Chandigarh

StateCommission

A/280/2016

Religare Health Insurance Company Ltd. - Complainant(s)

Versus

Ms. Preeti Bedi - Opp.Party(s)

Paras Money Goyal, Adv.

13 Oct 2016

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

                                                                 

First Appeal No.	:	280 of 2016
Date of Institution	:	06.10.2016
Date of Decision	:	13.10.2016

 

1. Religare Health Insurance Company Ltd., SCO No.28, 2^nd Floor, Sector 20-D, Chandigarh, through its Branch Manager.
2. Religare Health Insurance Company Ltd., D-3, District Centre, Saket, New Delhi-17, through its authorised representative.

…..Appellants/Opposite Parties

V e r s u s

Ms. Preeti Bedi wife of Late Rajnish Bedi resident of House No.1166, 1^st Floor, Sector 22-B, Chandigarh.

                       …..Respondent/Complainant

 

Appeal under Section 15 of the Consumer Protection Act, 1986.

 

BEFORE:   JUSTICE JASBIR SINGH (RETD.), PRESIDENT.

                 MR. DEV RAJ, MEMBER

                 MRS. PADMA PANDEY, MEMBER

 

Argued by:   Sh. Paras Money Goyal, Advocate for the appellants.

 

PER PADMA PANDEY, MEMBER

              This appeal is directed against the order dated 30.08.2016 rendered by the District Consumer Disputes Redressal Forum-I, U.T., Chandigarh (hereinafter to be called as the District Forum only), vide which, it accepted the complaint, filed by the complainant and directed the Opposite Parties, as under:-

    “(i)   To pay Rs.55,036/- to the complainant     being  the total claim amount with interest @ 9% per annum from the date of filing of this complaint till realization;

(ii)   To pay Rs.10,000/- as compensation for    mental agony and harassment caused to the complainant;

(iii)  To pay Rs.5,000/- as costs of litigation to the complainant. 

                  This order be complied with by the OPs within    one month from the date of receipt of its certified copy, failing which they 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.”

2.        The facts in brief, are that, the complainant purchased a Health Insurance Policy from the Opposite Parties, which was valid for the period from 22.01.2015 to 21.01.2016. It was stated that the complainant was insured upto Rs.5.00 lacs and she paid premium of Rs.11,774/-. It was further stated that the complainant was only issued the policy certificate (Annexure C-1) and the terms and conditions of the policy, were not supplied to her, by the Opposite Parties. It was further stated that during the currency of the policy, in question, the complainant had some problem in her left knee, for which she consulted a doctor at Shivalik Hospital & Trauma Centre on 12.04.2015 and thereafter, got conducted CTR and MRI.  It was further stated that on the basis of the reports dated 12.04.2015 and 13.04.2015, the doctor at the said hospital admitted the complainant for surgery of left knee Asthroscopy on 01.05.2015 and she was discharged on 02.05.2015. It was further stated that the complainant spent a sum of Rs.55,036/- on her medical treatment. It was further stated that the representatives of the Opposite Parties had assured the complainant that it was a cashless treatment, for which she had to pay nothing from her pocket, but they did not care to pay.
3.        It was further stated that the complainant ultimately lodged a claim with the Opposite Parties claiming medical expenses, incurred by her.  It was further stated that subsequently, in order to process the claim, the Opposite Parties demanded certain documents from the complainant, vide email dated 09.06.2015 which were duly supplied by her.  It was further stated that vide letter dated 04.07.2015, the Opposite Parties rejected her claim under clause 6.1 of the terms and conditions of the Health Insurance Policy, for non-declaring hyper-tension/diabetes for the last four years.  It was further stated that the Opposite Parties also threatened to cancel the policy, and the complainant vide its reply dated 28.07.2015 stated that they cannot cancel the policy, as she never concealed any fact. It was further stated that the aforesaid acts of the Opposite Parties, amounted to deficiency, in rendering service, as also indulgence into unfair trade practice. When the grievance of the complainant, was not redressed, left with no alternative, a complaint under Section 12 of the Consumer Protection Act, 1986 (hereinafter to be called as the Act only), was filed, directing the Opposite Parties.
4.        The Opposite Parties have filed joint reply and pleaded that the complainant obtained the policy for the first time in the year 2013, which was valid from 22.01.2013 to 21.01.2014. It was stated that the said policy was subsequently renewed from 22.01.2014 to 21.01.2015 and 22.01.2015 to 21.01.2016, on the basis of the facts disclosed by the proposer i.e. insured in the proposal form.  It was further stated that the policy kit consisting of proposal form, policy, policy terms and conditions was sent to the complainant vide Air-Way Bill (AWB) No.43995681984 on 28.01.2013, but, she has withheld the production of the entire kit at the time of filing the complaint. It was further stated that a claim was lodged by the complainant, for reimbursement of the medical expenses, incurred by her, on her treatment, which was denied vide letter dated 04.07.2015 for “Non-disclosure of Hypertension/Diabetes for last 4 years” wherein diabetes was erroneously mentioned in place of Migraine. It was further stated that a revised rejection letter dated 13.11.2015 with the reason of rejection recorded as “non-disclosure of Hypertension/ Migraine for the last 4 years”. It was further stated that the complainant by not disclosing true and correct facts about her health at the time of proposing, has violated ‘the principles of ‘uberrima fides’.
5.      It was further stated that true and correct facts been disclosed at the proposal stage, the contract would have been insured on separate terms and conditions. It was further stated that the Opposite Parties served a show cause/cancellation notice dated 18.09.2015 upon the complainant, to furnish the correct facts supported by valid document proof, in case she disputed the facts of non-disclosure of hypertension and Migraine, failing which it was made clear that the Opposite Parties would be entitled to cancel the policy, as per clause 6.1 of the policy terms and conditions. It was further stated that the complainant failed to submit any reply, as such, the Opposite Parties vide letter dated 20.10.2015 repudiated the claim and further informed her, that her health insurance policy stands void ab initio due to
   non-disclosure of material information and the premium stands forfeited and that Opposite Parties have no liability under the captioned policy and no further amount is payable. Thus, the OPs prayed for dismissal of complaint. It was further stated that there is no deficiency in service on their part, and the answering Opposite Parties had prayed for dismissal of the complaint.
6.     The complainant, filed rejoinder, to the written statement of the Opposite Parties, wherein she reiterated all the averments, contained in the complaint, and repudiated those, contained in the written version of Opposite Parties.
7.        The Parties led evidence, in support of their case.
8.        After hearing the Counsel for the parties, and, on going through the evidence, and record of the case, the District Forum, accepted the complaint, in the manner, referred to, in the opening para of the instant order. 
9.        Feeling aggrieved, the instant appeal, has been filed by the appellants/Opposite Parties.
10.        We have heard the Counsel for the appellants, at the preliminary stage and, have gone through the evidence, and record of the case, carefully. 
11.        After giving our thoughtful consideration, to the contentions, advanced by the Counsel for the appellants, and the evidence, on record, we are of the considered opinion, that the appeal is liable to be dismissed at the preliminary stage, for the reasons to be recorded hereinafter.
12.        Minute perusal of the record shows that the appellants while getting the policy renewed from the respondent were trying to prove that the appellant was suffering from Hypertension and Migraine by placing a copy of letter from Dr. Bhownesh Chander Mahajan, who certified that the respondent Ms. Preeti Bedi has been taking medicines for High BP and Migraine for the last four years and she had been visiting at his clinic as an outdoor patient. However, the appellants have not placed on record the affidavit of the said Dr. Bhownesh Chander Mahajan to show that he was maintaining the record of regular visits in his OPD for the last four-five years of the respondent. The appellants, thus, were deficient by not placing on record the said affidavit of the Doctor. The appellants have also relied upon a questionnaire obtained from Dr. Santosh Kumar Agrawal of Shivalik Hospital & Trauma Centre, from where the respondent had got done the surgery of her knee, and the questionnaire does not give a clear picture from when the patient was suffering from Hypertension. The appellants had also relied upon another questionnaire put to the respondent, in which respondent was asked to specify since how long she was suffering from Hypertension to which the respondent replied that she was suffering from Hypertension, for the last 1½ years, and taking Metolar 50 Mg OD and no consultation papers were available for treatment. With reference to another questionnaire, the respondent further replied that she was suffering from Migraine, for past four-five years, and taking treatment from Dr. Bhownesh Chander Mahajan, and no papers were available for the same. It is pertinent to mention here that Migraine has no nexus with the knee problem. It is a type of headache, which are commonly faced by many people, and accordingly, non-disclosure of such a disease cannot be said to be concealment of a material fact. Therefore, we find that the appellants have been grossly deficient in rendering their services, by denying the insurance claim, and accordingly, the said appeal is dismissed with no order as to costs.
13.        No other point, was urged, by the Counsel for the appellants.
14.       In view of the above discussion, it is held that the order passed by the District Forum, being based on the correct appreciation of evidence, and law, on the point, does not suffer from any illegality or perversity, warranting the interference of this Commission.
15.       For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, at the preliminary stage, with no order as to costs. The order of the District Forum is upheld.
16.      Certified copies of this order, be sent to the parties, free of charge.
17.      The file be consigned to Record Room, after completion

 

Pronounced.

13.10.2016

 

                                                                        Sd/-

[JUSTICE JASBIR SINGH (RETD.)]

PRESIDENT

                                                                                   

 

                                                                                       Sd/-

[DEV RAJ]

MEMBER

                                                                                     

 

                                                                                         Sd/-

[PADMA PANDEY]

 MEMBER

 

 

GP

 

 

STATE COMMISSION

(First Appeal No.280 of 2016)

(Religare Health Insurance Company Ltd. & Anr. Vs. Preeti Bedi)

 

 

Argued by:

Sh. Paras Money Goyal, Advocate for the appellants.

 

Dated the 13^th day of October 2016

 

ORDER

 

              Vide our detailed order of the even date, recorded separately, this appeal has been filed by the appellants/Opposite Parties, has been dismissed at the preliminary stage, with no order as to cost and the order passed by the District Forum, has been upheld.

 

      

 

Sd/-                                  Sd/-                                         Sd/-

(DEV RAJ) MEMBER	(JUSTICE JASBIR SINGH (RETD.)) PRESIDENT	(PADMA PANDEY) MEMBER

 

GP