BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.14 of 2018
Date of Instt. 03.01.2018
Date of Decision: 13.05.2019
1. Sh. Yash Pal Jain S/o Sh. Dina Nath Jain R/o H. No.104, Tagore Nagar, Near Shehnai Palace, Jalandhar.
2. Smt. Sunita Jain W/o Sh. Yash Pal Jain R/o H. No.104, Tagore Nagar, Near Shehnai Palace, Jalandhar.
..........Complainants
Versus
1. M/s Religare Health Insurance Company Limited, RHICL, Jalandhar-144001 through its Branch Manager.
2. 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.
….….. 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 Complainants.
Sh. R. K. Sharma, Adv Counsel for the OPs No.1 & 2.
Order
Karnail Singh (President)
1. The complainants have filed the instant complaint, wherein alleged that the complainant No.1 purchased Health Insurance Policy bearing No.10172896 for the health insurance of both the complainants for the period 28.01.2017 to 27.01.2018 for Rs.2,00,000/- each from the branch office of OP No.1 at Jalandhar. OP No.2 is the Head Office of the OP No.1 and as such, has made a party to the complaint being a necessary party. As per the said insurance policy, both the complainants were entitled to get reimbursement of all the expenses or their treatment during the aforesaid period of insurance. The complainant No.1 has also earlier been taking policies of insurance qua the health insurance of himself as well as his wife complainant No.2, ever since 28.01.2015 and there is no break in these policies of insurance issued to the complainants by the OPs. Prior to 28.01.2015, the complainants were getting health insurance policy from National Insurance Company Limited from 28.01.2006 onwards. Policy for the period 28.01.2012 to 27.01.2013, 28.01.2013 to 27.01.2014 and 28.01.2014 to 27.01.2015 issued by National Insurance Company Limited Co., are attached. Complainant No.2 namely Sunita Jain fell ill on 04.06.2017 and had loose motions watering from 18-20 times in the early morning, vomiting and had abdomen pain and slight fresh blood also came in the loose motion. Complainant No.2 remain admitted in Pawan Hospital and Maternity Home, Jalandhar and where-from she was discharged on 10.06.2017. Immediately, after discharge from the hospital, the complainant No.1 lodged a claim for a sum of Rs.41,215/- with OP No.1 for the treatment taken by OP No.2 from Pawan Hospital and Maternity Home, Jalandhar. At the time of filing of the said claim, the complainant No.1 submitted all the original bills, discharge summary, investigations and the entire record of the treatment taken by her. The OP has rejected the claim of the complainant No.2, vide rejection letter dated 20.07.2017 stating therein that the patient has hypertension since five years, which was not disclosed in the policy and the claim has been rejected due to non disclosure. The rejection of the claim of the complainant No.2 is without any basis, since the treatment for complainant No.2 has taken, not having any co-relation with hypertension. Moreover, Hypertension is not a disease and is a common ailment and it can be controlled by medicines and there is no question of disclosing the same at the time of taking the policy of insurance. The OPs are indulging in unfair trade practices and the services provided by the OPs are deficient and defective in nature and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to make payment of Rs.41,215/- along with interest @ 12% per annum to the complainants from the date of illness i.e. 04.06.2017 till the date of payment on account of medical expenses. OPs be further directed to pay compensation to the complainants, to the tune of Rs.1,00,000/- for causing harassment and further, OPs be directed to pay litigation expenses of Rs.15,000/-.
2. Notice of the complaint was given to the OPs and accordingly, both the OPs appeared and filed joint written reply, whereby contested the complaint by taking preliminary objections that the instant complaint is not maintainable against the OPs as the complainant cannot take advantage of his own wrongs. The complainant himself is guilty of Non-Disclosure of material facts at the time of taking policy and hence, no cause of action has arisen against the OPs, as such, the complaint is liable to be dismissed and further admitted that the complainant purchased a Health Insurance Policy from the OP bearing No.10172896 for both the complainants, for the period 28.01.2015 to 27.01.2016, but subject to the policy terms and conditions. The policy was further renewed for a period from 28.01.2016 till 27.01.2017 and again from 28.01.2017 till 27.01.2018. It is further averred that on the receipt of the claim and necessary documents, a query letter dated 27.06.2017 was sent to the complainant asking to provide all the treatment record related to Diabetes and Hypertension and Exact duration and past history of present ailment with 1st consultation papers. Further, on non-receipt of required documents, a reminder regarding the same subject matter was issued by the OP, vide letter dated 07.07.2017. The OPs subsequently triggered a reimbursement claim investigation which revealed that the patient was suffering from Hypertension since five years, which was not disclosed at the time of taking policy. A questionnaire was filled by the complainant on 04.07.2017, wherein himself accepted that he was suffering from Hypertension since 5 years i.e. before the inception of the policy and that fact was not disclosed by the complainant in the proposal form and as such, the complainant himself concealed the pre-existing disease and therefore, insurance claim of the complainant has rightly repudiated and further averred that there is neither any deficiency in service nor any negligence in service nor any unfair trade practice on the part of the OPs. Repudiating the claim, which is not payable as per terms and conditions of the insurance policy does not amount to any deficiency in service nor any negligence in service nor any unfair trade practice, as such, the complaint is liable to be dismissed. The claim of the complainant was repudiated as per terms and conditions of the insurance policy after due application of mind, vide letter of repudiation dated 20.07.2018 on the ground of Non-Disclosure or Pre-Existing Hypertension. On merits, it is admitted that the complainant purchased the insurance policy and also submitted medi claim and the same was admittedly repudiated. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA alongwith some documents Ex.C-1 to Ex.C-25 and closed the evidence.
4. Similarly, counsel for the OPs tendered into evidence affidavit of Prashant Singh, Manager (Legal) as Ex.OA alongwith some documents Ex.OP-1 to Ex.OP-16 and closed the evidence.
5. We bestowed our thoughtful consideration to the submissions made by learned counsel for the respective parties and also gone through the case file very minutely.
6. Just to avoiding repetition of facts of the complaint and its reply, we like to directly touch the issue in dispute, being a reason the factum in regard to purchase of the insurance policy as well as getting a treatment by Complainant No.2 from hospital and submitting the insurance claim and the same was repudiated by the OP and the aforesaid facts are not in controversy.
7. Now, we have to glance the repudiation letter, copy of the repudiation letter produced on the file by the complainant Ex.C-7 dated 20.07.2017 and the same is also produced on the file by the OP, the same is Ex.OP-12. Mainly the insurance claim of the complainant had been repudiated, as per repudiation letter Ex.OP-12, on the ground “The patient has Hypertension since 5 years which was not disclosed in policy and due to non disclosure”.
8. We find the matter in dispute is very small, which is required to be adjudged, whether the repudiation is on a legal ground or not or as per terms and conditions or not, regarding terms and conditions, we have accepted that the pre-existing disease is to be disclosed by each insured at the time of taking of policy and admittedly, in this case, the OP alleged that the complainants got insurance first time on 28.01.2015 and then the same was renewed time to time and last insurance is for the period 28.01.2017 to 27.01.2018 and copy of the same is Ex.C-1 for the year 2017-18 and Ex.C-2 for the year 2016-17 and Ex.C-3 for the year 2015-16, prior to that the complainants were taking insurance from the National Insurance Company and photostat copies of that insurance policies are Ex.C-4 to Ex.C-6. In order to establish that the complainants miserably failed to disclose pre-existing disease at the time of inception of the policy and regarding that the complainants furnished a proposal form and accordingly, the OP produced on the file the said Proposal Form Ex.OP-10 and if we go through the Proposal Form Ex.OP-10, wherein the complainants categorically disclosed in the column under the heading 'Pre-Existing Disease Details', that the complainant has never diagnosed, hospitalized or under any treatment for any illness/injury during the last 48 months or is suffering from any illness/disease and further made declaration that he has not been taking any medicines/tablets for any illness or injury. The said Proposal Form was furnished on 02.12.2014 and on that day, the declaration was given by the complainants that they have no pre-existing disease nor they are taking any treatment, but the OP has placed on the file a document of Pawan Hospital dated 06.05.2015 Ex.OP-8 and in the said hospital document Ex.OP-8, it has not been mentioned that the complainant is suffering from Hypertension/Diabetes for the last 5 years rather it is established that on 06.05.2015 at a first time, the complainant was having some problem in regard to Hypertension and if any problem was occurred to the complainant on 06.05.2015, then how it is possible to incorporate the said illness in the Proposal Forum, which was filled up by the official of the OP much prior to taking a medicine from Pawan Hospital. Further, the OP referred a History Sheet Ex.OP-6, but the said History Sheet is not proved to be prior to filling of the Proposal Form i.e. 02.12.2014, if so, then we can say that any problem occurred to the complainant in regard to Hypertension or Diabetes is after inception of the policy.
9. No doubt, the OP has brought on the file a Claim Form/Query furnished by both the complainants and its photostat copy is available on the file as Ex.OP-5, wherein it is described that complainant No.2 is suffering from Hypertension since 5 years, but it is not established on the file whether this query was furnished by the complainants themselves or it was filled by the official of the OP, usually these type of forms are to be filled by the official and thereafter, got a signature of the party, without explaining the contents of the said document, simply relying upon the questionnaire mentioned in the said document Ex.OP-5 is not sufficient to establish that there was a pre-existing disease of Hypertension/ Diabetes to the Complainant No.2.
10. Apart from above, it has been decided in various judgments that Hypertension is not a disease, it is general wear-tear of life, which occurred due to some pressure of busy life and moreover, this disease can be cured after taking a medicine and if the same has been cured, then it is not required to be disclosed at the time of filling of Proposal Form. So, with these observations, we are of the considered opinion that the claim of the complainant has been wrongly repudiated by the OPs and therefore, repudiation letter is hereby set aside.
11. As an upshot of our above detailed discussion, the complaint of the complainant No.2 Sunita Jain is partly accepted and OPs are directed to pay the medical expenses i.e. Rs.41,215/- to the Complainant No.2 along with interest @ 9% per annum from the date of repudiation of the claim i.e. 20.07.2017, till realization. Further, OPs are directed to pay compensation to complainant No.2, to the tune of Rs.15,000/- for causing mental tension and harassment to complainant No.2 and further, OPs are directed to pay litigation expenses to the complainant No.2, to the tune of Rs.10,000/- 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.
12. 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
13.05.2019 Member President
