Chandigarh

DF-I

CC/834/2017

Davinder Singh Jaaj - Complainant(s)

Versus

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

Ravi Inder Singh

11 Jul 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

 

                               

Consumer Complaint No.	:	CC/834/2017
Date of Institution	:	29/11/2017
Date of Decision	:	11/07/2019

 

Davinder Singh Jaaj r/o H.No.1053, Sector 27-B, Chandigarh.

… Complainant

V E R S U S

Religare Health Insurance Company Limited through its authorized representative, SCO 28, 1^st Floor, Sector 20, Chandigarh.

IInd Address : D3, P3B, Distt. Centre, Saket, New Delhi 110017.

… Opposite Party

 

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

                                                                    

ARGUED BY	:	Sh. Ravi Inder Singh, Counsel for complainant
	:	Sh. Vishal Sharma, Vice Counsel for Sh. Sachin Ohri, Counsel for OPs

 

Per Rattan Singh Thakur, President

1.         The long and short of the allegations are, since 29.3.2014 complainant had taken a health policy from the OP which was lastly renewed w.e.f 29.3.2016 to 28.3.2017.  His case is, on 18.7.2016, he was admitted in Fortis Hospital, Mohali for treatment of coronary artery disease (CAD) unstable agina and hypertension and discharged on 19.7.2016.  He was examined and treated by Dr. Rakesh Kumar Jaswal.  The complainant had paid the premium of Rs.33,306.36 and additional amount of Rs.8,326.59 as underwriting loading and service tax of Rs.6,036.78 total amounting to Rs.47,670/-. Additional amount was paid as the complainant had disclosed the pre-existing disease at the inception of the policy and sum assured was Rs.5.00 lakhs. OP had raised the bill of Rs.4,69,998/-and it was paid by the complainant as the OP did not agree to the request for the cashless treatment. On submission of the bill for reimbursement, it was repudiated vide letter dated 2.9.2016 on the ground that four years waiting period not expired for treatment of pre-existing disease and its complications. Hence, claim has been cancelled as patient IAK/C/O hypertension and the ailment is a complication of the same. These were the terms and conditions of the policy.  While the treatment which the complainant had taken for CAD is not exclusively the direct result of hypertension and it was being controlled. The repudiation of the claim without valid reasons amounts to deficiency in service.  Hence, the present consumer complaint with the prayer for the refund of Rs.4,69,998/-, Rs.3.00 lakhs on account of deficiency in service and unfair trade practice alongwith interest; Rs.3.00 lakhs on account of mental and physical harassment and Rs.1.00 lakhs as litigation fee.
2.         OP contested the consumer complaint and furnished its reply.  Crux of the reply is admittedly the complainant was suffering from pre-existing disease of hypertension and as per the terms and conditions of policy, there was four years waiting period for treatment of pre-existing disease which period had not expired as the original policy is 29.3.2014 and date of treatment is 2.9.2016. Before repudiating the claim of the complainant, opinion of two doctors was taken that the said CAD could be result of hypertension. As such, claim was repudiated per terms and conditions of the policy.  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 counsel 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, admittedly the pre-existing disease of hypertension was disclosed and extra premium was paid and as per terms and conditions of the policy, there was a four years waiting period for treatment of pre-existing disease. In the situation of the present pleadings and undisputed facts, complainant could only succeed if it is shown that Coronary Artery Disease (CAD) unstable agina was not result of hypertension which was pre-existing otherwise the claim is liable to fail for the simple reasons as waiting period of four years on date of treatment was not over.  Now let us examine the said proposition of law on point of fact and law as per claim of the parties.
7.         Per record produced, complainant was initially treated by Dr. Rakesh Kumar Jaswal, MD (Medicine) DM (Cardiology), Fortis Hospital and he had given his opinion at Annexure C-9 which is reproduced as under :-

“CAD is a multi-factorial disease.  Hypertension is a risk factor for Coronary Artery Disease. In the present case hypertension was not the only risk factor for CAD, patient is 71 years old Asian male with family history of CAD being the non-modifiable risks factor.  As per records available patient blood pressure was adequate controlled.”

 

8.         Per attending on doctor, his opinion reproduced hereinbefore, CAD is a multi-factorial disease and hypertension is one of the risk factors for coronary artery disease and per his report the patient was aged 71 years old Asian male with family history of CAD being non-modifiable risk factor.  We find logic in his report for the reason that the complainant on the date of treatment was aged 71 years i.e. nearing the autumn of his life and at that juncture due to degenerative changes, there is tendency of termination of life and his further opinion was blood pressure was adequately controlled. It is said that old age is in itself a disease, therefore when hypertension pre-existing disease was under control, it cannot be authentically said that CAD for which the complainant was treated is the result of said hypertension. 
9.         It is true that the OP had also taken the opinion of two doctors from Mumbai and their reports are on record which shows that conclusion of one of the doctors was patient Mr. Devinder Singh Jaaj’s coronary artery disease is attributable to his hypertension and although any hypertension treatment reduces the risk of coronary artery disease, it does not neutralize the risk of CAD. Even per opinion of the doctor from Mumbai, anti hypertensive treatment reduces the risk of CAD but it does not neutralize the risk of CAD.  It is also not the case of the OP, complainant was physically/ clinically examined by the said doctors from Mumbai and, thereafter, on examination of treatment record, they have opined so.  Their opinion is based on record produced. Even on the same record physical examination and treatment of doctor from Fortis Hospital, Dr. Rakesh Kumar Jaswal had opined that hypertension was not the risk in the present case.  Keeping in view the fact that attending on doctor had opined hypertension was not the risk and he physically and clinically examined the patient and treated him shows that more weight in comparison to the reports of doctors from Mumbai is to be attached to the report of Dr. Rakesh Kumar Jaswal whose report is logical one, complainant was aged 71 years at the fag end of his life and there was also a genetic history of his family suffering from CAD. From this record, we are of the opinion, report furnished by the doctors from Mumbai is not reliable as the report of Dr. Rakesh Kumar Jaswal appears to be more logical keeping in view the family history of the complainant and his age being 71 years. 
10.         There is no dispute about the contentions raised that this Forum cannot add, delete or create a new agreement between the parties and the insurer and the present insured have to be bound by the terms and conditions of the certificate of insurance.  But, in the present case, we record a finding that hypertension pre-existing disease had no nexus with the CAD.  We hold so in our opinion as such. 
11.         The learned counsel for the complainant has relied on case titled as Satish Chander Madan Vs. M/s Bajaj Allianz General Insurance Co. Ltd., 2016 (1) CPJ 613 (NC) and the relevant paragraphs No.9 to 11 thereof are reproduced as under :-

“9. We do not find merit in the above contention. On perusal of the copy of the medical report of the petitioner dated 4.6.2010 issued by Dr. David P. Lipkin as also the letter of the doctor dated 7.6.2010 addressed to Dr. M. Fertleman of Wellington Hospital would show that as per the observations of Dr. David P. Lipkin, the petitioner had a previous history of hypertension and he was on BP medicine Telmisartan. The above referred reports do not mention that the petitioner disclosed any previous history of heart problem. Therefore, the only fact established by the above reports is that the petitioner prior to obtaining insurance policy was having history of hypertension. This, however, does not lead to conclusion that petitioner was also having previous history of heart problem. Therefore, the insurance claim submitted by the complainant for treatment of his heart problem cannot be termed as a claim in respect of a pre existing disease. Thus, repudiation of insurance claim by the respondent opposite party is not justified.

10. Learned Counsel for the respondent has contended that it is established on record that the petitioner was having a previous history of hypertension and since hypertension can lead to heart problem, the respondent was justified in repudiating the claim on the ground that the heart problem suffered by the petitioner was caused by pre existing hypertension. There is no merit in this contention. Hypertension is a common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack. Therefore, the argument advanced by respondent is far fetched and is liable to be rejected.

11. In view of the discussion above, it is clear that State Commission has committed a grave error in deviating from the real facts in allowing the appeal of the respondent resulting in dismissal of complaint on conjectures and surmises. The impugned order, therefore, cannot be sustained. We, accordingly allow the revision petition, set aside the impugned order and restore the order of the District Forum.”

 

Further relied on case titled as Religare Health Insurance Company Ltd., Vs. Subhash Chander Aggarwal, 2017 (3) CLT 140 and the headnote is reproduced as under :-

                “Consumer Protection Act, 1986 Sections 2(1)(g) and 15 Medical claim – Repudiation and cancellation of policy and refund on ground of concealment of pre-existing disease hypertension – Deficiency in service – Complaint before District Forum allowed – Challenged – Whether Hypertension is a disease which is required to be referred in proposal form – Hypertension is a common disease and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack and repudiation on account of pre-existing disease was not justified – Therefore, ground that complainant suffering from hypertension not corroborated on basis of evidence on record – Further, as per terms and conditions of policy, OPs failed to prove on record that complainant before taking policy was suffering from any pre-existing disease which was concealed by him at the time of taking policy – Originally mediclaim policy taken by complainant from Star Health and Allied Insurance Co. Ltd. –In year 2010 and he shifted to OPs in year 2013 on representation of representative of OPs – It was continuous policy – In year 2011 he had some problem of Hypertension, it was after 2010 when mediclaim policy was taken for first time by complainant from Star Health and Allied Insurance Co. Ltd. and then shifted to OPs – Therefore, it is not a pre-existing disease – No material information was concealed by insured at time of taking policy – Claim was wrongly repudiated by OP on a frivolous ground for which they did not have any evidence – Hence, appeal dismissed with cost of Rs.10,000/- (2016) CP 613 (NC), relied on.”

 

12.         In view of the above discussion, the present consumer complaint succeeds and the same is accordingly partly allowed. OP is directed as under:-

1. To pay the claim amount of Rs.4,69,998/-to the complainant alongwith interest @ 9% per annum from the date of repudiation i.e. 2.9.2016 till realization.
2. To pay an amount of Rs.20,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay Rs.10,000/- to the complainant as costs of litigation.

13.         This order be complied with by the OP within thirty days from the date of receipt of its certified copy, failing which, it shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
14.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

	Sd/-	Sd/-
11/07/2019	[Surjeet Kaur]	[Rattan Singh Thakur]
hg	Member	President