DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

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1.       Naresh Bhatia r/o House No.1600, Mohalla Raj Prohit Manimajra, Chandigarh.

2.       Poonam Bhatia wife of Naresh Bhatia r/o House No.1600, Mohalla Raj Prohit Manimajra, Chandigarh.

…..Complainants

                                      V E R S U S

1.       Reliance General Insurance having its policy servicing branch office at SCO No.145-146, 2^nd floor, Sector 9-C, Chandigarh, Madhya Marg, through its Manager/Authorised representative.

2.       Reliance General Insurance having its registered office at reliance centre.19, Walchand Marg, Ballard Estate, Mumbai-40000, through its Manager/authorized representative.

……Opposite Parties

3.       Sir Ganga Ram Hospital, having its hospital at Sir Ganga Ram Hospital Marg, Rajinder Nagar New Delhi, through its Director/authorized representative. (Deleted vide order dated 06.11.2012)

                                                                             ….Performa Party.

QUORUM:   P.L.AHUJA                                                  PRESIDENT

                   RAJINDER SINGH GILL                                MEMBER

                   DR.(MRS) MADANJIT KAUR SAHOTA         MEMBER

ARGUED BY : Sh.Neeraj Sharma, Counsel for complainant.

                       OPs No.1 & 2 exparte.

                       OP No.3 deleted.

PER P.L.AHUJA, PRESIDENT

1.                Sh.Naresh Bhatia & his wife Smt.Poonam Bhatia, complainants have filed this consumer complaint under Section 12 of the Consumer Protection Act, 1986, against Reliance General Insurance & Ors. - Opposite Parties (hereinafter called the OPs), alleging that complainant No.1 purchased Reliance Health-wise Policy No.282520019181 dated 20.6.2007 from OPs No.1 and 2 in the year 2007 (Annexure A-1) after making payment of Rs.4344/-. The said policy was renewed by making yearly payment of Rs.5572/- dated 20.6.2008 vide Annexure A-2, Rs.3910/- dated 20.6.2009 vide Annexure A-3 and Rs.3715/- dated 20.6.2010 vide Annexure A-4. In this way, the policy was renewed till 19.6.2011. The complainant No.1 Mr.Naresh Bhatia insured himself and his wife Mrs.Poonam Bhatia, complainant No.2 and two children. The policy was having coverage of around Rs.3,00,000/- against hospitalization expenses and other expenses for treatment of various diseases and pre-existing diseases were covered after 2^nd year’s renewal. In the month of June, 2010, the complainant No.2 Mrs.Poonam Bhatia had severe pain in abdomen and went to Sir Ganga Ram Hospital Delhi, where various tests were prescribed. After seeing the reports of ultrasound and tests, Mrs.Poonam Bhatia, complainant No.2 was admitted in the hospital on 12.7.2010 and she was got operated and diagnosed for Dysfunctional Uterine Bleeding with Unhealthy Cervix (VIA positive).  The complainants spent approximately Rs.1,00,000/- upon the treatment, medicines and diagnosis of the disease. The copy of treatment record of Sir Ganga Ram Hospital is Annexure A-6. After treatment, the complainants lodged claim with OPs No.1 and 2 for payment/reimbursement of the expenses incurred on the treatment of complainant No.2 but the OPs No.1 and 2 repudiated the claim by taking the lame excuse that the complainant No.2 was suffering from pre-existing disease, whereas the insurance policy covers the pre-existing disease also after 2^nd year renewal. The copies of repudiation letters are Annexure A-7 and A-8.  The complainants sent a legal notice dated 10.4.2011 actually sent on 20.5.2011 – Annexure A-9 and A-10 to OPs No.1    and 2 but to no effect. The complainants have made a prayer for a direction to the OPs to make payment of claim No.5262490 lodged with OPs No.1 and 2 amounting to approximately Rs.1,00,000/-, apart from making payment of compensation and litigation expenses.

2.                OPs No.1 and 2 have contested the complaint. It has been averred that the complainants have not approached this Forum with clean hands and have concealed the material facts.  It has been stated that the complainant No.1 Mr.Naresh Bhatia lodged the claim for his wife Mrs.Poonam Bhatia, complainant No.2 and sent the documents to Medi Assist, TPA (Third Party Administrator) and on perusal of the claim documents, it was found that patient was admitted at Sir Ganga Ram Hospital for the treatment of Dysfunctional Uterine Bleeding with Unhealthy Cervix on 12.7.2010 and was discharged on 13.7.2010.  As per the discharge summary and other documents, it was observed that the patient was having complaints of pain abdomen and discharge P/V for the past 10 years and this was not disclosed by the patient at the time of inception of policy, which are the signs of Pelvic Inflammatory Disease leading to Unhealthy Cervix & Dysfunctional Uterine Bleeding. It has been stated that the hospitalization was primarily for investigations only and no active treatment was provided, warranting hospitalization. It has been stated that the claim of Mrs.Poonam Bhatia was rightly repudiated under policy exclusion clause 1, Condition No.2 and Exclusion – 28 of insurance policy, vide letter dated 20.9.2010.  It has been further stated that the complainants concealed the material facts about the pre-existing disease at the time of filling up the proposal form at the time of inception of policy, copy of which is Annexure R-1.     

3.                Initially Sir Ganga Ram Hospital was also impleaded as OP No.3 but on 06.11.2012 it was ordered to be deleted from the array of the parties, in view of the statement made by the learned Counsel for the complainants.

4.                The parties led evidence in support of their contentions.

5.                On 14.2.2013 when the complaint was fixed for reply and consideration on the application for additional evidence filed by the complainants, none appeared for OPs No.1 and 2 and they were proceeded exparte.

6.                On 15.3.2013 arguments were heard and the case was reserved for orders. Later on, an application for setting aside the exparte order was filed by the learned proxy Counsel for OPs No.1 and 2, which was dismissed vide order dated 30.4.2013.

7.                After going through the evidence on record and hearing the arguments of the learned Counsel for the complainants on 15.3.2013, we find that the complaint merits acceptance.

8.                The copies of the insurance policies – Annexure A-1 to A-4 reveal that the complainants Mr.Naresh Bhatia and Mrs.Poonam Bhatia along with their children Harsh Bhatia and Manish Bhatia had purchased a Reliance Healthwise Policy from OPs No.1 and 2 for the period from 20.6.2007 to 19.6.2008. The policy was renewed from 20.6.2008 to 19.6.2009, from 20.6.2009 to 19.6.2010 and then from 20.6.2010 to 19.6.2011. The said policy was covering hospitalization expenses to the tune of Rs.3 lacs. The copy of Discharge Summary Report – Annexure A-6 issued by Sir Ganga Ram Hospital shows that Mrs.Poonam was admitted in that hospital on 12.7.2010 and discharged on 13.7.2010. She was disagnosed for Dysfunctional Uterine Bleeding with Unhealthy Cervix (VIA positive). The complainants have specifically pleaded that they spent approximately Rs.1,00,000/- upon the treatment, medicines and diagnosis of the disease.  It is the admitted case of the OPs No.1 & 2 that the complainants lodged a claim with them for payment/reimbursement of the expenses incurred on the treatment of complainant No.2. However, OPs No.1 and 2 vide letter dated 20.9.2010 – Annexure A-7 and A-8 repudiated the claim on the ground that as per the discharge summary and other submitted documents the patient was having complaints of pain abdomen and discharge P/V for the past 10 years and it was not disclosed by the patient at the time of inception of policy, which are the signs of Pelvic Inflammatory Disease leading to Unhealthy Cervix & Dusfunctional Uterine Bleeding. It was stated that the particular ailment is found to be present to the inception of policy and the same was repudiated under policy exclusion clause 1, Condition 2 & Exclusion 28 of the policy. The OPs have also produced a copy of the proposal form in order to assert that the complainants failed to mention the factum of pre-existing disease/illness at the time of inception of the first insurance policy.

9.                A perusal of the premium certificate dated 20.6.2009 at page No.14 of the file shows that exclusions for pre-existing should be read as : Benefits will not be available for any condition(s) defined in the policy until 24 months of continuous coverage have elapsed, since inception of the first policy with OPs No.1 and 2.  The third policy was also got renewed by the complainants w.e.f 20.6.2010 to 19.6.2011. The discharge summary – Annexure A-6 of Sir Ganga Ram Hospital shows that complainant No.2 was admitted in the hospital with diagnosis of Dysfunctional Uterine Bleeding with Unhealthy Cervix (VIA positive) only on 12.7.2010 i.e. during the subsistence of the 4^th policy. The disease in question was discovered only after 36 months of obtaining the first policy, therefore, we feel that it was not covered under the exclusion clause and the OPs No.1 and 2 repudiated the claim illegally.

10.              As regards the contention of the OPs No.1 and 2 that the complainants concealed the material fact of pre-existing disease at the time of filling up of the proposal form, copy of which is Annexure R-1 is concerned, a bare perusal of Annexure R-1 shows that only first page of proposal form has been produced. The remaining pages in respect of the terms and conditions and the effect of pre-existing disease are not attached with the same.   To cap it all, the complainants have filed their own affidavits Annexure A-11 and A-12, wherein, they have specifically mentioned that Mrs.Poonam Bhatia was not having any pre-existing disease/illness at the time of inception of the insurance policy nor having the knowledge regarding the same. She was never operated or hospitalized nor took any treatment of Dysfunctional Uterine Bleeding with Unhealthy Cervix (VIA positive) before or at the inception of the insurance policy. It was in the month of June, 2010 that Mrs.Poonam Bhatia, complainant No.2 complained of severe pain in abdomen and she went to Sir Ganga Ram Hospital, Delhi where the doctors asked for various tests, which were conducted and doctors after seeing the reports of the tests, admitted her in the hospital on 12.7.2010 where she was got operated and diagnosed of the abovesaid disease for the first time ever. There is no reason to disbelieve the said affidavits of the complainants. The repudiation of the claim by the OPs No.1 and 2 on the ground that the particular ailment was found to be present prior to the inception of the policy is not based on any medical opinion. OPs No.1 and 2 rejected the claim of the complainants merely on the basis of assumption and presumptions. In P.Vankat Naidu Vs. Life Insurance Corporation of India & Anr. 2011(4) CLT Supreme Court 494, it was held that it was for the OPs who had come out with the case that the deceased did not disclose correct facts relating to his illness, to produce cogent evidence to prove the allegation. In the instant case, the OPs No.1 and 2 have not produced any cogent evidence to prove the allegation of suppression of material facts relating to pre-existing disease by the complainants. The OPs No.1 and 2 made a wild guesswork that the complainants had suppressed the facts relating to pre-existing disease of Mrs.Poonam Bhatia. In this view of the matter, we feel that the action of the OPs No.1 and 2 in repudiation of the claim of the complainants is patently illegal and amounts to deficiency in service on their part.

11.              For the reasons recorded above, we find merit in the complaint and the same is allowed. OPs No.1 and 2 are directed :-

i)                 To make payment of claim No.5262490 lodged with OPs No.1 and 2 for an amount of Rs.1,00,000/- to the complainants with interest @9% p.a. from the date of lodging of the claim, till its realization.          

ii)                To make payment of an amount of Rs.10,000/- for causing harassment and mental agony to the complainants.

iii)                To make payment of Rs.5,000/- to the complainants towards costs of litigation.

12.              This order shall be complied with by OPs No.1 & 2 within one month from the date of receipt of its certified copy, failing which, OPs No.1 & 2 shall be liable to refund the above said awarded amount to the complainants along with interest @12% p.a. from the date of lodging of the claim, till its realization, besides costs of litigation, as mentioned above.

13.              The certified copies of this order be sent to the parties free of charge. The file be consigned.