Chandigarh

DF-I

CC/1051/2016

Anand Singh Bisht - Complainant(s)

Versus

Religare Health Insurance Co. Ltd. - Opp.Party(s)

Gaurav Bhardwaj

23 Aug 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

 

                               

Consumer Complaint No.	:	CC/1051/2016
Date of Institution	:	06/12/2016
Date of Decision	:	23/08/2018

 

Anand Singh Bisht r/o # 158, Village Palsora, Chandigarh.

… Complainant

V E R S U S

1.     Religare Health Insurance Company Limited, D-3, District Centre, Saket, New Delhi-17 through its Managing Director.

2.     Religare Health Insurance Company Limited, SCO No.28, 2^nd Floor, Sector 20-D, Chandigarh, through its Branch Manager.

… Opposite Parties

 

CORAM :	SHRI RATTAN SINGH THAKUR	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                     

 

ARGUED BY	:	Sh. Gaurav Bhardwaj, Counsel for complainant
	:	Sh. Sachin Ohri, Counsel for OPs.

Per Rattan Singh Thakur, President

1.         The long and short of the allegations contained in the consumer complaint are, on 4.12.2015, complainant had taken online mediclaim policy from the OP and paid the amount of Rs.9,081/- as premium. The sum assured was Rs.5,00,000/- and the policy was valid from 5.12.2015 to 4.12.2016.  Suddenly on 15.9.2016, complainant had fever and remained admitted in the Max Hospital from 15.9.2016 till 21.9.2016. The bill raised and paid was Rs.70,654/- as the pre-authorization was rejected by the OPs on false ground as the complainant had pre-existing disease which was hidden by him at the time of filling up the declaration form. While the complainant claims, he is entitled to have the reimbursement of the amount and, therefore, there was deficiency in service on the part of the OPs.  Hence, prayer is made for directing the OPs to pay the claimed amount of Rs.70,654/- alongwith compensation for mental and physical harassment and costs of litigation. 
2.         OPs have contested the consumer complaint, filed their joint reply and, inter alia, raised preliminary objections denying the allegations of deficiency in service or unfair trade practice. The crux of their defence is, claim was repudiated as the complainant was suffering from serious pre-existing ailment of enhanced Haemangioma in liver alongwith migraine from the last five years and was under continuous treatment. There was concealment of material facts.  On these lines, the cause is sought to be defended.
3.         Rejoinder was filed and averments made in the consumer complaint were reiterated.
4.         Parties led evidence by way of affidavits and documents.
5.         We have heard the learned counsels for the parties and gone through the record of the case.  After appraisal of record, our findings are as under:-
6.         Per pleadings of the parties, the admitted facts are, health policy in question was in existence on the relevant date when the complainant was hospitalized and had taken treatment. These facts are also not in dispute that he had made the payment of Rs.70,654/- for the treatment to the hospital.  The disputed facts are, complainant had concealed the material facts at the time of declaration that he was suffering from serious ailment of enhanced haemangioma in liver. 
7.         We shall have a glance to the documents attached i.e. Annexure R-3 which reflects, in the Department of Radiodiagnosis & Imaging, PGIMER, Chandigarh, complainant had undergone CT scan on 30.5.2015 and he was diagnosed with well marginated geographical focal lesion in segment VI of liver with enhancement pattern characteristic of haemangioma.  Let a note be taken here that the date of issuance of online policy is 4.12.2015 while liver with enhanced haemangioma was detected on 30.05.2015 i.e. around 5-6 months before from the date of purchase of the health policy online by the complainant. 
8.         Not only this, there is also document (Annexure R-4) of Govt. Multi-Specialty Hospital, Sector 16, Chandigarh which shows, complainant had taken treatment of cystitis.  May be, migraine is not so serious an ailment, but, there was definitely treatment being taken by the complainant of enhanced haemangioma.  This benign tumour, needed to be controlled so that it may not cause any damage to the associated parts in the internal system of the body. Suffice it to say, this was material to be disclosed by the complainant in the declaration form on 05.12.2015. However, the declaration form itself shows, questions regarding pre-existing disease were answered in the negative by the complainant. This definitely tantamouts to concealment of material facts.
9.         We have also taken note of (Annexure R-7) and the letter of cancellation of the policy. Its perusal shows, after verification it was found, complainant was a known case of liver disease, which fact was hidden at the time of declaration furnished for the purchase of the policy.  Not only this, so much so, perusal of record i.e. photocopy of the letter dated 9.3.2017 shows the complainant was informed by the insurer i.e. OPs regarding the cancellation of the policy and the amount of premium was forfeited in terms of the insurance policy.
10.         It is settled principle of law, Consumer Forum cannot add or omit any terms and conditions of the policy.  The policy was purchased online and there was no bilateral sitting inter se parties, but, it was accepted by the OPs. The complainant was in no way misled and in the declaration form submitted online he had hidden the serious ailment referred to above thereby he had breached the terms and conditions of the policy. 
11.         The learned counsel for the OPs had relied on case titled as Shashikant Awadooth Rotkar Vs. National Insurance Company Limited, 2017 (3) CPR 424 (NC) vide which the Hon’ble National Commission  had held, it was the responsibility of the person insured to give detailed information of all his ailments and operations conducted upon him.  Suppression of the same amounts to guilty of breach of conditions and the claim was rightly repudiated. This Forum cannot add or subtract the terms and conditions of the policy to which both the parties were signatories.  The complainant is bound by the terms and conditions of the same.  We find no deficiency in service or unfair trade practice on the part of the OPs.
12.         In view of the above discussion, we are of the opinion that there is no merit in the present consumer complaint and the same is accordingly dismissed, leaving the parties to bear their own costs.
13.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-	Sd/-
23/08/2018	[Suresh Kumar Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
hg	Member	Member	President