District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 493/2020.
Date of Institution:22.12.2020.
Date of Order:07.04.2023.
Srishti Bhatia D/o late Shri Ashok Bhatia R/o E-583, SGM Nagar, Faridabad.
…….Complainant……..
Versus
1. Care Health Insurance.
2. Care Health Insurance Regd. Office, 5th floor, 19, Chawla House, Nehru Place, New Delhi.
3. Care Health Insurance Vipul Tech Square, Tower-C, Third Floor, Golf Course road, sector-43, Gurugram-122009.
Opposite parties.
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Ms. Savita , counsel for the complainant.
Sh. P.L.Garg , counsel for opposite parties.
ORDER:
The facts in brief of the complaint are that he got an insurance from Religare Health Insurance bearing No. 11463364 issued by the opposite party. He got insured and his right leg bone was fractured in November 2018 due to fall on road for which his treatment was done at private clinic at Faridabad and plaster was applied on it. The said plaster got dislocated on 11.12.2018 due to a fresh injury sustained in criminal assault and he was facing unbearable pain so on medical advice he was told to go for surgery, which was done in Asian Hospital Faridabad where he was admitted on 17.12.2018 and was discharged on 21.12.2018. After taking estimate from the Asian Hospital Faridabad which was an approved hospital of the opposite party insurance company intimation was given to the opposite party insurance company immediately and all documents were handed over to their representative before the admission formalities in the hospital, the claim was approved by the insurance company so he decided to go for the surgery in the Asian hospital Doctors and rod was fixed to support’ the bone. Opposite party was bound to give cashless facility for all such treatment to him hence approval was given by the company only then the treatment was started by the hospital but later on 21.12.2018 at the time of discharge the insurance company suddenly revoked it’s approval on the pretext that he was having diabetes, where as he neither had any diabetic history earlier nor he had any such problems now, the sugar level at that point of time might had increased due to acute stress and mental agony which he had faced and it was momentary only. Copy of said denial letter dated 21.12.2018 Mark A annexed with this complaint. When contacted the agents and officers of the opposite parties they assured that since cashless facility had been denied by the company but the reimbursement of medical bills would be made on submission of medical bills. He submitted all bills and documents to the company but no reimbursement had been done. He spent about Rs.3,50,000/- on his treatment and the same should to be reimbursed to him by the opposite parties alongwith an compensation of Rs.75,000/- alongwith counsel fee and other expenditure. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to reimburse all the medical bills and also pay a compensation and expenditure totaling of Rs.4,75,000/- alongwith interest to the complainant for the loss and inconvenience caused because of the opposite parties.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite parties Nos.1 & 2 refuted claim of the complainant and submitted that the present complaint was hopelessly time barred qua the opposite party company and deserves dismissal at this stage without trial as it had been filed after much more than 2 years from the date of rejection letter dated 21.12.2018 and no reason had been assign for filing time barred complaint thus the complaint in question was barred by limitation as per section 69(1) of the Consumer Protection act, 2019. Even otherwise the complainant never approached the opposite party after rejection of the claim. The complainant just filed a cashless claim. The complainant also did not approach the grievance redressal cell of the company after rejection of his claim. Hence, the complaint should be dismissed in limine as it lacks merit and was premature. As per clause 7.9 i.e Grievances of the policy terms and conditions, it was clearly specified that the policyholder can approach the grievance cell of the company via various channels and if the complainant was not satisfied with the resolution then he or she can approach the Hon’ble Insurance Ombudsman which were created by IRDAI solely for the purpose of resolving grievances of the policyholders.
The complainant had taken a Health Insurance Policy bearing No. 11463364 covering the complainant namely Srishti Bhatia w.e.f 25.07.2017 to 24.07.2018 for a sum insured of Rs.5,00,000/-. The said policy was renewed w.e.f 25.07.2018 to 24.07.2019 The policy issuance and its subsequent renewal were subject to policy terms & conditions governing the policy. The complainant through the treating hospital i.e. Asian Hospital Faridabad approached the opposite party with a cashless s request with respect to her hospitalization w.e.f. 17.12.2018 till 19.12.2018. As per the Retrieved Discharge Summary she was diagnosed with Right Malunited Medical Tibial Plateu Fracture. In order to properly analyse the claim, the company raised deficiency letter dated 15.12.2018, 20.12.2018 and reminder dated 16.12.2018 to provide the following documents:
i) Ist consultation paper immediately after incident.
ii) Copy MLC/FIR copy
iii) Detail narration of injury with exact date and time.
iv) Investigation report supporting Diagnosis X-Ray/MRI/CT scan
v) Others
vi) PAC Note
vii) Recent passport size photograph of proposer/Nominee Ms. Srishti Bhatia,
After perusal of the documents, the company came to know that the complainant was a known case of type-II diabetes mellitus:-
Non disclosure of material facts/pre-existing ailments at the time of proposal (H/O diabetes since prior to policy inception) initial approval also cancelled, rejection remains same.
Non disclosure of material facts/preexisting ailments at the time of proposal:
Though the case was approved initially, however, the same was not final approval and was subject to cancellation. The approval was cancelled post the rejection. In the approval letter itself a note was given on the lines that:-
This is an initial approval and stands cancel where misinterpretation of facts is noticed.
Evidence: The following documents establish non-disclosure of material facts on the part of the complainant:
- as per discharge summary under the hospital course, it was mentioned that “Physician (Dr. Bhowmik) consultation was done for type-II diabetes mellitus and advice followed”.
- As per the pre operative anesthesia evaluation record, she had history of diabetes Mellitus and was on insulin. It was pertinent to mention that she was Just 25-26 years old at the time when she was diagnosed with DM and on insulin.
- As per the underwriting guidelines of the company, our company would not have issued the policy had the complainant disclosed that she had diabetes and was on insulin at the age of 25-26.
Proposal Form: History of diabetes Mellitus was not disclosed at the time of taking the policy. The complainant was a known case of type-2DM and the same had to be disclosed at the time of policy inception i.e. at the time of filing the proposal form.
The following question was asked in the proposal form:
A. Does any person(s) to be insured has any pre-existing disease?
No.
It was submitted that without prejudice to the above mentioned facts ad documents, the complainant had deliberately tried to conceal her actual health history by not disclosing her pre-existing ailment i.e. history of diabetes since prior to policy inception. In accordance with clause 7.1 of policy terms & conditions, the complainant was bound to disclose the correct health history of her health to the opposite party company at the time of inception of policy. By not disclosing the material information pertaining to her health, the complainant had violated terms & conditions of policy. Opposite parties Nos.1 & 2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties–Religare Health Insurance Company Ltd. with the prayer to: opposite parties to reimburse all the medical bills and also pay a compensation and expenditure totaling of Rs.4,75,000/- alongwith interest to the complainant for the loss and inconvenience caused because of the opposite parties.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Srishti Bhatia, Ex.C-1 - test, Annx.-1 – Denial letter dated 21.12.2018, Annx.-2 – Final Bill summary, Annx.-3 – Discharge summary,, Annx.-4 – prescription of Medical Centre, Annx.-5 & 6– receipts, Annx.-7 – receipt o. 1654 dated 27.11.2018, Annx.8 – Cash memo dated 27.11.2018, Annx.-9 – Cash memo dated 27.11.2018, Annx.-10 & 11 – Cash memos, Annx.-12 & 13 – Cash memos, Annx.-14 – cash memo dated 15.12.2018, Annx.-15 – cash memo.
On the other hand counsel for the opposite parties strongly agitated and opposed. As per the evidence of the opposite parties Ex.RW-1/A – affidavit of Ravi Boolchandani of Care Health Insurance Co. Ltd., Ex.R-1 – policy certificate, Ex.R-2 – terms and conditions, Ex.R-3 –Pre Authorization Request Form, Ex.R-4 – Discharge summary, Ex.R-5 – Deficiency letter dated 15.12.2018, Ex.R-6 – Denial letter dated 20.12.2018, Ex.R-7 – Authorization letter dated 17.12.2018, Ex.R-8 – PAC note, Ex.R-9 – underwriting certificate, Ex.R-10 – proposal form – ‘Care” Annx.-11 – order dated 10 July 2009 in case titled Satwant Kaur Sandhu Vs. new India Assurance Company passed by Hon’ble Supreme Court of India.
6. After going through the evidence led by the parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant within 30 days from the date of receipt of the copy of order and pay the due amount to the complainant alongwith interest @ 6% p.a. from the date of filing of complaint till its realization. Opposite parties are also directed to pay Rs.2200/- as compensation for causing mental agony & harassment alognwith Rs.2200/- as litigation expenses to the complainant. Compliance of this order be made within 30 days from the date of receipt of copy of this order. File be consigned to the record room.
Announced on: 07.04.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
