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

 

Complaint Case No : RBT/CC/2018/223

Date of Institution : 27.03.2018/29.11.2021

Date of Decision : 21.06.2022

Inderyas Bhatti S/o Sh. B. Samuel R/o Samuel Villa, Baba Shri Chand Avenue, Verka Majitha Byepass, Gate Gurudwara Baba Tahli Sahib, Amritsar.    …Complainant

Versus

Care Health Insurance Ltd. GYC Global, Plot No. A-3, A-4, A-5, Sector 125, NOIDA (UP)-201301 through its Manager/Authorized Signatory, Branch Office Ranjit Avenue, B-Block, Shopping Complex, Amritsar. 

…Opposite Party

Complaint U/S 12 of The Consumer Protection Act

Present: Ms. Harsimrandeep Kaur Adv counsel for complainant.

Sh. RP Singh Adv counsel for the opposite party. 

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Smt. Urmila Kumari : 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 Inderyas Bhatti filed the present complaint under Section 12 of the Consumer Protection Act against Care Health Insurance Limited, Noida. (in short the opposite party). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant obtained insurance policy No. 10348659 AL No. 80152467-00 member ID 52349469 client ID 52349469 which is a cashless policy. Further, at the time of issuing the medical insurance policy to the complainant all the tests as required were got conducted by the company and after completing all the formalities the complainant was given the policy and all the terms and conditions settled or mentioned in the policy certificate. 

3. It is further alleged that the complainant approached Dr. Om Parkash Eye Institute Private Limited, Amritsar for his cataract treatment and for that the case was sent to the opposite party No. 1 for the payment of the said treatment as the doctors have advised to get the surgery on 27.12.2017 and pre operative instruction were give 24, 25, 26 of December 2017. Further, the complainant received a letter from the desk of the hospital and came to know that the cashless hospitalization cannot be approved as per the terms and conditions of the policy and it has been mentioned that the complainant has not disclosed the material facts. In fact at the time of getting the treatment the doctor took the past history and mentioned that there is no defect and in the column of hyper lipil pidemea it has been written as 10 to 12 years wrongly and complainant approached the hospital and hospital authorities gave a certificate to this effect that the said column was filled wrongly. The complainant received a letter of denial dated 8.3.2018 that it was informed that the cashless hospitalization cannot be approved as mentioned in the letter. The non approval of cashless hospitalization by the opposite party is totally illegal as the complainant was not suffering from any non disclosure of material facts nor the complainant has committed any mistake nor have ever concealed any ailment at the time of proposal. This act of the opposite party is deficiency in service and it caused harassment and mental agony to the complainant. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite party may be directed to give approval for cashless treatment for the said operation of the complainant from the said hospital.    

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

3) To pay Rs. 20,000/- as 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 complainant has not come to the Forum with clean hands and suppressed the material facts as in the present case after receiving the claim and documents it was transpired that the insured was suffering from hypertension for the last 10-12 years but this fact was not disclosed by the complainant in the proposal form, so the claim was repudiated as per Clause 7.1 of terms and conditions of the policy. Further, he has violated the terms and conditions of the policy, so the claim was rightly repudiated vide letter dated 28.12.2017. Further, he has no locus standi to file the present complaint.  

5. Further, the opposite party submitted that the opposite party issued Health Insurance policy to the complainant bearing No. 10348659 under the Plan Care with effect from 31.7.2015 to 30.7.2018 providing insurance coverage to the complainant only for sum insured of Rs. 4,00,000/- subject to policy terms and conditions. Further, during the policy period the complainant was got OPD treatment from Dr. Om Prakash Eye Institute on December 27, 2017 with chief complaints of blurring of vision from 4-5 months and he underwent cataract surgery. The complainant applied for the cashless facility request with the opposite party. On the basis of the documents received by the opposite party they became aware of the fact that the complainant is suffering from Hyperlipidemia from past 10-12 years i.e. before the policy inception period which was not disclosed by him to the opposite party at the time of policy inception so the opposite party denied the cashless request of the complainant vide letter dated December 26, 2017 on the basis of non disclosure of Hyperlipidemia since 10-12 years i.e. prior to the policy inception period. After that the complainant submitted Treating Doctor Certificate to the opposite party mentioning that the column of Hyperlipidemia was erroneously filled and opposite party reconsidered the claim of the complainant and came across the following observations.-

“As per the treatment record issued by Dr. Om Prakash Eye Institute, the complainant is suffering from Hypertension from past 10-20 years. 

As per Doctor Certificate of the Medical Superintendent of the concerned hospital authorities, it is mentioned that the patient (complainant) is having Hypertension for the last 10- 12 years.

From the said information it was clear that the complainant was having a history of Hypertension for the last 10-12 years which is prior to the inception of the policy and he concealed the material facts to fetch a health insurance policy. Accordingly, the opposite party denied the said request of the complainant vide letter dated 28 December 2017 under Clause 7.1 of the policy terms and conditions for non disclosure of material information. 

6. On merits, it is submitted that after receiving the documents it was clear that the insured was suffering from hypertension for the last 10-12 years but this fact was not disclosed by the complainant in the proposal form so the claim was repudiated. The remaining contents of the complaint are denied by the opposite party and lastly prayed for the dismissal of the present complaint.  

7. In support of his complaint, the complainant tendered into evidence his affidavit Ex.C-1, copy of policy certificate Ex.C-2, copy of letter dated 26.12.2017 Ex.C-3, copy of request for cashless hospitalization Ex.C-4, copy of certificate Ex.C-5, copy of certificate issued by Dr. Surinder Sharma Ex.C-6, copy of denial letter Ex.C-7 and closed the evidence. 

8. To rebut the case of the complainant, the opposite party   tendered in evidence affidavit of Arvind Singh Narula Ex.OP-1, copies of policy for the period from 2015-16, 2016-17 and 2017-18 Ex.OP-2 to Ex.OP-4, copy of terms and conditions Ex.OP-5, copy of cashless request Ex.OP-6, copy of denial letter dated 26.12.2017 Ex.OP-7, copy of treatment record Ex.OP-8, copy of certificate issued by hospital Ex.OP-9, copy of denial letter dated 28.12.2017 Ex.OP-10, copy of proposal form  Ex.OP-11, copy of medical examination form Ex.OP-12, copy of notice for cancellation Ex.OP-13, copy of authority letter Ex.OP-14 and closed the evidence on behalf of opposite party. 

9. We have gone through the record on the file carefully. Written arguments also filed by both the parties. 

10. It is admitted case of the opposite party that the complainant is medically insured with the opposite party. The complainant alleged in the complaint that he approached Dr. Om Parkash Eye Institute Private Limited Amritsar for his cataract treatment and the doctor have advised him to get surgery, therefore, the complainant applied for cashless treatment with the opposite party. The opposite party denied the cashless treatment vide letter dated 26.12.2017 i.e. Ex.C-3 and Ex.OP-7 on the ground of non disclosure of material facts at the time of proposal. The learned counsel for the complainant mentioned in the written arguments that the complainant approached the said doctor and the said hospital authorities gave a certificate to this effect that the said column was filled wrongly. The said letter is Ex.C-6 and Ex.OP-9. It is mentioned in the said certificate that the patient is having hypertension for the last 10-12 years we are sending the history of patient and the column was filled wrongly. The complainant sent the above said letter to the opposite party and applied again for the cashless treatment but the opposite party insurance company again denied the cashless treatment and repudiated the claim of the complainant on the ground that the complainant is suffering from hypertension for the last 10-12 years i.e. before the policy inception period which was not disclosed by the complainant to the opposite party at the time of policy inception. The second denial letter is Ex.OP-10. 

11. The learned counsel for the complainant mentioned in the written arguments that at the time of issuing the medical insurance policy to the complainant all the tests as required were conducted by the opposite party and after completing all the formalities the complainant was given the policy.

12. On the other hand, the learned counsel for the opposite party argued that the claim was rightly repudiated by the opposite party as the complainant was having history for hypertension for the last 10-12 years which is prior to the inception of the policy and he concealed the material facts from the opposite party. Therefore, the opposite party denied the said request of the complainant vide letter dated 28.12.2017 under Clause 7.1 of the policy terms and conditions for non disclosure of material information. 

13. The opposite party also produced the proposal form Ex.OP-11 in which the column regarding hypertension/high blood pressure was filled “No” by the complainant. It is clear from the proposal form produced by the opposite party that the complainant had not disclosed regarding the hypertension at the time of taking the insurance policy. Moreover, the complainant has not taken any treatment regarding the cataract surgery except the OPD. The complainant after taking the treatment can apply for the reimbursement of the claim amount. Therefore, at this stage there is no merit in the present complaint. 

14. In view of the above discussion, at this stage we found no merit in the present complaint and same is dismissed. 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:

        21st Day of June 2022

 

 

            (Ashish Kumar Grover)

            President

              

(Urmila Kumari)

Member