District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 108/2021.
Date of Institution: 25.02.2021.
Date of Order:19.07.2023.
Ashok Kumar R/o House No. FCA-108A, East Chawla colony, Ballabgarh, District Faridabad.
…….Complainant……..
Versus
1. M/s. Religare health Insurance Company Limited, Main HUDA Market, Sector-16, Faridabad (Haryana) through its MD/Director/Manager.
2. M/s. Religare health Insurance Company Limited, Unit No. 604-607, 6th floor, Tower-C, Unitech Clbr Park, Sector-39, Gurugram Haryana – 122001 through its Branch Manager/Authorized Signatory.
…Opposite parties
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Ms. Neena Sharma, counsel for the complainant.
Sh. N.K.Garg,counsel for opposite parties Nos.1 & 2.
ORDER:
The facts in brief of the complaint are that the complainant obtained one Health Insurance Policy under Group policy holder name Punjab National Bank, Plan bearing Group policy No. 17499225 certificate of insurance
NO. 17646696, Plan Name Group Care 360 (Punjab Platinum) valid w.e.f 30.06.2020 to 29.06.2021 from the opposite parties for the total insured sum of Rs.7,00,000/- in the name of the complainant and his family members. Previously the complainant had taken health insurance policy from the Oriental Insurance Company Limited since 03.06.2014 which was continued and this fact had also been clearly mentioned in the above mentioned policy issued by the opposite parties. The complainant felt headache and vertigo on 21.10.2020 hence the complainant was admitted in Metro Health Institute with Multispecialty Hospital, Sector-16A, Faridabad on 22.10.2020 where the complainant was treated with IV Pan by the concerned doctor. The complainant remained admitted in the said hospital as indoor patient w.e.f. 20.10.2020 to 22.10.2020. Although it was cashless policy and the opposite parties to make the payment of treatment charges of Rs.47,992/- plus Rs.497/- hospitalization charges i.e. total amounting to Rs.48,489/- at the time of discharge of the complainant but the opposite parties did not pay the same so the complainant which were spent by the complainant out of his own pocket. On 12.11.2020 the complainant filled up the claim form for reimbursement of amount of treatment charges of Rs.48,489/- with the opposite parties and tendered all treatment records with the opposite parties thereby requesting to reimburse the mediclaim amount of Rs.48,489/- to the complainant which were spent by the complainant out of his own pocket. Instead of reimbursing the amount of Rs.48,489/- to the complainant and rejected the claim of the complainant vide letter dated 16.12.2020 thereby stating that the complainant was not payable as per the policy terms and conditions listed below rejected non disclosure of hypertension, diabetes mellitus, CAD PTCA ASHMA Non disclosure. In this regard, it was submitted that prior to taking the health insurance group policy the opposite parties had got done the medical examination of the
complainant and after their full satisfaction the said policy was issued by the opposite parties. Hence, the opposite parties could not save themselves from the liability to pay the treatment amount of Rs.48,489/- to the complainant. After going through the documents on record, facts and circumstances of the case the opposite parties did not make the payment of claimed amount to the complainant. The complainant sent legal notice dated 06.01.2021 to the opposite parties through registered post but all in vain. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite parties to:
a) make the payment of treatment amou7nt of Rs.48,489/- interest @ 24% p.a. since the date of admission of discharge of the complainant from the hospital till upto date to the complainant.
b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite parties put in appearance through counsel and filed written statement wherein Opposite parties refuted claim of the complainant and submitted that the complainant Ashok Kumar had taken a Group Care 360 degree (PNB-Platinum)” bearing group policy NO. 17499225 with certificate of insurance NO. 17646696 from 30.06.2020 till 29.06.2021 insured upto Rs.7,00,000/- subject to policy terms and conditions. A cashless request (cashless request No. 80439099) was received from Metro Heart Institute with multi-specialty Hospital, Faridabad for the hospitalization of complainant from 20.10.2020 and he was provisionally diagnosed with BPPV R/o Post stroke. Upon receipt of the cashless claim, a query dated 20.10.2020 was raised and the hospital was asked to provide certain documents/information. The hospital replied to the aforesaid query. Upon receipt
of the request an internal investigation was also triggered to check the veracity of the claim and during investigation it came to the fore-front that he was having a history of DM, HTN, CAD and had undergone PTCA ¾ years back. The medical history/pre-existing diseases were not disclosed at the time of filing the proposal form and portability form. Therefore, on the basis of afore-mentioned findings the cashless request was rejected on the basis of non-disclosure of DM, HTM and CAD vide denial letter dated 21.10.2020. The post denial of cashless request, the complainant filed a reimbursement claim (reimbursement claim No. 91488606) for the same hospitalization i.e. Metro Heat Institute with Specialty Hospital, Faridabad from 20.10.2020 to 22.10.2020 and as per the discharge summary, he was diagnosed with Acute Vertigo with vomiting, CAD-Post PTCA, T2DM and HTN. As per the discharge summary, the complainant was mentioned to be K/C/O CAD-post PTCA, DM & HTN. Also during verification of cashless request, it came to the fore-front that he was having a history of DM, HTN, CAD and had undergone PTCA ¾ years back. It was pertinent to mention that the medical history/pre-existing issue were not disclosed at the time of filing the proposal form and portability form. Therefore, the claim of the complainant was rejected on the basis of hypertension, diabetes mellitus, CAD- PTCA & Asthama vide denial letter dated 16.12.2020 Since there were material non-disclosures on the part of the complainant the opposite party company sent a notice for cancellation to the complainant to show cause and revert within 15 days. However, no reply was received to the aforesaid notice and the policy was cancelled. Opposite parties 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 Ins.Co. Ltd. with the prayer to: a) make the payment of treatment amou7nt of Rs.48,489/- interest @ 24% p.a. since the date of admission of discharge of the complainant from the hospital till upto date to the complainant. b) pay Rs. 1,00,000/- as compensation for causing mental agony and harassment . c) pay Rs. 11,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Shri Ashok Kumar, Ex.C-1 - insurance policy, Ex.C-2 – premium acknowledgement,, Ex.C-3 PNB Oriental Royal Mediclaim Policy Schedule valid from 03.06.2014 to 02.06.2015, Ex.C-4 receipt, Ex.C-5 – PNB Oriental Royal Mediclaim Policy Schedule valid from 03.06.2015 to 02.06.2016, Ex.C-6 – Receipt, Ex.C-7 –Risk details,, Ex.C-8 - receipt, Ex.C-9 – photocopy of DD, Ex.C-10 – receipt, Ex.C-11 – PNB- Oriental Mediclaim Policy – 2017 Group Health Insurance Product policy valid from 03.06.2018 to 02.06.2019, Ex.C-12 – Receipt , Ex.C-13 - PNB-Oriental Mediclaim Policy-2017 valid from 03.06.2019 o 02.06.2020, Ex.C-14 – claim form, Ex.C-15 – Discharge summary, Ex.C-16 – invoice,, Ex.C-17 – receipt dated 20.10.2020, Ex.C-18 – Admission advance Receipt, Ex.C-19 – cancelled cheque, Ex.C-20(colly) – final bill, Ex.C-21 – legal notice,
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 Shri Sahil Chauhan, Authorized representative of M/s. Religare health Insurance Co. Ltd. (now known as M/s. Care health Insurance Ltd.), Ex.R-1 – certificate of
change in name issued by the Registrar of Cos. Delhi, Ex.R-2 – Insurance policy with terms and conditions, Ex.R-3 – Request for cashless hospitalization for medical insurance policy, Ex.R-4 –deficiency letter, Ex.R-5 – medical documents, Ex.R-6 – denial letter dated 21.10.2020 , Ex.R-7 – discharge summary, Ex.R-8 – Claim form, Ex.R-9 -Claim denial letter, Ex.R-10 – proposal form, Ex.R-11 (colly) – legal notice.
6. It is evident from medical documents vide Ex.R-5 that the internal investigation was also triggered to check the veracity of the claim and during investigation it came to the fore-front that he was also has a history of Bronchial Asthama on medication, Dm, HTN and CAD. As per discharge summary vide Ex.R-7, the complainant was diagnosed with Acute Vertigo with vomiting, CADPost PTCA, T2DM and HTN. As per the discharge summary, the complainant is mentioned to be K/C/O CAD-Post PTCA, DM. HTN. And during verification of cashless request, it came to the fore-front that he is having a history of DM,HTN, CAD and has undergone PTCA ¾ years back. The medical history/pre-existing disease were not disclosed at the time of filing the proposal form and portability form. Therefore, the claim of the complainant was rejected on the basis of hypertension, diabetes mellitus, CAD-PTCA, Asthama vide denial letter dated 16.12.2020 vide Ex.R-9.
7. During the course of arguments, the counsel for the complainant has placed on reliance Medical Insurance – Once Insurer Accepts that concealment of disease was not material, reimbursement & renewal can’t be refused passed by the Hon’ble Supreme Court of India on 6th July 2023.
Ratio of this authority is applicable to the facts of the present case
8. 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. There are no order as to costs. 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: 19.07.2023 (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.
