DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi- 110016
Case No. 3/2017
Rana Pratap Singh,
S/o Sh. Karan Bahadur Singh,
R/o 22, Upper Ground Floor,
Gautam Nagar, Andrewsganj,
New Delhi-110049
….Complainant
Versus
Religare Health Insurance Company Ltd.
Office: D3, P38, District Centre,
Saket, New Delhi-110017
Through its representatives
And also at
Religare Health Insurance Company Ltd.
Vipul Teck-Square,
Tower-C, 3rd Floor, Sector-43,
Golf Course Road,
Gurgaon-122009
….Opposite Party
Date of Institution : 04.01.2017
Date of Order : 22.03.2023
Coram:
Ms. Monika A Srivastava, President
Ms. Kiran Kaushal, Member
Sh. U.K. Tyagi, Member
ORDER
Member: Ms. Kiran Kaushal
- Facts as stated by the Complainant are :
Complainant held a bank account in Indusind Bank which introduced a scheme under the plan called “Care” for medical claim through Religare Health Insurance Company Ltd, hereinafter referred to as OP. Complainant opted for the said Insurance policy for period from 09.04.2016 to 08.04.2017 and paid premium of Rs. 10,256/- towards the same.
- It is stated that the Complainant on 03.08.2017 had chest discomfort with palpitations and was taken to Fortis Hospital. He was also suffering due to vomiting, dyspepsia since 02.08.2016 evening. After examination by the doctors, Complainant was admitted in CCU. After stabilising the Complainant, Coronary Angiography was performed on 04.08.2016 which showed single vessel disease for which PTCA and Stent to RCA was required to be done.
- Meanwhile Complainant sought cashless claim from OP and OP vide letter dated 04.08.2016 asked certain questions from the hospital which was replied by the hospital ; it was stated that the complainant at the request of OP will submit himself for medical examination by the OP’s nominated medical practitioner as soon as OP considers it reasonable and necessary.
- Complainant was shocked that OP rejected the cashless claim vide letter dated 5.8.2016 stating that there was “non-disclosure of material facts/pre existing ailments at the time of filling the proposal form (K/CO Hypertension since 6 years)” However, OP did not disclose the information on which OP had rejected the said medical claim of the Complainant.
- It is next stated that on 06.08.2016 a Cardiologist issued a certificate stating that “as per patient’s history and our record, he has no prior history of Hypertension and he did not require any blood pressure medicine during his stay in the hospital”. Thereafter Complainant issued legal notice to OP for wrongly rejecting the cashless claim. OP again sought some information from the Complainant which was clarified by the Complainant. Finally on 07.11.2016 OP rejected Complainant’s claim on the basis of non disclosure of material facts/pre existing ailments at the time of proposal and non co-operation in the investigation.
- Aggrieved by the claim being wrongly repudiated, Complainant approached this Commission with prayers for direction to OP to pay the medical claim of Rs. 2,14,460/-with interest @ 24% and also to pay compensation of Rs. 2 lacs with costs of litigation.
- Per contra, OP admitted the fact that Complainant had taken health insurance policy from OP which was to provide insurance coverage to the Complainant and his spouse. It is stated that Complainant duly filled the proposal form dated 02.04.2016 with the following disclosures under the head “pre-existing disease” :
Has anyone been diagnosed/hospitalised or under any treatment for any illness/injury during the last 48 months or is suffering from any illness/disease?
Hypertension/High Blood Pressure
Complainant has very categorically answered ‘No’ to this question.
- It is further stated that Complainant approached OP for cashless facility on 04.08.2016, upon receipt of the said request OP initiated cashless claim investigation in order to authenticate the same. During investigation, it was revealed that that the Complainant was suffering from Hypertension and was a known case of Hypertension from past six years. The said fact was corroborated by Complainant’s son statement written, signed and submitted to the Investigator. The said fact is further corroborated and substantiated from the video recording of Complainant’s son made during the investigation. Based on the said findings the cashless facility requests of the Complainant was rejected vide letter 5.8.2016 under Clause 6.1 of policy terms & conditions.
- Post denial of the cashless facility requests Complainant sent a reconsideration request to OP and sent a Doctor’s certificate wherein it was stated that Complainant does not have any history of Hypertension. OP maintained the stand of denying the said request. Thereafter, the Complainant again filed for reimbursement for the above stated hospitalisation with bill details of Rs. 2,14,460/- on 22.9.2016. OP again initiated claim investigation in order to assure proper assessment of Complainant’s claim as per policy terms & conditions. However, the Complainant refused to cooperate with OP during the said investigation which rendered the investigation incomplete and infructuous.
- Hence, on the basis of the findings of cashless claim investigation only claim of the Complainant was rejected vide letter dated 7.11.2016. It is next stated that depending upon the disclosure made by the Complainant in the proposal form before the inception of the policy OP decides whether to accept the risk. The fact of having pre existing condition of Hypertension from six years was not disclosed at the time of the inception of the policy, therefore the claim of the Complainant has been rightly rejected. In view of the same it is prayed that complaint be dismissed with exemplary costs.
- Rejoinder has been filed on behalf of the Complainant reiterating the averments made in the complaint. Evidence by way of affidavit and written submissions have been filed on behalf of the parties. Arguments advanced on behalf of parties have been considered and material placed on record is perused.
Relevant portion of the repudiation letter on the basis of which the claim of the Complainant is rejected is reproduced as under:
“Non Disclosure of material facts/pre-existing ailments at time of proposal/KCO of HTN for 6 years. Non co-operation in investigation and consent for investigation”.
- Prior to the final claim rejection OP had also rejected the cashless claim request of the Complainant on the ground of non disclosure of material facts/pre-existing ailments at the time of filling of proposal form. OP has reached this conclusion on the basis of the statement made by Complainant’s son in writing that his father had Hypertension for last about six years. OP has placed CD on record to establish the said fact.
OP while replying to the legal notice of the Complainant dated 26.08.2016 has submitted in its reply dated 15.09.2016 that:
“In light of your contention it needs to be mentioned that though your Client had submitted the doctor’s Certificate stating that your client does not have hypertension but at the same time the company can’t ignore the statement given by your Client’s son stating that your Client has hypertension since last 6 years.”
- OP was thus aware of the fact that a doctor had given a certificate that, complainant had no history of Hyper Tension. Similar was the finding in his discharge summary. Relevant portion of the Discharge Summary of the complainant is reproduced as under:
Diagnosis :
- Coronary artery disease
- Unstable angina
- Single vessel disease
- PTCA & stent to RCA done
- Normal LV systolic function
- Esophagitis with hiatus hernia
Present illness :
Mr. Rana Pratap Singh, 43 yrs. Male is normotensive, non-diabetic with no family history of coronary artery disease. He presented with complaints of chest discomfort with palpitations, ghabrahat since today and vomiting with severe dyspepsia since yesterday evening. In the ER, ECG showed ST-T changes in V1-V4. He was admitted for further evaluation and management.
- Discharge summary of the Complainant does not mention any history of hypertension and even the doctor who was the primary consultant has certified that the Complainant had no previous history of hypertension. We are of the opinion that doctor’s statement and discharge summary is more reliable and professional evidence viz a viz the statement made by Complainant’s 18 year old son, which was unauthorizedly and surreptitiously recorded. OP’s evidence which is thus from a non qualified source cannot have more value than the evidence given by the doctor and hospital.
- In view of the aforesaid discussion and in the absence of cogent evidence by OP, we hold OP to deficient in service and direct OP to pay the hospital bill amounting to Rs. 2,14,460/- alongwith interest @ 4% p.a. from the date of rejection of the claim i.e. 07.11.2016, within three months from the date of receipt of the order, failing which OP shall pay the above stated amount @ 8% p.a. from the date of rejection till realization.
Parties to be provided copy of order as per rules. Order be uploaded on the website.
File be consigned to the record room.
