Chandigarh

DF-I

CC/577/2019

Sunit Mahajan - Complainant(s)

Versus

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

In Person

15 Jan 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/577/2019
Date of Institution	:	04/06/2019
Date of Decision	:	15/01/2021

 

 

Sunit Mahajan, aged 34 years son of Shri Vijay Kumar R/o H.No.174, Ansal API, Sector 114, Kharar, District SAS Nagar, Mohali, Punjab.

… Complainant

V E R S U S

M/s Religare Health Insurance Limited, SCO No.56-57-58, 2^nd Floor, Sector 9-D, Chandigarh through its Manager.

… Opposite Party

 

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                               

ARGUED BY	:	None for complainant
	:	Ms. Niharika Goel, Vice Counsel for Sh. Paras Money Goyal, Counsel for OP

 

Per Rattan Singh Thakur, President

1.      The long and short of the allegations as set out in the consumer complaint are, on 18.1.2018 complainant had purchased an Online Health Insurance Policy from the OP which was valid from 18.1.2018 to 17.1.2019. The Sum assured was ₹6,00,000/- and the annual premium was ₹13,916/-. The policy covered cashless pre-hospitalization and post hospitalization medical expenses. His case is, the said policy was further got renewed from 18.1.2019 to 17.1.2020 and bonus of ₹3,00,000/- was added in the sum assured. 

         Maintained, on 27.4.2019 the complainant was admitted in emergency of the Fortis Hospital, Mohali due to sudden Transient Ischemic attack and anxiety neurosis. On request being made, the OP did not provide the cashless facility and the complainant remained admitted in the hospital for treatment of aforesaid disease till 28.4.2019. The complainant paid the bill of ₹43,834/- raised by the hospital. After discharge, the complainant again approached the OP, but, it refused to pay the claim vide letter dated 27.5.2019 with the remarks complainant is not entitled to the cashless hospitalization as per health insurance policy as he had concealed the pre-existing disease.  His case is, when the policy was taken he was perfectly alright, therefore, there was no concealment and the rejection of the claim by the OP tantamounts to deficiency in service and unfair trade practice on its part. Hence, the present consumer complaint for directing the OP to refund the amount of ₹43,834/-; pay compensation of ₹20,000/-; ₹10,000/- as litigation expenses and further to terminate the policy and refund the amount.

2.     OP contested the consumer complaint and filed its written reply. As per its reply, OP had come to know complainant was suffering from a disease ulcerative colitis since two years and the same was concealed by him at the time of taking the policy.  However, the facts with regard to payment of the premium and bonus given for no claim during the continuation of the policy first time is not denied. The case of the OP is, complainant had taken a treatment of numbness of left side of body including face at Fortis Hospital, Mohali and as per terms and conditions of the policy, complainant was supposed to disclose the material fact i.e. pre-existing ailment at the time of proposal which was not disclosed by him. Hence, as per terms and conditions of the policy, the claim was rightly repudiated. Reference was made to the numerous judgments with regard to concealment of material facts.  On these lines, the cause is sought to be defended.
3.     Rejoinder was filed by the complainant and averments made in the consumer complaint were reiterated.
4.     Parties led evidence by way of affidavits and documents.
5.     We have heard the learned counsel for the OP and gone through the record of the case. After scanning of record, including written arguments, our findings are as under:-
6.     Per pleadings of the parties, and the evidence led by way of affidavits, the purchase of the policy in question by the complainant for the first time w.e.f. 18.1.2018 to 17.1.2019 on payment of ₹13,916/- is not in dispute before us.  It is also the admitted fact, during this period of insurance coverage no mediclaim was raised by the complainant.  It is on account of this fact, OP had given him bonus of ₹3,00,000/- in the total sum assured.  Under the policy, the sum assured was ₹6,00,000/- plus added bonus of ₹3,00,000/- when the second time he got renewed the policy w.e.f. 18.1.2019 to 17.1.2020. This fact itself shows the claim being made by the complainant is bonafide and there is no hanky-panky involved in it.
7.     Per averments made in the consumer complaint plus the discharge summary of the Fortis Hospital shows, the diagnosis of the disease of the complainant was sudden Transient Ischemic attack and anxiety neurosis.  It is so mentioned in the discharge summary. There is reference in the past history of the complainant suffering from ulcerative colitis since two years. This past history was taken as a disqualification by the OP to deny the claim of the complainant as he had concealed the material fact of pre-existing disease of ulcerative colitis at the time of taking the first policy.
8.     Now let us thrash out whether the disease sudden Transient Ischemic attack and anxiety neurosis has any nexus, connection or link with the allegedly concealed disease of ulcerative colitis. In simple words, whether ulcerative colitis disease can lead to sudden Transient Ischemic attack and anxiety neurosis. To this effect we can press into service, the Webster’s New World Medical Dictionary compiled and authored by doctors and experts at MedicineNet.com and thereunder colitis ulcerative has been defined as follows :-

“colitis, ulcerative A common form of inflammatory bowel disease that is similar to a related disorder, Crohn disease.  Its cause is unknown. The end of the colon (the rectum) is always involved in ulcerative colitis.  When the inflammation is limited to the rectum, it is called ulcerative proctitis. The inflammation may extend to varying degrees into the upper parts of the colon. When the entire colon is involved, the terms pancolitis or universal colitis are used.  Intermittent rectal bleeding, crampy abdominal pain, and diarrhea can be symptoms of ulcerative colitis. Ulcerative colitis characteristically waxes and wanes. Many patients experience long remissions, even without medication. Ulcerative colitis may mysteriously resolve after a long history of symptoms. Direct visualization (sigmoidoscopy or colonoscopy) with sampling of the lining of the bowel is the most accurate diagnostic test.  Especially in new cases, infections and other diseases that can mimic ulcerative colitis have to be considered and excluded.  Long-standing ulcerative colitis increases the risk for colon cancer. Ulcerative colitis can also be associated with inflammation in joints, spine, skin, eyes, liver and bile ducts. Treatment of ulcerative colitis involves medications and/or surgery; changes in diet can sometimes help.”

 

A perusal of this description of colitis ulcerative shows, it may lead to inflammation in joints, spine, skin, eyes, liver and bile ducts.  It also shows it does not lead to sudden Transient Ischemic attack and anxiety neurosis.  Therefore, prima facie we have to believe, the disease for which the complainant had taken treatment i.e. sudden Transient Ischemic attack and anxiety neurosis has no nexus, connection or link with the alleged ulcerative colitis.

9.     In the history of colitis ulcerative as was opined and defined by the experts, which we have referred hereinbefore shows, ulcerative colitis may mysteriously resolve after a long history of symptoms and it has also got a period of remission.  It is an auto immune disease and it may mysteriously resolve after a long history of symptoms. Therefore, it could not be authentically said that when the first policy was taken on 18.1.2018 the complainant was suffering from ulcerative colitis. May be a fact that it was resolved, therefore, it cannot be authentically said, complainant had deliberately concealed this disease of ulcerative colitis.
10.     The OP had produced some material about the sudden Transient Ischemic attack and anxiety neurosis, but, that is in question answer form.  Who has authored the same has not been disclosed and it is an unauthenticated material and we have relied upon Webster’s New World Medical Dictionary, compiled and scribed by medical experts of the respective fields.  Thus, we place reliance on the aforesaid medical dictionary.
11.     The complainant has also relied upon and referred to case titled as Priya Blue Industries Ltd. Vs. New India Assurance Co. Ltd., Original Petition No.129 of 1998 decided on 19.5.2005 by the Hon’ble National Commission, vide which the rationality given is despite insurance coverage and receipt of large amount as premium, the insurance claim is not settled on one or other grounds for years together. The complainant further banked upon Unique Motor and Insurance Vs. Gnanambigai & Anr. decided on 4.1.1966 by the Hon’ble Madras High Court vide which it was held onus of proving non-disclosure or concealment is on the insurance company.  In the present case, no material was brought in to say complainant had been taking treatment for ulcerative colitis.
12.     The OP had relied upon simply the past history disclosed by the complainant at the time of taking the treatment in the Fortis Hospital of sudden Transient Ischemic attack and anxiety neurosis where it was stated complainant was suffering from this ulcerative colitis since two years.  No other material has been brought in to prove this in an authentic manner.  As such, the act of rejection of the claim by the OP amounts to deficiency in service and unfair trade practice.
13.     In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed. OP is directed as under :-

1. to reimburse and pay the claim of ₹43,834/- to the complainant alongwith interest @ 8% per annum from the date of rejection i.e. 27.5.2019 till realization.
2. to pay an amount of ₹10,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹5,000/- to the complainant as costs of litigation.

14.     This order be complied with by the OP within thirty days from the date of receipt of its certified copy, failing which, it shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
15.     Certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-	Sd/-
15/01/2021	[Suresh Kumar Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
hg	Member	Member	President