Chandigarh

DF-II

CC/168/2018

Jasmeen Kaur Bedi - Complainant(s)

Versus

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

R.S. Sidhu

12 Nov 2018

ORDER

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

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Consumer Complaint  No	:	168 of 2018
Date  of  Institution	:	19.03.2018
Date   of   Decision	:	12.11.2018

 

 

 

 

Jasmeen Kaur Bedi wife of Guruparkar Singh Bedi, resident of H.No.2385, Sector 44-c, Chandigarh.  

 

             ……..Complainant

Versus

 

1]  Religare Health Insurance Company Limited, Vipul Tech Square, Tower, 3^rd Floor, If Course Road, Sector 43, Gurgaon 122009 (Haryana)

 

2] Religare Health Insurance Company Limited Registered Office 5^th Floor, 19 Chawla House, Nehru Place, New Delhi 110019

 

3]   Mr.Manish Agent, Religare Health Insurance Company Limited, SCO No.56-58, Sector 9-D, Madhya Marg, Chandigarh 160017 {Deleted vide order dated 21.5.2018}

 

………. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

SMT.PRITI MALHOTRA        MEMBER

            SH.RAVINDER SINGH         MEMBER

 

Argued By: Sh.R.S.Sidhu, Adv. for complainant.

Sh.Sachin Ohri, Adv. for OPs No.1 & 2.

Opposite Party No.3 deleted.

 

PER PRITI MALHOTRA, MEMBER

 

         The case of the complainant, in brief is that, he has subscribed and been issued a cashless Health Insurance Policy by OPs for the period from 28.2.2015 to 27.2.2016 on 5.3.2015 after getting the through medical examination conducted.  It is averred that the complainant and his family members disclosed all the relevant information while proposing for the policy from Opposite Parties.  It is also averred that the said policy was got renewed from 6.3.2016 to 5.3.2017.  It is submitted that the complainant suffered hearing loss in the year 2010 due to loud sound and it was not connected with any disease.  Unfortunately, the complainant for the first time in July, 2017 was diagnosed for Brain Tumer (Schwannoma) as per MRI Report.  The complainant was treated at Medanta Hospital, empanelled with Opposite Parties (Ann.C-3 colly) for Brain Tumer (Schwannoma) and thereafter submitted all the bills payable by Opposite Parties for cashless insurance amount.  However, the OPs rejected the claim of complainant on ground that he has not disclosed the problem of hearing loss suffered in the year 2010 while availing the policy on 28.2.2015 (Ann.C-4 coly).  It is also submitted that the complainant again represented the OPs by sending emails, but the OPs on 1.2.2018 rejected the claim of the complainant and also arbitrarily cancelled the policy. Alleging the said act of the Opposite Parties as deficiency in service on the part of OPs, hence this complaint has been filed.

 

2]       The OPs No.1 & 2 have filed joint reply and while admitting the factual matrix of the case, stated that the complainant approached them with a cashless facility request w.r.t. planned Hospitalization of complainant in Medanta Medcity Hospital, Gurgaon for the treatment of Schwannoma (A non-cancerous tumor on the main nerve leading from the inner ear to the brain) with effect from 7.9.2017.  It is submitted that on perusal of the documents submitted by the complainant, as asked for, and after investigation, it came to the forefront that the complainant was suffering from Hearing Loss and Tinnitus since 2010 and the same was not disclosed at the time of taking the policy, therefore, the cashless facility request was denied as per Clause 7.1 of the policy (Ann.R-2).  It is also submitted that thereafter, the complainant lodged Reimbursement Claim for his hospitalization w.e.f. 7.9.2017 to 8.9.2017 for a billed amount of Rs.3,01,268/-.  It is stated that on perusal of the medical documents submitted by the complainant, it again revealed that the complainant had a history of hearing loss and tinnitus since 2010 and the same was not disclosed at the time of taking the policy, which is a breach of condition of Clause 7.1 of the policy and therefore, the claim was repudiated vide letter dated 10.11.2017 and policy was cancelled on 1.1.2018 in accordance with Clause 7.1 & 7.3 of the policy (Ann.R-8 & R-12).  It is submitted that the claim as well as policy of the complainant was rightly rejected & cancelled respectively for non-disclosure of pre-existing ailment at the time of taking the policy.  Pleading no deficiency in service and denying all other allegations, the OPs NO.1 & 2 have prayed for dismissal of the complaint. 

 

3]      Parties led evidence in support of their contentions.

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

 

5]       It is well evident on record that the complainant obtained Care Health Insurance policy from the Opposite Parties in the year 2015-2016 commencing from 28.2.2015 till 27.2.2016 and thereafter, again applied for the policy afresh in the year 2016 effective from 6.3.2016 to 5.3.2017 and got it renewed for further period from 6.3.2018 to 5.3.2018 (Ann.C-1 colly.). 

 

6]       Admittedly, the complainant was diagnosed with Schwannoma (Brain Tumer) and was treated for the same in Medanta Hospital, Gurugram, Haryana for the period from 7.9.2017 to 9.9.2017 and incurred expenditure to the tune of Rs.3,01,268/- (Ann.C-4).  The claim lodged by the complainant with the Opposite Parties under the policy for reimbursement of said medical expenses was repudiated, hence this complaint.

 

7]       In the backdrop of above evident facts, we have to see whether the repudiation done by the OPs is justified or not?  For such decision, it is pertinent to look into the reason quoted for the repudiation of the claim by the OPs.  The record reveals that it is so submitted by the OPs that during the investigation, while processing the claim lodged by the complainant, it revealed that the complainant was suffering from hearing loss and tinnitus since 2010 and as the same was not disclosed at the time of taking the policy in question, therefore, the cashless facility request was denied following the same the reimbursement claim was also denied and the policy has also been cancelled on 1.1.2018 by the OPs as per Clause 7.1 & 7.3 of the Policy.

 

8]       In view of the terms & conditions of the Policy, we have to see whether the complainant suppressed any fact required to be disclosed at the time of inception of the policy.  The record before us divulge that no suppression has been made by the complainant as she was not under obligation to disclose about any illness/injury suffered by her next before the period of 48 months from the date of policy inception. The record reveals that she was under obligation to answer the question asked in the proposal form whereby she was to disclose about her previous ailment.  For the sake of convenience, we reproduced the question as under:-  

Has anyone been diagnosed/hospitalized or under any treatment for any illness/injury during the last 48 months?

 

9]       It is so mentioned in the reply of the Opposite Parties that the complainant answered in negative to the above question in her proposal form, which in our opinion has rightfully been done by the complainant as there is nothing on record to show that the complainant ever underwent any treatment for the so called pre-existing ailment of hearing loss and tinnitus since 2010, when she was diagnosed for such problem.  There is no record to show that she ever taken any treatment for the same within the period of 48 months prior to inception of the policy in question. So to our considered opinion, the case of the complainant definitely does not fall under the category of suppression of fact as alleged by the OPs. Reiterated that no independent evidence has been brought forward by the Opposite Parties to establish that the complainant ever taken any treatment during the 48 months period prior to inception of the policy in question. 

 

10]      It is well admitted by the Opposite Parties that the complainant applied for the policy in question afresh in the year 2016 commencing from 6.3.2016 to 5.3.2017 and got it renewed for further period from 6.3.2017 to 5.3.2018 and was diagnosed for the ailment of hearing loss in the year 2010 only.

 

11]      From the above discussion, it is held that the Opposite Parties have wrongly & illegally rejected the claim of the complainant as well as cancelled the policy in question, which clearly amounts to gross deficiency in service and unfair trade practice on their part.  Therefore, the present complaint is allowed against the Opposite Parties with following directions:-

1. To reimburse the claim amount of Rs.3,01,268/- to the complainant along with interest @8% p.a. from the date of filing the complaint i.e. 19.3.2018 till realisation;
2. To restore the policy of insurance in the name of subscriber/insured with upto date benefits and renew the policy with same coverage in favour of the insured so applied by the complainant by paying the requisite premium;
3. To pay an amount of Rs.15,000/- as compensation for causing harassment & mental agony to the complainant;
4. To pay an amount of Rs.7000/- towards litigation expenses.

 

         This order be complied with by the OPs within a period of 30 days from the date of receipt of its certified copy, failing which they shall also be liable to pay additional cost of Rs.15,000/- apart from the above relief.

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

Announced

12^th November, 2018                                                              Sd/-

                                                                   (RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER