BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.357 of 2018
Date of Instt.31.08.2018 Date of Decision: 01.06.2021
1. Neeraj Khetarpal son of Sh. Piara Singh Khetarpal, resident of House No. 275, Punjab Avenue, Ladhewali Road, Jalandhar.
2. Neha Khetarpal wife of Neeraj Khetarpal, resident of House No.275, Punjab Avenue, Ladhewali Road, Jalandhar.
..........Complainants
Versus
Religare Health Insurance Co. Ltd., Registered Office D-3, P3 B, Distt. Centre Saket, New Delhi through its Regional Manager.
Religare Health Insurance Co. Ltd. Head Office at Plot No.A-3, A-4, A-5 Sector 125, Noida.
The Branch Manager Religare Health Insurance Co. Ltd. SCO-44, PUDA Complex, Jalandhar.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Kuljit Singh (President)
Smt. Jyotsna (Member)
Present: Sh. Jatinder Arora Adv. Counsel for Complainants.
Sh. Raman Sharma,, Adv. Counsel for the OPs.
Order
Kuljit Singh (President)
1. The instant complaint has been filed by the complainant on the averments that complainant no.1 got health insurance policy from ICICI Lombard to the year 2008 and continued with the same till December 2014. The complainant no.1 married with complainant no.2 on 09.03.2014 and was covered under corporate Health Insurance Plan. In the month of December 2014 the insurance policy was ported to New India Insurance and wife of the complainant was also added in the said health insurance policy and thereafter in the month of December 2016 again the policy was shifted to Religare Health Insurance vide policy no.10901916. In the month of August 2017, the complainant no.2 having some abdominal pain and she was admitted in the Modern Hospital Jalandhar on 03.09.2017. The entire expenditure on her treatment was approved by the OPs. In the month of September 2017 she again suffered some problem and she was admitted in DMC Ludhiana on 06.09.2017 and she remained there up to 09.09.2017. The complainant paid more than Rs.40,000/- on the treatment of complainant no.2 at DMC Ludhiana. The complainants claimed cashless medical insurance benefits from OPs but claim submitted by the complainants was rejected on 09.09.2017 on the ground that complainant no.2 did not disclose material facts about pre-existing disease. It was not out of place to mention here that the claim of Modern Hospital Jalandhar was approved by OPs but later on it was rejected without any reason. The repudiation letter dated 09.09.2017 is totally illegal, unlawful and against the principal of natural justice. Another claim was submitted by complainant no.2 when she again suffered from the same disease, but cashless claim was rejected 26.09.2017. Later on amount of Rs.9118/- was reimbursed and the claim was approved. Meaning thereby only second claim was rejected on the ground of pre-existing disease. Complainant no.2 also got issued certificate from Dr. PK Jain DHMS and the same were submitted before the OPs. The act of OPs of withholding and rejection of claim of complainants is illegal and against the principle of natural justice. Therefore, they had filed the present complaint and prayed that the OPs be directed to pay Rs.10.,00.000/- along with interest @ 24% per annum till realization and Rs.22,000/- as cost of litigation.
2. Upon notice, OPs appeared and filed joint written reply and contested the complaint of the complainant by raising preliminary objections that complaint is not maintainable. There is not deficiency in service or any negligence on the part of OPs. On merits, it was averred that complainant has having insurance policy with New India Assurance Co. and OPs had received portability request from the complainant and accordingly policy bearing no. 10901916 was issued with premium of Rs.11,010/-. The said policy was further renewed for the period 16.12.2017 to 15.12.2018. The contract of insurance is a contract of umberrimae fides and by not declaring correct and accurate information at the time of proposing for the referred policy. The complainant is guilty of breach of utmost good faith. Rest of the averments of the complainant was denied by OPs and they prayed for dismissal of the complaint.
3. In order to prove their respective versions, both the parties produced on the file their respective evidence.
4. We have heard the argument from learned counsel for the respective parties and also gone through the case file as well as written arguments submitted by counsel for the OPs, very minutely.
5. The glance of evidence is required for settlement of the case. The complainant has tendered in evidence copy of letter dated 14.12.2016 as Ex.C-1 in which policy period valid from 16.12.2016 to 15.12.2017. Ex.C-2 is patient final bill for Rs.42763.89. Ex.C-4 is copy of receipt for payment of Rs.10,000/- issued by DMC Ludhiana. Ex.C-5 is copy of deposit receipt for Rs.7907/-. The copy of payment receipt of Rs.5000/- issued by DMC Ludhiana. Ex.C-7 to Ex.C-11 are copies of tax invoice of different dates for different payments. Ex.C-12 is copy of discharge summary in which the date of admission is mentioned as 06.09.2017 and date of discharge is mentioned as 09.09.2017. In which the diagnose is mentioned as Acute Gastritis (Possibly Infective). Ex.C-13 is copy of discharged summary issued by DMC Ludhiana. Ex.C-14 is copy of claim form. Ex.C-15 is copy of claim denial letter dated 07.12.2017 on the ground that non-disclosure of material fact/ pre- existing ailments at the time of proposal. Patient is known case of Gastroesophageal Reflux Disease. Ex.C-16 is copy of OPD Card issued by DMC Ludhiana. Ex.C-18 is copy of non-registration of claim. Ex.C-19 is copy of authorization letter. Ex.C-20 is copy of legal notice dated 07.04.2018. Ex.C-21 is copy of reply to legal notice.
6. To refute this evidence of the complainant, OPs tendered in evidence copy of policy certificate is Ex.O-1 on the record. Ex.O-56 is copy of terms and conditions of the policy. Ex.O-7 is copy of report. Ex.O-9 is copy of non-registration of claim. Ex.O-10 is copy of repudiation letter.
7. It is an established fact that in the month of August 2017, complainant no.2 was having some abdominal pain and she was admitted to Modern Hospital Jalandhar on 03.09.2017. She was again admitted in DMC Ludhiana on 06.09.2017 and she remained there up to 09.09.2017. This fact is clear from copy of discharge summary Ex.C-12 on the record. In this document, it has been specifically mentioned that she was diagnosed as Acute Gastritis (Possibly Infective). Policy document supplied to the complainants in this document it has been specifically mentioned that the claim rejection on the basis of pre- existing disease. But in the case in hand, OPs have not produced anything on the record that the complainant no.2 suffered from pre existing disease. There is no vital evidence on the record to prove this fact that the complainant no.2 suffering from preexisting disease. There is no affidavit or certificate issued by any doctor on the record to prove that the complainant no.2 suffering from any pre-existing disease. Ex.C-12 is vital document on the record, from perusal of this document, it is clear the complainant admitted in the hospital as indoor patient as he admitted in the hospital on 06.09.2017 and discharged from the hospital on 09.09.2017, thus, he is entitled for claim. There is no document on the record to prove that complainant is suffering from any pre-existing disease. So, in the absence of this, we cannot decided that complainant no.2 is not entitled for insurance claim. The insurance companies collect the premiums from the insured and find ways to decline the claims without any valid reasons. This fact is settled by Hon’ble Punjab and Haryana High Court at Chandigarh in case titled as New India Assurance Company Limited versus Smt. Usha Yadav and others reported in 2008(3) RCR (Civil) Page 111 held as under:-
“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline the claims. All conditions which generally are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay cost of Rs.5000/- for luxury litigation being rich.”
8. From perusal of entire record of the case and after hearing submissions of counsel for the parties, we are considered opinion that the complainant no.2 is entitled for Rs.42,763/- as per Ex.C-2 the patient final bill and as such, the complaint of the complainant is partly accepted. The complainant no.2 is also entitled Rs.7000/- as compensation for mental harassment and Rs.3000/- as cost of litigation. The opposite parties are also directed to deposit Rs.3000/- as costs in the Consumer Legal Aid Account maintained by this Commission.
9. The compliance of the order be made within 45 days from copy of receipt of this order.
10. The complaint could not be decided within the stipulated timeframe, due to heavy pendency of the court cases and spread of Covid-19.
11. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
1st Day of June 2021
(Kuljit Singh)
President
(Jyotsna)
Member
