DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016
Case No.305/2016
Sh. Ramesh Chandra Garg
S/o Late Sh. Asha Ram
R/o 129/130, Pocket G-2, Sector-16,
Rohini, New Delhi ….Complainant
Versus
Religare Health Insurance Co. Ltd.
Regd. Office:
D-3, P3B, District Centre,
Saket, New Delhi-110017 ….Opposite Party
Date of Institution : 19.09.16 Date of Order : 18.12.18
Coram:
Sh. R.S. Bagri, President
Ms. Naina Bakshi, Member
Ms. Kiran Kaushal, Member
ORDER
Naina Bakshi, Member
Briefly stated, the case of the complainant is that purchased the policy No. 10026467 from OP which was valid upto 04.06.17. It is submitted that on 24.06.16, the complainant was residing at Haridwar, where at 10:00 PM, he felt problems and accordingly he visited Schan Clinic, Haripur Kalan, Haridwar. After giving first aid, the said clinic referred the complainant to Himalayan Hospital, Dehradun for further treatment. It is submitted that on the night of 25.06.16 at 12.30 A.M. the complainant went to Himalayan Hospital Dehradun by private taxi and was admitted in the emergency ward of Himalayan Hospital, Dehradun. On 25.06.16, the complainant applied for preauthorization of cashless hospitalization for him against the above policy but the OP denied on the reason of non-disclosure of material fact/pre-existing alignment at the time of proposal of patient is K/C/O DM since 10 years. The complainant was discharged from the hospital and paid Rs.17,688/- in cash to the hospital. On 29.06.16 the complainant submitted the claim with the OP alongwith all the documents. The OP did not replied after several calls but finally on 07.07.16 the OP asked vide email dated 07.07.16 to provide the documents such as (a) Pre-hospitalization) OPD consultation record (b) Indoor case papers and admissioning doctors notes and nurses notes. It is submitted that it was only a delaying tactics of the OP as the complainant had already replied vide email dated 07.07.16 that it was already attached with the earlier email and further Indoor cases papers of the hospital could not be supplied because the hospital had denied to give the copy. The OP vide email dated 08.07.16 stated that the documents are incomplete. The complainant again replied on 08.07.16 that no other treatment was taken from any clinic and hospital cannot provide any other documents except already sent. On 13.07.16 the OP against asked for clarification vide their email regarding the doctor, who wrote the prescription that the patient was diabetic and hypertension and also asked for duration of diabetic in Schan Clinic, which was sent through email. On 21.07.16 one employee of the OP visited complainant’s residence and made enquires from the son of the complainant and other persons which was related to the claim. The son of the complainant sent an email on the same day to the OP regarding the harassment caused by the OP. On 04.08.16 the OP vide email dated 04.08.16 declined the claim of the complainant and the reason was given that “ as per the discharge summary of Himalayan Hospital dated 27.06.16, patient was diagnosed with Vertigo under evaluation and ? TIA. However, as per submitted medical documents all vital parameters were normal throughout the hospital stay hence he was investigated/ evaluated during his hospitalization. Therefore, the referred claim has been repudiated as per policy terms and conditions i.e. hospitalization for evaluation/diagnostic purpose is not covered.” Hence, pleading deficiency in service and unfair trade practice on the part of the OP the complainant has filed the present complaint with the following prayers:
- Direct the OP to refund the sum of Rs.18938/- to the complainant for the claim already submitted.
- Direct the OP to pay a sum of Rs.80,000/- towards the compensation for the physical and mental harassment of the complainant .
- Direct the OP to pay to the complainant cost of litigation and miscellaneous charges.
In the written statement OP has inter-alia stated that the complainant approached the OP and was interested in porting his health insurance policy from National Insurance Company Ltd. to the OP. The complainant after being acquainted with the benefits of different policies opted for the policy namely ‘Care’. The complainant duly filled the proposal form, the OP issue a health insurance policy certificate bearing No. 10026467 subject to the policy terms and conditions which was valid for the period from 05.07.13 to 04.07.14 and was renewed till 04.07.17. It is submitted that the policy certificate alongwith the terms and conditions governing the insurance policy was supplied to the complainant. The complainant had requested for cashless facility for his hospitalization at Himalayan Hospital from 25.06.16 to 27.06.16 for Vertigo under evaluation. The said request was denied vide letter dated 25.06.16 as per policy terms and conditions for non disclosure of material fact/pre-existing cashless facility request. The complainant was a known case of diabetic mellitus since ten years and same was not disclosed at the time of issuance of policy. The complainant could have disclosed about his pre existing medical condition, but he chose not to do so, for reasons best known to him. The complainant filed a claim for reimbursement of his hospitalization expenses at Himalayan Hospital on 29.06.16. When the claim was filed a query was raised on 04.07.16 for providing the details, related to the hospitalization i.e. (a) pre hospitalization OPD consultation record (b) Indoor case papers, admission notes, doctors notes, nurse notes. It is submitted that as per the documents received in query replied to the above query, all the complainant’s body vitals were normal, also it seems that the complainant was hospitalization for evaluation/diagnostic purpose only, since he had undergone a number of tests and all of which suggested a normal study. On admission the complainant was afebrite conscious and oriented with the vital such as BP 120/80, pulse 90/min, RBS-152 mg/dl. Also all the systematic examinations were within normal limit thereby suggesting that the complainant was investigated extensively. Even cashless facility request form duly signed and stamped by the complainant’s doctor and claim form filed by the complainant himself mentioned “Vertigo under evaluation” under the diagnostic description category, therefore, the claim was rejected on 05.08.16, as per the policy terms and conditions as the complainant was hospitalized for evaluation/diagnostic purpose only. As per clause 4.3 (i) Annexure C (71)- permanent exclusion norm:
Any claim in respect of any insured member for, on arising out of or directly or indirectly due to any of the following shall not be admissible unless expressly stated to the contrary elsewhere in the policy terms and conditions:
(i) Any condition or treatment as specified in Annexure-C.
Annexure-C: List of expenses generally excluded (“non-medical”) in hospital indemnity policy:
(71) Hospitalization for evaluation/diagnostic purpose.
Therefore, as per clause 4.3 (A) (1) read with Annexure C (71)- Admission, primarily for investigation and evaluation is not covered under the policy and hence not payable.”
It is submitted that the complainant could have been managed at the OPD level and there was no need of admitting him in the hospital for the above mentioned symptoms. Accordingly the claim rejection letter was sent on 05.08.16. It is denied that the complainant has paid Rs.17688/- in cash to the hospital and he should be put to strict proof of the same. It is prayed that the complaint be dismissed.
Complainant has filed a rejoinder to the written statement of the OP. It is denied that the complainant after being acquainted with the benefits of different policies opted for the policy namely ‘Care’. It is also denied that the complainant dully filled the proposal form and the terms and conditions of the policy were accepted by the complainant. It is submitted that the agent of the OP had approached the complainant and explained the benefits for porting the policy from National insurance company to the OP. Due to lack of knowledge of legal and medical terms which were explained by the agent to the complainant, the complainant was not fully satisfied with the benefits of the new policy of the OP, but as assured by the agent the complainant filled up the form for porting the insurance policy of the OP and signed at the place where the agent had asked to sign without actually understanding the legal and medical terms. It is worthwhile to mention that the OP had got the complainant medically examined from their own doctor at the residence of the complainant and took sample of the blood, conduct ECG and other procedures at the cost of the complainant money but the report which was submitted by that the doctor to the OP and no copy was supplied to the complainant even demanding from the doctor and OP. However, when the doctor and the OP were satisfied with the health condition of the complainant, the OP agreed to port the policy of the OP. In the report of the doctor sent to the OP there was no diagnosis of any pre-existing disease specially sugar as the OP is claiming. Had the complainant being having any pre-existing disease the doctor of OP would have diagnosed and had sent a report to the OP thereby the OP would have refused to porting the insurance policy. It is submitted that the complainant was on holy visit/trip at Haridwar and was staying in Ashram. On 24-25/06/16 at night the complainant had developed the problem of continuous vomiting and dizziness. The helper of the complainant took the complainant to the local doctor for treatment but local doctor was not qualified. The doctor referred the complainant to the Himalayan Hospital, Dehradun and he was admitted in emergency at midnight and conduct the test which they considered necessary. The complainant was under treatment in the hospital and was treated by the emergency doctor. When the complainant applied for cashless hospitalization the OP refused to cashless facility on flimsy grounds. The OP wants the patient to be treated in the OPD only when he is in the emergency danger. The claim rejection is based on the presumption only which is not justified.
Complainant has filed his own affidavit in the evidence. On the other hand, affidavit of Sh. Prasant Singh, Manager (legal) has been filed in evidence on behalf of the OP and also an affidavit of Dr. C. S. Asrani to support the claim of the OP that the complainant was not required to be admitted in hospital.
Written arguments have been filed on behalf of the parties.
We have heard the arguments on behalf of the parties and have also gone through the file very carefully.
Complainant has filed the copy of letter dated 20.06.16 alongwith insurance policy received from the OP as Annexure C-1. The OP vide letter dated 25.06.16 informed the Himalayan Institute Hospital Trust that the cashless facility hospitalization cannot be approved as per the terms and conditions of the policy as Annexure C-2. The complainant sent letter dated 29.06.16 to the OP for submitting the claim form and document Annexure C-3. The OP vide email dated 13.07.16 informed the complainant to provide the clarification from the doctor Annexure C-4. The OP vide email dated 07.07.16 informed the complainant to provide the documents for further processing of the claim Annexure C-5. The OP vide email dated 05.08.16 repudiated the claim of the complainant Annexure C-6.
Admittedly, the complainant had purchased the policy No. 10026467 from OP which was valid upto 04.06.17. On 24.06.16, the complainant was residing at Haridwar where at 10:00 PM he felt problems and accordingly he visited Schan Clinic, Haripur Kalan, Haridwar. After giving first aid, the said clinic referred the complainant to Himalayan Hospital, Dehradun for further treatment. On the night of 25.06.16 at 12.30 A.M. the complainant went to Himalayan Hospital where he was admitted in the emergency ward of Himalayan Hospital, Dehradun. The complainant through Himalayan Hospital submitted his claim alongwith documents to the OP for providing cashless facility but the OP denied the claim of the complainant vide letter dated 25.06.16 on the ground that “ cashless hospitalization cannot be approved as per the terms and conditions of the policy. For case of your refusal, we have reproduced the reasons below:
“Reason for denial. Non disclosure of material facts/pre existing alignment at the time of proposal patient is K/C/O DM since ten years.”
The OP vide email dated 05.08.16 repudiated the claim of the complainant on the ground that:
“ We would like to inform that as per the discharge summary of Himalayan Hospital dated June 27, 2016, patient was diagnosed with Vetigo under evaluation & ? TIA. However, as per submitted medical documents all vital parameters were normal throughout the hospital stay hence he was investigated/evaluated during his hospitalization.
Therefore, the referred claim has been repudiated as per the Policy Terms and Conditions i.e. Hospitalization for evaluation/diagnostic purpose is not covered.
It is not disputed that the complainant has ported the insurance policy from National Insurance Company to the OP and the OP issued the Health Insurance Police Certificate No.10026467 to the complainant which was valid for the period 05.07.13 to 04.07.14 and was renewed till 04.07.17. At the time of submitting the claim form alongwith the documents it is clear that the complainant first visited Sachan Clinic near Bombay School, Haripur Kalan, Haridwar on 24.06.11. The clinic’s doctor referred to Himalayan Hospital, Dehradun. The complainant was admitted in the hospital on 25.06.16 at 1.40 a.m. The Himalayan Hospital conducted various tests and he was discharged from the hospital on 27.06.16. As per the discharge summary the complainant was suffering from Vertigo x on and off since 4 months and nausea tendency. Complainant has stated that at the time of porting the policy from National insurance Company to OP company, the OP’s doctor examined him and submitted the report to the OP and thereafter the insurance policy was issued by the OP. As per the discharge summary it is clearly mentioned that the complainant was suffering from Vertigo on and off since four months. It is clear that the complainant had took the policy from the OP in the year 2013 and the complainant was admitted in the hospital on 25.06.16 and discharged on 27.06.16 i.e. after about 3 years of taking the policy.
The claim in question was rejected by the OP because complainant had a pre-existing disease with vertigo under evaluation and ? TIA known and non-disclosure of the same by the complainant while taking policy in question amounted to mis-representation, mis-description or non-disclosure of material particulars. In our considered opinion, the OP was not justified in repudiating the claim of the complainant by taking recourse to such exclusion clause of the terms and conditions of the insurance policy in question. It is matter of common knowledge that many times the healthy persons are unaware of such silent ailments of diabetes and hypertension, which come to their knowledge first time during health checkup camps or in any emergent situation. Thus, OP cannot apply a hard and fast rule to presume that, the complainant was suffering for long duration i.e. before taking the policy. It was just a hypothetical presumption of OP to repudiate the claim of the complainant.
In the light of above discussions, we find OP to be guilty of deficiency in service and allow the complaint with the direction to OP to pay Rs.17668/- @ 6% per annum from the date of filing of the complaint till realization within one month from the date of receipt of copy of this order and Rs.10,000/- towards compensation for causing mental agony and harassment to the complainant including cost of litigation failing which OP shall liable to pay 9% interest on the above said amount.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
(Naina Bakshi) (Kiran Kaushal) (R.S. Bagri)
Member Member President
Announced on 14.12.18.
