Punjab

Ludhiana

CC/20/215

Swaranjit Kaur - Complainant(s)

Versus

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

S.S.Cheema

19 Jul 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 215 dated 05.10.2020.                                                        Date of decision: 19.07.2024. 

 

Swaranjit Kaur aged about 59 years wife of Sadhu Singh Gill, resident of Village Patti Gill, VPO Sudhar Tehsil Raikot, District Ludhiana.

                                                                                      ..…Complainant

                                                Versus

Manager/Authorized Signatory Religare Health Insurance Company Limited, SCO 13, Shanghai Tower, Feroze Gandhi Market, Ludhiana Punjab-141001.                                                                                             …..Opposite party 

Complaint Under Section 2, 12 and 14 of the Consumer Protection Act, 1986.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. S.S. Cheema, Advocate.

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

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that on 12.06.2019, the complainant went to Brisbane, Australia to meet his son Harsimran Singh Gill and she resided there till 01.09.2019 and before that he purchased International Travelling Insurance policy No.14231588 w.e.f. 11.06.2019 till 03.09.2019. The complainant claimed to have disclosed all the particulars regarding status of her death before purchasing the policy. Her age was 58 years at that time and she was hale and hearty without any health problem. Even the medical expert of the OP found her health quite well without having any problem. The complainant stated that during her stay at Australia, suddenly health problem occurred to her on 30.06.2019 night and she was taken to Matter Hospital, Brisbane where she was found to be suffering from some heart problem. She remained admitted for three days in the hospital and the hospital raised a bill of 7787.5 (Rs.4,18,811.75 INR) Australian Dollars on her treatment. She disclosed the hospital authorities that she is insured with the OP ho will pay the medical expenses incurred on her treatment. Then the staff of the hospital confirmed about the policy from the OP and the OP declared the policy to be genuine and assured the hospital to pay the medical expenses incurred on the treatment of the complainant. Thereafter, the complainant was discharged from the hospital.

                   The complainant further stated that after returning to India on 02.09.2019, she sent the bills to the OP but the OP remained reluctant  to make the payment to the hospital. However, after one year, the OP refused to make the payment of expenditure to the hospital without any reason on the lame excuse that that the disease of the complainant was pre-existing. The OP, at the time of purchasing the policy, represented the complainant that all the health problems occurred during her stay in Australia will be covered and the company is liable to pay all the bills and amount for any treatment. Even the staff of the OP made proper enquiry regarding her health and issued the policy after their full satisfaction. The complainant personally visited the officials of the OP with request to make the payment but they refused to listen to her requests. The complainant was constrained to serve legal notice dated 15.07.2020 upon the OP through Sh. Sukhwinder Singh Cheema, Advocate to which the OP sent an evasive reply. According to the complainant, her problem was not pre-existing rather she suddenly suffered the same at Australia. In the end, the complainant has prayed for issuing directions to the OP to make payment of 7787.5 Australian dollars equivalent to Rs.4,81,811.75 INR along with litigation expenses of Rs.22,000/-.

2.                Upon notice, the OP appeared and filed written statement on behalf of M/s. Care Health Insurance Company Limited, formerly known as Religare Heath Insurance Company Ltd. along with affidavit of Sh. Tejinder Singh, Manager (Legal), M/s. Care Health Insurance Limited assailed the complaint by taking preliminary objections on the ground of maintainability; the complainant is guilty of breach of contract; lack of jurisdiction and cause of action etc. The OP stated that the complainant purchased a travel policy vide policy No.14231588 covering herself and her spouse w.e.f. 11.06.2019 to 03.09.2019 for sum assured of USD 50000 subject to terms and conditions. As per claim filled by the complainant, she was admitted in Mater Hospital, Australia for ailment of Acute Coronary Syndrome/NSTEMI from 01.07.2019 by claiming AUD 7787.05 equivalent to INR 3,73,604.40. The OP further stated that on assessment of the documents, some facts came upfront which are reproduced as under:-

• “As per the Discharge Summary issued by the treating doctor the Complainant was a known case of Type II Diabetes and Hypertension.
• As per the Cashless Claim Form, the Complainant is mentioned to be a known case of Hypertension.
• As per the Certificate issued by the Local Pharmacy Store, Bansal Medical Store (Pul Sudhar Bazar) retrieved in course of investigation of the Claim, it is duly attested that the Complainant Mrs. Sawaranjit Kaur is suffering from Hypertension and Diabetes since 2018. It is pertinent to mention here that the Complainant has been purchasing medicine from the said Medical Store as is evident from the Prescription Note issued by Polyclinic: Ex Serviceman Health Scheme and Bansal Medical Store (Pul Sudhar Bazar wherein the Complainant has been duly purchasing medicine for Hypertension and Diabetes.”

OP further stated that in light of the fact that the complainant has past medical history of Diabetes Miletus and Hypertension since 2002 and on medication for same and no such Pre Existing Diseases had been disclosed at the inception of the Policy, her claim was rejected for Non Disclosure of Material Facts of Hypertension and Diabetes Miletus vide clause 5.1 of the Policy Terms and Conditions given the fact that the present ailment hospitalization for NSTEMI is directly related to Pre Existing Disease of Hypertension and Diabetes. The denial of the Claim was duly communicated via Letter dated 19.06.2020. The complainant in the Online Proposal Form, made mis-declaration under the heading ‘Additional Details’, which is reproduced as under:-

“Has anyone been diagnosed/hospitalized or under any treatment for any illness/injury during the last 48 months.

          No.”

According to the OP, the complainant was under obligation o disclose all material fats at the time of the policy as per clause 5.1 of the polity terms and conditions, which she violated and due to which her claim was rejected.

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

3.                The complainant filed replication to the written statement of the OP reiterating the facts mentioned in the complaint and controverted those mentioned in the written statement of the OP.

4.                In evidence, the complainant tendered her affidavit as Ex. CA and reiterated the averments of the complaint. The complainant also placed on record documents Ex. C1 is the copy of insurance policy, Ex. C2 is the copy of hospital bill, Ex. C3 is the copy of legal notice dated 15.07.2020, Ex. C4 is the postal receipt, Ex. C5is the copy of reply to legal notice by the OP, Ex. C6 and Ex. C7 are the copies of test reports of the complainant, Ex. C8 is the copy of Aadhar Card and closed the evidence.

5.                On the other hand, the counsel for the OPs tendered affidavit  Ex. RA of Sh. Tejinder Singh, Manager (Legal) of the OP along with documents Ex. R1 is the copy of  insurance policy, Ex. R2 is the copy of terms and conditions of the policy, Ex. R3 is the copy of discharge summary and medical record, Ex. R4 is the copy of Claim Form, Ex. R5 is the copy of certificate issued by Bansal Medical Store, Ludhiana, Ex. R6 is the copy of ECHS Card of the complainant, Ex. R7 is the copy of repudiation letter dated 19.06.2020, Ex. R8 is the copy of legal notice dated 15.07.2020 as well as reply to legal notice and closed the evidence.                                                     

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

7.                The complainant obtained an insurance policy from the OPs under plan Gold Ex US_Canada (Single) Ex. C1 = Ex. R1 on 11.06.2019 covering herself and her husband Sadhu Singh Gill having a coverage of 100000 USD on premium of Rs.11656/-. The policy was valid up to 03.09.2019 for 85 Travel Days. The complainant went to Brisbane, Australia on 12.06.2019 to meet her son Harsimran Singh Gill where she faced some heart problem and was admitted in Mater Hospital Brisbane on 30.06.2019. The complainant remained admitted in the said hospital for three days and incurred 7787.5 Australian Dollars (Rs.4,18,811.75) on her treatment. The complainant submitted her cashless claim with the OPs along with documents vide claim form Ex. R4 but the rejected the claim of the complainant vide repudiation letter dated 19.06.2020 Ex. R7 by invoking cause 5.1 of the policy terms and condition, Non-disclosure of pre-existing medical condition. The operative part of Ex. R7 reads as under:-

“We have received your request and hereby inform you that the cashless settlement for hospitalization cannot be approved as per the Policy Terms & Conditions. For ease of your perusal, we have reproduced the reason below:

CLAUSE 5.1: Non-disclosure of pre-existing medical condition:

1. Hypertension
2. Diabetes

If there has been a misrepresentation, mis-description or non-disclosure of any material particulars, the company shall have no liability to make payment of any claim.”

 

8.                Now the question arise whether the rejection of the claim on the ground mentioned therein is justified or not?

9.                The rejection of the claim of the complainant was effected by the opposite parties by invoking cause 5.1 of the policy terms and conditions that the complainant had not disclosed about the pre-existing disease of hypertension and diabetes. The OPs have made the discharge summary Ex. R3, the basis of rejection of the claim of the complainant as in the column of Past Medical History of Ex. R3 ‘T2DM and Hypertension’ has been mentioned. In the Data Sheet ‘EXPLORE’ Ex. R1 under the column of additional details, the insured the answered all the questions in negative. The claim of the complainant is sought to be rejected on the ground that she was a patient of hypertension and diabetes. It is a matter of common knowledge that as a normal practice the form is filled by the insurance agent. In addition to this, despite being of age of 56 years at the time of issuance of the policy, the complainant was not got medically examined by the OPs. Moreover, the insurance company may have additional questions for the insured or may ask her to undergo medical tests to complete full medical assessment. No evidence has been lead by the OPs as to whether any additional questions were put to the complainant or not nor any evidence has been adduced that the complainant was subjected to some medical tests at the time of issuance of the policy in the month of June 2019.

10.              In the present case, the complainant was admitted in Mater Private Hospital Brisband (Austraia) with principal diagnosis for Acute Coronary syndrome/NSTEMI as per discharge summary Ex. R3. As per discharge summary, under the column of reason for presentation, the patient presented with complaint of chest pain. Therefore, any treatment taken by the complainant prior to taking the policy about which no questions were asked in the proposal form, it cannot be said that the OPs are justified in rejecting the claim on the ground of non-disclosure of  pre-existing disease of hypertension and diabetes. Further, the OPs have not produced any evidence of medical record with regard to diagnosis and treatment of the said pre-existing disease of the complainant. Even the report or the affidavit of any investigator was not brought on record to substantiate its claim. Only one certificate Ex. R5 of Bansal Medical Store has been produced stating that the complainant is suffering from DM and HTN since 2018 and taking regular treatment. In this certificate a specific note has been given stating “No any history CAD”. The complainant was admitted in the said hospital for her treatment as she was suffering from Acute Coronary Syndrome/NSTEMI. Non-ST-elevation myocardial infarction (NSTEMI) is a type of involving partial blockage of one of the coronary arteries, causing reduced flow of oxygen-rich blood to the heart muscle. As such, there is no nexus between the diagnosed disease and the alleged pre-existing disease. It is well settled that on account of non-disclosure of such general diseases, the genuine claim cannot be rejected. In this regard, 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 that hypertension is a common disease and can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack. Further reference can be made to Tarlok Chand Khanna Vs United India Insurance Co. Ltd. 2012(1) C.P.J. 84 whereby it has been held by Hon’ble National Consumer Disputes Redressal Commission, New Delhi  that the onus to prove that the insured was suffering from pre-existing disease was on the insurer and if the insurer has not produced the expert opinion, the reasons for repudiation of the claim were held to be unjustified. A reference can be further made to Lakhwinder Singh and another Vs United India Insurance Company etc.  decided in Appeal No.29 of 2009 whereby it has been held by Hon’ble State Consumer Disputes Redressal Commission, U.T, Chandigarh that the maladies like diabetes, hypertension being normal wear and tear of the life cannot be treated as pre-existing diseases.

11.              Further 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 observed 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.               

Therefore, in our considered view, the repudiation of the claim on the basis of non-disclosure of pre-existing diseases such as hypertension and diabetes could not have been made a ground to reject the claim.  The insurance companies are required to be more liberal in their approach without being too technical. In this case, the complainant had raised a claim of 7787.5 Australian Dollars equivalent to Rs.4,18,811.75INR for her treatment. In the given set of above said facts and circumstances, it would be just and appropriate if the OP is directed to settle and reimburse claim lodged by the complainant in respect of her treatment at Mater Private Hospital Brisbane along with composite costs of Rs.10,000/-

12.              As a result of above discussion, the complaint is partly allowed with direction to the OP (Now known as M/s. Care Health Insurance Limited) to settle and reimburse the claim lodged by the complainant in respect of her treatment Mater Private Hospital Brisbane within period of 30 days from the date of receipt of copy of the order failing which the OP shall pay interest @8% per annum on the settled amount to the complainant from the date of order till its actual payment. The OP shall further pay a composite cost of Rs.10,000/- (Rupees Ten Thousand only) to the complainant. Payment of costs shall be made within a period of 30 days from the date of the receipt of the copy of this 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)                              (Sanjeev Batra)               Member                                         President  

 

Announced in Open Commission.

Dated:19.07.2024.

Gobind Ram.