BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No.846 of 2013

Date of Institution: 20-12-2013

Date of Decision: 24-06-2015  

Shri Harjeet Singh Dhillon son of Shri Didar Singh Dhillon, aged about 66 yeas, resident of Kothi No.41-A, Basant Avenue, Amritsar.

Complainant

Versus

1. Religare Health Insurance Company Limited, Taneja Towers, SCO-28, Ranjit Avenue, District Shopping Complex, Amritsar-143001.
2. AEGON Religare Life Insurance Company Limited, through its Managing Director/ Chief Executive, 2^nd Floor, Paranjpe ‘B’ Scheme, Subhash Road, Near Garware House, Vileparle (East), Mumbai-400057.
3. Director Consumer Services, AEGON Religare Life Insurance Company Limited, 2^nd Floor, Paranjpe ‘B’ Scheme, Subhash Road, Near Garware House, Vileparle (East), Mumbai-400057.

Opposite Parties

Complaint under section 12 & 13 of the Consumer Protection Act, 1986.

Present: For the Complainant: Sh. Vijayant Khanna, Advocate

              For the Opposite Parties: Sh. Sunil Nayyar, Advocate

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member  

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Sh.Harjeet Singh under the provisions of the Consumer Protection Act alleging therein that he had opted for a health insurance policy of the Opposite Parties in the product name of AEGON Religare Health Plan (UIN-138N021V01) bearing policy No. 6110030047819 commenced from 31.3.2011 to 31.3.2014. Complainant alleges  that said policy was issued by Opposite Party No.1 after due medical check-up of the complainant, duly conducted by the authorized medical examiner of the Opposite Parties  before proceeding in the matter. Said policy was for a sum insured upto Rs.4,90,000/- which includes various benefits as mentioned in the policy. Said policy was enhanced upto 10% as there was no claim reported by the complainant and it was extended upto Rs.11 lacs as per the details of revised  benefits given to the complainant vide letter ref.No.6110030047819-Silver. On 17.6.2013 the complainant had felt some pain in his chest and he got his check up from Fortis Hospital, Amritsar where he had spent a sum of Rs.10,750/- for conducting his angiography and he was further  referred for bye-pass surgery of his heart and sum of Rs.1,000/- for preparing CD of ailment was also given by the complainant to Fortis Hospital, Amritsar at that time totaling into Rs.11,850/-. As per the instructions of doctors of Fortis Hospital, Amritsar, the complainant got admitted himself in Fortis Hospital at Mohali on 24.6.2013 and got operated on 25.6.2013 and after recovery, he was discharged from the said hospital on 2.7.2013 and in the said operation, the complainant spent a sum of Rs.2,22,723/- for  bye-pass surgery of his heart in the said hospital. The aforesaid policy was cashless policy and the Fortis Hospital is a listed/ empanelled hospital as per said insurance policy, but the Fortis Hospital refused to give cashless benefit on the account of said cashless policy to the complainant at the time of his discharging from the said hospital and accordingly the complainant paid a sum of Rs.2,22,523/- to the Fortis Hospital before he got discharged from the said hospital. Subsequently, the complainant submitted his health claim  before Opposite Parties on 10.7.2013 alognwith all the formalities within the stipulated time period and on 16.7.2013 the complainant received a letter from the Opposite Parties in respect of  certain demands of documents, which were duly supplied by the complainant to the Opposite Parties  within the stipulated time and thereafter, the complainant wrote various letters to the Opposite Parties  particularly on 14.8.2013 and 16.9.2013 for realization of his genuine claim amount, but the Opposite Parties  did not pay any heed to the request of the complainant. Thereafter, the complainant also served legal notice upon the Opposite Parties  through his counsel on 15.10.2013 and also issued a reminder of notice dated 12.11.2013 upon the Opposite Parties  calling them to remit the genuine claim of the complainant, but to no avail.   Alleging the same to be deficiency in service, complaint was filed seeking directions to the Opposite Parties to realize the genuine claim amounting to Rs.2,22,523/- and Rs.10,750/- alongwith Rs.1,000/-, in all Rs.2,34,273/- alongwith interest @ 18% per annum from the date of claim till the actual realization of the payment, in favour of the complainant.  Compensation and litigation expenses were also demanded.
2. On notice, Opposite Parties  appeared and filed written version in which it was submitted that the complainant himself has not supplied the material documents demanded by the Opposite Parties  vide their letter dated 10.6.2013 for satisfying  his claim. On receipt of the application and required documents a policy bearing No.611030047819 was issued  to the insured and the policy was duly delivered to the insured on the address provided by him in the proposal form. The complainant applied for cashless facility for his admission and treatment in the said hospital and has submitted the preauthorization claim form duly filled by the said hospital.  The treating doctor of the said hospital advised CABG for the treatment of Coronary Artery Disease (Triple Vessel Disease), therefore in view of the pre-existing nature of disease and non disclosure in the health plan, the said cashless facility was denied by TPA- Paramount Health Services (TPA) Private Limited vide letter dated 26.6.2013. Moreover, in response to the claim dated 15.7.2013, TPA vide letter dated 16.7.2013 requested the complainant to provide the documents to process the claim of the complainant, but despite receipt of the letter dated 16.7.2013 and without providing the documents as sought  in the said letter, the complainant again filed a claim with the Opposite Parties  and provided some documents which are available with him. It is denied that the policy in question was issued after the medical check up of the complainant before the empanelled doctor. It is submitted that the life assured appeared before the empanelled doctor of the Opposite Parties, who put  a questionnaire to the life assured as per medical examination report (MER) and the life assured stated that he has neither suffered  from any disease nor is suffering from any disease and further stated that he has never been treated for symptoms of high blood pressure, diabetes, heart attack or heart disease, stroke, chest pain etc. disorder of bone, spine or muscle and he signed the same.  Had the life assured given the above stated information correctly at the time of taking the said insurance policy, the Opposite Parties  would not have issued the said policy to him. It is submitted that the medical examination report was also falsely filed up by the deceased life assured,  and even as such, the medical examination  report is not a lie detecting test and cannot be read against the insurer since the MER and proposal forms are both accepted under the principles of Uberrima Fide.   While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence his affidavit Ex.CW1/A alongwith documents Ex.C1 to Ex.C25 and closed the evidence on behalf of the complainant.
4. Opposite Parties tendered into evidence affidavit of Sh.Kamlesh Jagetia, Vice President Ex.OP1 alongwith documents Ex.OP2 to Ex.OP9 and closed the evidence on behalf of the Opposite Party.
5. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant got the health insurance policy namely  AEGON Religare Health Plan (UIN-138N021V01) bearing policy No. 6110030047819 commenced from 31.3.2011 upto 31.3.2014 from Opposite Party No.1. Complainant alleges  that Opposite Party No.1 issued the said policy to the complainant after due medical check-up of the complainant, duly conducted by the authorized medical examiner of the Opposite Parties  before issuing the policy in question as is evident from the schedule of policy Ex.C1 for a sum assured upto Rs.4,90,000/- which was enhanced upto 10% as there was no claim reported by the complainant.  On 17.6.2013, the complainant felt some pain in his chest and he got his check up from Fortis Hospital, Amritsar and spent a sum of Rs.10,750/- for conducting his angiography. The complainant was further  referred for bye-pass surgery of his heart and he spent  Rs.1,000/- for preparing CD of ailment. Thereafter, as per the instructions of doctors of Fortis Hospital, Amritsar, the complainant was admitted  in Fortis Hospital at Mohali on 24.6.2013 and was operated on 25.6.2013 and was discharged from the said hospital on 2.7.2013. The complainant spent a sum of Rs.2,22,723/- for  bye-pass surgery of his heart in the aforesaid hospital. The policy was cashless policy and  the Opposite Parties were duly intimated in this regard, but the Opposite Parties refused the cashless benefit and the complainant had to pay the aforesaid amount of Rs.2,22,723/- to Fortis Hospital authorities. Thereafter, the complainant lodged claim vide claim form Ex.C2 with the Opposite Parties  on 10.7.2013 alongwith all the relevant documents. The complainant received letter dated 16.7.2013 Ex.C2 whereby the Opposite Parties  required certain documents from the complainant which were supplied by the complainant to the Opposite Parties. Thereafter, the complainant wrote letter dated 14.8.2013 Ex.C5 and letter dated 16.9.2013 Ex.C6 to settle the claim of the complainant, but the Opposite Parties  did not pay any heed to the request of the complainant. Thereafter, the complainant served legal notice to Opposite Parties  dated 15.10.2013 Ex.C14 through registered post, postal receipts of which are Ex.C15 to Ex.C17, but in vain. Then the complainant served another legal notice in the form of reminder dated 12.11.2013 upon the Opposite Parties Ex.C18, postal receipts of which are Ex.C19 to Ex.C23. But inspite of all these facts, Opposite Parties  did not settle the claim of the complainant.   Ld.counsel for the   complainant  submitted that all this amounts to deficiency of service on the part of the Opposite Parties and the complainant was forced to file the present complaint on 20.12.2013.   
7. Whereas the case of the Opposite Parties  is that the complainant has concealed the material facts in the proposal form which were well within the knowledge of the complainant and he obtained the insurance policy by misrepresentation and fraud. The complainant became ill on 17.6.2013 and was admitted in hospital on 24.6.2013 with complaint of chest pain and was discharged on 2.7.2013 and the past history of the complainant shows that patient is known case of hypertension as per discharge summary of the complainant Ex.OP5. Since the complainant was advised   CABG for the treatment of Coronary Artery Disease (Triple Vessel Disease), therefore in view of the pre-existing nature of disease and non disclosure in the health plan, the said cashless facility was denied by TPA- Paramount Health Services (TPA) Private Limited vide letter dated 26.6.2013 Ex.OP7. Thereafter, the complainant lodged the claim with Opposite Parties  vide claim form dated 19.7.2013 Ex.C2 and the complainant was required to furnish certain documents/ information vide letter dated 16.7.2013 Ex.C2 and letter dated 3.8.2013 Ex.C3, but the complainant did not provide the documents. As such, the Opposite Parties  could not settle the claim of the complainant.   Since the complainant was advised   CABG for the treatment of Coronary Artery Disease (Triple Vessel Disease), therefore in view of the pre-existing nature of disease and non disclosure in the health plan, the said cashless facility was denied by TPA- Paramount Health Services (TPA) Private Limited vide letter dated 26.6.2013 Ex.OP7. Ld.counsel for the Opposite Parties  submitted that there is no deficiency of service on the part of the Opposite Parties.
8. From the entire above discussion particularly from the perusal of the documents produced by both the parties, it is clear that the complainant obtained  health insurance policy namely  AEGON Religare Health Plan (UIN-138N021V01) bearing policy No. 6110030047819, schedule of which is Ex.C1. The commencement date of the policy was 31.3.2011 and upto 31.3.2014. The complainant became ill and he approached Fortis Hospital, Amritsar where his angiography was done on 17.6.2013 and the CD of ailment was  prepared and the complainant was referred  for  bye-pass surgery of his heart. The complainant spent Rs.11850/- on the aforesaid tests. Then the complainant was admitted in Fortis Hospital, Mohali on 24.6.2013 where  he  was operated on 25.6.2013 and was discharged from the said hospital on 2.7.2013 as is evident from the discharge summary Ex.OP5. The complainant paid Rs.2,22,723/- for  bye-pass surgery of his heart to the aforesaid hospital authorities as per bill Ex.C5, details of which are Ex.C7 to Ex.C14. No doubt, the policy in question was cashless, but the Opposite Parties  declined the cashless facility to the complainant and the complainant had to pay the aforesaid amount to Fortis Hospital, Mohali and thereafter, the complainant lodged claim on the requisite claim form Ex.C25 with the Opposite Parties  on 10.7.2013.  The Opposite Parties  as well as its TPA demanded certain  documents from the complainant vide letter dated 16.7.2013 Ex.C2 and letter dated 3.8.2013 Ex.C3 which were supplied by the complainant to the Opposite Parties, but the Opposite Parties  did not settle the claim of the complainant on the ground that the complainant while obtaining the policy in question, has not disclosed the true facts. As per the history of the complainant written by Fortis Hospital in their discharge card Ex.OP5, the complainant is said to be a known case of hypertension which is the cause of CAD and which led to CABG i.e. bye-pass surgery of the heart of complainant. The Opposite Parties  did not settle the claim of the complainant on this ground only as mentioned by the Opposite Parties  in their written version. But the Opposite Parties  have failed to produce on record  any medical treatment record of the patient/ insured that he was known case of hypertension at the time when he obtained the policy in question from the Opposite Parties  on 31.3.2011 nor Opposite Parties  have examined any medical officer or medical expert to prove that he treated the complainant for the disease of hypertension nor the Opposite Parties  could produce any medical treatment record of the complainant to prove that he had been taking medicines for hypertension prior to taking the policy in question from the Opposite Parties. Except history mentioned on the discharge card of the complainant Ex.OP5 on 2.7.2013, the Opposite Parties  could not produce any record to prove that the complainant was suffering from disease of hypertension. It has been held by the Hon'ble National Commission in case New India Assurance Co.Ltd & Anr Vs. Murari Lal Bhusri 2011(III) CPJ 198 (NC) that where the Insurance company failed to produce any evidence to show that respondent was aware of any pre-existing disease at the time when insurance policy was taken, opposite party was not justified in repudiating the claim of the complainant on the ground of pre-existing disease. It has been held by the Hon'ble Supreme Court of India in case P.Vankat Naidu Vs. Life Insurance Corporation of India & Anr 2011(3) CPC 350 that where no cogent evidence was produced by the respondent to prove that insured/deceased had concealed any fact about his illness or hospitalization, it was held that no material fact was suppressed by the deceased in this respect. It has been held by the Hon'ble State Commission of Punjab in case Life Insurance Corporation of India Vs. Miss Veenu Babbar and another 2000(1) CLT 619 that repudiation on the basis of history recorded in the hospital records is illegal and arbitrary and the same could not be treated as substantive material to base any decision. Same view has been taken by the Hon'ble National Commission in case Life Insurance Corporation of India & Ors. Vs. Kunari Devi IV(2008) CPJ 89 (NC) that where no document has been produced in support of allegation of suppression of disease at the time of taking policy or revival of policy, history recorded in hospital's bed ticket, not to be treated as evidence as doctor, recording history not examined, suppression of disease not proved, insurer was held liable under the policy. It has further been held by the Hon'ble National Commission in case Sahara India Life Insurance Co. Ltd. & Anr Vs. Hansaben Deeepak Kumar Pandya IV(2012) CPJ 13(NC) that where the opposite party insurance company has failed to produce on record any evidence to show that deceased insured ever consulted doctor for taking treatment of heart disease, the repudiation of the claim on the ground of suppression of material fact is totally illegal. Apart from this at the time of proposal and issuing the policy to the complainant, the medical examination of the complainant was conducted by medical expert of the Opposite Parties  as is evident from the policy schedule Ex.C1 which proves that even  the ECG of the complainant/ insured was  got done by the Opposite Parties  on 31.3.2011. So, the Opposite Parties can not be allowed to say that the complainant had concealed the material facts while taking the policy in question or  in any way misled the Opposite Parties. The Opposite Parties  were therefore, not justified in not settling the claim of the complainant only on the ground that the complainant was suffering from disease of hypertension and he did not disclose the same to the Opposite Parties  at the time of taking of the policy in question from the Opposite Parties. The claim was lodged by the complainant with the Opposite Parties  on 10.7.2013, but till today, the Opposite Parties  have not settle the claim of the complainant. All this amounts to deficiency of service on the part of the Opposite Parties.
9. Consequently, we allow the complaint of the complainant with costs and the Opposite Parties  are directed to pay an amount of Rs.2,34,273/- alongwith interest @ 9% per annum from the date of filing of the complaint till the payment is made to the complainant. The Opposite Parties  are also directed to pay the costs of litigation to the tune of Rs.2000/- to the complainant.   Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 24-06-2015.                                                   (Bhupinder Singh)                                                                                               President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

              Member                         Member