Punjab

Ludhiana

CC/20/120

Kapil Manggi - Complainant(s)

Versus

Religare Health Insurance Co.Ltd. - Opp.Party(s)

M.S.Sethi

01 Jun 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:120 dated 30.07.2020.                                                         Date of decision: 01.06.2023.

 

1. Kapil Manggi s/o. Late Narinder Kumar, BI-574, Kundan Puri, Civil Lines, Ludhiana, Punjab-141001.   
2. Aarti Manggi w/o. Kapil Manggi, BI-574, Kundan Puri, Civil Lines, Ludhiana, Punjab-141001                                                                                                                                             ..…Complainants

                                                Versus

1. M/s. Religare Health Insurance Company Limited, 5^th Floor, 19 Chawla House, Nehru Place, New Delhi-110019 through authorized signatory.
2. M/s. Religare Health Insurance Company Limited, SCO 13, Shanghai Tower, Feroze Gandhi Market, Ludhiana, Punjab-141001 through authorized signatory.

…..Opposite parties 

Complaint Under the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainants            :         Sh. M.S. Sethi, Advocate.

For OPs                          :         Sh. G.S. Kalyan, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainants obtained Family Health Insurance Policy from the opposite parties from 12.06.2017 to 11.06.2018 for sum assured of Rs.5,00,000/- against portability from previous insured Max Bupa Heath Insurance Company. According to the complainants, they were paying premiums to Max Bupa Health Insurance Co. since 12.06.2012. Complainant No.1 paid the premium of Rs.17,150/- to the opposite parties against the policy named “Care” and cover type “Floater” for which proposal form was also got signed by opposite parties from complainant No.1 and thereafter issued policy documents dated 13.06.2017 including policy schedule bearing policy No.11361438. The complainants further stated that the policy was regularly renewed for the period from 12.06.2019 to 11.06.2020 for sum assured of Rs.3,30,000/- against 4 members by paying premium of Rs.17,150/-.

                   Complainant No.2 bearing member ID 56483234 was admitted in Hero DMC Heart Institute, Ludhiana on 04.11.2019 and she remained admitted till 09.11.2019 and was treated against triple vessel disease and primary PTCA with stenting to RCA was done on the same day for which the complainants submitted cashless facility with opposite party No.1 but pre-authorization was denied vide letter dated 05.11.2019 by raising following objection:

1. Non disclosure of material facts/pre-existing ailments at the time of proposal diabetes and hypertension for 6 year.
2. Non disclosure of material facts/pre-existing ailments at the time of proposal.

The hospital vide email dated 05.11.2019 informed opposite party No.1 that patient having diabetes from 1.6 years and it has been wrongly mentioned on the treatment chart but opposite party refused to pay and advised the complainants to submit the bills after discharge. After discharge of complainant No.1 from the hospital on 09.11.2019, the complainants paid the hospitalization charges and medical expenses amounting to Rs.1,52,669/-. Thereafter, the complainants lodged claim via email with opposite parties along with clarification letter dated 27.11.2019 from the treating doctor and refusal letter dated 04.11.2019 of the hospital to correct their record. The complainants also submitted earlier record of treatment for blood pressure and diabetes taken from Sachdeva Clinic but the claim was repudiated by opposite party No.1 vide letter dated 31.01.2020 sent through email, on the following grounds:-

                   “Claim repudiated for non disclosure of DM & HTN & non                       disclosure.”

The complainants further started that they again lodged their protest with opposite parties on 31.01.2020 and opposite party No.1 vide letter dated 04.03.2019 threaten to cancel the policy giving 15 days time to the complainants to submit correct facts supported by valid documents failing which they would cancel the policy and forfeit the entire premium. According to the complainants, the repudiation of the claim is illegal and not based on real facts as complainant No.2 was not suffering from diabetes and hypertension prior to issuance of policy from Max Bupa Insurance or from the opposite parties from 12.06.2017.  The opposite parties are taking false and baseless defence of being suffering from pre-existing disease for last 6 years by complainant No.2 as complainant was having no such disease from last 6 years. Dr. Bishav Mohan also wrote to opposite parties on 05.11.2019 and 29.11.2019 of having diabetes from 1.6 years. The repudiation of the claim on the basis of false and baseless grounds, amounts to deficiency in service and unfair trade practice on the part of the opposite parties. In the end, the complainant prayed  to set aside the repudiation letter dated 05.11.2019 and 31.01.2020 and to direct the opposite parties to pay the claim of Rs.1,52,669/- along with compensation of Rs.50,000/- and litigation expenses of Rs.22,000/-.

2.                Upon notice, the opposite parties appeared and filed joint written statement and by taking preliminary objections, assailed the complaint on the ground of maintainability of the complaint, misrepresentation and concealment of facts and lack of cause of action etc. The opposite parties stated that they issued policy namely CARE bearing policy No.11361438 in favour of Mr. Kapil Manggi, Mrs. Aarti Manggi and their son for the period from 12.06.2017 to 11.06.2018 for sum insured of Rs.5,00,000/-. The policy was renewed from 12.06.2018 to 11.06.2019; 12.06.2019 to 11.06.2019 and lastly from 12.06.2019 to 11.06.2020. The policy was ported from Max Bupa. According to the opposite parties, a cashless request was received from Dayanand Medical College and Hospital, Ludhiana where insured Mr. Aarti Manggi remained admitted from 04.11.2019 for the complaint of breathlessness. As pre pre-authorization form, the insured was diagnosed with IWMI, DM and HTN. As per treatment form and progress notes, the complainant had a history of DM and HTN since 6 years i.e. before the policy inception which was not disclosed by the insured before purchasing the policy and as such, cashless request was denied vide denial letter dated 05.11.2019. The opposite parties further stated that reimbursement claim along with documents was received from the complainant as per which the insured was admitted at DMC Hospital from 04.11.2019 till 09.11.2019. After receipt of claim documents, query letter dated 09.12.2019 was sent to the complainant and was asked to provide certain documents. On receiving no reply, reminder letter dated 19.12.2019 was sent to the complainant followed by another query letter dated 26.12.2019 and as no reply was further received, so reminder letter dated 05.01.2020 was sent to the complainant. As the required documents were not provided, therefore, query letter dated 22.01.2020 was sent to the complainant. As the insured had not disclosed about his history of DM and HTN to the opposite parties, the claim of insured was denied vide denial letter dated 31.01.2020 on the ground of non-disclosure only.

                     The opposite parties further stated that as per the treatment form received from the hospital along with pre-authorization form, it was mentioned that the complainant had a history of DM and HTN since 6 years and due to non-disclosure on the part of the complainant, a notice of cancelation dated 04.03.2020 was sent to the complainant. In the proposal form, the complainant intentionally did not disclose that the insured is a known case of DM & HTN. According to the opposite parties, the following questions were asked from the complainant in the proposal form:-

          “Health and Lifestyle Information

“Does any proposed insured currently or in past diagnosed/suffered/ treated/taken medication for any of the following conditions. If yes, please provide details in the additional information section below:-

          Hypertension/High Blood Pressure (BP)/ High Cholesterol.

          Answer marked as NO

          Diabetes Mellitus/High Blood Sugar/Diabetes on Insulin or              medication

          Answer marked as NO”

The complainant also declared in proposal form that all the statements or particulars given by him are true and complete in all respects. The complainant did not disclose about pre-existing disease at the time of submitting portability form. According to the opposite parties depending upon the disclosures made by the complainant at the time of proposal, they decide whether to accept the risk and provide the policy to the customer or not. It is the duty of the insured to disclose correct and accurate information about his current health status at the time of proposal for the accurate assessment of risk but the complainant by not disclosing the correct health status of the patient has blatantly violated the principle of Good faith i.e. Uberrimae Fides and the policy terms and conditions which is the basis of contract between the complainant and the company. The relevant clause of policy terms and conditions is reproduced as under:-

“7.1. Disclosure to Information Norm

If any untrue or incorrect statements are made or there has been a mis-representation, mid-description or non-disclosure of any material particulars or any material information having been withheld or if a claim is fraudulently made or any fraudulent means or devises are used by the policyholder or the Insured Person or any one acting on his/their behalf, the Company shall have no liability to make payment of any claims and the premium paid shall be forfeited ab initio to the company.”

The opposite parties further stated that the Insurance Regulatory and Development Authority of India (IRDAI) (Protection of Policy Holder’s Interest) Regulations, 2017 under Cause 19(4) enumerating the “General Principles” casts in absolute duty to disclose all material facts to the Insurer in order to assess the risk as per its capacity which is reproduced as under:-

“The policyholder shall furnish al information that is sought from him by the insurer, either directly or through the distribution channels which the insurer considers as having a bearing on the risk to enable the insurer to assess properly the risk covered under a proposal for insurance.”

 

 

                    On merits, the opposite parties reiterated the crux of averments made in the preliminary objections. The opposite parties have denied that there is any deficiency of service and have also prayed for dismissal of the complaint.

3.                In support of their claim, the complainants tendered their joint affidavit Ex. CA in which they reiterated the allegations and the claim of compensation as stated in the complaint. The complainants also tendered documents i.e. Ex. C1 is copy of portability details of the insured, Ex. C2 is the copy of policy certificate w.e.f. 12.06.2017 to 11.06.2018, Ex. C3 is the copy of policy certificate w.e.f. 12.06.2019 to 11.06.2020, Ex. C4 is the copy of discharge summary of Hero DMC Heart Institute, Ludhiana, Ex. C5 is the copy of denial letter dated 05.11.2019, Ex. C6 to Ex. C9 are the hospital bills/receipts, Ex. C10 is the copy of certificate dated 27.11.2019 of Hero DMC Heart Institute, Ludhiana, Ex. C11 and Ex. C12 are the copies of prescription slip of Sachdeva Clinic, Ex. C13 is the copy of claim denial letter dated 31.01.2020, Ex. C14 is the copy of email dated 31.01.2020, Ex. C15 is the copy of notice of cancellation of policy dated 04.03.2020, Ex. C16 is the copy of reply to letter dated 04.03.2020 and closed the evidence.

4.                On the other hand, counsel for the opposite parties tendered affidavit Ex. RA of Sh. Lakshay Juneja, Manager (Legal) of the opposite parties along with documents Ex. R1 is the copy of policy documents, Ex. R2 is the copy of proposal form, Ex. R3 is the copy of portability form, Ex. R4 is the copy of pre-authorization form, Ex. R5 is the copy of treatment form, Ex. R6 is the copy of denial letter dated 05.11.2019, Ex. R7 is the copy of claim form, Ex. R8 is the copy of discharge summary, Ex. R9 is the copy of deficiency letter dated 09.12.2019, Ex. R10 is the copy of deficiency letter dated 26.12.2019, Ex. R11 is the copy of claim denial letter dated 31.01.2020, Ex. R12 is the copy of notice of cancellation dated 04.03.2020 and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.

6.                The complainants are the regular subscribers to health insurance policies since 12.06.2012 Ex. C1. The complainants obtained a family health insurance policy w.e.f. 12.06.2017 to 11.06.2018 vide policy Ex. C2, which was renewed w.e.f. 12.06.2019 to 11.06.2020. During the subsistence of coverage of said policy, complainant No.2 remained hospitalized from 04.11.2019 to 09.11.2019 and Coronary Angiography was performed. An amount of Rs.1,52,669/- Ex. C6 to Ex. C9 were incurred on her treatment. Her pre-authorization request was declined on 05.11.2019 vide letter Ex. C5 on the following grounds:-

“We have reviewed your request, and hereby inform you that the cashless hospitalization cannot be approved as per the terms and conditions of the policy stated below:

• Rejection remain same – Non disclosure of material facts/pre-existing ailments at the time of proposal diabetes & hypertension for 6 years.
• Non disclosure of material facts/pre-existing ailments at time of proposal.”

Thereafter, the complainant submitted a claim for reimbursement along with clarificatory letter Ex. C10 and record of previous treatment at Sachdeva Clinic Ex. C11 and Ex. C12. On the receipt said documents, the opposite parties sent query letters/reminders dated 09.12.2019 Ex. R9, dated 19.12.2019 and dated 26.12.2019 Ex. R10. Thereafter, on 31.01.2020 vide email/letter Ex. C14 = Ex. R11, the claim of the complainant was repudiated on following grounds:-

“We have reviewed the claim filed by you pertaining to Health Insurance policy (11361438) and hereby inform you that the claim is not payable as per policy terms and conditions listed below:-

• Claim repudiated: Non disclosure of DM and HTN.
• Non disclosure.”

The complainant was also served with a notice of cancellation dated 04.03.2020 which was suitably replied by the complainant.

7.                The main basis of repudiation of the claim by the opposite parties is that complainant No.2 had history of Diabetes Mellitus and Hypertension since six years. The opposite parties did not produce any evidence in the form of medical record with regard to the diagnosis and treatment of said pre-existing disease since six years. Even the report or affidavit of any investigator has not been brought on record to substantiate its claim. Rather on the other hand, the complainants have produced the certificate Ex. C10 of Dr. Bishav Mohan, Prof. & Sr. Consultant Cardiologist , which is as under:-

“This is to certify that Mrs. Aarti Manggi, 40 years old female w/o. Sh. Kapil Manggi, R/o. #B-574, Kundan Puri, Civil Lines, Ludhiana was admitted on 04-11-19 as a case of Type II Diabetes Mellitus, Hypertension, CAD-Acute Inferior Wall MI, EF=40-42%, Vide Adm No.019078142, MRD No-842725 under Dr. Bishav Mohan in the department of cardiology of Hero DMC Heart Institute, Ludhiana. She presented with chief complaints of chest pain radiating to shoulder few hours prior to admission. Coronary Angiography was done on 04-11-19 which showed Tripe Vessel Disease. Primary PTCA with stenting to RCA was done on 04-11-19. As per the history narrated by the patient self at the time of admission, the history of Hypertension & Type II DM is 1.6 years. Patient was discharged on 09-11-19 from the hospital in stable condition.”

Perusal of previous medical record produced by the complainant as Ex. C1 and Ex. C12 also shows that complainant No.2 visited Sachdeva Hospital for the first time on 22.05.2018. A conjoint reading of medical certificate and record produced by the complainant clearly shows that the history of diabetes mellitus and hypertension was not six years old. Even seeing from another aspect, the complainant had been availing policies for the last more than 7 years and the history of diabetes mellitus and hypertension came into force during subsistence of continuous coverage under the policy(s) itself.

8.                Further reference can be made to Religare Health Insurance Company Ltd. Vs Subhash Chander Aggarwal in 2017(3) CLT 140 whereby it has been held by Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh the hypertension is a common disease and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack and repudiation on account of pre-existing disease was not justified.

8.                The counsel for the opposite parties has referred to the proposal form Ex. R2 dated 09.06.2017 under the head of medical/lifestyle related information, the complainants have denied having Hypertension/High Blood Pressure(BF)/High Cholesterol. But in the present case, hospitalization pertains to subsequent policy which was having coverage from 12.06.2019 to 11./06.2010. No proposal form at the time of renewal of policy under reference has been produced by the opposite parties. In the absence of any duly signed and authenticated proposal form the matter in controversy cannot be adjudicated upon in favour of the opposite parties. The online proposal form is material document from which it could have been easily assessed whether there was a concealment on the part of the complainant. Non-production of proposal form leads to inevitable inference that either the proposal form was not got executed before issuing the policy or there are certain anomalies and discrepancies in the proposal form, production of which may prove adverse to the rights of the opposite parties. It was also well within the legitimate rights of the opposite parties to get the complainant medically examined by the empanelled doctors but no such option was exercised.

9.                In a case titled as Manmohan Nanda Vs United India Assurance Co. Ltd. and others 2022(I) CPJ 20 (SC) wherein the Hon’ble Supreme Court of India has held as under:-

(i) There is a duty or obligation of disclosure by the insured regarding any material fact at the time of making the proposal. What constitutes a material fact would depend upon the nature of the insurance policy to be taken, the risk to be covered, as well as the queries that are raised in the proposal form.

(ii) What may be a material fact in a case would also depend upon the health and medical condition of the proposer.

(iii) If specific queries are made in a proposal form then it is expected that specific answers are given by the insured who is bound by the duty to disclose all material facts.

(iv) If any query or column in a proposal form is left blank then the insurance company must ask the insured to fill it up. If in spite of any column being left blank, the insurance company accepts the premium and issues a policy, it cannot at a later stage, when a claim is made under the policy, say that there was a suppression or non­disclosure of a material fact, and seek to repudiate the claim.

(v) The insurance company has the right to seek details regarding medical condition, if any, of the proposer by getting the proposer examined by one of its empanelled doctors. If, on the consideration of the medical report, the insurance company is satisfied about the medical condition of the proposer and that there is no risk of pre­existing illness, and on such satisfaction it has issued the policy, it cannot thereafter, contend that there was a possible pre­existing illness or sickness which has led to the claim being made by the insured and for that reason repudiate the claim.

(vi) The insurer must be able to assess the likely risks that may arise from the status of health and existing disease, if any, disclosed by the insured in the proposal form before issuing the insurance policy. Once the policy has been issued after assessing the medical condition of the insured, the insurer cannot repudiate the claim by citing an existing medical condition which was disclosed by the insured in the proposal form, which condition has led to a particular risk in respect of which the claim has been made by the insured.

(vii) In other words, a prudent insurer has to gauge the possible risk that the policy would have to cover and accordingly decide to either accept the proposal form and issue a policy or decline to do so. Such an exercise is dependant on the queries made in the proposal form and the answer to the said queries given by the proposer.               

10.                        In the light of above said facts and circumstances, the opposite parties were not justified in repudiating the claim of the complainant and as such, there is deficiency in service on the part of the opposite parties. In the given facts and circumstances of the case, if the opposite parties are directed to settle and reimburse the claim with respect to hospitalization of the complainant No.2 at Hero DMC Heart Institute, Ludhiana from 04.11.2019 to 09.11.2019 in terms of policy terms and conditions along with interest @8% per annum on the settled amount from the date of filing of complaint till its actual payment. The opposite parties are also burdened with composite costs of Rs.10,000/-.

12.              As a result of above discussion, the complaint is partly allowed with direction to the opposite parties to settle and reimburse the claim with respect to hospitalization of the complainant No.2 at Hero DMC Heart Institute, Ludhiana from 04.11.2019 to 09.11.2019 in terms of policy terms and conditions along with interest @8% per annum on the settled amount from the date of filing of complaint till its actual payment within 30 days from the date of receipt of copy of order. The opposite parties shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the complainants within 30 days from the date of receipt of copy of order.  Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

13.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                     (Sanjeev Batra)

Member                         Member                                       President         

 

Announced in Open Commission.

Dated:01.06.2023.

Gobind Ram.

 

 

Kapil Manggi etc.  Vs Religare Health Insurance Co.                CC/20/120

Present:       Sh. M.S. Sethi, Advocate for the complainants.

                   Sh. G.S. Kalyan, Advocate for the OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with direction to the opposite parties to settle and reimburse the claim with respect to hospitalization of the complainant No.2 at Hero DMC Heart Institute, Ludhiana from 04.11.2019 to 09.11.2019 in terms of policy terms and conditions along with interest @8% per annum on the settled amount from the date of filing of complaint till its actual payment within 30 days from the date of receipt of copy of order. The opposite parties shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the complainants within 30 days from the date of receipt of copy of order.  Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

 

(Monika Bhagat)          (Jaswinder Singh)             (Sanjeev Batra)

Member                         Member                              President        

 

Announced in Open Commission.

Dated:01.06.2023.

Gobind Ram.