BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.333 of 2016
Date of Instt. 11.09.2017
Date of Decision: 11.02.2019
Deepak Bhatia S/o Sh. Chaman Lal Bhatia R/o S-39, Industrial Area, Jalandhar.
..........Complainant
Versus
1. M/s Religare Health Insurance Company Limited, Vipul Tech Square, Tower-C, 3rd Floor, Gold Course Road, Sector-43, Gurgaon-122009 (Haryana) through its Managing Director.
2. M/s Religare Health Insurance Company Limited, RHICL, Jalandhar-144001 through its Branch Manager.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Sh. A. K. Arora, Adv Counsel for the Complainant.
Sh. R. K. Sharma, Adv Counsel for OPs No.1 & 2.
Order
Karnail Singh (President)
1. This complaint has been filed by the complainant, wherein alleged that the complainant purchased health insurance policy for the period 18.05.2017 to 16.06.2017 for his Europe Tour from the branch office of OPs i.e. OP No.1 at Jalandhar and OP No.2 is its Head Office. The said insurance policy bearing No.11214952 issued to the complainant for Euro 30000 which contain benefits qua the reimbursement of hospitalization expenses up to 30000 Euro under cashless facility and the risk qua Trip Cancellation and interruption to the tune of 750 Euro, Daily allowance of Euro 25 per day subject to maximum of 5 days, beside other benefits detailed in the policy of insurance.
2. That only the policy schedule was provided to the complainant at the time of issuance of policy of insurance and no terms and conditions of the policy of insurance including any hidden exclusion clauses were not provided to the complainant and as such, any hidden exclusion clause in the policy of insurance is not binding upon the complainant. When the complainant was in Austria, the complainant suddenly had a feeling of sinking of heart, which was life threatening and as such, he immediately shifted to Federal State Hospital Kiosterneuburg on 06.06.2017. The ailment of the complainant was diagnosed as Bradycardia (abnormally slow heart action). Thereafter, from the said hospital the complainant was referred to University Clinic Tulln-Clinical Ward for internal Medicine, Kari Land Steiner Private University for Medical Sciences and was further diagnosed SSS-Sinus-Bradycardia and Arterial Hypertension-Moderate Concentric Left Ventricular Hypertrophy, Diastolic Relaxation Dysfunction Grade-II. The complainant remained admitted in the said hospital from 08.06.2016 to 13.06.2017. After his admission in University Clinic Tulln, cash less for the reimbursement of medical expenses to be incurred by the complainant in the hospital was lodged, but no reply whatsoever was received from the OPs. The complainant was discharged from the hospital on the assurance and guarantee of the brother of the complainant that the entire dues of the hospitals would be paid as and when the claim is received. The ailment of the complainant was sudden, which require emergency hospitalization and as such, the cashless facility was to be allowed by the OPs for payment of the bills of the hospital as per the terms and conditions of the policy. That the Hospital Authorities i.e. State Federal Hospital and University Clinic Tulln issued bills of 1375 Euro dated 31.07.2017 and 4400 Euro for the treatment of the complainant in these hospitals. The OP instead of paying the genuine claim of the complainant, repudiated the insurance claim of the complainant, vide letter dated 09.08.2017 by referring clause 5.1 of the policy of insurance stating therein non disclosure of pre-existing medical conditions i.e. hypertension. The disease for which the complainant has taken treatment was not a pre-existing disease. Hypertension is not a disease and is a common ailment and it can be controlled by medicines and the present illness of the complainant i.e. bradycardia has nothing to do with it. The history of the complainant recorded in the hospital at the time of his admission in the hospital was not got recorded by the complainant, but was got recorded by the attendant, who has taken the complainant to the hospital, who had no first hand knowledge of any disease of the complainant. The said history recorded in the hospital is false and baseless as the complainant has no previous record of any ailment qua heart. That the trip of the complainant from Viena to Zurich on 9th June 2017 was also interrupted because of the aforesaid illness of the complainant and because of his hospitalization in the aforesaid hospital and for that the complainant entitled in 750 Euro from the OPs. After return from the Europe Tour, the complainant also lodged a claim for the interruption of the trip from Viena to Zurich on 9th June, which is also declined by the OPs. The act and conduct of the OP is tantamount to deficiency in service and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OP be directed to make payment of 5796 Euro to the complainant on account of medical expenses as per bills submitted by the hospitals and further OPs be directed to pay 750 Euro to the complainant on account of Trip Cancellation and interruption and further OPs be also directed to make payment of 125 Euro to the complainant on account of daily allowance for five days @ 25 Euro per day for a period of 5 days and OPs be also directed to pay interest on the aforesaid amount @ 18% per annum and further OPs be directed to pay compensation of Rs.1,00,000/- for causing mental tension and agony to the complainant and OPs be also directed to pay litigation expenses of Rs.20,000/-.
3. Notice of the complaint was given to the OPs and accordingly, both the OPs appeared through its counsel and filed joint reply, whereby contested the complaint by taking preliminary objections that the complaint of the complainant is not maintainable because the complainant himself guilty of Non-Disclosure of material facts at the time of taking policy and as such, the complaint is liable to be dismissed. It is further averred that the insurance claim of the complainant has been repudiated as per the terms and conditions of the insurance policy, vide letter dated 09.08.2017 on the ground of Non-Disclosure of Material facts/Pre-existing Ailments i.e. Hypertension at the time of Proposal, which the complainant was required to disclose in the proposal form at the time of inception of the insurance policy. It is further alleged that there is neither any deficiency in service nor any negligence on the part of the OPs and as such, the complaint of the complainant is liable to be dismissed. On merits, the OPs admitted that the complainant purchased the policy, but the same was subject to terms and conditions of the policy and further admitted that the claim of the complainant has been repudiated and the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits and the same may be dismissed.
4. In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavits of the complainant Ex.CA and Ex.CB along with some documents Ex.C-1 to Ex.C-20 and closed the evidence.
5. Similarly, counsel for the OPs No.1 and 2 tendered into evidence affidavit of Parshant Singh, Manager Legal as Ex.OA along with some documents Ex.O-1 to Ex.O-8 and closed the evidence.
6. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.
7. There is no dispute in this complaint in regard to purchase of insurance policy by the complainant for the period 18.05.2017 to 16.06.2017 from opposite parties and even there is no dispute that the said policy gave the benefits qua reimbursement of hospitalization expenses under cashless facility and the risk qua trip cancellation and interruption to the tune of 750 Euro as well as Daily Allowance of Euro 25 per day subject to 5 days, but according to terms and conditions of the policy.
8. It is also not disputed by the OP that the complainant remained admitted in the hospital in Austria from 06.06.2017 to 13.06.2017 and further the complainant also submitted an insurance claim to the OP, which has been admittedly repudiated by the OP, vide letter dated 09.08.2017 Ex.C-14. Now, the entire dispute is revolving around the said repudiation letter Ex.C-14 dated 09.08.2017, in order to justify whether the ground taken in the said repudiation letter are correct or not. Accordingly, we directly came to said repudiation letter Ex.C-14 dated 09.08.2017, wherein the plea taken by the OP, on the basis of Clause 5.1 of the Insurance Policy i.e. Non-Disclosure of pre-existing medical condition, i.e. Hypertension, on medication Olmetrack 40 and Numlo. In order to justify the plea taken in the said repudiation letter, the OP referred a prescription slip Ex.O-3 issued by Dr. Rishi Kumar Arya, wherein the name of the complainant Deepak Bhatia is very well mentioned and medicines were prescribed to him on 23.02.2017, means prior to the inception of the insurance policy from the OP, similarly the OP also referred a document Ex.O-4 issued by Foreign Hospital, where from the complainant obtained the treatment and in that document Ex.O-4 at Page No.3, the said medicine has been also recommended for the purpose of Hypertension.
9. Except the aforesaid two documents, there is no other medical expert evidence came on the file to establish that the complainant is chronic patient of the said disease. As per our opinion, the disease of Hypertension is not permanent, it is curable after taking medicine and if, for the time being, in the month of February, 2017, if the complainant once got checked his blood pressure from Dr. Rishi Kumar Arya, who recommended the medicine and for the sake of argument, if we accepted that the complainant took that medicine, but there is no any further evidence that he continuously taking the same medicine till the date of purchase of the insurance policy i.e. 18.05.2017. We may presume that he take the medicine and his blood pressure became normal on the day of purchase of the policy, if so, then the question does not arise to disclose whether he is a patient of high blood pressure/hypertension. So, under these circumstances, we are of the opinion that the complainant has not suppressed any thing from the OP.
10. Further in order to give strength to our above observation, we like to refer a pronouncement of Hon'ble National Commission, cited in 2012(4) C.P.J. 839, titled as “Bajaj Allianz General Insurance Co. Ltd. Vs. Valsa Jose”, wherein his Lordship held as under:-
“Consumer Protection Act, 1986 Sections 2(1)(g), 14(1)(d) and 21(a)(ii) Mediclaim Policy, Medical reimbursement - Mediclaim Policy- Medical reimbursement- Repudiation of claim- Angiogram and Angioplasty of right coronary artery- Respondent had been taking medicine for hypertension and for cholesterol which was reportedly normal, Patient was taken medicine for hypertension for some time does not amount to suppression of material fact because as is well known hypertension is usually a lifestyle disease and easily controlled with conservate medication, There is no evidence that it was so acute or high that it was responsible for respondents subsequent Angioplasty or any other past major illnesses- Repudiation of claim rightly held to be unjustified.”
Similar view has been taken by our own Hon'ble State Commission in a judgment, cited in 2017(3) CLT 140, titled as “Religare Health Insurance Company Ltd Vs. Subhash Chander Aggarwal”.
And further there is an other pronouncement of Hon'ble National Commission, cited in 2016(1) CPJ 613, titled as “Satish Chander Madan Vs. M/s Bajaj Allianz General Insurance Co. Ltd.”, wherein his Lordship held as under:-
“Consumer Protection Act, 1986 Sections 2(1)(g) and 21(b) Insurance Policy - Bypass surgery – Claim for insurance – Repudiation – Grounds of concealment of pre- existing disease- Alleged deficiency in service – complaint filed – Allowed by District Forum – State Commission allowed appeal – Hence, revision petition before National Commission- Fact that, petitioner prior to obtaining insurance policy was having history of hypertension – 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 disease- Claim was wrongly repudiated- Finding of the State Commission regarding suppressing of material fact is based upon surmises and conjectures and it cannot be sustained- Revision petition allowed.”
11. If we analyze the case of the complainant coupled with the aforesaid judgments of the Hon'ble National Commission as well as our own Hon'ble State Commission, then we can say without any hesitation that the case of the complainant has been wrongly and illegally repudiated by the OP simply on the pretext of pre-existing disease of hypertension, which is virtually not a disease as hold by the Hon'ble National Commission as well as State Commission. So, with these observations, we are of the opinion that the complainant is entitled for the relief claimed.
12. As an upshot of our above detailed discussion, the complaint of the complainant is partly accepted and OPs are directed to make payment of Rs.5796 Euro to the complainant for medical expenses and further directed to make payment of 750 Euro to the complainant on account of Trip Cancellation and interruption, qua the other relief, the case of the complainant is not proved and accordingly, the OP are further directed to pay the aforesaid amount of Euro by converting into Indian Currency, by adjudging the rate of Euro with the Indian Currency, on the day when the complaint filed i.e. 11.09.2017, after converting the aforesaid Euro into Indian Currency, the OPs further directed to pay interest thereon @ 12% per annum from the date of filing complaint i.e. 11.09.2017 and further OPs are directed to pay compensation to the complainant, to the tune of Rs.20,000/- for causing mental tension and harassment to the complainant and further OPs are directed to pay litigation expenses of Rs.7000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
13. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Karnail Singh
11.02.2019 Member President
