Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 227
Instituted on : 09.05.2019.
Decided on : 19.12.2023.
Ritesh Gupta age 44 years, s/o Sh. Jagdish Rai Gupta R/o H.No.183, W.No.34, Near Tara Hotel WaliGali, Janta colony, Rohtak.
………..Complainant.
Vs.
- Religare Health Insurance Co. Ltd. GYS Global, Plot No.A-3, A-4, A-5, Noida, UP through its Director-Services/Authorized official.
- Branch Office: Lower Ground Floor, Shop No.D, Ashoka Plaza, Delhi Road, Rohtak through its Branch Manager/authorized official.
……….Opposite parties/respondents.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR.VIJENDER SINGH, MEMBER
Present: Sh.Birender Saini, Advocate for complainant.
Sh.PuneetChahal, Advocate for the opposite party no.1.
Opposite party No.2 already given up.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case as per complainant are that on 28.07.2015 the complainant availed a health policy covered for the medical claims etc. including the family members of the complainant. The opposite parties issued the policy vide no.10344992 dated 28.07.2015 to 27.07.2016 for Rs.500000/- and thereafter the same was renewed as per the annual schedule and lastly renewed for the period 05.08.2018 to 04.08.2019. . In the month of November 2018, the spouse of complainant namely Veena Gupta suffered a Gynaecological disorder and the doctor advised for a surgical operation regarding the condition of the spouse of the complainant. Consequently an operation was conducted by the doctor and uterus of the spouse of the complainant was removed at Chaudhary Maternity &Surgical Hospital, Rohtak on 08.11.2018 and she was discharged on 11.11.2018. The complainant filed the claim under the policy in question and furnished all the requisite documents and form for disbursement of the claim. Opposite parties sent an intimation dated 04.12.2018 regarding some deficiency in the claim and the complainant in due compliance of the said letter submitted all the requirements before the opposite parties. Thereafter, the opposite parties sent 3 claim denial letters dated 24.12.2018, submitting therein that : “Non disclosure of chronic cervicitis and secretory endometrium at the time of policy inception and non disclosure of material facts/pre- existing ailments at the time of proposal respectively”, which are self contradictory and self unjust of claim for the spouse of complainant. The act of opposite parties of repudiating the claim on unreasonable grounds is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that opposite parties may kindly be directed to pay the insurance amount of Rs.100000/- plus other benefits in accordance with the terms and conditions of the policy alongwith interest, compensation of Rs.50000/- on account of mental agony & harassment and Rs.21000/- as litigation expenses to the complainant.
2. After registration of complaint notices were issued to the opposite parties. Opposite party No.1 in its reply has submitted that complainant had approached the respondent company with reimbursement claim for the hospitalization of insured Ms.Veena Gupta at Chowdhary Maternity & Surgical hospital from 08.11.2018 to 11.11.208. The said claim form was received on 29.11.2018 .The opposite party sent a query letter dated 04.12.2018 requesting the complainant to provide the following documents for proper assessment of the claim:
i. Please provide 5 years record of polymenorrhea with all investigation report.
ii. Exact duration and past history of present ailment with 1st consultation paper and all past treatment records.
Hypertension and polymenorrhea.
iii. Pre hospitalization OPD Treatment record.
Polymenorrhea.
iv. Complete indoor case papers with admission notes, history sheet, doctor’s notes, nursing notes and vital chart.
The complainant replied to the above mentioned query letter dated 04.12.2018 .The respondent company after carefully perusing the reply and documents submitted by the complainant, rejected the claim of the complainant vide denial letter dated 24.12.2018 alongwith the following observation: “Claim repudiated: Non disclosure of chronic cervicitis and secretory endometrium at the time of policy inception, non disclosure of material facts/pre-existing ailments at the time of proposal”. It is further submitted that discharge summary also stated that the insured had a known case history of Chronic Cervicitis&Polymenorrhea since last 5 years. Moreover, as per the report of Vidya Vision dated 15.09.2014 mentions that the insured was diagnosed with Chronic Cervicitis with some features suggestive of HPV infection and secretory endometrium. In light of the fact that the insured did not disclose the pre-existing case history of Chronic Cervicitis at the time of making the proposal of the insurance. Therefore the claim of the complainant was denied vide claim rejection letter dated 24.12.2018. There is no deficiency in service on the part of opposite parties and dismissal of complaint has been sought. However, opposite party No.2 was given up vide order dated 15.09.2021 of this Commission on the separate statement of complainant.
3. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C22 and closed his evidence on 06.02.2023. Ld. Counsel for the opposite party No.1 has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R8 and closed his evidence on 01.03.2023.
4. We have heard learned counsel for the partiesand have gone through material aspects of the case very carefully.
5. We have perused the documents placed on record by both the parties.The claim of the complainant has been repudiated by the opposite parties vide their letter Ex.R4 on the ground that :Non disclosure of chronic cervicitis and secretory endometrium at the time of policy inception, non disclosure of material facts/pre-existing ailments at the time of proposal”. The insurance company came into the conclusion that the complainant had pre existing disease and she concealed some material facts from the insurance company.The main contention of the opposite parties is that insured has not disclosedabout chronic cervicitis and secretory endometrium at the time of policy inception, non disclosure of material facts/pre-existing ailments at the time of proposal. To prove the same opposite parties have placed on record copy of claim form Ex.R2, copy of letters Ex.R1 & Ex.R3 (through which they have demanded some documents), Ex.R5 discharge slip issued by ChowdharyMaternity & Surgical Hospital, Ex.R6 is the Pathology report issued by Vidya Vision, Ex.R7 is proposal form. We have minutely perused the proposal form Ex.R7. Initially the policy was taken by the complainant in the year 2015 and at that time in the column of pre-existing disease, it is mentioned that “yes” “Due to stone operation in March 2014”. Thereafter the policy was renewed in the year 2017 to 2019 continuously. The discharge slip issued by Chowdhary Maternity & Surgical Hospital is for the period of 08.11.2018 to 11.11.2018. Opposite party has not placed on record any document to prove the fact that at the time of renewal of the policy for the period 05.08.2018 to 04.08.2019, any ailment/disease was not disclosed by the insured Ms.Veena Gupta. We have perused the discharged summary Ex.R5 given by Chowdhary Maternity & Surgical Hospital. As per this discharge summary, the complainant was suffering from Menorrhagia&polymenorrhea for 5 years and she was taking treatment for last five years. As per report Ex.C22 issued byD.R.K.Chowdhary, Chowdhary Hospital dated 03.02.2023, it is submitted by the doctor that “Patient Veena Gupta, had problem of menorrhea for last few years. Menorrhea, in women, is a routine problem and that does not require hysterectomy” It is further submitted that “this problem of p/v & cervical erosion was only for few days old at the time of surgery”. Meaning thereby, the insured Veena Gupta had not any serious ailment at the time of proposal for the policy. We have also perused the definitions of Chronic cervicitis, Menorrhagia&polymenorrhea and Secretory Endometrium.
As per the medical literature,
“Cervicitis is an inflammation of the cervix, the lower, narrow end of the uterus that opens into the vagina. Possible symptoms of cervicitis include bleeding between menstrual periods, pain with intercourse or during a pelvic exam, and abnormal vaginal discharge. However, it's also possible to have cervicitis and not experience any signs or symptoms”.
The definition itself shows that a patient possibly have cervicitis and not experience any signs or symptoms and without any symptoms, she cannot disclose that she has any ailment.
“Menorrhagia is heavy or prolonged menstrual bleeding. It is a common problem in women. It is caused by hormone problems, problems with the uterus, or other health conditions. Menorrhagia is diagnosed with a pelvic exam, ultrasound, pap test, and sometimes a biopsy.”
“Polymenorrhea, also known as frequent periods, frequent menstruation, or frequent menstrual bleeding, is a menstrual disorder in which menstrual cycles are shorter than 21 days in length and hence where menstruation occurs more frequently than usual.”
“Secretory Endometriumis the final phase of the uterine cycle. Secretory endometrium is considered as a non-cancerous thickening in the endometrium of the uterus. Here, the corpus luteum produces a high level of progesterone that makes the endometrium ready for implantation. Also, the cervical mucus thickens.”
6. After going through the alleged medical text and the documents placed on record by both the parties, it is observed that there are certain hormonal changes in the body of a woman when she attains the age of menopause and there are certain changes/irregularities in menstruation, which can vary among women. It cannot be treated as a serious ailment as explained by the doctor in the certificate Ex.C22. Hence the repudiation of claim by the opposite parties is illegal and amounts to deficiency in service. As such complainant is entitled for the claim amount. As per claim form Ex.R2, complainant has demanded an amount of Rs.50194/- from the opposite parties and has placed on record copy of bills Ex.C21(pages 1 to 27).
7. In view of the facts and circumstances of the complaint, we hereby allow the complaint and direct the opposite parties to pay the amount of Rs.50194/-(Rupees fifty thousand one hundred and ninety four only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 09.05.2019 till its retaliation and Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
8. 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:
19.12.2023.
.....................................................
Nagender Singh Kadian, President
..........................................
Vijender Singh, Member.
