Chandigarh

DF-I

CC/251/2018

Jarnail Singh S/o JAi PAl Singh - Complainant(s)

Versus

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

Abhishek

10 Jul 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I,

U.T. CHANDIGARH

========

 

                                     

Consumer Complaint No.	:	CC/251/2018
Date of Institution	:	30/05/2018
Date of Decision	:	10/07/2019

 

1.      Jarnail Singh S/o Jai Pal Singh, R/o Village Potli, P.O. Khurdban, District Yamuna Nagar (Haryana).

 

2.      Suresh Devi W/o Jarnail Singh S/o Jai Pal Singh, R/o Village Potli, P.O. Khurdban, District Yamuna Nagar (Haryana).

 

3.      Sonam d/o Jarnail Singh S/o Jai Pal Singh, R/o Village Potli, P.O. Khurdban, District Yamuna Nagar (Haryana).

 

4.      Prerak S/o Jarnail Singh S/o Jai Pal Singh, R/o Village Potli, P.O. Khurdban, District Yamuna Nagar (Haryana).

…..Complainants

 

V E R S U S

 

1.      Religare Health Insurance Co. Limited, SCO 56-58, Sector                     9-D, Chandigarh, through its Manager.

 

2.      Jai Laxmi Corporate Services, SCO 5-A, 2^nd Floor, Sector 7-C, Madhya Marg, Chandigarh, through its Manager.

…… Opposite Parties

QUORUM:	RATTAN SINGH THAKUR	PRESIDENT
	MRS.SURJEET KAUR	MEMBER
	DR.S.K.SARDANA	MEMBER

                               

ARGUED BY	:	Sh.Abhishek Singh, Counsel for Complainants.
	:	Sh.Sachin Ohri, Counsel for OP No.1.
	:	OP No.2 ex-parte.

 

PER SURJEET KAUR, MEMBER

1.         The facts, in brief, are, the Complainant and his family opted to port their family health policy of the Oriental Insurance Co. Limited to Religare for the period 18.12.2013 to 17.12.2014 by paying the requisite premium. Finding that the representative of Opposite Parties clicked the option of no port in the form, the Complainants raised the said issue vide letter dated 26.05.2014, upon which the agents of the Opposite Parties forced the Complainants to pay another premium of Rs.25,412/- and issued a new policy ran from 01.06.2014 to 31.05.2015. Thereafter, the Complainants got their health policy renewed till 31.05.2018 by paying the premium for three years. On 26.05.2015, the Complainant No.2 suffered extreme stomach pain and was suggested for biopsy. The Complainant No.2 went to Medanta Hospital, Gurgaon and remained admitted there from 15.07.2015 to 17.07.2015. A bill amounting to Rs.33,643/- was raised, but to the shock and surprise Opposite Party No.1 refused to pay the same and the Complainant has to pay the same. On the discharge summary, it was mentioned that the Complainant No.2 had a history of Menorrhagia since 8 years. The Complainant approached the doctor and sought clarification, who on 25.07.2015 gave his medical opinion that Menorrhagia is not a disease and it is normal being an episode of heavy bleeding. Thereafter, on 31.07.2015 after going through the reports and tests, Complainant No.2 was advised further to get admitted in order to start treatment and possible surgery by the Medanta Hospital and was given an estimate of Rs.1,96,560/- for the same. The Complainant No.2 immediately applied pre-authorization request. However, Opposite Party No.1 denied clearance by giving a baseless reason of non-disclosure of material fact of case of heavy bleeding since 8 years vide letter dated 03.08.2015. Eventually, Opposite Party No.1 served a notice to the Complainant vide letter dated 02.11.2015 and threatened to cancel the policy. The Complainant replied to the said notice vide letter dated 07.12.2015. However, without taking into consideration the reply sent by the Complainant, Opposite Party No.1 arbitrarily cancelled the policy and forfeited the premium amount vide letter dated 10.01.2017. Alleging that the aforesaid acts amount to deficiency in service and unfair trade practice on the part of the Opposite Parties, the complainants have filed the instant complaint.
2.         Notice of the complaint was sent to Opposite Parties seeking their version of the case. However, nobody appeared on behalf of Opposite Party No.2 despite service, therefore, it was proceeded ex-parte on 30.11.2018.
3.         Opposite Party No.1 contested the complaint and filed its written statement, inter alia, admitting the basic facts of the case. It has been pleaded that the policies issued to the Complainants were subject to policy terms and conditions. It has been urged that the Complainant approached the answering Opposite Party for the cashless facility with respect to hospitalization of his wife Suresh Devi in Medanta Hospital, Gurgaon for chest pain, shortness of breath and scleroderma (under observations) with effect from 15.07.2015. Since the insured was admitted in the hospital for conducting investigations only, therefore, cashless claim for the same was rejected as per terms and conditions of the policy. Further, the Complainant again approached the answering Opposite Party for cashless facility request for the admission in Medanta Hospital, Gurgaon with Complaints of abnormal uterine bleeding from 23.07.2015 to 24.07.2015. The said claim was settled to the tune of Rs.33,227/-. However, in the light of subsequent non-disclosure of material facts by the Complainant, recovery process from the Complainant has been initiated for taking a benefit from a non-payable claim. The Complainant further lodged a cashless request for the planned hospitalization of the Complainant’s wife in Medanta Hospital, Gurgaon for undergoing Total Laparoscopic Hysterectomy from 03.08.2015 for an expected amount of Rs.1,96,560/-. The request was thoroughly examined in the light of the documents provided by the Complainant and finding that the insured had a history of Menorrhagia since 8 years and was on medical management for the same from past two years i.e. before the inception of the policy period as well as exertional breathing since 2-3 years and the same was not disclosed by the insured at the inception of the policy, the cashless claim of the Complainant was rejected. Thus, pleading that there is no deficiency in service or unfair trade practice on its part, Opposite Party No.1 has prayed for dismissal of the complaint.
4.         The complainants have filed a rejoinder, wherein they have reiterated all the averments, contained in the complaint, and repudiated those, contained in the written version of Opposite Party No.1.
5.         The parties led evidence in support of their contentions.
6.         We have gone through the entire record and have also heard the arguments addressed by the Learned Counsel for the parties.
7.         In the present case, the claim of the Complainants was denied by the Opposite Parties on the ground that Complainant No.2 was admitted in the hospital for conducting investigations only, therefore, per terms & conditions of the policy, cashless claim for the same was rightly rejected.
8.         Opposite Party No.1 has taken the plea that for conducting tests there was no need to get admitted. Hence, the claim being ingenuine was denied.
9.         It is noteworthy that Complainant No.2 was admitted to the hospital on the advice of doctors who were the experts in their field and it was not a hotel but a hospital where the admission and treatment is done at command of doctors and not the patients and this fact is corroborated by Annexure R-3 where the doctor treating the Complainant No.2 has specifically asked the patient to be admitted. Further, it is relevant to mention that Annexure R-4 clearly shows that doctors found the Complainant No.2 was suffering from severe joint pain and shortness of breath and therefore, for further management and treatment she was admitted on the advice and orders of doctors. Hence, the plea taken by the Opposite Party No.1 is nothing but a clever ploy to run away from its liabilities and to deny the Complainants their rightful claim.
10.         It also has been contended by the Opposite Party No.1 that the fact of ailment of the Complainant No.2 was not disclosed by the insured at the time of inception of the policy. But, as per Annexure C-9 the doctor has specifically stated that the bleeding is not a disease but is a natural phenomenon. Notably, the first policy was taken by the Complainants in the year 2012 and at that time Complainant No.2 was not suffering from any disease including the shortness of breath as is evident from the fact that she was duly examined by the doctors on the panel of the insurance company.
11.         The case in hand is squarely covered by the decision of the Hon'ble National Commission in Neelam Chopra Versus Life Insurance Corporation and Others, R.P. No. 4461 of 2012, decided on 08.10.2018, wherein it was held that the disease for exclusion has to be prevailing at the time when form was filed and if it is under control at that time then claim cannot be rejected. Furthermore, here we are fortified by the decision of the Hon'ble Supreme Court of Indian in Civil Appeal No. 8245 of 2015 titled as Sulbha Prakash Motegaonkar and Ors. Versus Life insurance Corporation of India, wherein the Hon'ble Apex Court has held that even suppressing of common disease does not disentitle the claim completely and in this case the bleeding being a natural phenomenon was not even a concealment of disease. This fact gains strength from the constitutional bench verdict of Hon'ble Supreme Court in Sabrimala’s case in Writ Petition No. 373 of 2006, wherein the Hon'ble Court has held that bleeding is not a disease. It is not the case of the Insurance Company that the ailment with which the Complainant No.2 was suffering from, was a life threatening disease. In fact, the clear case is that the bleeding being a natural phenomenon is not a concealment of disease. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the Complainant No.2 from getting her life insured, the repudiation of the claim was incorrect and not justified.
12.         In the wake of above, it is clear that Opposite Parties have miserably failed in their duties towards the insured and the pain and loss that the Complainant has gone through is solely due to their negligent act. We feel that having created a shield for themselves in coining the lame excuse of as set out herein also amounts to an unfair trade practice on the part of Opposite Parties. Once the question of liability arises the companies resort to one technical objection and the other. These companies really chase people and literally promise everything at the time of selling policy. It is usual to see people struggle to run after Agents to get their rightful claims.  Such agents then look other way and make insurers to make rounds to company offices. Insurers are then made to approach the Courts and are even dragged to this Court on one technical plea or the other. No one really is made to read the terms while making him to sign on the printed forms for selling policies. This attitude must change.
13.         In the light of above observations, the present complaint of the Complainant deserves to succeed against the Opposite Parties, and the same is allowed, qua them. The Opposite Parties are, jointly and severally, directed, to:-

[a]    To accept the premium and renew the policy by treating it in continuity w.e.f. 30.05.2018;

[b]     To pay Rs.33,643/- to the Complainant being the hospital charges paid on 17.07.2015, along with int. @ 9% per annum w.e.f. 10.01.2017 (i.e. the date of repudiation), till it is actually paid.

[c]     To pay Rs.10,000/- to the Complainant on account of deficiency in service, unfair trade practice and causing mental agony and harassment; 

[d]    To pay Rs.7,000/- as cost of litigation;

 

14.         The above said order shall be complied within 30 days of its receipt by the Opposite Parties; thereafter, Opposite Parties shall be liable for an interest @12% per annum on the amount mentioned in sub-para [b] above w.e.f. 10.01.2017, till it is paid. The compensation amount as per sub-para [c] & [d] above, shall carry interest @12% per annum from the date of institution of this complaint, till these are paid, apart from compliance of the directions as in sub-para [a] above.
15.         The certified copies of this order be sent to the parties free of charge. The file be consigned.

 

	Sd/-	Sd/-	Sd/-
10/07/2019	[Dr.S.K.Sardana]	[Surjeet Kaur]	[Rattan Singh Thakur]
	Member	Member	President
“Dutt”