CONSUMER DISPUTES REDRESSAL COMMISSION – X

                           GOVERNMENT OF N.C.T. OF DELHI

                     Udyog Sadan, C – 22 & 23, Institutional Area

                                       (Behind Qutub Hotel)

                                        New Delhi – 110016

  Case No:107/2019

Parnika Rathi

W/o Lt. Sh. Anupam Rathi, aged about 50 years

R/o 6, Sadhna Enclave, Panchsheel Park

Malviya Nagar, New Delhi-110017.                …..COMPLAINANT

Vs.   

Religare Health Insurance Co. Ltd.

Chawla House, 5^th Floor, 19 Nehru Place

New Delhi-122009.                                                 …..RESPONDENTS

          Date of Institution-24.05.2019

          Date of Order- 04.10.2024

  O R D E R

RITU GARODIA-MEMBER

1. The complaint pertains to deficiency in service in repudiating the health claim of the complainant.

2. Facts as stated in the complaint are that the complainant purchased a policy no. 10003628 from OP in 2012. The said policy was renewed every year on payment of regular premiums.

3. In September 2018, the complainant experienced severe vaginal bleeding and was taken to Breach Candy Hospital Trust, Mumbai. The complainant was diagnosed with Gallbladder Polyp and Uterine Fibroids. She underwent laparoscopic cholecystectomy and Vaginal Hysterectomy. She was admitted in the aforementioned hospital on 07.10.2018. On 08.10.2018, both the surgeries were successfully undertaken and the complainant was discharged on 12.10.2018.

4. The total hospitalization expense of the surgeries was Rs.7,12,060/- and the pre-hospitalization expense for the surgeries was of Rs.42,330/-. The total expenditure of the complainant in respect of her medical expenses was of Rs.7,54,390/-

5. The complainant lodged a claim with OP. The claim was repudiated for non-disclosure of material facts vide denial letter dated 04.12.2018. The reasons given were the complainant was suffering from choriocarcinoma before the inception of the policy.

6. It is clarified that at the time of delivery of complainant’s first child in year 1991, a piece of placenta was left inside, which turned into choriocarcinoma. The complainant underwent treatment and was completely cured in 1992. Since then, the complainant had been living healthy life and in the year 1999, the complainant also gave birth to her second child through a normal delivery.

7. It is further submitted that after almost 20 years in year 2012, she took a policy from OP by filling proper details. The complainant was asked to provide details of any illness or disease that she was suffering at the time of filling the form or she have been hospitalized or under treatment for any illness/ injury during the last 48 months, for which complainant answered “No”.

8. The complainant prays for payment of health claim of Rs.7,54,390/- with interest @18%, Rs.40,000/- as compensation for harassment and agony and Rs.10,000/- towards litigation expenses.

9. OP in its reply submits that a health insurance policy (Product-Care) bearing Policy Number 10006238 was issued to the complainant w.e.f. 23.11.2012 till 22.11.2013. The policy was further renewed till 26.11.2019. The complainant along with her daughter, was covered under the policy for a sum insured of Rs.50,00,000/- subject to policy terms and conditions.

10. The complainant had applied for a reimbursement of claim on 21.11.2018 pertaining to hospitalization for the treatment of gallbladder polyp and uterine fibroids at Breach Candy Hospital, Mumbai, from 07.10.2018 to 12.10.2018. As per discharge summary dated 12.10.2018, the complainant has a history of choriocarcinoma prior to policy inception. The same was never disclosed by the complainant at the time of taking the policy. The reimbursement claim was rejected by OP vide claim denial letter dated 04.12.2018 under Clause 7.1 of the policy terms and conditions on the ground of non-disclosure of material information.

11. OP alleges that the complainant had an opportunity to disclose her history of choriocarcinoma under the head of pre-existing disease in the proposal form but she did not exercise that option. The policy of the complainant was cancelled under Clause 7.13 vide letter dated 04.03.2013 and 30.03.2013.

12. The complainant has filed evidence by way of an affidavit and has exhibited the following documents:

1. Copy of the insurance policy is exhibited as Exhibit CW1/1.
2. Copy of premium acknowledgement is exhibited as Exhibit CW1/2.
3. Copy of proposal form  is exhibited as Exhibit CW1/3.
4. Copy of the medical/treatment records is exhibited as Exhibit CW1/4.
5. Copy of medical bills is exhibited as Exhibit CW1/5.
6. Copy of claim form is exhibited as Exhibit CW1/6.
7. Copy of denial letter is exhibited as Exhibit CW1/7.
8. Copy of correspondences and emails is exhibited as Exhibit CW1/8.
9. Copy of Registered Grievance is exhibited as Exhibit CW1/1.

13. OP has filed evidence by way of an affidavit and has exhibited the following documents:

1. Copy of certificate of incorporation is exhibited as Ex.R1.
2. Copy of insurance Policy certificate is exhibited as Ex.R2.
3. Copy of terms and conditions is exhibited as Ex.R3.
4. Copy of proposal form is exhibited as Ex.R4.
5. Copy of claim form is exhibited as Ex.R5.
6. Copy of discharge summary is exhibited as Ex.R6.
7. Copy of claim denial letter is exhibited as Ex.R7 & 8.
8. Copy of notice for cancellation is exhibited as Ex.R9.
9. Copy of letter for cancellation is exhibited as Ex.R10.

14. The Commission has considered the pleadings and documents on record. It is admitted by both the parties that complainant was continuously insured by OP since year 2012. It is also admitted that the complainant underwent hospitalization from 07.10.2018 to 12.10.2018.  It is also admitted by both the parties that the complainant had suffered from choriocarcinoma in the year 1992. The discharge summary of the hospital also cites the patient history as “Choriocarcinoma in 1992, treated with Methotrexate”.

15. OP rejected the claim of the complainant vide letter dated 11.12.2018 on the following grounds:

• Insured is suffering from choriocarcinoma prior to policy inception and same was not disclosed. Hence claim is repudiated under non-disclosure.
• Benefit not covered in policy.

16. OP also cancelled the complainant’s policy vide letter dated 04.03.2019. OP has filed the terms and conditions of the policy. Both the parties have relied on the said terms and conditions. Relevant clauses as follows:
17.  

          7.1-   Disclosure to information norm

         If any, untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particular or any material information having been withheld or if a claim is fraudulently made or any fraudulent means or devices are used by the policyholder or the insured person or anyone 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.

17. OP has filed proposal form. Relevant portion of the said form is as follows:

Pre-existing Disease Details:

Is any of the member proposed to be insured suffering from any illness or disease? If yes, please provide details.

Has anyone been diagnosed/ hospitalized or under any treatment for any illness/injury during the last 48 months.

18. OP has relied on terms and conditions which states that pre-existing disease means any ailment which was diagnosed within 48 months prior to the first policy issued.  OP had submitted that the first policy was issued from 23.11.2012.  As per the terms and conditions, the complainant had to disclose any disease suffered by her within 48 months i.e. from 23.11.2008 onwards.  It is also admitted by both the parties that choriocarcinoma was diagnosed in year 1992.  The complainant was cured and had another child in year 1999.  OP has not placed on record any document to substantiate that the complainant was suffering from choriocarcinoma in year 2008.  As a matter of fact, complainant was quite healthy even after the policy was issued in 2012.   It was only in year 2018, that the complainant underwent surgery and was hospitalized. 

19. Hon’ble National Commission in Smt. Daya Rani Vs Life Insurance Corporation of India IV(2009) CPJ174(NC) has held complainant is not liable to give voluntarily information which is not sought for by the insurer. 

20. The complainant has filed medical bills from Breach Candy Hospital for Rs.7,12,060/-.  Hence, we hold OP guilty of deficiency in service and direct it to refund Rs.7,12,060/- with 7% interest from the date of hospitalisation i.e. 12.10.2018 till payment.  We also award a compensation of Rs.1,00,000/- for mental harassment, physical inconvenience inclusive of litigation expenses.

21. Order be uploaded within 30 days and file be consigned to record room.