Haryana

Bhiwani

CC/7/2019

Sukhbir - Complainant(s)

Versus

Religare Health ins. - Opp.Party(s)

A.K Vashist

17 Nov 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BHIWANI.

 

                                                             Consumer Complaint No. : 07 of 2019

                                                        Date of Institution           : 08.01.2019

                                                                  Date of order                  : 17.11.2023

 

Sukhbir son of Sh. Diwana, R/o village Bass Badshahpur, Tehsil Hansi, District Hisar.

  

           ……Complainant.

 

Versus

 

1. Religare Health Insurance, registered office: 5^th Floor, 19 Chawla House, Nehru Palace, New Delhi-110019, Corresp. Office, Vipul Tech Square Tower-C, 3^rd Floor, Golf Course Road, Sector-43, Gurugram 122009. (Haryana).

 

2. Indusind Bank Ltd., Circular Road, Dr. Chaudhary Hospital’s building, Bhiwani, Tehsil and District Bhiwani-127021.

 

…… Opposite Parties.

 

COMPLAINT U/S 12 OF CONSUMER PROECTION ACT, 1986.

 

BEFORE:       Hon’ble Mrs. Saroj Bala Bohra, Presiding Member.

  Hon’ble Ms. Shashi Kiran Panwar, Member.

 

Present:-        Sh. A.K. Vashisth, Advocate for complainant.

Sh. Rajesh Kumar Kaushik, Advocate assisted by Sh. Sudhir Kumar, Advocate for OP No.1.

OP No.2 exparte.

ORDER:

 

Saroj Bala Bohra, Presiding Member:

 

1.                 In brief, facts of this case are that complainant purchased a health insurance policy no.13197365 from OP NO.1 by paying Rs.10,770/- on 23.10.2018 for a term of one year commencing from 24.10.2018 to 23.10.2019. In second week of November, 2018, complainant fell ill and remained admitted in O.P.Jindal Hospital, Hisar.  The hospital sent request for pre-authorization of cashless hospitalization of the complainant but the request was denied by OP No.1 on 03.12.2018 that complainant not disclosed material fact of pre-existing ailment of hyper tension and heart disease. Complainant has submitted that his necessary medical examination was conducted by the authorized doctor of OP No.1. While admission of the complainant in the hospital, it was known that he was suffering from heart disease and on such treatment Rs.3.00 lac were incurred by complainant. Hence, the present complaint has been preferred alleging deficiency in service on the part of Op resulting into monetary loss as well as mental and physical harassment with a prayer for issuance of directions to OPs to pay Rs.3.00 lac which incurred on treatment, Rs.1.00 lac as compensation for harassment and Rs.5000/- as litigation expenses. Any other relief to which this Commission deems fit has also been sought.

2.                 OP No.1 appeared through counsel and tendered reply raising preliminary objections that the present complaint is not maintainable; that complainant has no locus standi to file the present complaint and that concealment of true facts. On merits, it is submitted that complainant approached the OP to avail the cashless facility request for the planned hospitalization of complainant at O.P. Jindal Hospital on 29.11.2018 with complain of pain in abdomen i.e. intestinal perforetious for an expected amount of Rs.72,000/-. On perusal of the medical record of complainant, it came to forefront that complainant was a known case of hypertension and heart disease since last 4 to 5 years and that complainant was taking tab. cardivas for hypertension.  As such, in light of non-disclosure of pre-existing disease, the claim of complainant was rejected under cause 7.1 of the policy terms & conditions, under intimation. In the end, prayer for dismissal of complaint has been made.

3.                 OP No.2 did not appear despite issuance of registered notices, as such, it was proceeded against exparte vide order dated 07.03.2019.

4.                 In evidence of complainant, affidavit Annexure CW1/A alongwith documents Annexure C-1 to Annexure C-23 were tendered and then closed the evidence.

5.                 In evidence of OP No.1, affidavit Ex. RW1/A alongwith documents Annexure R-1 to Annexure R-7 were filed and closed the evidence.

6.                 We have heard learned counsel for the contesting parties and perused the record minutely.

7.                 The case of complainant is that during the period of insurance policy, complainant fell ill, diagnosed as heart disease and remained admitted in the concerned hospital and spent a sum of Rs.3.00 lac but the OP insurance company did not reimburse the same rather repudiated the claim of complainant vide letter Annexure C-4. Ld. Counsel for complainant has argued that due to such act & conduct of OP, complainant has to suffer monetary loss as well as mental and physical harassment. In support of his contention, Ld. counsel has placed reliance on case laws delivered by National Consumer Disputes Redressal Commission, New Delhi in  case titled Bajaj Allianz Life Insurance Co. Ltd. and 2 ors. Vs. Kanduru Gangadha Rao reported in 2021 (4) CPR-235; and Bajaj Allianz Life Insurance Company Limited and Anr. Vs. Mudapaka Rama Rao reported in 2021 (3) CPJ-188.

8.                 On the other side, learned counsel for OP No.1 has argued that the complainant has suppressed material facts qua his ailment prior to commencement of the policy. As such, the  repudiation was well within the policy terms and conditions. 

9.                 It is not in dispute that on the relevant period of time complainant was under the insurance cover.  Complainant to prove that he was under treatment and incurred a sum of Rs.1,56,810/- on his treatment has placed on record bills/documents Annexure C-5 to Annexures C-7, C-9 to C-11, C-12 to C-22 but the said amount was not released by the OP. The OP insurance company has repudiated the claim of complainant on the ground that the complainant was having pre-existing disease before commencement of the health insurance policy which is violation of terms & conditions of the  policy. Perusal of record reveals that the OP has repudiated the claim of complainant in a casual manner without mentioning any cogent and convincing reason thereof which shows that the OPs insurance company has adopted a trend not to release claim of the poor persons rather compel them to knock the doors of the Consumer Commission. It is worthwhile to mention here that the OP(s) are not settling even genuine claims of consumers/complainants which is illegal and amounts to indulgence into unfair trade practice/malpractice.  We have carefully gone through the case laws relied upon by complainant side, which are very much relevant to the facts and circumstances of the present case and thus are helpful in deciding the present case.  No role of OP No.2 has come out in the present matter, as such no liability is attributed against the OP No.2.

10.               In view of the above discussion and going through the situation as well as facts and circumstances of the present case, it is clear that OP No.1 insurance company has wrongly repudiated the claim of complainant just to cheat and harass the complainant which amounts to deficiency in service and mal-trade practice on their part resulting into monetary loss as well as mental and physical harassment.  Hence, the complaint is allowed and the OP No.1 is directed to comply with the following directions within 40 days from the date of order:-

(i)       To pay a sum of Rs.1,56,810/- (Rs. One lac fifty six thousand eight hundred ten) to the complainant so incurred by him on treatment alongwith simple interest @ 9% per annum from the date of filing of complaint till actual realization.

(ii)      To pay Rs.15,000/- (Rs. Fifteen thousand) as compensation  on account of mental agony and physical harassment. 

3. To pay Rs.5000/- (Rs. Five thousand) as litigation expenses.

                    In case of default, the OP No.1 shall liable to pay simple interest @ 12% per annum on the aforesaid amount for the period of default. Certified copies of the order be sent to parties free of costs. File be consigned to the record room, after due compliance.

Announced.

Dated:17.11.2023.