DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No.222/2016
Ms. Mahima Arora
R/o C-548, 2nd Floor,
J.V.T.S. Garden, Chattarpur Extn.
New Delhi- 110074
….Complainant
Versus
Religare Health Insurance Co. Ltd.
Having its registered office at:
D3, P3B, District Centre,
Saket, New Delhi- 110001
….Opposite Party
Date of Institution : 26.07.2016
Date of Order : 30.03.2022
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Sh. U.K. Tyagi, Member
ORDER
Member: U.K. Tyagi
Complainant has requested for to pay an amount of Rs.1,43,202/- alongwith interest @24% p.a. from the 14.10.2015 till the date of actual payments; to pay a sum of Rs.3,00,000/- as compensation on account of harassment; mental agony etc.; to pay a sum of Rs.50,000/- towards the cost of litigation etc.
The facts leading to the case are that the Complainant bought one health insurance policy bearing No.10420199 for the period from 15.10.2015 to 14.10.2016 for which a sum of Rs.5,761/- was paid to the Religare Health Insurance Company Ltd. (hereinafter referred as OP) as premium. It is also added that the Complainant believing the false assurances given by the representative of OP to be true, decided to opt for the said health insurance policy. It is averred that the Complainant had suffered severe pain in her abdomen and vomiting in February, 2016 and was rushed to the Saket City Hospital on 04.02.2016 at midnight. The Complainant was under treatment at the said hospital from 04.02.2016 to 12.02.2016 and discharged on 12.02.2016. The discharge summary is exhibited at C-13. It is also stated that on 04.02.2016, a pre-authorisation request was sent to OP by the Hospital itself where upon the OP sought clarification from the treating doctor. The OP, after due follow up, sent an authorisation letter to the hospital on 05.02.2016 for guarantee of payment of Rs.20,000/- initially. The same is exhibited at C-12 (colly).
The OP again on 10.12.2016 requested the hospital to send updated case summary which was also duly supplied by the hospital. OP, despite having received the updated case summary with respect to treatment; finally denied the claim of the Complainant on 10.02.2016. The same is exhibited at C-5.
The Complainant further states that the reason of denial as per letter dated 10.02.2016 are as follow:-
“Reason for Denial”
2 year waiting: treatment of internal tumor, skin tumors, cysts, nodules, polyps including breast lumps (each of any kind) unless malignant; gastric polyp”.
The Complainant maintains that no such pre-condition was either been informed or ever explained to her. The case in hand does not come under the purview of above quoted reason. The treating doctor again stated that the symptoms of abdomen pain and vomiting are unlikely to be due to gastric polyp. The said report is exhibited at C-6 & C-7. The Complainant has to pay a sum of Rs.1,43,202/- to the hospital towards expenses incurred during her hospitalization. The Complainant also maintained that all the investigation reports etc. also were shared but it is not understood why OP has come this conclusion that her treatment was only for polyp.
The Complainant’s father/relative had visited the office of OP several times to press for the claim and convince the OP about the genuineness of the claim. After having exhausted all avenues, she got the legal Notice served on the OP. As such, the OP did not bother to consider the request and resultantly OP is liable for deficiency in service and ignorance.
On the other hand, the OP vehemently denied the charges/averments made by the Complainant. As per undated case summary received on 10.02.2016, the Complainant was diagnosed with Gastric Polyp which was subsequently removed. As per the UGI endoscopy report dated 05.02.2016, the Complainant was diagnosed with sessile polyp. The same is exhibited at OP-4. Having consideration of the above, the cashless facility request of the Complainant was denied as treatment of polyp comes within the purview of 2 year waiting period clause. The same is exhibited as OP-5.
The post denial of Cashless Facility Request and the Doctor’s Certificates dated 11.02.2016 and 12.02.2016 were reconsidered and found clearly after though process on the part of Complainant. As per certificate, the Complainant was found to have gastric polyp which was removed. The same is exhibited as OP-6. The Complainant did submit the hospitalization expenses to the office of OP for reconsideration. The same was rejected after having considered the same on the basis of terms and conditions of the policy. The same is reproduced here for ease of reference.
“Clause 4.1(B) Specific Waiting Period –
- Any claim for or arising out of any of the following illnesses or Surgical Procedures shall not be admissible during the first 24(twenty four) consecutive months of coverage of the insured person by the company from the first Policy Start Date:
(x) Internal tumors, skin tumors, cysts,, nodules, polyps including breast lumps (each of any kind) unless malignant”.
The Complainant also stated to have the legal Notice served on the OP. The same was duly replied vide letter dated 18.05.2016 which is exhibited as OP-10 & 11. The OP also mentioned that the terms and conditions of policy is subject to free look period of 15 days. The same is reproduced:
“6.11 Free Look Period
(a) The Policy Holder may, within 15 days from the receipt of the Policy documents, return the Policy stating reasons for his objections, if the Policy holder disagrees with any policy Terms and Conditions.”
OP further maintains that no such communication was received from the complainant. The Hon’ble Supreme Court of India in the matter of United India Insurance Co. Ltd. V/s Harchand Rai ChandanLal, Civil Appeal No. 6277 of 2004 held that:
“It is settled law that terms of the policy shall govern the contract between the parties, they have to abide by the definition given therein and all those expressions appearing in the policy should be interpreted with reference to the terms of policy and not with reference to the definition given in other laws. It is a matter of contract and in terms of the contact, the relation of the parties shall above and it is presumed that when the parties have entered into a contract of insurance with their eyes wide open, they cannot rely on definition given in other enactment.”
The Hon’ble Supreme Court further stated that:
“It is possible that an insured may sustain loss in technical terms of the criminal law, but no relief can be given to him unless his case is covered by the terms of the policy. It is not open to interpret the expression appearing in policy in terms of common law; but it has to give meaning to the expression as defined in the policy.” The said judgment of Hon’ble Supreme Court considered and is found not having similarity to the facts of this case.
Both the parties have filed written submissions and evidence by way of affidavits. Rejoinder is also on record so is the written statement. Oral arguments were heard and concluded.
This Commission has gone into the material placed on record carefully and also given the serious thought to the oral arguments made by the respective parties. It is also noted that during the hearing on 26.03.2018, Ms. Bhawana Salwan Adv. proxy for the OP appeared before the Commission and filed Authority Letter. She made the statement – “According to the OP, OP is ready to pay an amount of Rs.56,000/- to the Complainant towards full and final settlement.” The authority letter is issued on behalf of AV Law Associates and is on record. After going through ordersheet, there is no mention of its acceptance or contention/denial. Neither OP nor its authorized law firm had withdrawn the said statement. In the absence of such denial, this Commission feels that the OP to some extent accepts its liability to pay the hospitalization expenses incurred by the Complainant during her stay in said hospital. It is also concluded that this amount might have been arrived at by the OP on some basis. To that extent, the OP is found deficient in service and negligent.
In view of the above facts and circumstances mentioned above, this Commission feels that the amount so offered by the representative of the OP may be allowed as full and final amount alongwith interest @7% p.a. from the date of bill paid by the Complainant. Also it is directed to pay Rs.10,000/- as compensation for mental agony etc. and Rs.5,000/- as litigation charges failing which the rate of interest shall be levied @9% p.a. on the whole amount of Rs.56,000/- so directed to be paid by the OP.
File be consigned to the record room after giving a copy of the order to the parties as per rules. Order be uploaded on the website.
