Chandigarh

DF-I

CC/644/2015

Asha Rani Mehta - Complainant(s)

Versus

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

Anju Arora

25 May 2016

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

============

Consumer Complaint  No	:	CC/644/2015
Date  of  Institution	:	24/09/2015
Date   of   Decision	:	25/05/2016

 

 

 

 

 

Asha Rani Mehta wife of Shri S.C. Mehta, resident of House No.2647, Sector 47-C, Chandigarh.

 …………… Complainant.

Vs

 

[1]  Religare Health Insurance Company Ltd., through its Managing Director, GYS Global, Plot No.A3, A4, A5, Sector 125, Noida, U.P. 201301, having its registered office, Religare Health Insurance, D-3, District Centre, Saket New Delhi-17.

 

[2]  Jai Lakshmi Cooperative Services, Intermediary Code 20005799, Intermediary RM Code HARSWARUP C/o GYS Global, Plot No.A3, A4, A5, Sector 125, Noida, U.P. 201301, having its registered office, Religare Health Insurance, D-3, District Centre, Saket New Delhi-17.

 

[3]  Branch Manager, Religare Health Insurance Company Ltd., SCO No.28, 2^nd Floor, Sector 20-D, Chandigarh.

 

……………  Opposite Parties

 

BEFORE:    MRS.SURJEET KAUR                PRESIDING MEMBER

           SH.SURESH KUMAR SARDANA         MEMBER

 

For Complainant	:	Ms. Anju Arora, Advocate
For Opposite Parties	:	Sh. Sahil Abhi, Advocate

 

PER SURJEET KAUR, PRESIDING MEMBER

 

 

          The facts germane to this Consumer Complaint are these. The Complainant had purchased Health Insurance Policy No.10198939 of OP-Insurance Company, commencing from 25.1.2015 to 24.1.2016, by paying a premium of Rs.22,775/-. It has been averred that it was only after thorough examination of the Complainant by the doctors of the OP-Insurance Company, the policy was issued to her. The Complainant was diagnosed by PGIMER, Chandigarh as “Colon (biopsy) – Adenocarcinoma, moderately differentiated” and was advised Surgery of SigmoidalCA during first week of September 2015. On 31.08.2015 the Complainant was admitted in Fortis Hospital, Mohali for her treatment and was operated upon 1.9.2015. It has been alleged that upon intimation, the cashless facility was denied by Opposite Party No.1 on the ground that the Complainant was a known case of hypertension since last 7-8 years, which fact she did not disclose at the time of policy proposal. According to the Complainant, Hypertension has no nexus or relation with the disease with which she was treated for. Hence, with the cup of woes brimming, the Complainant has filed the instant consumer complaint, alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties.

 

2.      Notice of the complaint was sent to Opposite Parties seeking their version of the case.

 

3.      Opposite Parties in their joint written statement have pleaded that there was non-disclosure, suppression and concealment of material facts regarding the health of the Complainant by her at the time of obtaining the insurance policy. After the receipt of the cashless authorization and other supporting documents and information from Hospital and the Complainant and after due application of the mind by the Officials and panel of the Company, the cashless authorization request of the Complainant so raised, was declined vide letter dated 3.9.2015 on the ground that the Complainant was a known case of Hypertension for the past 7-8 years which was not disclosed at the time of policy proposal, hence cashless claim was rejected. All other allegations made in the Complaint have been denied and pleading that there was no deficiency in service on their part, Opposite Parties have prayed for dismissal of the complaint.

 

4.      The complainant has filed a rejoinder, wherein she has reiterated all the averments, contained in the complaint, and repudiated those, contained in the written version of Opposite Parties No.1 to 3.

 

5.      Parties were permitted to place their respective evidence on record, in support of their contentions.

 

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

 

7.      Learned counsel for the Complainant contended that the Complainant availed health insurance policy, valid from 25.1.2015 to 24.1.2016, from Opposite Parties, after undergoing thorough medical examination, as required by the Opposite Parties a pre-condition to be fulfilled before issuing the policy in question. It has been further contended that as per the opinion of the expert doctor of the Opposite Parties the Complainant was not suffering from any ailment and was found completely fit to get the insurance under the policy in dispute. It has been urged that unfortunately the Complainant during the currency of the above said insurance policy was diagnosed as the case of Adenocarcinoma moderately differentiated vide biopsy no. –S-18274/2015 on 10.08.2015 (after brief illness) and was further advised surgery of SigmoidalCA and such treatment was availed by the Complainant as per the advice.

 

8.      The main grouse of the Complainant is that despite widely covered under the above Policy, the Opposite Parties declined her reimbursement of the claim raised. Challenging the rejection by the Opposite Parties being illegal and arbitrary, the Complainant has claimed the reimbursement of her medical expenses, along with compensation for harassment and litigation expenses.  

 

9.      On the contrary, the learned counsel for the Opposite Parties submitted that they rightly rejected the claim of the Complainant only after thorough examination of the documents and the terms & conditions of the policy. It has been submitted that from the medical record of the Complainant, it is revealed that she was having medical history of hypertension since 7-8 years, which she concealed and did not disclose against the column mentioned in the proposal form mandating true disclosure of her health status. It has been further claimed that as per Clause 6.1 of the policy terms & conditions i.e. Disclosure to information norm “If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particulars or any material information having been withheld or if a claim is fraudulently made or any fraudulent means or devices are used by 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 to the company”. 

 

10.      It has further been stated that the Fortis Hospital had sent cashless authorization on behalf of the Complainant to Opposite Parties, for processing and settlement of the medi-claims in accordance with the terms & conditions of the policy. After the receipt of the authorization request for cashless remittance under the aforesaid policy on behalf of the Complainant, Opposite Parties vide their letter dated 29.08.2015 and 02.09.2015 called upon the Hospital to submit the documents/ information as detailed in the said letter in order to process the cashless remittance under the policy in question. Simultaneously the case was investigated in order to judge the viability of the claim. As per the information provided by the Complainant herself in the questionnaire supplied by the Opposite Parties, the Complainant was taking treatment for Hypertension for the past 7-8 years from Dr. Goyal and has been taking the tablet Zorat-H for past few years. Also for past 4-5 years she has bene taking treatment for depression from PGI Chandigarh, which was not disclosed at the time of taking of the policy in question.  It has been further averred that insurance contract is a contract based on good faith and the principle of Uberrimae fides. The Complainant was under duty to disclose all correct facts about her health at the time of the proposal, but she failed to do so.

 

11.      It is pertinent to note that vide Annexure  R-4 dated 29.08.2015 and Annexure R-5 dated 02.09.2015, the Opposite Parties enquired from the Hospital and asked for certain clarification about the Complainant’s ailment. But, surprisingly, the Opposite Parties issued the cashless denial Annexure C-3 on the very next day of the same i.e. on 03.09.2015, without placing on record the required information, which was supplied by the Hospital and sought by the Opposite Parties themselves.

 

12.      At the outset, it is right to state that denial of the claim by the Opposite Parties is not genuine for the reason that record reveals that before issuing the policy in question the Complainant undergone thorough medical examination and was declared as a fit person to avail the Policy in question. The medical examination record has been placed on record by the Opposite Parties themselves corroborates the above finding. The claim of the ops that the Complainant concealed her previous history of Hypertension in order to avail the Policy is totally wrong and baseless. In our opinion, once the Complainant presented herself for the thorough medical examination as mandated by the Opposite Parties, then the question of concealment, non-disclosure, has no relevance. The policy in question was not a policy which was issued only on the basis of disclosure made by the Complainant rather, in order to enquire the truthfulness of the disclosures made in the proposal form specific medical examination was required. We have thoroughly gone through the check list for ‘Religare Health Insurance’ placed on record at page no.123 by the Opposite Parties. This medical test report nowhere reveals that the Complainant was suffering from any disease. The doctors who conducted the medical examination of the Complainant were required to take three readings at 10 minutes interval in order to record the blood pressure of the Complainant, but it has revealed that only one reading was taken. Meaning thereby, the doctor was satisfied about the health status of the Complainant only in the first instance of the blood pressure check-up. This shows that the doctors of the Opposite Parties either lagged in performing their duties as expected or required. Thus, the Opposite Parties have no right to blame that the Complainant did not disclose the factum of her disease of Hypertension in the proposal form. If the Opposite Parties have to believe only the disclosure made by the Complainant in the proposal form, then what was the necessity of mandating the medical examination before issuing the Policy? Therefore, the denial of the medi-claim by the Opposite Parties despite the fact that insured (Complainant) was thoroughly medically examined by the doctors of the Company and no abnormality was found in the health, is not justified at all. The Opposite Parties have miserably failed to prove their case.

 

13.      In the light of above observations, we are of the concerted view that the Opposite Parties are found deficient in giving proper service to the complainant and having indulged in unfair trade practice. Hence, the present complaint of the Complainant deserves to succeed against the Opposite Parties, and the same is allowed, qua them. Pertinently, it is revealed vide bill annexed at page no.55 of the paper book that the Complainant incurred an amount of Rs.4,03,602/- for her treatment; whereas, as per the Policy Annexure C-1 the Complainant is insured for Rs.4,00,000/-. Therefore, we are of the opinion that the Complainant is entitled for reimbursement up to the extent of the sum insured only. The Opposite Parties are directed, jointly and severally, as under:-

1. To reimburse the medi-claim of the Complainant to the tune of Rs.4,00,000/- being sum assured as per the terms & conditions of the Policy.
2. To pay Rs.20,000/- as compensation for mental agony and harassment caused to the complainant;
3. To pay Rs.10,000/- as costs of litigation. 

 

14.      This order be complied with by the Opposite Parties within one month from the date of receipt of its certified copy, failing which they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @12% per annum from the date of filing of the present complaint till realization, apart from compliance of direction at Sr.No.(iii) above.

 

15.      The certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced

25^th May, 2016                                           Sd/-          

(SURJEET KAUR)

PRESIDING MEMBER

 

Sd/-

(SURESH KUMAR SARDANA)                                                                                                      MEMBER

“Dutt”