Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 500
Instituted on : 15.10.2018
Decided on : 04.10.2023
Chanda Singh Pehal S/o Sh. Jai Lal Pehal R/o 897/28, Bharat Colony, Near Sheela Bye-pass, Rohtak.
………..Complainant.
Vs.
Religare Health Insurance Co. Ltd., Vipul Tech Square Tower-C, 3rd Floor, Sector-43, Golf Course Road, Gurugram(Haryana).
……….Opposite parties.
COMPLAINT U/S 35 OF CONSUMER PROTECTION ACT,2019.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR. VIJENDER SINGH, MEMBER.
Present: Sh. Jagdeep Singh, Advocate for the complainant.
Sh. Puneet Chahal, Advocate for opposite party.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case as per complainant are that complainant obtained the Health Insurance Policy for Foreign Travel on 22nd March 2018 on Tourist Visa to travel Australia on 24th March 2018 from opposite party vide policy No.12274705 of plan name gold Ex-US_Canada(single). It was valid from 23rd March 2018 to 12th May 2018 for sum insured USD50000. He paid Rs.10616/- as premium to the opposite party via online medium from Rohtak. It is further submitted that during the stay in Australia he felt slightly indisposed and consulted a private doctor who charged Australian 80 Dollar as consultation fee for the same. After some time he suffered from coughing constantly then referred to Hospital Monash Emergency on 10th April, 2018 and get treatment. During the treatment some fluid was found in his lungs and was admitted in the hospital where the payment of Emergency expenses of Australian Dollar 570 was made. On 11th April, 2018 the complainant was shifted to Hospital Monash Heart and gone through various pathological tests, chest X-ray and heart ECG and heart Echo. After receiving the examination report of test, doctor suggested further treatment which would incurred doctor fees, bed charges and other expenses to Australian Dollar 4000, which the complainant was unable to afford by himself. In order to get further treatment the complainant shared his policy details to Monash Heart Health Staff. On that hospital staff filled Religare Cashless Hospitalization for medical insurance policy form and sent to Religare for treatment approval. Thereafter hospital staff sent various reminders to Religare team and waited for their cashless approval for almost 24 hours. But no update was received from the Religare Health Insurance Team and they finally requested the complainant to be discharged from the hospital as he was unable to afford their daily charges. During the treatment, the complainant had paid all the medical expenses incurred during the stay in the hospital which include one day CCU charges, Chest X-ray, Pathological test and 2D Echo. He had paid total 4780.60AUD and according to Indian currency Rs.2,50,981/-. Due to non-payment of cashless insurance the complainant decided to come back to his country earlier and pre-pond the Airlines ticket of Rs.13,270/- and returned to India on 09th April, 2018. On 30th April, 2018 the complainant received a cashless rejection letter from Religare Health Insurance Co. Ltd. as the company refused to pay the Health Expenses due to hospitalization. Hence, this complaint and the complainant has prayed that opposite parties may kindly be directed to clear all the medical expenses and Airline Ticket fare of Rs.2,64,951/- and to pay Rs.1,00,000/- as compensation and Rs. 25,000/- as litigation expenses to the complainant.
2. After registration of complaint, notice was issued to the opposite party. Opposite party in its reply has submitted that the complainant was admitted on 11.04.2018 till 12.04.2018 at Monash Health Hospital for NSTEMI, Decompensated left heart failure. He applied for cashless facility request for hospitalization. However the same was denied by the opposite party vide letters dated 30.04.2018 under Clause 5.1 of the policy terms and conditions for non-disclosure of material information. The complainant had a history of congestive cardiac failure, coronary artery disease with NSTEMI and is also specified to have undergone CAG in May 2017 and the same was not disclosed to the opposite party at the time of policy inception. As per the discharge card dated 21.05.2017 prepared by Holy Heart advanced cardiac care and research centre, the complainant is specified to have undergone Transradial CAG on 21.05.2017. As per the Coronary Angiography Report dated 21.05.2017, the complainant is specified to have triple vessel disease. It is further submitted that as per the discharge summary prepared by Monash Health, the complainant is specified to have Past Medical History of CCF, Severe LV dysfunction with moderate AR, moderate MR and NSTEMI, Dyslipidemia, triple vessel disease. The complainant had purchased the policy online and had to answer certain questions with respect to any pre-existing history with reference to any illness but the same were not disclosed by the complainant at the time of filling up the proposal form. However the complainant has only disclosed about his pre-existing disease of Hypertension and has failed to disclose about the history of Coronary Artery Disease as the same has not been selected by the complainant in the Online questionnaire. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint.
3. Ld. Counsel for the complainant in his evidence has tendered affidavit Ex.PW1/A, documents Ex.P1 to Ex.P9 and has closed his evidence on dated 11.09.2019. On the other hand, ld. counsel for the opposite party has tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R8 and has closed his evidence on dated 21.12.2020.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. The main objections of the respondents are that the complainant was having pre-existing disease at the time of commencement of the policy. To prove this fact opposite party has placed on record copy of report Ex.R6, which is a report issued by Holy Heart Hospital Rohtak. This report has been issued regarding Coronory Angiography report. Perusal of this report shows that the complainant was suffering from Triple Vessel Disease on dated 21.05.2017. In fact the complainant purchased an insurance policy from the respondent for a period of 51 days i.e. 23.03.2018 to 12.05.2018 and he visited abroad i.e. Australia. The complainant also made a declaration at the time of purchase of policy which is placed on record as Ex.R7 & Ex.R8 by the insurance company. As per the complainant he suffered some cough and uneasiness on dated 10.04.2018 and took treatment from Monash Health hospital and was discharged on 12.04.2018 and spent an amount of 3300AUD on medical treatment. The main contention of the insurance company is that the complainant has concealed the material facts from the insurance company and has not disclosed the true facts before the insurance company at the time of purchase of the policy. We have minutely perused Ex.R6 and Ex.R7. The complainant himself had declared that he was suffering from PED(pre-existing disease) and in reply the complainant has mentioned – ‘Yes’. Moreover he disclosed his pre existing dieses as hypertension and blood pressure. After perusal of this proposal form and declaration we came into the conclusion that after perusal of these documents it is the prime duty of the insurance company to take some other relevant documents to establish that for how many days, he was suffering from hypertension and blood pressure and insurance company could have taken more treatment documents, information and clarification but the insurance company failed to do so. They have not demanded any treatment documents and issued the insurance policy to the complainant without any clarification. Hence there is no concealment on the part of complainant and the repudiation of claim by the opposite party is illegal and amounts to deficiency in service. As such opposite party is liable to pay the treatment expenses to the complainant amounting to $4780.60AUD i.e. total Rs.250981/- as explained in complaint and is proved from the bills placed on record.
6. In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite party to pay an amount of Rs.250981/-(Rupees two lac fifty thousand nine hundred and eighty one only) alongwith interest @9% p.a. from the date of filing the present complaint i.e. 15.10.2018 to till its realization and to pay Rs.10000/-(Rupees ten thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant. Order shall be complied within one month from the date of decision.
7. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
04.10.2023.
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Nagender Singh Kadian, President
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Tripti Pannu, Member.
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Vijender Singh, Member.
