DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

Udyog Sadan, C-22 & 23, Qutub Institutional Area

(Behind Qutub Hotel), New Delhi-110016

Case No.12/2019

Sh. Vishwa Prakash

S/o Late Sh. Budh Prakash 

R/o A-873, Mahawar Nagar

Kotla Mubarakpur, New Delhi                                          ….Complainant

Versus

1.      M/s  Religare Health Insurance Company Ltd. 

Through its Managing Director

At 1201-1202, 12^th floor,

Vikrant Tower-4, Rajendra Place

New Delhi-110008

2.      Max Hospital

Saket, (East Block) Delhi                              ….Opposite Parties

                                                Date of Institution        :         07.01.2019     Date of Order      :         21.01.2021

Coram:

Ms. Rekha Rani, President

Ms. Kiran Kaushal, Member

ORDER

Ms. Kiran Kaushal, Member

1. Facts as pleaded in the complaint are that the Complainant Mr. Vishwa Prakash purchased a medical policy for himself and his wife for a period of one year w.e.f. 23.02.17 to 22.02.18 and paid premium of Rs.22,504/- for the same.  After completion of one year the said policy was renewed for further period w.e.f. 23.02.18 to 22.02.19 and payment of Rs.23,091/- as premium was made to M/s  Religare Health Insurance Company Ltd. (OP-1). It is averred that on 29.06.2018 Complainant felt chest pain and suffocation, thereafter he approached National Heart Institute, New Delhi where medical check-up was done and he was prescribed some medicines. Again on 02.07.18 the Complainant got chest pain and suffocation and he visited Max Hospital, Saket (OP-2) where the doctors advised him Coronary Angiography which was done on 03.07.18 by a heart specialist. Meanwhile the Max Hospital sent the information regarding the admission of the Complainant on 03.07.18 to OP-1 Company with all documents as per rules which are duly acknowledged by the insurance company.  During investigation, it was found that a Stent was required for a proper treatment of the Complainant and accordingly a Stent was put in the body of the Complainant to save his life. The hospital raised a bill for Rs.3,84,715/- including the cost of stent and other hospital charges.

1. Complainant made a request to OP-1 to reimburse the bill amount raised by the hospital but the OP-1 Company outrightly rejected the claim of the Complainant saying “we are not registering your claim”.  It is pleaded that the reason for disallowing the claim of the Complainant cannot be said as a reasonable ground. The letter of rejection dated 04.07.18 is annexed as Annexure-B.
2. It is next averred that the Complainant paid the bill of the hospital by borrowing loan on interest from relatives and friends. The Complainant again visited the hospital and further incurred sum of Rs.21,206/- as doctor fees and medicines. Thus a total amount of Rs.4,10,211/- has been borne and incurred by the Complainant  for his treatment. The medical bills are annexed as Annexure-C.
3. The Complainant alleges deficiency of service on the part of OP-1 Complainant avers that the rejection letter of OP-1 is against the provisions of law of land as the Complainant has already paid the premium as per the terms and conditions of the policy obtained by him, hence the Complainant is entitled to the whole amount of the bill raised by the hospital. Accordingly it is prayed that Rs.1 lac be paid to the Complainant for mental torture, harassment besides the amount of Rs.4,10,211/-  with interest @ 15% p.a. raised by the hospital for the treatment of the Complainant.
4. Complainant in support his claim has placed following documents on record:

(a) Photocopy of first policy, (b) Photocopy of second policy, (c) rejection letter of OP, (d) photocopy of the discharged summary and (e) original bills of the hospital incurred by the Complainant.

2. OP-1 was served notice. As none appeared on behalf of OP to contest the case it was proceeded exparte vide order dated 04.06.19.
3. Averments made by the Complainant have remained uncontroverted and unchallenged.
4. Exparte evidence by way of affidavit and written arguments are filed on behalf of the Complainant.
5. We have heard the Ld. Counsel for the Complainant and perused the material placed on record carefully.
6. It is evident from the documents placed on the record that the Complainant purchased a health policy for himself and his spouse by paying a premium of Rs.22,504/- on 23.02.17.  The said policy was renewed on 23.02.18 and the Complainant paid premium of Rs.23,091/- to OP for the same. It is noticed in the documents at page No.7 that when the Complainant was issued the first policy the Complainant was given a ‘know your policy better’  kit that accompanied the policy which constituted-

Policy certificate

Premium acknowledgement

Key policy information

Policy terms and conditions.

Claim process.

Complainant has annexed the policy certificate, premium acknowledgement and proposal form with the documents. However, key policy information and the policy terms and conditions have not been annexed thereto.  The letter of rejection of the claim is appended at page No. 18 alongwith the complaint. The claim of the Complainant was not registered and was repudiated on the following ground:

• 2 YEAR WAITING PERIOD:HYPERTENSION RELATED COMPLICATION/CARDIOMYOPATHIES/MYOCARDIAL INFARCTION/HEART FAILURE/ARRHYTHMIA/HEART BLOCKS.

• NON- REGISTRATION OF CLAIM. 

7. Complainant developed heart related problems within four months of getting the policy renewed. Complainant nowhere has specifically denied that there was no such clause of Two year waiting period, the ground on which his claim was rejected. The Complainant has entered into the agreement with OP-1 wherein the said clause was given in the terms and conditions of the policy. This Commission is of the opinion that the Complainant has specifically not denied the said clause and has chosen not to place on record the terms and conditions of the policy. Therefore, we assume that the Complainant was having the knowledge of the said clause and knowingly he had entered into agreement with OP. Hence, this Commission will not interfere with the terms of contract entered into by the parties. In the facts of aforesaid circumstances we are of the opinion that OP has rightly repudiated the claim of the Complainant, hence we dismiss the complaint with no order as to costs.    

          Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations.  Thereafter file be consigned to record room.

Announced on 21.01.2021.