BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No. 702 of 2015
Date of Institution: 08.12.2015
Date of Decision: 01.07.2016
Jagjit Singh son of Kuldip Singh, resident of Village: Kherabad, P.O: Central Jail, Ajnala Road, Amritsar.
Complainant
Versus
Religare Health Insurance Company Limited, having its Branch Office at Taneja Tower, Ist Floor, SCO No. 28, Ranjit Avenue, Amritsar-143001 through its Branch Manager/ Authorised Person.
Opposite Party
Complaint under section 11 & 12 of the Consumer Protection Act, 1986 as amended upto date.
Present: For the Complainant: Sh.S.S.Channa, Advocate
For the Opposite Party: Sh. R.P.Singh, Advocate
Coram
Sh.S.S.Panesar, President
Ms.Kulwant Kaur Bajwa, Member
Mr.Anoop Sharma, Member
Order dictated by:
Sh.S.S. Panesar, President.
1. Sh.Jagjit Singh has brought the instant complaint under section 11 & 12 of the Consumer Protection Act, 1986 on the allegations that he had availed the services of Opposite Party by availing a Health Care Policy for cashless facility during his treatment in the hospitals recognized by Opposite Party. Opposite Party had assured the complainant that they will provide him the best of services without being negligent and in case of any treatment, cashless facility will be provided to the complainant. The policy was valid for the period w.e.f 15.7.2014 to 14.7.2017. The complainant got seriously ill due to severe head ache & seizure and was as such admitted in LifeKare Multispeciality Hospital on 21.10.2015 which is on the empanelment of Opposite Party, where he remained admitted for seven days from 21.10.2015 to 27.10.2015. Immediately after admission of the complainant, the officials of LifeKare Multispeciality Hospital informed the Opposite Party regarding the cashless facility available to the complainant and requested for availing the same. Initially, the hospital provided the history of the complainant as well as the reports etc. to Opposite Party, but to the utter surprise of the complainant, Opposite Party rejected the request/ claim of the complainant vide their letter dated 24.10.2015 addressed to LifeKare Multispeciality Hospital, by holding that cashless facility can not be provided to patient as per exclusion clause i.e. treatment of mental illness or psychiatric disorder. The complainant had to pay Rs.24,100/- on the treatment from his own pocket at the time of discharge from the hospital inspite of having medi claim policy. The detail of the expenses occurred on the treatment of complainant during his stay at LifeKare Multispeciality Hospital is given below:-
a) Admission fee Rs. 500/-
b) Room Charges Rs.13500/-
c) Nursing Charges Rs. 1800/-
d) Medical Officer Charges Rs. 3000/-
e) Doctor Visiting Charges Rs. 6000/-
f) Laboratory Charges Rs. 1700/-
Total Rs.24100/-
The cashless facility was availed by the complainant from Opposite Party after paying consideration for the same, at the time of obtaining medi claim policy with the hope of obtaining cashless facility. The illegal rejection by the Opposite Party of the claim submitted by the complainant proves beyond doubt that Opposite Party to be deficient in providing efficient services. The copies of the hospital bills alongwith discharge card are annexed. The complainant due to the negligent and illegal acts of the Opposite Party has suffered lot of pain and mental agony. The aforesaid acts of the Opposite Party completely speaks of gross negligence and deficiency in service, the complainant had approached the Opposite Party after discharge from the hospital who did not bother to listen to the genuine request of the complainant, as such, the necessity to approach this Forum has arisen. The complainant has sought the following reliefs vide instant complaint.
- To reimburse the amount of Rs.24,100/- incurred on the treatment of the complainant alongwith interest @ 18% per annum.
- Compensation of Rs.1 lac on account of medical agony, harassment suffered by the complainant may also be awarded to the complainant.
- The cost of litigation to the tune of Rs.20,000/- may also be awarded to the complainant.
- Any other relief to which the complainant is found entitled under law and equity be also awarded to him.
Hence, this complaint.
2. Upon notice, Opposite Party appeared and contested the complaint by filing written statement taking preliminary objections therein inter alia that the Opposite Party in good faith issued policy bearing No.10124729 to the complainant alongwith his son and daughter on 15.7.2014 for a period of three years. However, the same was cancelled as per Clause 6.1 and Clause 6.13 of the policy terms and conditions for non-disclosure of material fact by the complainant at the time of procuring the policy violating the ‘good faith’ obligation. Copy of the policy certificate is annexed. The complainant first approached the company on 25.5.2015 with a reimbursement request bearing No. 90108280 for an amount of Rs.30,258/- for the hospitalisation of the son of complainant namely Sargun Singh for the ailment of Upper Respiratory Tract Infection (URTI). However, the same was rejected on 30.5.2015 by the company on the basis of Non-disclosure Clause in the policy terms and conditions (Clause 6.1: Non disclosure of Material facts/ pre-existing ailments at the time of proposal). The complainant has concealed the true and material facts from this Forum. As per the medical record submitted by the complainant, the son of the complainant was suffering from mental illness, stress and psychiatric disorders. The aforementioned fact is corroborated and substantiated by the consultation sheet of the complainant’s son dated 6.4.2014; that the complainant again approached the company on 22.10.2015 through his hospital for a cashless request bearing No. 80055530 for the hospitalisation of the complainant himself for seizures. However, the claim was rejected vide letter dated 24.10.2015 qua the permanent exclusion clause in the terms and conditions of the policy procured (Clause4-3(A)(XI): Treatment for mental illness or psychiatric disorders). The copy of the policy terms and conditions are annexed; that the complainant is not entitled to any claim qua the terms and conditions of the policy taken by the complainant as he was suffering from and underwent treatment for an ailment which was not covered within the terms and conditions of the policy. As per the Pre-authorisation request form and the document of LifeKare Multispeciality Hospital, and the reply to the query dated 23.10.2015, the complainant was suffering from seizures and was treated for the same. Therefore, the pre authorisation request for cashless treatment of the complainant was declined vide letter dated 24.10.2015 qua permanent exclusion Clause 4-3(A)(XI). As per the Clause 4.3 (a)
(a) “Any claim in respect of any insured person, for , arising out of, or directly or indirectly due to an of the following shall not be admissible unless expressly stated to the contrary elsewhere in the policy terms and conditions:
(xi). “Treatment of mental illness, stress or psychiatric disorders.
Copy of the Pre-Authorization Request Form and the Pre-Authorization Request denial letter is annexed; that the present complaint pending adjudication before the Forum is not maintainable as complainant is estopped by his own act and conduct from filing the present complaint; that the present complaint pending adjudication before this Forum is not maintainable as the complainant has filed the present complaint without any cause of action against the Opposite Party, therefore liable to be dismissed; that the complainant at the time of procuring the policy provided the Opposite Party with wrong, incorrect and inaccurate information and concealed the material facts of pre-existing ailment of the insured; that the complainant has no locus standi to file the present complaint; that the Opposite Party reserves its right to file any additional written statement for any disclosure of any new fact which is material for the adjudication and disposal of this matter. On merits, it is submitted that Opposite Party had assured to provide the best of its services and providing the cashless facility, subject to the policy terms and conditions only. It is further submitted that the complainant is not entitled to any claim whatsoever for any treatment as the complainant has concealed material facts regarding the pre existing disease of his son while procuring the policy from the company and violated the fundamental principal of good faith. It is further submitted that the complainant was suffering from seizures, and was admitted for the treatment for the same. This medical condition is a permanent exclusion as per the Policy Terms and conditions, Clause 4.3(A(xi), therefore, his claim was duly declined. Remaining facts mentioned in the complaint are also denied and a prayer for dismissal of the complaint with cost was made.
3. In his bid to prove the case, complainant tendered into evidence his duly sworn affidavit Ex.CW1/A in support of the allegations made in the complaint and also produced copy of policy Ex.C1, copy of health card Ex.C2, copy of letter of premium Ex.C3, copy of letter of denial Ex.C4, copy of discharge card of the complainant Ex.C5, copies of bills Ex.C6 to Ex.C13, copy of payment receipt Ex.C14 and closed his evidence.
4. On the other hand, to rebut the evidence of the complainant, Opposite Party tendered into evidence the affidavit of Sh.Ramnik Sachar Legal Manager Ex.OP1, copy of policy Ex.OP2, proposal form Ex.OP3, copy of claim form Ex.OP4, copy of claim rejection letter Ex.OP5, copy of discharge summary Ex.OP6, copy of request for cashless Ex.OP7, copy of patient treatment record Ex.OP8, cop of query letter Ex.OP9, copy of query reply Ex.OP10, copy of treatment record Ex.OP11 and close the evidence.
5. We have heard the ld.counsel for the parties and have carefully gone through the evidence on record.
6. On the basis of evidence on record, ld.counsel for the complainant has vehemently contended that this is an admitted fact that the complainant obtained Health Care Policy for cashless facility which was valid w.e.f. 15.7.2014 to 14.7 2017 from the Opposite Party, on payment of premium, copy of insurance policy accounts for Ex.C1. It is also not denied that the complainant got seriously ill due to severe head ache & seizure and was admitted in LifeKare Multispeciality Hospital where he remained w.e.f. 21.10.2015 to 27.10.2015. It is also not denied that LifeKare Multispeciality Hospital was one of the empanelled hospital of the Opposite Party. But however, Opposite Party did not allow the cashless facility to the complainant without any reasonable cause and the claim filed by the complainant was rejected by the Opposite Party vide letter dated 24.10.2015, copy whereof is Ex.OP5. The complainant was not suffering from mental illness or psychiatric disorder and the complainant has proved on record the medical treatment provided to him in the hospital, copy of the discharge summary accounts for Ex.C5. The Opposite Party has wrongly attracted the clause 4.3(A)(XI) of the policy in question, to disallow the claim of the complainant and rejection letter does not conform to the terms and conditions of the insurance policy. There is no misrepresentation or suppression of any material facts from the Opposite Party, rather the exclusion has been invented to disallow the genuine claim of the complainant and it is contended that the complaint may be allowed in view of the request made in the complaint.
7. But however, from the appreciation of the facts and circumstances of the case, it becomes evident that the complainant is guilty of suppression of material facts. The instant insurance policy covers the health not only of the complainant, but his son and daughter also. The complainant earlier approached the Opposite Party on 25.5.2015 with reimbursement request bearing No.90108280 for an amount of Rs.30,258/- for the hospitalisation of the complainant’s son namely Sargun Singh for the ailment of Upper Respiratory Tract Infection (URTI). However, the same was rejected on 30.5.2015 by the company on the basis of Non-disclosure Clause in the policy terms and conditions as per Clause 6.1 and Clause 6.13 of the policy terms and conditions on account of Non disclosure of Material facts/ pre-existing ailments at the time of proposal and the complainant has not disclosed the factum to the Opposite Party as per medical record submitted by the complainant, copy whereof accounts for Ex.C5 on the record. As per the medical record submitted by the complainant, the son of the complainant was suffering from mental illness, stress and psychiatric disorders. Copy of discharge summary of complainant’ son namely Sargun Singh is Ex.OP6 on record. Reliance in this regard can be had in case Life Insurance Corporation of India Vs. Mansa Devi 2003(1) Judicial Reports Consumer 501 (NC) where it has been held that where the insured has suppressed the material facts of existence of any pre-existing disease and had undergone treatment for that, the suppression of such a material fact renders the contract of insurance illegal, invalid, void abinitio and unenforceable. Hon'ble National Commission further held that the contract of insurance is of utmost good faith i.e. Ubremma Fidei and the life assured is bound to disclose honestly, truthfully and correctly all the answers in the proposal form concerning the state of his health. The same view has been taken by the Hon'ble National Commission in case Sr. Divisional Manger, LIC of India Vs. Smt. Satwant Kaur Sandhu Legal Digest April 2011 page 85 as well as in case Panchal Ramabhai Motibhai Vs. LIC of India Legal Digest April 2011 page 83.
8. Now the fact remains as to whether the ailment suffered by the complainant was mental illness or psychiatric disorder in nature or not. For that purpose, the medical record of the complainant adduced by Opposite Party of LifeKare Multispeciality Hospital is Ex.OP7 to Ex.OP11. The treatment record of the complainant shows that the treatment provided to the patient pertains to mental illness or psychiatric disorder & the complainant has been treated by Neuro-Surgeons throughout during his hospitalization w.e.f 21.10.2015 to 27.10.2015. In such a situation, the claim of the complainant has rightly been repudiated by the Opposite Party and no fault can be found therein. There is no deficiency in service on the part of the Opposite Party and the complaint filed by the complainant has got no merit and as such, same is ordered to be dismissed accordingly. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.
Announced in Open Forum
Dated: 01.07.2016. (S.S.Panesar) President
hrg (Anoop Sharma) (Kulwant Kaur Bajwa) Member Member
