Before the District Consumer Dispute Redressal Commission [Central], 5th Floor ISBT Building, Kashmere Gate, Delhi
Complaint Case No.-54/07.03.2019
Abhishek Sharma r/o H. No. 16, Street No.1
A-Block, Sunder Vihar Colony Near Jiwan,
New Delhi, Delhi-110084 ...Complainant
Versus
Religare Health Insurance Co. Ltd.
1201 & 1202, Vikrant Tower-4, Second Floor,
45, Rajendra Place, New Delhi, Delhi-110008
Also at:-
5th floor, 19th Chawla House, Nehru Place,
New Delhi-110019 ...Opposite Party
Order Reserved on: 10.03.2023
Date of Order: 02.06.2023
Coram: Shri Inder Jeet Singh, President
Ms. Shahina, Member -Female
Shri Vyas Muni Rai, Member
Vyas Muni Rai
ORDER
1.1. The present complaint has been filed by Sh. Abhishek Sharma ( in short ‘the complainant’) against Religare Health Ins. Co. Ltd. (in short ‘the OP’) under Section 12 of the Consumer Protection Act, 1986, the complainant on 24.10.2017 purchased a policy bearing no. 11696985 for sum assured Rs. 5,00,000/- having premium of Rs. 12,843/-; the validity period of the policy was 25.10.2017 to 24.10.2018 [the policy document is available at page no. 9 of the paper-book]; In the said policy insured were i.e. 1. Ms. Shashi Sharma, 2. Mr. Parmod Sharma, mother and father of the complainant respectively.
1.2. On 19.10.2018 father of the complainant, Sh. Parmod Sharma (insured) had leg injury and was taken to the Sant Parmanand Hospital, Civil Line, Delhi- a hospital empanelled with the OP; the father of the complainant was examined in the emergency ward and on examination it was found that Mr. Parmod Sharma had fractured his leg which required prompt surgery/ operation.
1.3. The complainant informed concerned staff of the hospital about his mediclaim policy; and accordingly request was submitted with OP, so that, expenses related to hospitalization of father of the complainant could be paid by the OP.
1.4. It is also the case of the complainant that OP without any justification denied to pay the hospitalization expenses of the father of complainant vide letter dated 19.10.2018 [pre-authorisation of cashless hospitalization] stating therein that “we are in receipt of your request for pre-authorisation hospitalization of Mr. Parmod Sharma, we have reviewed your request and hereby inform you that cashless hospitalization cannot be approved as per the terms and conditions of the policy as stated below:-
- Non-disclosure of material facts/ pre-existing ailments at the time of proposal (HTN for insured Ms. Shashi Sharma). Remain same.
- Non-disclosure of material facts/ pre-existing ailments at time of proposal [denial letter dated 19.10.2018 is kept at page no. 12 of the paper-book]
1.5. In the aforesaid circumstances, the complainant borrowed some money and paid the required expenses of the treatment, hospital room, medicines etc., amounting to Rs. 1,09,942/- [hospital bills are at page no. 15-16 of the paper-book].
1.6. After the father of the complainant was discharged; his claim for reimbursement of expenses incurred during the hospitalization of his father but the claim/ payment was denied vide claim denial letter; [stating therein that; the claim is not payable as per policy terms and conditions listed below:-
- Non-disclosure of material facts/ ailment at time of proposal (Hypertension for insured Ms. Shashi Sharma).
- Non-disclosure.]( page no. 19 of the paper-book)
1.7. Subsequent thereof; complainant had to approach the hospital for routine check-up; as advised by the treating doctor who reviewed his father, time and again and complainant incurred Rs. 6,578/- for post hospital treatment [pharmacy bills are at page no. 20-26 of the paper-book]. It has also been alleged that conduct of the OP is unjustified, unreasonable, motivated and illegal and the same has caused financial loss; besides harassment and prejudice to the interests of the complainant.
1.8. Based on the rejection of the claim of the complainant by OP, the complainant has prayed for appropriate order or direction to the OP to pay the claim amount of Rs. 1,16,950/- (in respect of one of the insured members of the aforesaid policy i.e. Sh. Parmod Sharma) at the rate of 24% pa w.e.f. 21.10.2018- the date of discharge from hospital of the father of the complainant till the realization of the same, along with Rs. 25,000/- damages for harassment, apart from Rs. 15,000/- towards litigation cost.
2.1. OP has filed the reply under the signature of one Kashif Nazki s/o Muzzafar Ahmed Nazki [stated to be an officer and authorized representative of OP]; there is no dispute about the medi-claim policy; names of the insured, sum insured, its premium and validity period; it is the case of the OP that complainant approached to OP with a claim with respect to hospitalization of the insured; who was hospitalised in the Sant Parmanand Hospital w.e.f. 19.10.2018 till 21.10.2018; for treatment of fractured left ankle; the complainant applied for cashless facility for an estimated amount of Rs. 1,50,000/-; cashless claim was denied considering the fact that the mother of the complainant (other insured member) had not disclosed the history of hypertension; and the same was informed to the complainant/ insured vide letter dated 19.10.2018; before filing the health claim for the hospitalization of his father, the complainant had first approached the OP; with a cashless request vide claim no. 80203374; with respect to the hospitalization of complainant’s mother (Ms. Shashi Sharma) as on 13.09.2018 for Fibroid Uterus and same was denied for non-disclosure of hypertension which was mentioned on the cashless request form [ copy of cashless form is available at page no. 55-56/ Annexure-C]; and cashless denial letter dated 19.10.2018 is at page no. 57/ Annexure-D; letter dated 05.09.2018 rejecting the pre-authorisation for Ms. Shashi Sharma from the OP depicting non-disclosure of material facts/ pre-existing ailment at the time of proposal; having history of hypertension; prior to inception of policy is at page no. 60/ Annexure-F.
2.2. OP further pleads that, after denial of the cashless claim, complainant approached the OP with a reimbursement claim with respect to the said hospitalization for the insured for a claimed amount of Rs. 1,09,942/- and on receipt of the claim form and perusal of the documents thereof, reimbursement claim of the insured was denied in accordance with Clause 7.1 of the policy terms and conditions; for non- disclosure of material facts of hypertension of other insured members [ Ms. Shashi Sharma, mother of complainant] and same was informed to the complainant vide letter dated 27.11.2018 (page no. 63 of paper-book/ Annexure-H) and copy of the clam form is kept at page no. 64-66/Annexure-I].
2.3. It has also been pleaded by OP that complainant had purchased the policy online and had to answer certain question with respect to any pre-existing history with regard to any illness/ disease/ injury of the insured members; and complainant in all the relevant columns, while answering the questions online; have described “NO” [this aspect will be discussed further at appropriate stage] [copy of the online questionnaire are at page no. 67-73/ Annexure-J].
2.4. OP, relying upon the aforesaid disclosure and declarations to the effect that insured persons had no history of pre-existing disease/ illness/ injury issued the health insurance policy; wherein pre-existing disease specified against the insured was “NO” only; since the complainant never disputed the contents of the said proposal forms provided to him, the same are deemed to be admitted on the part of the complainant; however, the complainant by not disclosing the correct health condition; has acted in breach of the principle of utmost good faith and the policy terms and conditions which form the basis of the contract between the insurer and the insured; had the complainant disclosed correct health condition at the time of inception of the policy, OP would not have offered the policy to the complainant or offered the cover on different terms and conditions; therefore, OP has pleaded no deficiency in service on its part in rejecting the claim of the complainant and present complaint is liable to be dismissed on this ground alone.
2.5. In its reply, OP has not disputed the expenses amounting to Rs. 1,16,950/- incurred by the complainant on treatment of his father- Sh. Parmod Sharma (the insured) rest of the contentions of complainant in his complaint are denied by the OP; OP has also cited judgement/ order of Hon’ble Supreme Court and Hon’ble NCDRC which is discussed in para no. 7.6.
3. Complainant has filed rejoinder to the reply of OP and has taken the objection that the reply filed by the authorized representative of OP; is not supported with the Board Resolution or authority letter; and affidavit filed by authorized representative of OP; is not verified by Advocate of OP; complainant has also denied that the mother of the complainant had history of hypertension; complainant reserves its right of taking appropriate action(s) against the said alleged report generated by the hospital; further, the alleged past history of mother of the complainant cannot be linked with the father of the complainant and OP had every right to terminate the policy of the complainant; but the policy was not terminated by the OP as per Clause 7.13 of the policy; had the OP terminated the policy of the complainant, the complainant would have availed the benefit of the other medical facilities/ policies available to him; OP slept over the matter; and neither reimbursed the genuine claim of the complainant; nor communicated to the complainant about termination or forfeiture of the policy; therefore, OP is liable to be reimburse the claimed amount by the complainant; the breach of conditions of clause 7.1 of the policy’s terms and conditions has also been denied by the complainant; OP also, after acknowledging the request of the complainant, vide its Annual Health Check-up Authorization letters; both dated 17.10.2018; authorised parents of the complainant for Annual Health Check-up on 20.10.2018 at Express Clinics Pvt. Ltd., Rohini, Sector-7, Delhi; which depicts that policy of the complainant was still in effect; Unfortunately, father of the complainant could not take benefit of Annual Health Check-up on 20.10.2018 being admitted in the hospital; but the mother of the complainant availed the benefit of the said Annual Health Check-up [copies of the Annual Health Check-up report dated 17.10.2018, 20.10.2018 are available Annexure-6 and 7 (colly.) at page no. 11-18 with the rejoinder]. OP’s allegation in its pleading that the contents of the complaint involves complicated question of the facts which cannot be decided in a summary trial and can only be decided by leading detailed evidence and cross- examination in a Civil Court; has also been denied. Rest of the contents of the parts of reply by OP has also been denied by the complainant in the rejoinder.
4. Both the parties have filed their affidavits of evidence, the complainant has filed affidavit under his signature and pleadings of the complaint have been narrated and reiterated; OP has filed the affidavit under the signature of one Kashif Nazki; stating to be authorized representative/ officer; and perusal of the contents are only the narration and repeatition of the pleadings/reply.
5. Both the parties have also filed their written arguments which are only the depiction of their cases already detailed. We have also heard the oral submission of both the parties.
6.1. We have carefully considered and perused the pleadings, affidavits, documents available on record and written submission, apart from oral arguments of both the sides.
6.2. OP emphasizes that complaint involves dispute and complicated question of facts, which cannot be decided in a summary trial and can only be decided by leading detailed evidence and cross-examination in a Civil Court; has no substance as has also been pleaded by the complainant in his rejoinder.
7.1. There has been mediclaim insurance contract, purchase of policy under reference having names of Ms. Shashi Sharma and Mr. Parmod Sharma- mother and father of the complainant (insured) for some insured to the tune of Rs. 5,00,000/-; having Rs. 12,843/- premium amount and the validity of policy from 25.10.2017 to 24.10.2018, hospitalization and treatment of Sh. Parmod Sharma (insured) father of the complainant; denial of the medi-claim amount by OP and existence an continuation of valid insurance contract between the parties; all these are undisputed and admitted facts.
7.2. OP has rejected the claim of the complainant banking upon Clause 7.1 of terms and conditions of policy which is being quoted as under:-
“7.1. Disclosure to information norm:- if any untrue or incorrect statement are made or there has been a misrepresentation, misdescription 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 policy holder or the Insured Person or any one 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”. [copy of the policy terms and conditions are available at page no. 19-53/ Annexures-B submitted by OP along with reply].
Based upon the aforesaid clause; OP has pleaded that the father (insured) of the complainant was hospitalized at the Sant Parmanand Hospital, Delhi from 19.10.2018 till 21.10.2018; for treatment of fracture Trimalleolar Left Ankle; and complainant applied for cashless facility for an estimated amount of Rs. 1,50,000/-; the said cashless claim was denied; considering the fact that the mother of the complainant; other insured member had not disclosed the history of hypertension; and same was informed to the complainant vide letter dated 19.10.2018.
7.3. OP’s plea that before filing the health claim for the hospitalization of complainant’s father, the complainant had first approached OP with a cashless request vide claim no. 80203374 with respect to the hospitalization of the complainant’s mother [Ms. Shashi Sharma- insured] on 13.09.2018; for Fibroid Uterus and same was denied for non-disclosure of hypertension; which was mentioned in the cashless request form; [Page no. 55 and 56/ Annexure-C]; therefore, claim of the father of the complainant was rejected vide denial letter 19.10.2018 for non-disclosure of material facts/ pre-existing ailment [page no. 57/ Annexure-D]; OP has also submitted on record the denial letter dated 05.09.2015 of Ms. Shashi Sharma [insured]; mother of the complainant and the same is also based on non-disclosure of material facts/ pre-existing ailment at the time of proposal and also the patient having history of hypertension prior to inception of policy [page no. 60 of paper-book/ Annexures-F].
7.4. OP has further asserted that after denial of the claim of Sh. Parmod Sharma [insured and father of complainant]; complainant approached OP for reimbursement of the claim amounting to Rs. 1,09,942/-; but same was also denied in terms of Clause 7.1 of the policy terms and conditions, for non-disclosure of material facts of hypertension of other insured member [Ms. Shashi Sharma, mother of the complainant] and same was informed to the complainant vide letter dated 27.11.2018 as mentioned in the para no. 2.2.
7.5. It is also the cases of OP that complainant had to answer certain questions with respect to any pre-existing history with respect to any illness/ disease/ injury of the insured member; and complainant made the declarations and disclosures in the online proposal as under:-
“A. Does any person(s) to be insured has any pre-existing diseases?
Insured 1(Shashi Sharma)- No
B. Have any of the person(s) to be insured ever filed a claim with their current/ previous insurer?
Insured 1- No
C. Has any proposal for Health insurance been declined, cancelled or charged a higher premium?
Insured 1- No
D. Is any of the person(s) to be insured, already covered under any other health insurance policy of Religare Health Insurance?
Insured 1- No”
From the aforesaid declarations; it is clear that complainant did not disclose the pre-existing disease of Ms. Shashi Sharma- insured, who is the mother of the complainant.
7.6. OP has relied upon the case law i.e. Satwan Kaur vs New India Assurance Company Ltd. (2009) 8SCC 316; wherein, it has been observed that the expression “material fact” is to be understood to mean as any fact which would influence the judgment of a prudent insurer, in deciding whether to accept the risk or not. If the proposer has knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal form. Any inaccurate answer will entitle the insurer to repudiate their liability because there is a clear presumption that any information sought for in the Proposal Form is material for the purpose of entering into a contract of insurance, which is based on the principle of utmost faith- uberrimae fides. OP has also relied upon another case titled Life Insurance Corporation of India vs Shrimati Neelam Sharma pronounced by Hon’ble NCDRC on 30.09.2014; that the statement made in the proposal form were untrue and incorrect and therefore in breach of the Policy Terms and conditions. Thus, it was held that it is not for the insured to determine whether the information sought for the questionnaire was material for the purpose of policies.
7.7. OP’s pleadings to the effect that; had the complainant disclosed current health condition at the time of the inception of the policy, OP would not have offered the Policy to the complainant or otherwise to offer the cover on different terms and conditions; this stand of OP carries weight.
7.8. We also perused the submissions of complainant in his rejoinder; wherein, inter alia, complainant has denied that his mother had history of hypertension; complainant further states that he reserves his right for taking appropriate action(s) against the report generated by the hospital; however, report of the treating doctor has been proved by OP that Ms. Shashi Sharma had history of hypertension since last 8 years; the stand of the complainant that the alleged past history of mother of the complainant cannot be linked with the father of the complainant; but in our considered views since both the insured/ beneficiary [mother and father] of the complainant are covered by medical policy which is result of insurance contract between complainant & OP pursuant to proposal and its acceptance, which constitute contract and both the parties are governed by the insurance contract entered between them vide policy under reference; therefore, terms and conditions of the policy document; having contract between the parties are equally binding both persons, covered under the policy.
8. In view of the above discussions, considerations and examinations of the rival contentions of the parties, we reach to the conclusion that we find no deficiency of service on the part of OP; complainant has failed to prove his stand/ claim; therefore, complaint fails and we hereby dismiss the complaint; no order to cost.
9: Announced on this 2nd June, 2023. Copy of this Order be sent/provided forthwith to the parties free of cost as per rules for necessary compliance.
10. Case file be consigned to record room.
[Vyas Muni Rai] [ Shahina] [Inder Jeet Singh]
Member Member (Female) President
