about the hospitalization of the patient from 19.08.2020 till 24.08.2020. Upon receipt of the claim a query was also sent vide letter dated 06.09.2020 whereby the complainant was asked to provide some documents. No reply was received and a reminder letter dated 16.09.2020 and 26.09.2020 were again sent to the complainant. OP submits that there has been no disclosure, on the part of the complainant, therefore, the claim was rejected by denial letter 12.10.2020 on the basis of non-disclosure of right side small kidney of the child diagnosed in January 2020. The complainant had the chance to disclose about fact of insured’s small kidney at the time of filling the on line proposal form.
5. The legal notice of the complainant was replied by the OP on 03.12.2020 thereby the complainant was asked to provide complete treatment record of insured to clarify as to when right side small kidney was diagnosed.
6. OP further submits that contract of insurance is a contract of uberrimae fides, and by not declaring true correct and accurate information at the time of proposal for policy, complainant is guilty of breach of the principle of utmost good faith. As per clause 7.1 of the policy terms and conditions, the complainant was under obligation to disclose all material facts at the time of taking the policy. Also, IRDAI (Insurance, Regulatory and Development Authority of India) regulations, 2017, clause 19 (4) enumerating the general principles. Thus the policyholder/complainant acted in breach of the insurance policy terms and conditions and violated the above stated principles and regulations, accordingly there is no deficiency in service on the part of OP and rejection of the claim of the complainant is rightful. Hence, the complaint is liable to be dismissed.
7. Complainant has filed rejoinder negating the contents of the reply of the OP and reiterated his version in the complaint. Both the parties have filed their respective evidence with documents in support of their case.
8. Complainant has filed following documents: –
   1. Copy of Legal Notice dated 06.11.2020 Ex.CW1/A;
   2. Reply of Legal Notice dated 06.11.2020 Ex.CW1/B;
   3. Denial Letter dated 22.08.2020 Ex.CW1/C
   4. Claim Form Received dated 28.12.2020 Ex.CW1/D;
   5. Doctor Opinion dated 19.08.2020 Ex.CW1/E;
   6. Advance deposit Receipt dated 19.08.2020 Ex.CW1/F;
   7. Bill dated 19.08.2020  Ex.CW1/G;
   8. Discharge summary alongwith other medical documents and reports Ex.CW1/H;
   9. Adharcard Ex.CW1/I
9. OP has filed following documents :–
   1. Policy Ex.R1;
   2. Policy terms and conditions Ex.R2;
   3. Denial Letter  dated 22.08.2020  Ex.R3;
   4. Cashless Form (Colly) Ex.R4;
   5. Query letter dated 19.08.2020 Ex.R5;
   6. Reminder – 1 letter dated 20.08.2020 Ex.R6;
   7. Reminder – 2 letter dated 21.08.2020 Ex.R7;
   8. Rejection letter dated 22.08.2020 Ex.R8;
   9. Query reply Ex.R9;
   10. Treatment sheet dated 17.08.2020 (Colly) Ex.R10;
   11. Rejection letter dated 23.08.2020 Ex.R11;
   12. Legal Notice Ex.R12;
   13. Reply to the Legal Notice dated 03.12.2020 Ex.R13;
   14. Claim denial letter dated 12.10.2020 Ex.R14;
   15. Discharge Summary dated 24.08.2020 Ex.R15;
   16. Query letter dated 06.09.2020 Ex.R16;
   17. Reminder – I dated 16.09.2020 Ex.R17;
   18. Query letter dated 26.09.2020 Ex.R18;
   19. Consultation paper dated 13.08.2019 (Shreyas Clinic) Ex.R19;
   20. Incorporation Certificate Ex.R20;
10. The Commission has perused the record and heard the arguments of both the parties. The policy, the admission of the child into the hospital are not in dispute. The only dispute is whether there was concealment of the material fact from OP while taking the policy by the complainant.
11. Before deciding the matter on merit, the objection of the OP with respect to the existence of the Religare Health Care is to be decided. The OP has filed the documents showing that name changed from Religare Health Care to Care Health Insurance Limited. It is true that case has been filed in the name of Religare Health Care. By replying the notice of the present complainant case in the name of Care Health Insurance Limited the OP itself has dissolved the issue. The name has also been substituted in the further pleadings filed by the OP subsequently. Therefore this contention has already been set at rest.
12. The documents on record show that child was of two years four months old when he was admitted into the hospital and has been kept in ICU for four days and was diagnosed with typhoid. There is a document dated 23.08.2020 place on record by the complaint which was sent to the OP along with request for reconsideration for cashless treatment on record issued by the hospital wherein this has been specifically mentioned that a small contracted kidney is an accidental kidney and it has not got any relationship to the above illness. Child has never been getting any treatment to it. It is neither hidden nor concealed. Any patient can have any accidental kidney and same does not bar him from getting insurance for present illness.
13. There was no evidence on record filed by the OP to show that the complainant has already taken treatment for the same from any of the hospital earlier than the filing of the claim. Even if the complainant is child was having such a small kidney, but such fact was not into his knowledge till the child was admitted into the hospital for the treatment of typhoid. Before that there was no chance for him to know the fact about this. Moreover, the treatment of typhoid has no relationship with a small kidney no it has any hindrance in his treatment and has no effect on his treatment. Neither the illness has been caused because of the small kidney nor the treatment was for the same.
14. Further, what was required to be disclosed in Proposal Form was any pre-existing disease w.r.t. “Kidney stones/Renal failure/Dialysis/Chronic kidney disease/prostrate disease or any other disease of kidney, Urinary track or reproductive organs” to which complainant has replied in “No”. The query implies any ailment of which proposer had positive knowledge of. If the proposer had no knowledge of any ailment till the time of filing proposal form, then obviously there would be no instance of non disclosure of any ailment or sickness.     The complainant was not into the positive knowledge of the existence of the right small kidney in his child.
15. Hon,ble Supreme Court in Manmohan Nanda Vs. United India Insurance Co. Ltd. CA 838/15 has observed that – “The object of seeking a mediclaim policy is to seek indemnification in respect of a sudden illness or sickness which is not expected or imminent and which may occur overseas. If the insured suffers a sudden sickness or ailment which is not expressly excluded under the policy, a duty is cast on the insurer to indemnify the appellant for the expenses incurred there under.” In view of this fact that case law cited by the OP is not Para Materia to the facts of the present case.
16. In view of the facts and circumstances of the case and the judgement of the honorable Supreme Court, this commission is of the view that repudiation of the claim by the OP is not legal rather is arbitrary & is not in accordance with law & therefore OP is deficient in it’s service which has caused inconvenience, trouble, & mental agony to the complainant and therefore is directed to pay the insurance amount of Rs.1,24,458/- along with compensation of Rs. 25,000/- (including litigation cost) to the complainant within 30 days from the date of order failing which OP shall be liable to pay an interest at the rate of 6% per annum till date of final realization by the complainant on the entire amount i.e. on 1,49,458/-.
17. The copy of the order be given to the parties in terms of rules of CPA 2019 and file be consigned to record room.
18. The order contains 08 pages each wear our signature.
19. Announced on 03^rd August, 2023.