DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT AT AMRITSAR, PUNJAB.

 

Complaint Case No : RBT/CC/2018/338

Date of Institution : 10.05.2018/29.11.2021

Date of Decision : 16.08.2022

Deepak Kumar age 57 years son of Late Shri Puran Chand Gupta, resident of House No. 40, Katra Sher Singh, Scheme No. 2, Amritsar. …Complainant

Versus

1. Religare Health Insurance Company Limited, GYS Global, Plot No. A-3, A-4 and A-5, Scheme 125, Noida (UP). 

2. Religare Health Insurance Company Limited, C-Block, District Shopping Complex, Ranjit Avenue, Amritsar. 

…Opposite Parties

Complaint U/S 11 and 12 of The Consumer Protection Act, 1986

Present: Sh. Varun Bedi Adv counsel for complainant.

Sh. RP Singh Adv counsel for the opposite parties.

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Sh. Navdeep Kumar Garg : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant filed the present complaint under Section 11 and 12 of the Consumer Protection Act against Religare Health Insurance Company Limited, Noida and another. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant obtained Health Insurance Policy from the opposite parties vide policy No. 10031675. The complainant is obtaining Health Insurance policy from the opposite parties since 2013 a which facts is also admitted by the opposite parties. The last premium was paid by the complainant to the opposite parties in the month of July 2017 amounting to Rs. 22,592/-. 

3. It is further alleged that in the month of November 2017 during the existence of said insurance policy complainant suffered chest pain for which he contacted with the doctors of Shri Guru Ram Dass Hospital, Amritsar who advised the complainant to get his ECG conducted. The complainant conducted his angiography from where it has been opined that some blockage is in the heart of the complainant and doctors advised him to get treatment from Fortis Hospital, Amritsar. Before admitting to Fortis Hospital the complainant contacted Sh. Sandeep Mehta Incharge of opposite parties at Amritsar who also advised the complainant to get his treatment from Fortis Hospital. Then, complainant remained admitted in Fortis Hospital and Bye Pass surgery of heart of the complainant was conducted for which he incurred a sum of Rs. 2,12,235/- towards medicines and other test charges. The report of bye pass surgery was prepared by Dr. Rishi Goenka of Fortis Hospital in which he negligently made remarks that the complainant is suffering from Hypertension for the last 20 years and signatures of the complainant was taken by the officials of the opposite parties on that wrong report when complainant was under the treatment and was provided Anesthesia and was not in sound position. Later on when Dr. Goenka realized his mistake he made necessary correction on the report by putting his signatures and made the actual facts that complainant is suffering from hyper tension for the last 20 months instead of 20 years. Thereafter discharge report of complainant has been prepared by the hospital authority which was neglected by the opposite parties. It is further alleged that before getting health insurance policy in the year 2013 opposite parties have conducted entire medical test of the complainant which clearly shows that the complainant was not suffering from any kind of disease including hypertension, diabetics etc and it has been mentioned in the medical report that complainant is quite fit and fine and not suffering from any disease. Since the day of discharge the complainant has been roaming from one door to another of opposite parties but they linger on the matter on one pretext or the other. The complainant also served legal notice dated 19.3.2018 upon the opposite parties and opposite parties have given false and frivolous reply dated 10.4.2018 and in para No. 2 of the reply it is admitted by the opposite parties that complainant was not suffering from hypertension and high blood pressure but failed to make payment of medical bill of the complainant, which amounts to deficiency in service and unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to make the payment of the medical bill of the complainant of Rs. 2,12,235/- alongwith interest at the rate of 18% per annum from the day when the bills were submitted by the complainant to the opposite parties.  

2) To pay Rs. 50,000/- on account of compensation for mental agony and harassment. 

3) To pay Rs. 22,000/- as litigation expenses.

4) Any other relief to which the complainant is found entitled. 

4. Upon notice of this complaint, the opposite parties filed written statement taking preliminary objections that complainant has not come to the court with clean hands. In this case after receiving the claim and documents it has transpired that complainant was suffering from hypertension for the last 20 years but this fact was not disclosed by the complainant in the proposal form so the claim was repudiated as per Clause 7.1 of terms and conditions of the policy which stated that 'If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particular or any material information having been withheld or if a claim is fraudulently made or any fraudulent means or devices are used by the policyholder or insured person or any one acting on his/her behalf the company shall have no liability to make payment of any claim and the premium paid shall be forfeited to the company.”

5. The complainant approached the opposite parties with a cashless facility request via treating hospital with respect of the hospitalization of the complainant in Fortis Hospital, Amritsar for CAD-ACS, TVD with effect from 21.11.2017. On receipt of cashless facility request and perusal of medical documents submitted thereof it was found that the complainant is mentioned in the cashless form to have a history of hypertension since 6 months. The opposite parties sent a query letter dated 21.11.2017 to the complainant the provide some documents for proper assessment of claim and complainant submitted requisite documents. The opposite parties also initiated claim investigation and found that complainant has a pre existing history of hypertension for the last 20 years and same was not disclosed at the time of taking the policy in the proposal form, so the cashless facility request of the complainant was denied vide clause 7.1 and same was informed to the complainant vide letter dated 22.11.2017. After that complainant approached the opposite party with a reimbursement claim with the respect to the said hospitalization of the complainant from 21.11.2017 to 28.11.2017. On perusal of documents submitted with claim it came to notice that as per record sheet dated 21.11.2017 issued by treating hospital the complainant is mentioned to have hypertension since 20 years. Further, as per questionnaire administered by the investigator to the complainant dated 22.11.2017 the complainant duly mentioned to have suffering from hypertension for the last 20 years. The said questionnaire is duly signed by the complainant. The opposite parties also took an expert opinion to substantiate the fact that the current CAG-TVD disease is related to the history of hypertension of complainant. The complainant's coronary artery disease with triple vessel disease is attributable to his 20 years history of hypertension. So, the reimbursement claim of the complainant was denied vide letter dated 20.12.2017. It is mentioned in the proposal form that 1) Is any member proposed to be insured suffering from any illness or disease ? If yes, please provide details: The complainant replied in Negative. 2) Hypertension The complainant replied in Negative 3) Has anyone been diagnosed/hospitalized or under any treatment for any illness/injury during the last 48 months? The complainant replied in Negative. It is the duty of the complainant to disclose all material facts to the insurer in order to assess the risk as per its capacity. The complainant breached the policy terms and conditions. The complainant was subjected to pre-policy medical examination test but he did not disclose that he is suffering from hypertension so relevant tests have not been carried out by the opposite parties. In the medical examination form also it is mentioned that Please Select if you have suffered from any of the following conditions: High Blood Pressure: Yes/No Answer: No. So the claim was rightly repudiated and notice for cancellation of policy was issued dated 3.2.2018 and since no reply was given by the complainant the policy has been cancelled vide letter dated 17.3.2018. The complainant has no cause of action or locus standi to file the present complaint. 

6. On merits, the opposite parties submitted the same submissions as mentioned in the preliminary objections so there is no need to repeat the same. However, the opposite parties submitted that if the complainant has procured any report regarding suffering from hypertension for the last 20 months which is wrong, which shows that the complainant has influenced the doctor to get the favorable report to get the claim whereas he was suffering from hypertension for the last 20 years. Lastly, the opposite parties prayed for the dismissal of the present complaint.

7. To prover his case the complainant tendered in evidence his  own affidavit Ex.C-1/A, affidavit of Sahil Gupta Ex.C-1, affidavit of Vinod Kumar Ex.C-2, discharge summary report Ex.C-3, documents Ex.C-4 to Ex.C-20 and closed the evidence. 

8. To rebut the case of the complainant the opposite parties tendered in evidence copies of documents Ex.OP-1,2/1 to Ex.OP-1,2/18,  copy of policy 2014-15 Ex.OP-1,2/19, copy of policy 2015-16 Ex.OP-1,2/20, copy of policy Ex.OP-1,2/21, copy of policy 2017-18 Ex.OP-1,2/22, copy of correction made by the doctor in Pre Anesthesia  check up Ex.OP-1,2/23 and closed the evidence.   

8. We have heard the learned counsel for the parties and gone through the record on the file. Written arguments also filed by the opposite parties. 

9. The complainant alleged in the complaint that the complainant obtained Health Insurance Policy from the opposite parties since 2013 and the last premium was paid by the complainant to the opposite parties in the month of July 2017. During the month of November 2017 complainant suffered chest pain for which he contacted with the doctors of Shri Guru Ram Dass Hospital, Amritsar who advised the complainant to get his ECG conducted. The complainant conducted his angiography from where it has been opined that some blockage is in the heart of the complainant and doctors advised him to get treatment from Fortis Hospital, Amritsar. Then, complainant remained admitted in Fortis Hospital and Bye Pass surgery of heart of the complainant was conducted for which he incurred a sum of Rs. 2,12,235/- towards medicines and other test charges. The report of bye pass surgery was prepared by Dr. Rishi Goenka of Fortis Hospital and he negligently made remarks that the complainant is suffering from Hypertension for the last 20 years instead of 20 months. The complainant further alleged in the complaint that before getting health insurance policy in the year 2013 opposite parties have conducted entire medical test of the complainant which clearly shows that the complainant was not suffering from any kind of disease including hypertension, diabetics etc. The complainant applied for reimbursement of the claim amount with the opposite parties but the same has been repudiated by the opposite parties, which amounts to deficiency in service and unfair trade practice.  

10. On the other hand the opposite parties filed written version and alleged that in this case after receiving the claim and documents it has transpired that complainant was suffering from hypertension for the last 20 years but this fact was not disclosed by the complainant in the proposal form so the claim was repudiated as per Clause 7.1 of terms and conditions of the policy which stated that 'If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particular or any material information having been withheld or if a claim is fraudulently made or any fraudulent means or devices are used by the policyholder or insured person or any one acting on his/her behalf the company shall have no liability to make payment of any claim and the premium paid shall be forfeited to the company.” The rest facts of the complaint are admitted by the opposite parties regarding the submission of claim and treatment. The opposite parties alleged in the written version that complainant was suffering from Coronary Artery Disease with Triple Vessel Disease is attributable to his 20 years history of hypertension so the reimbursement claim of the complainant was denied vide letter dated 20.12.2017. The opposite parties further alleged in the complaint that the complainant concealed this fact while taking the policy in the proposal form. The opposite parties further alleged that the complainant breached the terms and conditions of the policy and the claim was rightly repudiated and notice of cancellation of policy was issued on 3.2.2018 and since no reply was given by the complainant the policy has been cancelled vide letter dated 17.3.2018. 

11. The only dispute in the present complaint is that whether complainant was suffered from hypertension for the last 20 years or 20 months because the claim has been repudiated by the insurance company only on this ground that the complainant was suffered from hypertension for the last 20 years and he has concealed material facts from the insurance company/opposite parties.

12. The complainant mentioned in the complaint that Dr. Rishi Goenka of Fortis Hospital, Amritsar initially made remarks that complainant was suffering from hypertension for the last 20 years. Thereafter, the said doctor made necessary correction by putting his signatures/initial and made the actual fact that the complainant is suffering from hypertension for the last 20 months instead of 20 years. The complainant has produced the discharge card dated 28.11.2017 Ex.C-3 in which the column regarding the past history is filled hypertension x 20 months. It is cleared from the said document that while discharging from the hospital they have mentioned the past history of hypertension disease of complainant was 20 months. The complainant has also produced document Ex.C-14 of Fortis Hospital Pre-Anesthesia Check Up Questionnaire and Record in which doctor cut the 20 years and mentioned 20 months and put his signatures on the correction. 

13. The learned counsel for the complainant argued that before getting the health insurance policy in the year 2013 the opposite parties have conducted entire medical tests of the complainant which clearly shows that the complainant is not suffering from any kind of disease i.e. hypertension and high blood pressure etc. The learned counsel for the complainant also argued that the opposite parties have produced the document Ex.OP-1.2/14 on 13.7.2018 i.e. Medical Examination Form vide which it established that the Health India TPA Services Private Limited examined the complainant before issuing the policy on 22.7.2013 in which Dr. Ravinder Pal Singh clearly mentioned that the complainant is not suffering from any chest pain or high blood pressure. Learned counsel for the complainant further argued that from the documents produced by the opposite parties it established that before commencement of the policy the complainant was not suffering from any kind of hypertension and this fact is also established from Ex.OP-1.2/14. 

14. On the other hand the learned counsel for the opposite parties argued that the complainant was suffering from hypertension for the last 20 years and the opposite parties also produced the document Ex.OP-1.2/7 i.e. Pre-Anesthesia Check Up Questionnaire and Record in which it is mentioned that the complainant is suffering from hypertension for the last 20 years. The learned counsel for the opposite parties further argued that the medical reports and treatment was examined by Dr. CH Asrani and he made his opinion regarding that.- 1) Is hypertension a significant risk factor for coronary artery disease Answer Yes as referenced above hypertension is an established and accepted strong predictor of coronary artery disease. 2) Can Patient's coronary artery disease be attributed to his 20 years history of hypertension? Answer Yes, patient's coronary artery disease with triple vessel disease is attributable to his 20 years history of hypertension as it has been established that hypertension is strong predictor of coronary artery disease. Learned counsel further argued that the claim of the complainant was rightly repudiated as per terms and conditions of the policy because the complainant has concealed his disease while taking the policy. 

15. In reply learned counsel for the complainant argued that the report/opinion given by Dr. CH Asrani is based upon the medical record which was sent by the opposite parties. The medical record sent by the opposite parties is not correct as the form of Pre-Anesthesia Check Up and Record was corrected later on by doctor of Fortis Hospital and the said doctor mentioned 20 months instead of 20 years, therefore, the said report has no value because same opinion was given by Dr. CH Asrani on the basis of documents/medical record given by opposite parties.

16. From the above discussion it established that from Ex.C-3 the discharge card of the complainant the hospital clearly mentioned that the patient was history of hypertension for last 20 months and the doctor of hospital also corrected the Pre-Anethesia check up and record and cut 20 years by mentioning 20 months. The said document is Ex.C-14. The opposite parties have failed to produced any strong evidence to prove that the complainant was suffering from hypertension for the last 20 years and it is also established that before issuing the policy in the year 2013 the Health India TPA Services Private Limited examined the complainant and doctor made the report that the complainant was not suffering from any chest pain or high blood pressure. Therefore, it established that the claim of the complainant was repudiated vide letter dated 20.12.2017 was unreasonable and unjustified. The complainant has produced the receipts of hospital i.e. Ex.C-15 to Ex.C-19, total of whose comes to Rs. 2,01,505/-. 

17. In view of the above discussion and evidence produced by both the parties the present complaint is partly allowed and opposite parties are directed to pay the amount of Rs. 2,01,505/- to the complainant on account of treatment taken by him from Fortis Hospital Amritsar alongwith interest at the rate of 6% per annum from the date of filing of present complaint till actual realization. The opposite parties are also directed to pay Rs. 15,000/- to the complainant as compensation for mental tension and harassment and Rs. 5,500/- as costs and litigation expenses. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Both the opposite parties jointly and severally liable to comply with the above mentioned order. Copy of the order will be supplied to the parties by the District Consumer Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar. 

ANNOUNCED IN THE OPEN COMMISSION:

        16th Day of August 2022

 

 

            (Ashish Kumar Grover)

            President

              

(Navdeep Kumar Garg)

Member