Chandigarh

DF-II

CC/934/2017

Birinder Singh Dhillon - Complainant(s)

Versus

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

In Person

30 Apr 2018

ORDER

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

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Consumer Complaint  No	:	934 of 2017
Date  of  Institution	:	14.12.2017
Date   of   Decision	:	30.04.2018

 

 

 

 

Birinder Singh Dhillon s/o Jarnail Singh Dhillon, R/o 146, Advocates Society,Sector 49-A, Chandigarh.   

             …..Complainant

Versus

1]  Religare Health Insurance Co. Ltd., Vipul Tech Square, Tower-C, 3^rd Floor, Sector 43, Gold Course Road, Gurgaon – 122009 through its Manager.

2]  Religare Health Insurance Co. Branch Office SCO 56-57-58, Second Floor, Sector 9-D, Chandigarh 160017 through its Branch Manager.  

   ….. Opposite Parties 

 

BEFORE:  SH.RAJAN DEWAN             PRESIDENT

         MRS.PRITI MALHOTRA             MEMBER 

                               

 

 

Argued by :- Sh.B.S.Dhillon, Adv. for the complainant.

  Sh.Sachin Ohri, Adv. for Opposite Parties.

 

 

PER PRITI MALHOTRA, MEMBER

 

         Briefly stated, the complainant purchased Health Insurance Policy No.10261390 from OPs, which was renewed twice and the present policy is effective from 23.4.2017 to 22.4.2018 (Ann.C-1). It is averred that the Opposite Parties issued the said Health Insurance Policy after got conducted the health check-up of the complainant.  It is also averred that the complainant first time faced the problem of hypertension at work and came to know from the Checkup of High Court Dispensary and started taking medicine on 25.1.2017 onwards as per prescription (Ann.C-3).  It is submitted that on 22.10.2017 the complainant suddenly fell sick and as such was admitted in Max Hospital at Bathinda on 22.10.2017 and was discharged from the Hospital on 25.10.2017 (Ann.C-4).  It is also submitted that the request of the complainant at the hospital for cashless facility was rejected arbitrarily.  Ultimately, the complainant had to make the payment of the bill of the hospital to the tune of Rs.27,617/-. Thereafter, the complainant lodged a claim with OPs for reimbursement of said medical bill, but the same was also rejected by the OPs on the ground that the disease of hypertension was pre-existing to the policy.  A legal notice was also sent to the Opposite Parties, but to no avail. Hence, this complaint has been filed alleging deficiency in service on the part of OPs.

 

2]       The OPs have filed joint reply and while admitting the factual matrix of the case, stated that the claim of the complainant was rejected under Clause 6.1 of the Terms & Conditions of the Policy for non-disclosure of material information as the complainant was a known case of Hypertension prior to the inception of the policy.  It is stated that as per Out Patient Card (Ann.R-3) the complainant is specified to be having a history of Hypertension since 7-8 years, which he had concealed from the OPs.  It is also stated that the claim of the complainant has rightly been rejected. Pleading no deficiency in service and denying other allegations, the Opposite Parties have prayed for dismissal of the complaint.

 

3]       Rejoinder has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of the reply filed by OPs.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have also perused the entire record.

 

6]       It is not disputed by the Opposite Parties that the Health Insurance Policy in question obtained by the complainant is running in 3^rd year being continuingly renewed from its inception from 2015-2016, 2016-2017 and 2017-2018. 

 

7]       It is also not disputed that before issuing the Health Insurance Policy in question, at the time of its inception, the complainant was made to undergo thorough medical examination and then was issued the policy in question when was found healthy. Thus, in the given circumstances, it does not lie in the mouth of the OPs to claim that the complainant is suffering from pre-existing disease, when a claim under the policy has been raised by the complainant for the treatment undergone for ‘Acute Anaphylactic Reaction’ (Ann.C-4) during the coverage period.  The OPs have failed to prove the alleged pre-existing disease, claimed to have been suffered by the complainant since 7 to 8 years, by any independent evidence, based on their own enquiry.  The disease suffered by the complainant i.e. ‘Acute Anaphylactic Reaction’ and the alleged hypertension stands far apart and there is no nexus between them, terming the claim untenable under the policy in question. So, the rejection of the claim on account of pre-existing disease or on account of non-disclosure of material information, is not tenable.  Therefore, the repudiation of the claim of complainant done by the OPs is held to be unjustified and amounts to deficiency in service on their part. 

 

8]       From the above discussion and findings, the deficiency in service on the part of Opposite Parties has been proved, which certainly has caused harassment and humiliation to the complainant.  Therefore, the complaint stands allowed against the OPs with direction to reimburse an amount of Rs.27,617/- to the complainant and also to pay compensation cost of Rs.7,000/- along with litigation expenses of Rs.5000/- to the complainant. 

         This order shall be complied with by the Opposite Parties jointly & severally within a period of 30 days from the date of receipt of its certified copy, failing which they shall be liable to pay additional compensation cost of Rs.10,000/- apart from above relief.

 

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

30^th April, 2018                                                                                                                                                              Sd/-

(RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (PRITI MALHOTRA)

MEMBER