Chandigarh

DF-II

CC/634/2017

Ashwani Doegar - Complainant(s)

Versus

M/s Religare Health Insurance Company Limited - Opp.Party(s)

07 Feb 2018

ORDER

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

Consumer Complaint  No	:	634 of 2017
Date  of  Institution	:	23.08.2017
Date   of   Decision	:	07.02.2018

 

 

 

 

Ashwani Doegar s/o Sh.Jagdish Ram, Resident of House No.1107, Sector 7, Panchkula, Haryana 134109

 

              …………..Complainant

 

VERSUS

 

M/s Religare Health Insurance Company Limited, SCO 56-58, Second Floor, Sector 9-D, Chandigarh

 

…………… Opposite Party

 

 

                     AND

Consumer Complaint  No	:	635 of 2017
Date  of  Institution	:	23.08.2017
Date   of   Decision	:	07.02.2018

 

 

 

 

Ashwani Doegar s/o Sh.Jagdish Ram, Resident of House No.1107, Sector 7, Panchkula, Haryana 134109

 

              …………..Complainant

 

VERSUS

 

M/s Religare Health Insurance Company Limited, SCO 56-58, Second Floor, Sector 9-D, Chandigarh

 

…………… Opposite Party

 

 

BEFORE:   SH.RAJAN DEWAN          PRESIDENT

                                MRS.PRITI MALHOTRA           MEMBER

SH.RAVINDER SINGH            MEMBER

                            

Argued by: Complainant in person.

Sh.Sachin Ohri, Adv. for Opposite Party

 

 

RAVINDER SINGH, MEMBER

 

 

        The above mentioned two consumer complaints No.634/2017 & 635/2017 are within the same parties and have identical facts in issue, hence being decided by this common judgment.

 

2]       The facts are being taken from Complaint Case No.634 of 2017 – Ashwani Doegar Vs. M/s. Religare Health Insurance Company Limited.

 

3]       The facts in issue are that the complainant earlier had a health insurance policy with Max Bupa Health Insurance, which was ported with Opposite Party and then Opposite Party issued insurance policy effective from 10.12.2016 to 9.12.2017 on receipt of premium of Rs.35,292/- having sum insured of Rs.5 lakh (Ann.C-1).  It is averred that the said policy includes hospitalization expenses (in-patient as well as day care) as well as pre hospitalization and post hospitalization medical expenses among other benefits.  It is also averred that on 1.3.2017, the complainant consulted Dr.G.S.Brar at Sangam Netralaya, Sector 70, Mohali regarding cloudy vision in the eye and he was advised cataract surgery for his left eye in respect of age related nuclear cataract.  Accordingly, the surgery was conducted on 10.3.2017 of left eye and bill of Rs.28,597/- was paid by the complainant and the surgery of right eye was conducted on 11.8.2017 and bill of Rs.39,804/- was paid by the complainant.  Thereafter, the complainant lodged a claim with Opposite Party, but the Opposite Party rejected the claim of Rs.28,597/- vide letter dated 30.5.2017 and also claim of Rs.39,804/- vide letter dated 1.8.2017 stating that there was non-disclosure of material facts/pre-existing ailment at the time of proposal (Ann.C-3).  It is submitted that the complainant was also issued a certificate by surgeon Dr.G.S.Brar wherein he has categorically stated that the complainant’s treatment in the past at PGIMER, Chandigarh pertaining to CSR in left eye retina has no correlation/bearing with age related nuclear cataract for which he was operated and for which he had presented his claim.  It is also submitted that after rejection of the claim, the complainant personally visited the Opposite Party and clarified the matter, but the Opposite Party did not pay any heed.  Hence, this complaint has been filed alleging the said rejection of the claim as illegal and deficiency in service on the part of Opposite Party.

 

4]       The Opposite Party has filed reply and while admitting the factual matrix of the case, stated that as per Discharge Summary dated 10.3.2017 issued by treating hospital i.e. Sangam Netralaya, the complainant has been diagnosed with Nuclear Cataract and is further mentioned to have Chronic CSR (Central Serous Retinopathy).  It is stated that from the perusal of the consultation note date 12.9.2007 issued by PGIMER, Chandigarh, the complainant is duly mentioned to have B/L CSR (Central Serous Retinopathy in both eyes) and L>R (Left Eyes has grater CSR than right eye) and thus, it is clear that the complainant has been continuously seeking consultations for the said ailment i.e. from 2007 to 2017.  It is also stated that after detailed analysis, the claim of the complainant was repudiated on the ground that complainant was taking treatment for chronic CSR since 2007 and has blurred vision in left for more than 6 months, that is, before the inception of the policy. It is submitted that the complainant himself admitted that he has a problem in retina in a left Eye at the time of purchase of the policy.   It is also submitted that the complainant had intentionally not disclosed the fact of pre-existing Chronic CSR while submitting the proposal form (Ann.R-6) as well as in the medical examination form, which was duly signed by him and hence breached the terms & conditions of the policy and therefore, the claim of the complainant was rightly repudiated. Pleading no deficiency in service and denying rest of the allegations, the Opposite Party has prayed for dismissal of the complaint.

 

5]       The complainants also filed rejoinder reiterating contentions as raised in the complaint.

 

6]       Parties led evidence in support of their contentions.

 

7]       We have heard the complainant in person, ld.Counsel for the OP and have carefully examined the facts and pleadings along with entire evidence on record.

 

8]       The claims of the complainant for reimbursement of the amount Rs.28,597/- & Rs.39,804/- respectively incurred by him on account of Cataract surgeries on left & right eye done 10.3.2017 and 11.8.2017 respectively, have been rejected by the Opposite Party on the ground of pre-existing ailment of CSR (Central Serous Retinopathy). 

 

9]       The complainant was having medical insurance policy from Max Bupa Health Insurance Company since Dec., 2014, which was ported to M/s Reliance Health Insurance Company Limited/Opposite Party vide Policy No.10902286 valid from 10.12.2016 to 9.12.2017 (Ann.C-1). At the time of portability, the Opposite Party has conducted a proper & thorough medical examination of the complainant through their authorised doctor Dr.R.K.Jain on 11.12.2016 (Ann.R-7) and only then after finding the complainant medically fit, has approved the portability of the insurance policy and issued the policy in question.  In the medical examination dated 11.12.2016 got conducted by the Opposite Party through their authorised medical practitioner, nothing adverse found against the complainant in issue of insurance policy.

 

10]      The Opposite Party noticed concealment/non-disclosure of pre-existing disease on 30.5.2017, but it did not rescinded the policy and refunded the insurance premium. If the Opposite Party was not satisfied with the inception of the policy, it was having the right & authority to cancel the policy itself since its inception, but it did not do so. The Opposite Party since have accepted the insurance policy of the complainant and allowed it to operate till its maturity/validity i.e. 9.12.2017.  Now at this stage, the Opposite Party cannot repudiate the genuine claim of the complainant for Rs.28,597/- & Rs.39,804/- respectively merely on the ground of pre-existing disease. 

 

11]      The complainant has paid Rs.35,292/- as premium to the Opposite Party and after getting such a huge premium, is being discarded on flimsy ground, which are neither acceptable nor tenable under the law.  The Opposite Party has indulged in unfair trade practice as well as suffered from deficiency in service on its part by way of rejecting the bona fide claims of the complainant. 

 

12]      Keeping into consideration the facts & circumstances, as discussed in preceding paragraphs, the Consumer Complaints NO.634/2017 & 635/2017 are allowed against Opposite Party.

         The Opposite Party is directed in Consumer Complaint No.634/2017 as under:-

1. To reimburse/pay an amount of Rs.28,597/- to the complainant;
2. To pay Rs.5,000/-as compensatory cost on account of mental agony and harassment suffered by the complainant.
3. To pay litigation cost of Rs.5,000/- to the complainant/policy holder

   

13]      Similarly, in the connected complaint Case NO.635 of 2017 – Ashwani Doegar Vs. Religare Health Insurance Company, the Opposite Party is directed as under:-

1. To reimburse/pay an amount of Rs.39,804/- to the complainant;
2. To pay Rs.5,000/-as compensatory cost on account of mental agony and harassment suffered by the complainant.
3. To pay litigation cost of Rs.5,000/- to the complainant/policy holder.

 

         The OP shall comply with this order within a period of 30 days from the date of receipt of copy of this order.

 

14]      A copy of this order be placed in connected complaint Case NO.635 of 2017 – Ashwani Doegar Vs. Religare Health Insurance Company, which shall be deemed to form a part of that order.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

7^th February, 2018                      Sd/

(RAJAN DEWAN)

PRESIDENT

 

 

Sd/

 (PRITI MALHOTRA)

MEMBER

 

Sd/

(RAVINDER SINGH)

MEMBER