Haryana

Karnal

CC/156/2020

Sat Pal Malhotra - Complainant(s)

Versus

Naman Sharma Agent Of Religare Health Insurance COmpany Limited - Opp.Party(s)

Mandeep Singh

07 Mar 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 156 of 2020

                                                        Date of instt.13.03.2020

                                                        Date of Decision:07.03.2023

 

Satpal Malhotra son of Shri Buta Ram Malhotra, resident of house no.117, near Bajaj Market, Matak Majri Indri (Hakim Boota Ram Hospital Garhi Birbal Road Indri, District Karnal.

 

                                               …….Complainant.

                                              Versus

 

1.     Naman Sharma (code no.2010524) agent of Religare Health Insurance Company Limited, office situated at Insurance Solution Point near PNB Bank Indri, District Karnal.

 

2.     Parteek Singla, (Sales Manager) Religare Health Insurance Company Limited Panipat Royal-1, 1175-B, Second Floor near Kotak Nahindra Bank, adjoining Gurudwara Paneli Patshani, g.T. Road, Panipat.

 

3.     Religare Health Insurance Company Limited, registered office 5^th floor 19 Chawla House Nehru Place, New Delhi 110019 through its Manager.

                                                                      …..Opposite Parties.

 

Complaint Under Section 12 of the Consumer Protection Act, 1986 and after amendment Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.

              Sh. Vineet Kaushik…….Member

      Dr. Rekha Chaudhary…….Member

                   

 Argued by: Shri Mandeep Singh, counsel for the complainant.

                    Shri R.S. Dhanda, counsel for the OP no.1.

                    OP no.2 given up.

                    Shri Ashwani Kumar Popli, counsel for the OP no.3.

 

                    (Jaswant Singh President)

 

ORDER:   

                

                   The complainant has filed the present complaint Under Section 12 of the Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant had taken a Health Insurance Policy from National Insurance Company Limited for a sum assured of Rs.2,00,000/- in the year 2005 and after taking the policy, the complainant had making the payment of premium regularly to the National Insurance Company without any default upto 2018. In the month of November, 2018 the OPs no.1 and 2 came to the house of complainant and told that the Religare Insurance has launched a Health Insurance Plan for sum  assured of Rs.5,00,000/- and he also told that the life of wife of the complainant also got insured in that policy and he further told that the company would also include the period of previous health insurance policy. On the false allurement of OP no.2, complainant got the Religare Health Insurance Policy no.13262058 for a period of 8^th November, 2018 to 7^th November, 2019 and the OP no.2 assured the complainant that the life of the complainant as well as his wife has been fully insured upto the sum assured of Rs.5,00,000/-. In the month of March, 2019 complainant fell ill and complainant got admitted in Pushpawati Singhania Hospital Research Institute Delhi on 02.03.2019 and the complainant was discharged on 03.03.2019 with a advise to take proper treatment from higher cancer hospital and at that time the complainant spent a sum of Rs.48,096/- . The said claim amount was reported with Panipat office through Mr. Parteek Singla i.e. OP no.2 but instead of receiving the claim cheque, notice of cancellation of policy no.13262058 dated 11.03.2019 received, falsely alleging that there has been non-disclosure of material facts/pre-existing ailments at the time of proposal. OP no.2 informed about this notice to which he assured that the claim would be settled as exclusion of pre-existing ailment is not applicable in this case as the previous policy of National Insurance Policy is effective from 2005 as claim free with 50% bonus. After that complainant got treatment as outdoor patient in Sir Ganga Ram Hospital, Delhi for further test and treatment and also got treatment as outdoor patient in Max Hospital Delhi for cancer treatment. The complainant has spent a sum of Rs.3,95,137/- for the aforesaid treatment. After discharging from the hospital, complainant contacted the OP no.1 and told regarding the aforesaid disease and treatment and lodged the claim and made request to the OPs to pay the aforesaid amount on account of mediclaim. The complainant also submitted all the relevant documents with the OP for reimbursement of the abovesaid amount. It is further averred that complainant received a letter dated 02.09.2019 regarding notice for cancellation of policy in question whereby OPs have mentioned that for issuance of this notice within 15 days, the complainant should furnish correct facts supported by valid documents proof in case dispute the same, failing which the OPs be entitled to cancel the policy as per policy terms and conditions and forfeit the entire premium. After receiving the said letter, complainant approached the OPs no.1 and 2 and asked regarding the aforesaid notice and again submitted all the required documents with the OPs but after receiving all the documents OPs did not settle the claim of the complainant and lingered the matter on one pretext or the other. Then complainant sent a legal notice dated 05.10.2019 to the OPs but it also did not yield any result. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OP no.1 appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action and concealment of true and material facts. On merits, it is pleaded that on asking of the OP no.2, the OP no.1 met with the complainant and OP no.2 disclosed him regarding the health policy launched by the OP no.2. At that time the complainant has given the correct information and disclosed all thing and the OP admitted the same. On the assurance of the OP no.2, complainant got purchased the Religare Health Insurance Policy no.13262058 for a period commencing from 08^th November, 2018 to 07^th November, 2019 and OP no.2 assured that the life of the complainant as well as his wife has been fully insured upto the sum assured of Rs.5,00,000/-. It is further pleaded that after discharge from the hospital, the complainant contacted the OP no.1 and narrated regarding his disease. After coming to know this fact the OP submitted all the relevant documents in the office of the OP no.2 for passing his claim, but OP no.3 has not passed the claim knowing and intentionally. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             OP no.2 has given up by the learned counsel for the complainant being unnecessary party, vide his statement dated 22.07.2021.

4.             OP no.3 filed its separate written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that complainant herein has only filed for cashless facility request and has not filed for any reimbursement claim. It is further pleaded that company has only registered one claim for an amount of Rs.48096/-. No other claim for an alleged amount of Rs.3,95,137/- has been registered with the company. Therefore, it is requested that the complainant may submit the requisite claim documents as alleged to have been submitted with the company or alternatively file a fresh claim with complete medical documents alongwith bills and receipts etc. where after, the company will consider it in accordance with policy terms and conditions. The company also intends to continue the policy subject to deposition of premium in continuity. It is further pleaded that OP issued a Health Insurance Policy Plan namely “Care Floater” vide policy no.13262058 to the complainant providing insurance coverage to himself and his spouse w.e.f.08.11.2018 till 07.11.2019 for a sum insured of Rs.5,00,000/- subject to Policy Terms and Conditions. As per records the said policy was ported from National Insurance Co. Ltd. with the date of first enrollment being 08.11.2017. It is further pleaded that during the continuation of the policy, a cashless request was received from the hospital on behalf of the complainant. The complainant was required to be admitted at PSRI, Delhi from 02.03.2019 for being diagnosed with Carcinoma Prostate. In order to check the veracity of the claim, the OP triggered an investigation and subsequently raised a query letter dated 02.03.2019 asking the following information:

1.     Exact duration and past history of present ailment with 1^st Consultation Paper and All past treatment records.

2.     Investigation Report Supporting Diagnosis

        HPE Report.

3.     Pre-Hospitalization OPD Treatment Record.

        During the investigation, it was found that the complainant as a history of hypertension since 4 months i.e. prior to policy inception, the same was concluded by the OP during the investigation where an Audio Video Recording of the insured/complainant was made, and it has been clearly stated that the complainant was having hypertension since 4 months and is also taking medication for the same.

That in view of the above finding, the OP rejected the cashless request vide Denial Letter dated 03.03.2019 on the following grounds:

        Non-Disclosure of Material Facts/Pre-existing Ailments at the time of Proposal (Hypertension since before policy inception)

Reimbursement Claim

a.     That post cancellation of cashless request, the complainant filed a reimbursement claim with the OP for the above hospitalization at PSRI Hospital, Delhi w.e.f.02.03.2019 till 03.03.2019. The said claim was received with the OP on 09.04.2019. As per Discharge Summary, complainant was diagnosed with Prostate Cancer and was performed with TRUS guided prostatic biopsy under GA.

b.     That meanwhile an investigation was triggered by the OP company to check the veracity of the claim.

c.      In view of the aforesaid claim, the OP raised a query vide Query letter dated 11.04.2019 seeking additional information as under:-

1.     Exact duration and past history of present ailment with 1^st consultation paper and all past treatment records.

        Hypertension (First Consultation 4 months back)

2.     Pre-Hospitalization OPD Treatment Record.

        All past treatment Records of Prostate.

3.     Complete Indoor Case Papers with admission notes, history sheet, Doctor’s notes, Nursing notes and vital chart.

A reminder was sent in respect to above query letter, vide reminder letters dated 21.04.2019 and 01.05.2019. Another query letter dated 17.05.2019 was sent to the complainant seeking documents pertaining to First Consultation of Hypertension and First Consultation for poor stream urine  and urine urgency and all treatment records for Hypertension, OP closed the reimbursement claim vide Denial letter dated 20.05.2019 on the grounds of “Deficiency not replied” in accordance with clause 6.2, 6.3 and 6.5 of the policy terms and conditions. It is further pleaded that in order to process the claim, OP needed to complete documents and since the same have not been provided by the complainant, OP had no option but to close the claim. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

5.             Parties then led their respective evidence.

6.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of notices by Religare dated 11.03.2019, 06.08.2019, 02.09.2019 Ex.C1 to Ex.C3, copy of policy certificate of Religare Ex.C4, copy of policy details Ex.C5, copy of insurance policy of National Insurance Company Ex.C6, copy of detail of policy of National Insurance Company Ex.C7, copy of health card of National Insurance Company Ex.C8, copy of Aadhar card of complainant Ex.C9, copy of medical bill of PSRI, Hospitals Ex.C10 and Ex.C11, copy of medical bills of Sir Ganga Ram Hospital Ex.C12 and Ex.C13, copy of medical bills of Max Hospital Ex.C14 to Ex.C17, copy of medical bills of Su Diagnostic Ex.C18, copies of medical bills of Amit Drugs and Surgicals Ex.C19 to Ex.C21, copies of medical bills of Shri Balaji Medical Ex.C22 to Ex.C27, copy of legal notice dated 04.09.2018 Ex.C28, postal receipt Ex.C29, copy of reply of legal notice Ex.C30, copy of claim form Part A and Part B Ex.C31 and Ex.C32, postal receipts of claim form Ex.C33  and closed the evidence on 18.08.2021 by suffering separate statement.

7.             On the other hand, learned counsel for the OP no.1 has tendered into evidence affidavit of Naman Sharma Agent of Religare Health Insurance Company Ex.OP1/A and closed the evidence on 24.11.2021 by suffering separate statement.

8.             Learned counsel for OP no.3 has tendered into evidence affidavit of Lakshay Juneja Manager Ex.OPS1/A, copy of policy certificate Ex.OP1, copy of terms and conditions of the policy Ex.OP2, copy of proposal form Ex.OP3, copy of portability form Ex.OP4, copy of cashless form Ex.OP5, copy of query letter dated 02.03.2019 Ex.OP6, copy of denial letter dated 03.03.2019 Ex.OP7, copy of claim form Ex.OP8, copy of discharge summary Ex.OP9, copy of final bill Ex.OP10, copy of I.R. report Ex.OP11, copies of query letters dated 11.04.2019, 17.05.2019 Ex.OP12 and Ex.OP15, copy of reminders dated 21.04.2019, 01.05.2019 Ex.OP13 and Ex.OP14, copy of query reply Ex.OP16, copy of denial letter dated 20.05.2019 Ex.OP17, copy of clinical evidence Ex.OP18, copy of prompt investigation Ex.OP19, copy of cancellation notice Ex.OP20, copy of legal notice Ex.OP21, copy of reply of legal notice Ex.OP22 and closed the evidence on 07.02.2022 by suffering separate statement.

9.             We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

10.           Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that that complainant had taken a Health Insurance Policy from National Insurance Company Limited in the year 2005 and paid the premium regularly without any default upto 2018. In the month of November 2018, agent of OP allured the complainant to got ported the health insurance policy from National Insurance Company to OPs’ company for more benefits and on allurement of agent of the OPs complainant got ported his policy from National Insurance Company to OPs’ company. In the month of March, 2019 complainant fell ill and complainant got admitted in Pushpawati Singhania Hospital Research Institute Delhi  and spent a sum of Rs.48,096/-. Complainant again got admitted in Sir Ganga Ram Hospital, Delhi and also got treatment as outdoor patient in Max Hospital Delhi for cancer treatment. The complainant has spent a sum of Rs.3,95,137/- for the aforesaid treatments. After discharging from the hospitals, complainant lodged the claim with the OPs for reimbursement of the said amount and submitted all the relevant documents. Complainant received a letter dated 02.09.2019 regarding notice for cancellation of policy. OPs inspite making the payment of treatment has cancelled the health insurance policy without any cogent reason and lastly prayed for allowing the complaint.

11.           Per contra, learned counsel for OP no.1, while reiterating the contents of written version, has vehemently argued that complainant purchased the Religare Health Insurance Policy for the  sum assured of Rs.5,00,000/-. OP no.1 submitted all the relevant documents in the office of the OP no.2 for passing his claim, but OP no.3 has not passed the claim knowingly and intentionally.

12.           Learned counsel for the OP no.3, while reiterating the contents of written version, has vehemently argued that OP issued a Health Insurance Policy Plan namely “Care Floater” policy to the complainant providing insurance coverage to himself and his spouse for a sum insured of Rs.5,00,000/-. He further argued that complainant is suffering from pre-existing disease i.e. hypertension and did not disclosed the same at the time of portal of the policy and lastly prayed for dismissal of the complaint.

13.           We have duly considered the rival contentions of the parties.

14.           Admittedly, insured has availed the health insurance policy from National Insurance  Co. Ltd. in the year 2005. It is also admitted that the said policy was ported in the OPs’ company on 07.11.2018. It is also admitted that during the subsistence of the insurance policy complainant was admitted in Pushpawati Singhania Hospital Research Institute, Delhi, Sir Ganga Ram Hospital, Delhi and Max Hospital, Delhi.

15.           The claim of the complainant has been denied by the OPs, vide letter Ex.OP7 dated 03.03.2019 on the ground that non-disclosure of material facts/pre-existing ailment, at the time of proposal (hypertension since before policy inception) and non-disclosure.

16.           The complainant had purchased the health insurance policy from National Insurance Company Limited and complainant regularly paying the premium without any fault upto 2018. The said policy has been ported on the assurance of OP no.1 i.e. agent of the OP no.3. This fact has not been denied by the OP no.1.

17.           The claim of the complainant has been denied by the OP no.3 on the ground that complainant was having pre existing disease at the time of portal of the policy. The onus to prove its version was relied upon the OP, but OP has miserably failed to prove its version by leading any cogent and convincing evidence. The case of the OP based upon the discharge summary Ex.OP9 and investigation report Ex.OP19. OP neither examined the doctor nor the investigator who have issued the said discharge summary and investigation report. In the investigation report Ex.OP19, it has been mentioned that treated doctor has not provided his statement. If the said doctor has not given any statement with regard to pre-existing disease, it cannot be ascertained that complainant was suffering any pre-existing disease.  OP has also alleged that complainant has disclosed that he had taken treatment from doctor V.K. Singla but OP also failed to place on file any record from the said doctor.

18.           Furthermore, if for the sake of arguments, if it be presumed that the life assured was suffering from hypertension at the time of obtaining the insurance policy, in that case also the claim of the complainant cannot be denied on the said ground, because Hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension. In this regard, we are also fortified from the observations of the Hon’ble State Commission, New Delhi, titled as Life Insurance Corporation of India Versus Sudha Jain 2007 (2) CLT 423, in which Hon’ble State Commission has drawn conclusion in para 9 of the order and the relevant clause is 9 (iii), is reproduced as under:-

        “9(iii) Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.” Taking into consideration the facts of the present case and law laid down by the Hon’ble Superior Fora in the above referred cases, we are of the view that OPs were not justified in repudiating the claim of the complainant and are thus liable to pay the amount which the complainant had incurred on his treatment”.

19.           It is evident from the policy cover note Ex.OP4, the complainant was 62 years old at the time of portal of the policy in question. In that eventuality, as per instructions issued by Insurance Regulatory & Development Authority of India (IRDAI), it was duty of the OPs to put the thorough medical examination of deceased life assured. We rely upon the case law titled as National Insurance Company Ltd. Versus Harbirinder Singh appeal no.220 of 2016 decided on 30.09.2016. State Commission U.T. Chandigarh has nothing abovesaid fact and failure on the part of the insurance company to get thorough medical examination of the insured before issuance of mediclaim insurance policy, dismissed appeal filed by the insurance company by observing as under:-

        “To deny claim raised by the complainant, reliance has been placed upon self declaration form R-2 (page 74 of the original paper book). The said declaration form has been signed by Saranbir Kaur on 5.2.2013. There is nothing on record to show that policy was issued to the complainant and his wife on the said date, by believing above document. The policy infact was issued on 13.02.2013. The appellants have failed to co-relate the said declaration form with the policy (C2) referred above. A note is appended on the said declaration form that it needs to be filled up if the age of the member is above 45 years. The complainant and his wife both are older than the said age. There is nothing on record to show that before insurance policy was issued to them, the appellants got them medically examined, which as per instructions issued by Insurance Regularly & Development Authority of India (IRDAI) is must in such like cases. 

20.           Similar view was taken by Hon’ble Chandigarh State Commission in case of M/s Max Bupa Health Insurance Co.Ltd. Vs. Rakesh Walia, appeal no.191 of 2016 decided on 18.08.2016  wherein it was also stated that if contrary to the instructions issued by IRDAI, an insured above the age of 45 years, was not put to through medical examination, claim raised after issuance of insurance of policy cannot be rejected on account of non-disclosure of the fact of pre-existing disease when policy was obtained.

21.           Nowadays it has become a trend of insurance companies that they get portal the policy done by giving false assurances and while giving claim amount, they make excuses for early claim and pre-existing disease etc.

 22.            Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

                “It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”. OP has not only denied the claim but also cancelled the policy in question of the complainant without any cogent reason.        

23.           Keeping in view that the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OPs while denial of the claim and cancellation of the insurance policy of the complainant amounts to deficiency in service and unfair trade practice, which is otherwise proved genuine one.

24.           The complainant claimed Rs.3,95,137/- and in this regard he has placed on file medical bills Ex.C10 to Ex.C27-. The said bills have not been rebutted by the OPs. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

25.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP no.3 to pay Rs.3,95,137/- (Rs.three lakhs ninety five thousand one hundred thirty seven only) to the complainant alongwith interest @ 9% per annum from the date of denial of the complaint till its realization. We further direct the OP no.3 to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses.  OP no.3 is also directed to continue the policy in question on receipt of pending premium amount, if any, and complainant is also bound to pay the premium amount. This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 07.03.2023

                                                                President,

                                                      District Consumer Disputes

                                                      Redressal Commission, Karnal.

 

             (Vineet Kaushik)     (Dr. Rekha Chaudhary) 

                   Member                  Member