Punjab

Patiala

CC/19/98

Iqbal Singh - Complainant(s)

Versus

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

Inperson

15 Feb 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION

PATIALA.

 

                                      Consumer Complaint No. 98 of 27.2.2019

                                      Decided on:         15.2.2023

 

Iqbal Singh, aged about 36 years son of Sh.Amarjit Singh, resident of H.No.16, Gulab Nagar, Near Gurdwara Sahib, Rajpura, District Patiala.

 

                                                                   …………...Complainant

                                      Versus

1. Religare Health Insurance Co. Ltd., Regd. Office 5^th Floor, 19 Chawla House, Nehru Place, New Delhi, through its M.D.

 

2. Religare Health Insurance Co. Ltd., SCO 56-57-58, Top Floor, Sector 9-
   D, Chandigarh, through its Area Head.

 

3. Area Head, Religare Health Insurance Co. Ltd., SCO 56-57-58, Top Floor, Sector 9-D, Chandigarh

 

4. Priyanka, Religare Health Insurance Co. Ltd., SCO 56-57-58, Top Floor, Sector 9-D, Chandigarh, Now resident of H.No.284, Haridass Colony, Nabha, District Patiala.

                                                                   …………Opposite Parties

Complaint under the Consumer Protection Act

 

QUORUM

                                      Hon’ble Mr.S.K.Aggarwal, President

                                      Hon’ble Mr.G.S.Nagi,Member         

 

 

PRESENT:                   Sh.Iqbal Singh, complainant in person.

                             Sh.Amit Gupta, counsel for OPs.

         

                              

 

                                     

 ORDER                                          

1. The instant complaint is filed by Iqbal Singh S/o Amarjit Singh  (hereinafter referred to as the complainant) against Religare Health Insurance Co. Ltd. and others (hereinafter referred to as the OP/s) under the Consumer Protection Act ( for short the Act).
2. The averments put forth by the complainant are as follows:

          That complainant purchased health insurance policy No.10800426 from OP No.1 through OP No.4 and paid requisite premium for the same. On 18.8.2018 complainant suffered from some health problem and was taken to Civil Hospital, Rajpura, where first aid was provided. Thereafter he was asked to consult a cardiologist for further checkup and treatment. Complainant consulted Dr.Anil Grover at SAS Nagar, Mohali on 20.8.2018 when certain medical tests including ECG were conducted. After thorough check up, it was found that complainant is suffering from some heart problem. He was referred to PGI Chandigarh. Complainant approached the concerned doctors of PGI Chandigarh on 24.8.2018. He was admitted there on 25.8.2018. He was again admitted there on 28.8.2018 when pace maker was inserted in the body of the complainant. Thereafter, complainant was discharged on 2.9.2018.Complainant spent Rs.2,30,000/- on his treatment, medical tests, operation and consultation fee etc.

          Complainant lodged medical claim for reimbursement of the said amount with OPs No.1&2 and also sent original documents to them on their demand. He also completed all the formalities as per their requirements. Vide letter dated 19.11.2018, claim was rejected due to non disclosure of material facts/pre-existing ailments at the time of proposal, whereas he was not suffering from any pre-existing disease. Furthermore, official of OPs No.1to4 after satisfying themselves regarding the health of the complainant, issued the policy. They also renewed the policy after expiry of one year. Complainant also sent legal notice dated 17.1.2019 to the OPs who filed reply on flimsy grounds. The denial of the claim amounts to deficiency in service as well as unfair trade practice on the part of the OPs, which caused mental agony and harassment to the complainant. Consequently, prayer has been made for acceptance of the complaint.

3. Upon notice, OPs appeared through counsel and filed written statement having taken various certain preliminary objections. It is pleaded that the complainant has suppressed material information with regard to his health and has made false declaration in the proposal form. On the basis of information given by the complainant and in good faith the proposal was accepted by the OPs and insurance policy was issued with effect from 18.9.2016 to 17.9.2017 strictly subject to the terms and conditions of the policy. The said policy was further renewed from 18.9.2017 to 17.9.2018 and thereafter from 18.9.2018 to 17.9.2019. The complainant lodged a claim with regard to his treatment at PGI Chandigarh w.e.f. 25.8.2018 to 2.9.2018 for treatment of Symptomatic Bifascicular Block and a sum of Rs.2,13,153/- was claimed,  vide claim letter dated 9.10.2018.On receipt of this letter OPs sent letters dated 12.10.2018 and 4.11.2018  for certain queries from the complainant. Complainant replied the queries and submitted the requisite documents. The OPs also initiated an investigation to check the veracity of the claim from where it came to the knowledge that the insured has pre existing condition and history of cerebral infarct, hypertension, dyslipidemia, prior to policy inception. Therefore, reimbursement claim of the complainant was rejected in accordance with clause 7.1 of the policy’s terms and conditions. Same was intimated to the complainant vide letter dated 19.11.2018 and pre-post hospitalization claim was rejected vide letter dated 11.12.2018.There is no deficiency of service on the part of the OPs and the complaint is liable to be dismissed. On merits, the OPs reiterated the facts taken in the preliminary objections, contents of which are not repeated for the sake of brevity. After denying all other averments made in the complaint, the OPs have prayed for the dismissal of the complaint.
4. In support of his complaint, complainant tendered in evidence his affidavit Ex.CW1/A, copies of OPD slips, Exs.C1 and C2, copies of lab reports, Exs.C3 and C4, copies of ECG reports, Exs.C5 to C7, copy of receipt of Dr.Anil Grover, Ex.C8, copy of OPD card of PGI, Ex.C9, copy of admission and discharge record of PGI, Ex.C10, copy of ECG report,Ex.C11, copy of payment bills of PGI (8 pages) Ex.C12,  copy of medicine bills (12 pages),Ex.C13, copy of pace maker bill, (two pages),Ex.C14, copy of rejection letter dated 19.11.2018,Ex.C15, copy of legal notice, Ex.C16, postal receipts of legal notice, Exs.C17 to C20, copy of legal notice,Ex.C21, copy of adhaar card,Ex.C22 and closed the evidence.
5. Ld. counsel for OPs tendered in evidence Ex.OPA, affidavit of Shreya Chansoria, Manager Legal, Religare Health Insurance, Ex.OP1, copy of proposal form, Ex.OP2 copy of insurance policy, Ex.OP3 copy of claim form, Ex.OP4 copy of deficiency letter,Ex.OP5 and Ex.OP6, copy of prescription slip,Ex.OP7, copy of discharge summary of PGI, Ex.OP8, copy of questionnaire,Ex.OP9, copy of claim denial letter,Ex.OP10, copy of letter dated 22.4.2019 and closed the evidence.
6. We have heard the complainant present in person, ld. counsel for the OPs and have also gone through the record of the case, carefully.
7. Concededly, complainant has purchased health insurance policy bearing No.10800426, Ex.OP2, valid for the period 18.9.2016 to 17.9.2017 and paid premium of Rs.15176/- for the same. The said policy was extended from 18.9.2017 to 17.9.2018 after payment of premium of Rs.15572/-(Ex.OP2). The complainant suffered from some health problem on 18.8.2018 and he visited Civil Hospital, Rajpura for checkup. The OPD slips in this regard are Exs.C1 and C2. Complainant was advised to consult a cardiologist. Various tests alongwith ECG were conducted on 18.8.2018, copies of which are Exs.C3 to C5. Thereafter complainant consulted Dr.Anil Grover, cardiologist, vide Ex.C8 and the case was discussed by the consulting doctor with Dr.Manoj, Professor of Cardiology, PGI and complainant was asked to consult him for further treatment. Complainant reported to Dr.Manoj at PGI on 25.8.2018 as per OPD card, Ex.C9. Complainant was treated in PGI and pace maker was inserted. He was discharged on 2.9.2018, as per history of admission,Ex.C10. Thereafter, claim was lodged with the OPs, which was repudiated on 19.11.2018, vide claim denial letter, Ex.OP9, on the ground of non disclosure of material facts with regard to pre existing ailment i.e. cerebral infarct, hypertension, dyslipidemia,  at the time of proposal.
8. OPs have relied upon the proposal form Ex.OP1, submitted by the complainant at the time of taking the insurance policy, wherein complainant had stated that he was not suffering from hypertension/ high blood pressure. The OPs have further stated that the proposal was accepted in good faith and policy was issued for a period of one year from 18.9.2016 to 17.9.2017, though the OPs were kept in dark about the pre existing ailment. The policy was further renewed by the OPs for another period of one year and was valid till 17.9.2018.
9. OPs have argued that claim for Rs.2,13,362/- was lodged by the complainant as  per claim letter,Ex.OP3. Complainant was asked to clarify the various queries by issuing deficiency letters dated 12.10.2018 and 4.11.2018 Exs.OP4. The documents demanded from the complainant were submitted by him vide letter, Ex.OP5,Ex.OP7 and Ex.OP8. OPs have relied upon the consultation paper of Dr.Anil Grover,Ex.OP5/Ex.C8. OPs have argued that the consultation is dated 21.8.2014 whereas the complainant stated that the document is dated 21.8.2018 and the date has been inadvertently mentioned as 21.8.2014.
10. Complainant has relied upon the observations recorded in the said consultation paper that the matter was discussed with Dr.Manoj, Professor of Cardiology in PGI Chandigarh and complainant had as such consulted Dr.Manoj on 25.8.2018 immediately after consulting Dr.Anil Grover on 21.8.2018 and as such date of consulting Dr.Anil Grover cannot be 21.8.2014.
11. The OPs have also relied upon the document,Ex.OP6 having been issued by Dr.Anil Grover, which states that the patient was diagnosed with headache and was on medication i.e. Acitrom for three years as one of the ground for rejection of the claim. But this document clearly states that he was on Acitrom for three years till 2005 i.e. a long period of 13 years before the occurrence of the present ailment and can in no way be held as valid ground for the rejection of the claim.
12. Moreover, the OPs were well within their right to get the medical examination of the complainant done at the time of issuing the policy or at the time of extension of the policy, which they did not do and have submitted that the policy was issued oi good faith. This submission of the OPs is not tenable. Thus, we are of the opinion that the claim has been wrongly rejected by the OPs.
13. Consequently, we allow the complaint and direct the OPs to settle the claim of the complainant by paying Rs.2,13,362/- to  him within 30 days from the date of the receipt of certified copy of this order, as he has stated at bar that he is satisfied if, this amount is awarded to him without any other relief, whatsoever. No order as to costs.
14. The instant complaint could not be disposed of within stipulated period due to Covid protocol and for want of Quorum from long time.
85109252238716.  
85109252238717.  

 

                                              G.S.Nagi                           S.K.AGGARWAL

                                              Member                          President