Punjab

Ludhiana

CC/22/1

Bhushan Kumar - Complainant(s)

Versus

Reliance General Insurance Co.Ltd - Opp.Party(s)

A.N.Juneja Adv.

13 Sep 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                             Consumer Complaint No:  01 dated 04.01.2022.                               Date of decision: 13.09.2024. 

 

Bhushan Kumar aged 46 years son of Shri Sohan Lal, resident of House No.2288, Sector 32-A, Chandigarh Road, Ludhiana.9646800471.                                                                                                 ..…Complainant

                                                Versus

1. Reliance General Insurance Company Limited, Regd. Office: H Block, 1^st Floor, Dhirubhai Ambani Knowledge City, Navi Mumbai-400710, through its Director/M.D.
2. Reliance General Insurance Company Limited, 7^th Floor, Surya Tower, 108, The Mall, Ludhiana, through its Manager.
3. Bank of India, Chandigarh Road, Ludhiana, through its Manager.                                                                                  …..Opposite parties 

Complaint Under Section 35 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. A.N. Juneja, Advocate.

For OP1 and OP2          :         Sh. G.S. Kalyan, Advocate.

For OP3                         :         Ms. Arpita, Advocate. (Defense of OP3 already                                           struck of vide order dated 01.08.2022)

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that previously the complainant was availing medical policy from State Health & Allied Insurance Company. On 14.09.2015, the complainant approached OP3 Bank of India with request to port the policy from Star Health & Allied Insurance Company Ltd. to their group insurance policy by issuing policy with all previous benefits and vide said letter disclosed about his previous ailment of bye-pass surgery. The letter was received by Manager of OP3 bank, who issued BOI National Swasthya Bima Policy No.401604/48/15/8500000148 of National Insurance Company Ltd. having validity from 15.09.2015 to 14.09.2016 as at that time OP3 was having contract/tie up with National Insurance Company Ltd. and as such, the complainant became a member of group insurance policy of OP3. The complainant further stated that on 18.07.2017, he again made written request to OP3 to provide all the previous benefits of his mediclaim policy. As OP3 was having contract/collaboration with National Insurance Company Limited and subsequently in the year 2019, OP3 entered into fresh contract/tie up with OP1 and OP2 and even got issued fresh insurance policy to the complainant from OP1 and OP2. According to the complainant, OP3 ported his policy to OP1 and OP2 automatically as per their fresh collaboration/contract/tie up.

                   The complainant further stated that during the subsistence of policy, he suffered heart problem/heart attack and he remained admitted in D.M.C. & Hospital, Ludhiana from 09.09.2021 to 13.09.2021 where his Angioplasty was done for which he incurred Rs.2,50,000/- on his hospitalization, medicines, investigation/tests. The complainant lodged cashless claim with OPs for a sum of Rs.1,78,000/- but his claim was rejected/repudiated by the Ops vide letter dated 11.09.2021 by stating that “The patient admitted in hospital for management of CAD TVD Angina II as per received claim documents, patient is suffering with CAD from 2015 and the same was not disclosed in the proposal copy during policy inception with Reliance General Insurance dated 17.09.2019, hence the claim is repudiated.” The complainant further stated that he had already disclosed OP3 vide letter dated 14.09.2015 regarding the above said ailment and as such, the repudiation of his claim is illegal and it amounts to deficiency in service and unfair trade practice due to which the complainant has suffered mental pain, agony, harassment etc. In the end, the complainant has prayed for issuing directions to the OPs to make payment of claim amount of Rs.2,50,000/- along with compensation of Rs.2,00,000/- and litigation expenses of Rs.21,000/-.

2.                Upon notice, OP1 and OP2 appeared and filed joint written statement and assailed the complaint by taking preliminary objections as well as submission on the grounds of maintainability; the complainant has not approached with clean hands; concealment of material facts; lack of cause of action etc. OP1 and OP2 stated that the complainant approached them for health cover and they explained entire terms and conditions to him which he after reading and understanding, purchased RGI_BOI Swasthya Bima Policy by submitting a proposal form, seeking insurance coverage on floater basis for himself, spouse and daughter for a sum insurance of Rs.3,00,000/- having validity from 17.09.2019 to 16.09.2019, which was further renewed from 17.09.2020 to 16.09.2021. According to OP1 and OP2, the complainant was completely aware regarding terms and conditions of the policy and he himself gave declaration regarding this fact. OP1 and OP2 further stated that they received claim for reimbursement of medical expenses incurred during hospitalization of the complainant in Dayanand Medical College and Hospital, Ludhiana from 09.09.2021 to 13.09.2021 for treatment of CAD POST CABG ANINA OF EXERTION. On careful perusal of the claim documents, it was observed that patient is suffering from CAD from 2015, evident from discharge summary dated 13.09.2021, previous discharge summary of Dayanand Medical College and Hospital and the questionnaire dated 10.09.2021 in which the complainant himself has specified about his past history of CAD suffering since April 2015 which the complainant neither disclosed about this at the time of inception of policy with previous insurer i.e. National Insurance Company. OP1 and OP2 further stated that the complainant was insured with them from 17.09.2019 and earlier he was insured with National Insurance company since 15.09.2015 as such, he has willfully suppressed the information regarding pre-existing disease  before obtaining the insurance policy with them due to which his claim was repudiated vide letter dated 06.10.2021.

                   On merits, OP1 and OP2 reiterated the crux of averments made in the preliminary objections and submission. OP1 and OP2 have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

3.                OP3 appeared but did not file written statement along with affidavit and documents despite grant of sufficient opportunities and as such, defence of OP3 was struck of vide order dated 01.08.2022.

4.                In evidence, the complainant tendered his affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents i.e. Ex. C1 is the copy of insurance policy from Star Health and Allied Insurance Co. Ltd. w.e.f. 15.09.2010 to 14.09.2011, Ex. C2 is the copy of policy schedule w.e.f. 15.09.2011 to 14.09.2012 of Star Health and Allied Insurance Co. Ltd., Ex. C3 is the copy of policy schedule w.e.f. 15.09.2012 to 14.09.2013 of Star Health and Allied Insurance Co. Ltd., Ex. C4 is the copy of policy schedule w.e.f. 15.09.2013 to 14.09.2014 of Star Health and Allied Insurance Co. Ltd., Ex. C5 is the copy of policy schedule w.e.f. 18.09.2014 to 17.09.2015 of Star Health and Allied Insurance Co. Ltd., Ex. C6 is the copy of insurance policy w.e.f. 15.09.2015 to 14.09.2016 issued by National Insurance Co. Ltd., Ex. C7 is the copy of insurance policy w.e.f. 15.09.2016 to 14.09.2017 issued by National Insurance Co. Ltd., Ex. C8 is the copy of policy schedule w.e.f. 15.09.2017 to 14.09.2018 of National Insurance Co. Ltd., Ex. C9 is the copy of policy schedule w.e.f. 17.09.2018, to 16.09.2019 of National Insurance Co. Ltd., Ex. C10 is the copy of certificate of insurance w.e.f. 17.09.2019 to 16.09.2020 issued by OP1 and OP2, Ex. C11 is the copy of certificate of insurance w.e.f. 17.09.2020 to 16.09.2021, Ex. C12 is the copy of letter dated 18.07.2017 of the complainant written to OP3, Ex. C13 is the copy of letter dated 14.09.2015 written to OP3, Ex. C14 is the copy of In-Patient Final Bill dated 13.09.2021, Ex. C15 to Ex. C26 are the copies bills/invoices, Ex. C27 is the copy of treatment prescription, Ex. C28 is the copy of discharge summary dated 21.04.2015 of DMC Hospital, Ex. C29 is the copy of discharge summary dated 13.09.2021 of DMC Hospital, Ex. C30 is the copy of cashless denial letter dated 11.09.2021 and closed the evidence.

5.                On the other hand, the counsel for OP1 and OP2 tendered affidavit  Ex. RA of Sh. Suryadeep Singh Thakur, Manager of OP1 and OP2 along with documents i.e. Ex. R1 is the copy of Application Form for RGI_BOI Swasthya Bima, Ex. R2 is the copy of certificate of insurance w.e.f. 17.09.2020 to 16.09.2021, Ex. R3 is the copy of Health Claim Form, Ex. R4 is the copy of discharge summary dated 21.04.2015, Ex. R5 is the copy of discharge summary dated 13.09.2021 and closed the evidence.                    

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written statement along with affidavit and documents produced on record by both the parties.                 

7.                The complainant, a holder of successive insurance policies was admitted in Dayanand Medical College and Hospital, Ludhiana on 09.09.2021 and was discharged on 13.09.2021. He was diagnosed of CAD POST CABG-ANGINA ON EXERTION disease and Coronary Angiography was done. The complainant incurred Rs.2,50,000/- on his hospitalization, medicines and investigations etc. but his cashless claim was declined by OP1 and OP2 vide letter dated 11.09.2021 Ex. C30 by invoking Swasthya Bima Yojna wording Duty of Disclosure under clause 5.1.2 The crux of the repudiation letter was that the complainant was suffering from CAD from 2015 which was not disclosed in proposal form at the time of  inception of the policy with OP1 and OP2 Reliance General Insurance Company Limited. OP1 and OP2 have also relied upon discharge summary Ex. R4 issued by Dayanand Medical College and Hospital wherein the complainant remained  admitted from 11.04.2015 to 21.04.2015.

8.                Now the point of determination arises whether OP1 and OP2 were justified in repudiating the claim of the complainant?

9.                The complainant started subscribing to the insurance policy in the year 2010 and the following are the details of the policies which the complainant held till 16.09.2021:-

Sr. No.	Name of the Policy	Name of Insurance Co.	Sum assured	Validity
1.	Family Health Optima Insurance Plan (Ex. C1)	Star Health and Allied Insurance Co. Ltd.	Rs.2,00,000/-	15.09.2010 to 14.09.2011
2.	Family Health Optima Insurance Plan (Ex. C2)	Star Health and Allied Insurance Co. Ltd.	Rs.2,00,000/-	15.09.2011 to 14.09.2012
3.	Family Health Optima Insurance Plan (Ex. C3)	Star Health and Allied Insurance Co. Ltd.	Rs.3,00,000/-	15.09.2012 to 14.09.2013
4.	Family Health Optima Insurance Plan (Ex. C4)	Star Health and Allied Insurance Co. Ltd.	Rs.3,00,000/-	15.09.2013 to 14.09.2014
5.	Family Health Optima Insurance Plan (Ex. C5)	Star Health and Allied Insurance Co. Ltd.	Rs.3,00,000/-	15.09.2014 to 14.09.2015
6.	BOI National Swasthya Bima Policy (Ex. C6)	National Insurance Co. Ltd.	Rs.3,00,000/-	15.09.2015 to 14.09.2016
7.	BOI National Swasthya Bima Policy (Ex. C7)	National Insurance Co. Ltd.	Rs.3,00,000/-	15.09.2016 to 14.09.2017
8.	BOI National Swasthya Bima Policy (Ex. C8)	National Insurance Co. Ltd.	Rs.3,00,000/-	15.09.2017 to 14.09.2018
9.	BOI National Swasthya Bima Policy (Ex. C9)	National Insurance Co. Ltd.	Rs.3,00,000/-	15.09.2018 to 14.09.2019
10.	Master Policy (Ex. C10)	Reliance General Insurance Co. Ltd.	Rs.3,00,000/-	17.09.2019 to 16.09.2020
11.	Master Policy (Ex. C11)	Reliance General Insurance Co. Ltd.	Rs.3,00,000/-	17.09.2020 to 16.09.2021

 

The aforesaid tabular form clearly depicts and proves that the first policy incepted in the year 2009 and there is no break in between successive policies. Although OP1 and OP2 have invoked nondisclosure clause 5.1.2 as contained in the policy Ex. R2 but very conveniently overlooked the provisions  of waiting period and continuity benefits as contained in the certificate of insurance Ex. R2.

Waiting Period

30 day and 1st year waiting period for treatment of specified illness (refer Policy Wordings) and 2 year waiting period for named ailments (Refer Policy Wordings)

Continuity Benefits

Continuity benefits allowed as per the duration of policy one is holding in earlier/existing scheme operated by Bank of India and on renewal wishes to renew the policy with us, then he/she shall be given the benefit of continuity on the expiring Policy’s Sum Insured. Example 1: If a policyholder of earlier/existing scheme operated by Bank of India joint us after a continuous coverage in that policy for three years with same Sum Insured as the policy’s expiring Sum Insured., then in our policy PED will be covered from DAY ONE. It is to be noted that, barring above mentioned deviations, policy holder will be governed by all the terms and conditions of our policy once he/she opts for our policy. Example 2: If a policy holder of earlier/existing scheme operated by Bank of India joins us after a continuous coverage in that policy for three years with higher Sum Insured as compared to the expiring policy’s Sum Insured, subjected to all the terms and conditions of the RGI policy then in our policy PED will be covered from DAY ONE for the expiring Sum Insured and there will be a 36 MONTHS of waiting period on the extra sum insured (i.e. Sum Insured Opted with RGI minus Sum Insured of expiring policy)

 

10.              A conjoint reading of aforesaid provisions makes it crystal clear that the continuity benefits were to be allowed as per duration of the policy and same were to be extended on the renewal of the policy. In the present case, OP1 and OP2 counted the years for waiting period from the inception of their own policy i.e. 17.09.2019 omitted to take into consideration the continuity of the earlier policies since the year 2010.  As such, repudiation of claim is arbitrary and unjustified. Therefore, in the given facts and circumstances, it would be just and appropriate if OP1 and OP2 are directed to disburse the medical expenses of Rs.1,65,252/- (claimed vide claim form Ex. R3) to the complainant incurred by the complainant on his hospitalization with DMC and Hospital from 09.09.2021 to 13.09.2021 along with interest @8% per annum from the date of denial i.e. 11.09.2021 as well as to pay a composite costs of Rs.10,000/-. The complaint against OP3 is hereby dismissed.

11.              As a result of above discussion, the complaint is partly allowed with direction to OP1 and OP2 to disburse the medical expenses of Rs.1,65,252/- (claimed vide claim form Ex. R3) to the complainant incurred by the complainant on his hospitalization with DMC and Hospital from 09.09.2021 to 13.09.2021 along with interest @8% per annum from the date of denial i.e. 11.09.2021 within 30 days from the date of receipt of copy of order. OP1 and OP2 shall further pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Compliance of the order be made within 30 days from the date of receipt of copy of order. However, the complaint as against OP3 is hereby dismissed. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

12.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:13.09.2024.

Gobind Ram.