Chandigarh

DF-I

CC/671/2021

Shivani - Complainant(s)

Versus

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

Amandeep Singh Nirmaan

02 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

Shivani w/o Late Sh.Amit Swami, R/o 131 ward No.9 Nalagarh, ITI Road, Nalagarh (T) Nalagarh, Solan, Himachal Pradesh-174101.

… Complainant

V E R S U S

1. Religare Health Insurance Co. Ltd. SCO 56,57,58 Sector 9 Chandigarh-160017 through its Manager/Authorized Signatory.

Email: Religare Health Insurance Co. Correspondence address Vipul tech Square, Tower C, 3^rd Floor, Sector 43, Golf Course Road Gurgaon-122009 through its Manager/Authorized Signatory.

Email: … Opposite Parties

Per Suresh Kumar Sardana, Member

1.      Averments are that the complainant’s husband got himself insured from Max Bupa Health Insurance for a cover of Rs.5,00,000/- (Annexure C-1). The complainant’s husband got the insurance renewed again for another one year and took a top up medical insurance policy from OPs and got himself insured for a sum of Rs.25,00,000/-. The Complainant’s husband paid a premium of Rs.6152/- and validity of the insurance policy was from 18.09.2018 to 17.09.2019 (Annexure C-2). It is submitted that the husband of the complainant was admitted at Fortis Hospital Mohali on 07.07.2019. The husband of the complainant was diagnosed with Jaundice and Pneumonia in 2017. Thereafter, the husband of the complainant was shifted to Max Super specialty Hospital on 19.07.2019 and after undergoing treatment for few more days, unfortunately on 26.07.2019, complainant’s husband died (Annexure C-4 colly). The complainant submitted the claim of her husband for reimbursement with the OPs. It is further submitted that Max-Bupa Health Insurance reimbursed the medical claim of Rs.5,50,000/- (Annexure C-5). The complainant submitted all the relevant requisite documents with the OPs. The complainant received a letter from OPs on 15.02.2020, wherein it was stated by the OPs that her claim is not payable as per policy terms and conditions. The rejection of the claim is due to non-disclosure of chronic liver disease (Annexure C-7). The complainant again approached the OPs vide various emails and requested the OPs time and again to settle the claim. But the OPs did not pay any heed to the requests of complainant and rejected the claim of the complainant (Annexure C-8 colly). Hence this present consumer complaint.
2.     OPs contested the consumer complaint, filed their written reply and stated that as per the medical documents and discharge summary, the insured was admitted to the hospital for treatment of chronic liver disease (CLD) Cryptogenic/Nash related with de-compensated Cirrhosis with massive UGI variceal bleed, ischemic hepatitis among other things. The complainant had the opportunity to disclose at the time of proposal that he was having history of chronic liver disease, diabetes and dyslipidemia prior to policy inception date, however, the said pre-existing condition/ailment was deliberately and intentionally not disclosed by the complainant/insured in order to get benefit out of health insurance policy from the OP-company. Therefore, the OP-company has rightly rejected the claim in accordance with Clasue 7.1 of the policy terms and conditions. The copy of the terms and conditions are annexed as Annexure OP-11. It is also submitted that the complainant had earlier approached the Hon’ble Ombudsman Chandigarh wherein the complaint was dismissed vide order dated 28.08.2020 (Annexure OP-13). On these lines, the case 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.
6.     It is observed that the complainant has filed the complaint against the OPs for non-payment of mediclaim and submitted that insurance company denied to pay claim for her husband who was covered under its policy. The complainant stated that her husband took a top up policy of the OPs.  As per complainant the legitimate claim with regard to the treatment of her late husband has been denied by the OPs. It is observed that the insurance company issued health insurance policy No.13011658 w.e.f 18 September, 2018 to 17^th September, 2019 wherein, the insurance coverage was provided to the complainant's husband Mr.Amit Swami for a sum insured of Rs.25,00,000/-. The complainant approached the insurance company for reimbursement claim for the treatment of the insured at Fortis Hospital for treatment of CLD. It is also observed that company carried an investigation in order to check the veracity of claim. Further upon careful consideration of the documents received pertaining to claim, the following observations were made by the OPs:

    (i) As per LAMA summary of Fortis Hospital, Mohali dated 18/07/2019, the insured was a known case of Chronic Liver Disease (CLD) since 2 years and was also having the history of jaundice and Pneumonia in 2017.

    (ii) As per the discharge summary of Fortis Hospital Mohali dated 30.07.2013, the insured was a known case of diabetes mellitus and was diagnosed with Dyslipidemia and Thrombocytopenia. As per progress notes of Fortis Hospital dated 29.07.2013, the insured was also diagnosed with indirect Hyperbilirubinemia. As per the inpatient history and physical record of Fortis Hospital dated 29/07/2013, the insured was present with Alcohol Abuse. As per report of Fortis Hospital, the insured was a known case of alcoholic liver disease. As per report of Fortis Hospital the insured was having de-compensated CLD-Ethanol related.

7.      It is observed that the claim was rejected as per policy terms and conditions under clause 7.1 related with disclosure to information norms. It is also pertinent to mention that the insurance regulatory and development authority (protection of Policy holders' interest) regulations, 2017 under clause 19(4) enumerating the General Principles casts an absolute duty to disclose all material facts to the insurer in order to assess the risk as per its capacity. In view of above discussion, we are of the view that the insured had acted in breach of the policy terms and conditions governing the policy, and also has acted in blatant violation of the above stated principals and regulations. Hence, in our view the claim of the complainant was duly repudiated by the OPs as per terms and conditions under clause 7.1 of the policy terms & conditions due to non-disclosure of chronic liver disease, diabetes and dyslipidemia.

8.       In view of the above discussion, we do not find any deficiency in service or unfair trade practice on the part of the OPs. Accordingly, the consumer complaint, being meritless, is hereby dismissed, leaving the parties to bear their own costs.

9.      Certified copies of this order be sent to the parties free of charge. The file be consigned.