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

 

Complaint Case No : RBT/CC/2018/209

Date of Institution : 27.03.2018/29.11.2021

Date of Decision : 16.08.2022

Mr. Suresh Sondhi S/o Sh. Om Parkash R/o H. No. 80, Green Field, Majitha Road, Amritsar. …Complainant

Versus

Care Health Insurance Limited through its Chairman/ Managing Director/Principal Officer through its Branch Office at District Shopping Complex, Ranjit Avenue, Amritsar through its Branch Manager. 

…Opposite Party

 

Complaint U/S 12 and 13 of The Consumer Protection Act, 1986

Present: Sh. Deepinder Singh Adv counsel for complainant.

Sh. RP Singh Adv counsel for the opposite party.

 

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 12 and 13 of the Consumer Protection Act against Religare Health Insurance Company Limited, Amritsar. (in short the opposite party). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant is getting health policy since long before the year 2008 from the United India Insurance Company Limited regularly and later got ported to Health Benefit Mediclaim insurance to opposite party covering the risk 21.7.2015 to 20.7.2016. 

3. It is further alleged that unfortunately complainant feel ill and was to be hospitalized and under the treatment of Kidney Hospital and Lifetime Medical Institutions, Jalandhar from 25.9.2015 to 21.12.2015 and also to undergo the medical procedure and the treatment cost of the said hospitalization came to Rs. 4,81,400/-. The opposite party was immediately informed about the said hospitalization and treatment to be taken thereof as the said policy was issued on cashless basis and sum insured for medical benefit is for Rs. 5 lacs. The complainant underwent organ transplant and as per condition over the cover note issued to the complainant the donor is also entitled for Rs. 1 lac. The opposite party instead of making the said payment issued the letter dated 10.12.2015 that the complainant was having pre-existing diseases of diabetes and hypertension and was given 15 days to respond the letter. The complainant approached the opposite party and requested that he never taken any treatment nor was suffered for the said diseases prior to issuance of insurance policy but of no use. Further, no terms and conditions were supplied to the complainant and provided only with the cover note. The act of the opposite party amounts to deficiency in service and unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite party may be directed to pay the amount of Rs. 4,81,400/- and Rs. 1,00,000/- alongwith interest at the rate of 12% per annum from the date of payment till realization.   

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

3) To pay adequate litigation expenses.

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

4. Upon notice of this complaint, the opposite party filed written statement taking preliminary objections that the present complaint is time barred as the claim was lodged for the admission in hospital from 25.9.2015 till 21.12.2015, cashless request was made and claim was repudiated vide letter dated 20.10.2015 after that notice of cancellation of policy was issued on 10.12.2015 and policy was cancelled vide letter dated 6.1.2016 but the present complaint  has been filed on 3.4.2018 after the expiry of two years so the present complaint is liable to be dismissed being time barred. The complainant has not come to the court with clean hands. In this case cashless request was made and same was rejected vide letter dated 20.10.2015 under clause 6.1 of terms and conditions of policy but complainant concealed these facts from this Commission. The complainant did not disclose material facts at the time of taking policy and given wrong answers in the proposal form and wrong declaration has been made by the complainant. The complainant has no cause of action and locus standi to file the present complaint.

5. It is further alleged that the opposite party issued Health Insurance policy to the complainant under Plan Care w.e.f. 21.7.2014 to 20.7.2015 and renewed from 20.7.2015 to 21.7.2016 providing insurance coverage to the tune of Rs. 5,00,000/- subject to terms and conditions of policy. During the policy period the complainant was admitted on 26.10.2017 at Kidney Hospital and Lifeline Medical Institutions, Punjab for the treatment of surgery of Kidney Transplant. The complainant was diagnosed with CKD V, Diabetes Millets and Hypertension. The complainant approached the opposite party and filed a cashless claim for the expected cost of said hospitalization. It is clearly mentioned on the cashless request from that the complainant has past history of diabetes millets since 1993 and hypertension since 2009 and provisional diagnosed with CKD-V, DM, hypertension. As per note of Dr. KS Chugh dated 21.6.2013 it is mentioned that the complainant has past history of Diabetes millets for 10 years and he has shifted on insulin from last 4 years. Decrease in vision of both eyes from last 4 years. Further, as per consultation note of same doctor dated 17.1.2014 it is mentioned that the complainant has been suffering from diabetes millets with neuropathy which means kidney disease or damage. As per clause No. 6.1 “If any untrue or incorrect statements are made or there has been a misrepresentation, mis-direction or nondisclosure of any material particulars or any material information having been withheld or if a claim is frequently made or any fraudulent means or devices are used by the policyholder or the insured person or anyone acting on his/their behalf, the company shall have no liability to make payment of any claims and the premium paid shall be forfeited to us.”

6. In the proposal form the question Has anyone been diagnosed/hospitalized or under any treatment for any illness/injury during the last 40 months or is suffering from any illness/disease? The answer marked by the complainant Yes but only disclosed about the hospitalization of January 2012 because of injury. Diabetes Hypertension/High Blood Pressure kidney disease other, the answer marked was No. Further, at the time of pre-policy medical examination, the complainant could have disclosed about the history of diabetes, hypertension and decrease in vision of both eyes but he concealed this material information from the answering opposite party. Even in Pre-Policy medical examination form he filled the columns as under.-

Please select if you have suffered from any of the following.-

High Blood Pressure- No

Diabetes- No

Any disorder of eyes, ear, nose throat or mouth .- No

Have you ever been/or presently are on any kind of medication: No

Are you presently in good health, entirely free from any mental or physical impairments or deformity .- Yes

In the last 5 years have you been medically examined, received medical advice or treatment or been hospitalized .- No

Based upon the disclosures in the prepolicy medical examination form the company provide the policy to the customer or not so it is the duty of the complainant to disclose correct information about his current health status. 

7. Further, the insurance company took the medical legal opinion from Dr. Asrani that is Diabetes and hypertension is directly related to the complainant's present ailment of CKD V and the same was confirmed by Dr. CH Asrani in his opinion. The insurance company believed the disclosures made by the patient in the proposal form issued the said policy. 

8. On merits, it is admitted that cashless request of the claim from the complainant was received and after going through the contents of the cashless request form and made it was found that the complainant was suffering from diabetes, hypertension so the claim was rejected under clause 6.1 of the terms and conditions of the policy and due intimation was given to the complainant vide letter dated 20.10.2016. Further, notice for cancellation of policy was given to the complainant vide letter dated 10.12.2015 but no reply was given by the complainant so policy was cancelled and due intimation was given vide letter dated 6.1.2016. The terms and conditions were given to the complainant alongwith the policy. There is no deficiency in service and unfair trade practice on the part of the opposite party. Lastly, the opposite party prayed for the dismissal of the present complaint.

9. To prove his case the complainant tendered in evidence his  own affidavit Ex.C-1, copy of policy certificate Ex.C-2, copy of cancellation of policy Ex.C-3, documents Ex.C-4 to Ex.C-14 and closed the evidence. 

10. To rebut the case of the complainant the opposite party tendered in affidavit of Arvind Singh Naruka Legal Manager Ex.OP-1, copy of policy 2014-15 Ex.OP-2, copy of policy 2015-16 Ex.OP-3, copy of terms and conditions Ex.OP-4, copy of cashless request Ex.OP-5, copy of OPD slip dated 21.6.2013 Ex.OP-6, copy of OPD slip dated 17.1.2014 Ex.OP-7, copy of OPD slip dated 15.6.2015 Ex.OP-8, copy of pre authorization request dated 20.10.2015 Ex.OP-9, copy of the proposal form Ex.OP-10, copy of medical examination form Ex.OP-11, copy of the letter dated 10.12.2015 Ex.OP-12, copy of policy cancellation dated 6.6.2013 Ex.OP-13, copy of certificate issued by Dr. HS Asrani Ex.OP-14, copy of affidavit of HS Asrani Ex.OP-15 and closed the evidence.   

11. 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. 

12. Before going into the merits of the present case firstly we decide the specific objection taken by the opposite party that the present complaint is hopelessly time barred. They mentioned in the written version that the claim was lodged for the admission in the hospital from 25.9.2015 till 21.12.2015, cashless request was made and claim was repudiated vide letter dated 20.10.2015. After that notice of cancellation of policy was issued to the complainant on 10.12.2015 which was duly received as admitted by the complainant in his complaint and policy was cancelled vide letter dated 6.1.2016 duly received by the complainant. The opposite party specifically mentioned in the written version that the present complaint has been filed on 3.4.2018 after the expiry of two years, so the present complaint is time barred. 

13. We have perused all the documents mentioned by the opposite party in their written version. Admittedly, the complainant was  taken the treatment from Kidney Hospital and Lifeline Medical Institution, Jallandhar from 25.9.2015 to 21.12.2015 and admitted in the hospital on 24.10.2015 and discharged from hospital on 13.11.2015 vide copy of discharge card Ex.C-4. He made cashless request Ex.OP-5 to the opposite party but the same was denied by the opposite party on 20.10.2015 vide letter Ex.OP-9. The complainant was discharged from the hospital on 13.11.2015. We have perused all the documents filed by the complainant very carefully and did not find any document vide which he ever claim the insurance amount through reimbursement as the opposite party denied the cashless request of the complainant but he was not barred from applying the claim through reimbursement. Thereafter, the opposite party issued the notice of cancellation of policy vide letter dated 10.12.2015 Ex.OP-12 and the opposite party vide letter dated 6.1.2016 Ex.OP-13 finally cancelled the policy and intimated the complainant accordingly. The complainant admitted that he had received the letter. The complainant never filed his insurance claim through reimbursement and filed the present complaint on 27.3.2018 after the expiry of more than two years of last cause of action or communication on behalf of opposite party vide letter dated 6.1.2016 Ex.OP-13. 

14. As per Section 24-A of The Consumer Protection Act 1986 the limitation period for filing a complaint before the District Commission is as under.-

“ 24-A. Limitation period

(1) The District Forum, the State Commission or the National Commission shall not admit a complaint unless it is filed within two years from the date on which the cause of action has arisen.

(2) Notwithstanding anything contained in sub-section (1), a complaint may be entertained after the period specified in sub-section (1), if the complainant satisfies the District Forum, the State Commission or the National Commission, as the case may be, that he had sufficient cause for not filing the complaint within such period. 

Provided that no such complaint shall be entertained unless the National Commission, the State Commission or the District Forum, as the case may be, records its reasons for condoning such delay.”

The complainant has not filed any application for condonation of delay in the present complaint or mentioned any reasons for delay in filing the present complaint. Therefore, in view of the above mentioned facts and circumstances and as per Section 24-A of the Consumer Protection Act 1986 present complaint is barred by limitation.

15. In view of the above discussion and evidence produced by opposite party the present complaint is dismissed being time barred.  However, no order as to costs or compensation. 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