Haryana

Fatehabad

CC/338/2020

Suresh Kumar Munjal - Complainant(s)

Versus

Reliance Health Insurance Company Ltd. - Opp.Party(s)

Amit wadhera

03 May 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION FATEHABAD.

                                         Sh.Rajbir Singh, President.                                                     

Dr.K.S.Nirania and Smt.Harisha Mehta, Members

 

                                                                    C.C.No.338 of 2020.                                                                                           

Date of Instt.: 11.12.2020.                                                                                   Date of Decision:03.05.2024

Suresh Kumar Munjal son of late Sh.Mohan Lal resident of 44-A, Model Town, Fatehabad  District Fatehabad.

                                                                             ..Complainant

                              Versus

1.Religare Health Insurance Company Limited Service Branch, Vipul Tech Square Tower-C, Third Floor, Sector 4-,Golf Course Road, Gurugram - 122009 through its Managing Director.

                                                                             ..Opposite Party.

Complaint U/S 12 of the Consumer Protection Act, 1986             

Present:                 Sh.Amit Wadhera, Advocate for complainant.                                                       Sh.Sudhir Kumar Advocate for Op.                                                                                                                                                  

ORDER

SH.RAJBIR SINGH, PRESIDENT

1.                                 Brief facts of the present complaint are that the complainant had obtained medi-claim policy No.12077639 from OP having validity from 03.02.2018 to 02.02.2021 by making the premium to the tune of Rs.1,01,142/-  on 01.02.2018; that the complainant had also paid extra premium to the tune of Rs.14,285/- of No Claim Super facility  as under the said No Claim Bonus super category 50 % of sum assured for each claim free year, maximum upto 100 % of sum insured reduced by 50 % of sum insured in case of claim was applicable; that at the time of obtaining the policy in question, the complainant was not having previous history of any kind of ailment; that in the month of April, 2020, the complainant suffered with problem of loss of weight appetite and weakness, therefore, some tests were done on 27.04.2020 and on finding some evidence of malignancy in the body biopsy was done on 01.06.2020; that despite regularly taking medicines and treatment since April, 2020  complainant did get any relief , therefore, in the month of September, 2020 the complainant was taken to Medanta Hospital Gurgaon where tests FDG, PTT and CECT on the person of complainant were conducted besides biopsy test; that the complainant had spent Rs.29,300/- and Rs.25,000/- on the tests; that after conformation of malignancy complainant was again admitted in the same hospital on 24.09.2020 and thereafter Thoracic Surgery was conducted upon the complainant and he was discharged on 02.10.2020 in stable condition; that the complainant also intimated about all the treatment to give cashless benefits for the hospitalization, treatment and operation but no response was given to him; that the complainant had paid Rs.6,78,153/- from his own pocket despite the fact that it was the duty of the insurance company to clear and pay the same but the Op did not discharge the legal duty for which the premium with extra benefit of on account of No claim Bonus was obtained by it; that the complainant requested the Op several times to reimburse the amount but it repudiated the claim on 27.10.2020 on the ground of non disclosure of depression; that the complainant again shocked and surprised with the letter dated 29.10.2020 for cancellation of policy No.12077639. The act and conduct of the Ops clearly amounts to deficiency in service on their part.

2.                          Averments of the complaint have been strongly opposed in the written statement filed on behalf of Op wherein preliminary objections such as maintainability, cause of action, estoppal, concealment of material facts from this Commission and Jurisdiction etc. have been taken. It has been further submitted that cashless request was received from the hospital qua admitting of complainant in Medanta Hospital on 23.09.2020 for complaints of weight loss and being provisionally diagnosed with Mesothelioma and underwent Thoracic Surgery; that upon perusal it reveals that the patient was having history of depression since 2014 i.e. prior to inception of policy, therefore, the claim was repudiated vide letter dated 23.09.2020 on the ground that Cashless rejected under non disclosure of material facts/pre existing disease at the time of proposal (depression since 2014);  that since there was material concealment qua the health status of the complainant, therefore, the claim was rejected on 27.10.2020 as per the clause 7.1 of the terms and conditions of the policy. Relevant term and condition 7.1 of the policy is as under:

                   Clause 7.1 Disclosure of information Norm

If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particulars or any material information having been withheld, or if a claim is fraudulently made or any fraudulent means or devices are used by the policy holder or the insured person or any one acting on his/their behalf, the company shall have no liability to make payment of any claims and the premium paid shall be forfeited ab-initio to the company.

 

That due to material concealment, the policy of the insured was also terminated/cancelled  as per the clause 7.13 of the terms and condition of the policy.  The insurance company has rightly rejected the claim of the complainant, therefore, there is no deficiency in service and unfair trade practice on the part of the OP. Other contentions have been controverted and prayer for dismissal of the complaint has been made.

3.                          In evidence, learned counsel for the complainant has tendered affidavit of complainant as Annexure C22 with documents whereas learned counsel for the Op has tendered affidavit Ex.RW1/A with documents Annexure R1 to Annexure R10.

4.                          We have heard oral final arguments from both sides. We have also perused the case file minutely.

5.                          Fact qua purchasing of policy, having validity from 03.02.2018 to 02.02.2021, by the complainant from the Op is not disputed and even it is also not disputed that the complainant felt ill during the subsistence of the policy. Submission of claim form for cashless policy during the hospitalized period with the Op by the complainant is also not disputed.

6.                          Learned counsel for the complainant has argued that since the complainant had paid the premium (Rs.1,01,142/-  on 01.02.2018) for the policy (Annexure R1) in question besides making extra premium to the sum of Rs.14,285/- for the benefit of No Claim Super facility, therefore, the sum assured would be automatically increased upto 50 % therefore, the total sum insured in the present matter in question is Rs.7,50,000/- and the complainant had spent Rs.6,78,153/- on his treatment and the Op being insurer of the complainant is liable to reimburse the amount as the complainant felt ill and took treatment during the subsistence of the policy in question but the Op firstly denied the cashless facility and in the end not only rejected the claim  on 23.09.2020 (Annexure R5) on 27.10.2020 (Annexure R7) and also cancelled the policy in question vide letter Annexure R9.

7.                          Now, poser before this Commission is whether the complainant had concealed his state of health from the Op qua having hypertension disease since 2014 would become a ground to repudiate the claim under policy or not? Answer to this poser is in negative. The discharge summary Annexure R6 reveals that the patient was admitted and underwent ultrasound guided biopsy on 12.09.2020 18G bioposy taken from left pleural based lesion, four courses acquiring and sent for examination.  In this very document it is also mentioned that the patient was admitted with complaints of pleural based lesion on left side and surgery (ultrasound guided biopsy) was done on 12.09.2020.  Perusal of reply filed by the Op and the documents produced on behalf of the Op make one thing clear that the only ground for repudiation of the claim of complainant which is mentioned at page No.3 of the reply is to the effect that As per OPD sheet dated 21.09.2020 of Medanta Hospital, the insured is stated to have H/O Depression since 2014. It is pertinent to mention here that even if the patient was taking medicine for depression/hypertension for some time, it does not amount to suppression of material fact because it is well known that hypertension/depression is usually a life style disease and can be easily controlled with normal medication. There is no evidence that it was so acute or high that it was responsible for any other past or present illness. On this point learned counsel for the complainant has rightly relied upon the case law titled as Vidya Vs. Life Insurance Corporation of India and another 2004 (3) RCR (Civil) 793 wherein Punjab & Haryana High Court has held that Mental depression or anxiety cannot by itself be termed as a disease material to be disclosed and deliberate suppression of any material fact.   Moreover, on this point reliance can also be taken from case law titled as Oriental Insurance Company Limited Vs. Jyotsna Bali –III (2020)  CPJ 60 (UT Chd.)  wherein it has been held that Exclusion clause-Concealment of hypertension problem alleged-Deficiency in service-Hypertension was neither pre-existing disease which could attract exclusion clause nor it was root cause of complications patient had faced- Rightly granted compensation along with interest @ 9 % per annum and to pay amount as compensation for causing mental agony and harassment. Undisputedly, the complainant was treated by a doctor who is full of professional skills and did have a long standing experience and he must have concluded with reasonable competence regarding the ailment of the complainant on the certificate as well as the discharge summary. Repudiating the genuine claim of the complainant seems a conscious wrong/dis-service on the part of the OP which certainly resulted in exploitation of the complainant in the form of paying huge premium and medical expenses for the treatment taken.  Hence, the act of the OP for repudiating the genuine claim of the complainant proves deficiency in service on its part.

8.                          Undisputedly, the complainant had purchased policy in question for a sum assured of Rs.5 lacs but besides the premium for this he had also paid Rs.14,285/- for the benefit of No Claim Super facility. During the course of arguments learned counsel for the complainant placed on file booklet of terms and conditions of the policy in question and drew the attention of this Commission towards condition No.2.10 of the terms and condition of the policy, which is hereby reproduced as under:

                    Benefit 10: No Claim Bonus

At the end of each policy year, the company will enhance the sum insured by 10 % flat on a cumulative basis, as a No Claim Bonus for each completed and continuous policy year provided that no claim has been paid by the company in expiring policy year and subject to the conditions specified below:

1. In any policy year, the accrued No Claim Bonus, shall not exceed 50 % of the sum insured available in the renewed policy.          

The fact qua receiving of extra premium for the said facility under No Claim Bonus is not denied by the Op and in Annexure R1 i.e. policy it is clearly mentioned that the No Claim Bonus-Super is applicable being an optional cover. Therefore, we have hitch to reach at the conclusion that the complainant is entitled for the benefit for which he had paid the extra premium, therefore, the IDV would be automatically increased from Rs.5 lac to Rs.7.50 lac. Though the complainant has prayed for allowing the claim for Rs.678153/-  but perusal of the case file reveals that he has placed on case file bill amounting to Rs.629790/-, therefore, the end of justice would met if we allow the present complaint keeping in view the amount as mentioned in the bill.

9.                           Keeping in view the above facts and circumstances of the case, this Commission is of the considered view that the present complaint deserves acceptance because the Op has indulged in the unfair trade practice as well as dis-service to the complainant, as discussed above. Accordingly, we allow the present and declare that the Op has wrongly and illegally rejected the claim of the complainant. The OP is directed to the Op to pay Rs.6,29,790/- (Rs.Six Lac Twenty Nine Thousand Seven Hundred Ninety Only) alongwith interest @ 7 % per annum from the date of filing of the complaint till its realisation. We further allow Rs.11,000/-, (Rs.Eleven Thousand) in lump sum, towards mental harassment and agony suffered by the complainant and also towards litigation expenses. The compliance of the order be made by the Ops within 45 days from today, failing which the above mentioned relief amount would carry interest @ 12 % per annum from date of filing of the present complaint till actual realization.

10.                        In default of compliance of this order, proceedings against respondents shall be initiated under Section 72 of Consumer Protection Act, 2019 as non-compliance of court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extenzd to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both. A copy of this order be sent to the parties free of cost. This order be also uploaded forthwith on website of this Commission, as per rules, for perusal of parties herein. File be consigned to the record room after due compliance.     

Announced in open Commission.                                                                Dated: 03.05.2024

 

                                                                                                        

          (K.S.Nirania)                    (Harisha Mehta)                             (Rajbir Singh)                                 

                   Member                               Member                                                  President