Punjab

Ludhiana

CC/19/212

Lakhvir Singh - Complainant(s)

Versus

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

Roshan Lal Adv.

11 Aug 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:212 dated 08.05.2019.                                                         Date of decision: 11.08.2023.

 

Lakhvir Singh son of Sh. Piara Singh, resident of House No.863/27, St. No.1, New Baldev Nagar, Bajra, Ludhiana.                                                                                                                                                 ..…Complainant

                                                Versus

1. Religare Health Insurance Co. Limited, having its registered office at D-3, P3B, District Centre, Saket, New Delhi-110017, through its Managing Director.   
2. Religare Health Insurance Co. Limited, GYS Global Plot No.A3, A4, A5, Sector 125, Noida-201301, UP through its CEO/Branch Head.
3. Religare Heath Insurance Co. Limited, Golden Plaza, 1^st Floor, The Mall, Mall Road, Ludhiana through its Branch Manager. 
4. Raksha Health Insurance, TPA, SCO-122 (basement) Cabin No.5, Feroze Gandhi Market, LLudhiana-141001 through its Branch Manager.                                                                               …..Opposite parties 

Complaint Under section 12 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Roshan Lal Rana, Advocate.

For OP1 to OP3             :         Sh. Gurjeet Singh Kalyan, Advocate.

For OP4                         :         Name of OP4 already deleted vide order dated                                            15.11.2019.

 

 

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant purchased a medi-claim policy bearing No.10647356 for a sum assured of Rs.3,00,000/- w.e.f. 10.05.2016 to 09.05.2019 from opposite party No.1 to 3 by covering himself, his wife Amarjit Kaur, two sons namely Kamaljit Singh and Ram Jaiswal. The complainant stated to have paid a total lump sum premium for 3 years amounting to Rs.64,200/- being single premium. The complainant stated that he and his family members were medically examined and checked up by medical officer of the opposite parties and after obtaining relevant reports, the policy in question was issued by the opposite parties. On 28.05.2018, Ram Jaiswal, son of the complainant aged about 17 years was diagnosed suffering from abdomen infection and was admitted in Fortis Hospital, Chandigarh Road, Ludhiana where he remained admitted for 8 days i.e. from 28.05.2018 to 04.06.2018. The complainant spent a sum of Rs.68,350/- on his treatment. The complainant immediately informed the opposite parties regarding admission of his son in Fortis Hospital, Ludhiana and requested for making the policy cashless and to make payment direct to the hospital but they failed to do so. The complainant further stated that at the time of selling the policy, he was told that the policy is cashless and opposite party No.4 had issued card to get treatment on cashless basis as and when required. According to the complainant, the opposite parties have neglected to do their duties and comply with the terms of the policy and as such, they have committed unfair trade practice and deficiency in service as despite receipt of claim for a sum of Rs.68,350/- opposite party No.4 arbitrarily, malafidely, illegally and un-justifidely at the instance of opposite party No.1 to 3 repudiated his claim vide letter dated 28.05.2018.  Even opposite parties No.1 to 3 did not respond to the various representations and phone calls of the complainant. The complainant further stated that it was not necessary to renew the policy every year rather the policy was issued and valid for three years and premium was paid in lump sum for three years and as such, there was no logic or rationale to get it renewed every year. The act and conduct of the opposite parties amounts to deficiency in service and unfair trade practice due to which the complainant has suffered financial loss and mental agony and he is entitled to compensation. The complainant also sent a legal notice dated 02.03.2019 through his counsel upon the opposite parties to which they sent a false and frivolous reply dated 04.04.2019 alleging that the medi-claim policy was got cancelled in the year 2017 but prior to it the opposite parties did not even sent a single letter nor intimation to the complainant and even they did not return back the premium amount paid by the complainant for purchase of the policy and now they had filed the false and frivolous plea which is not tenable as no money was refunded nor any letter or intimation was ever sent to the complainant  regarding cancelation of the policy. Hence this complaint, whereby the complainant has prayed for directing the opposite parties to pay a sum of Rs.68,350/- incurred on treatment of his son and also to pay compensation of Rs.1,00,000/- besides litigation expenses of Rs.55,000/-.

2.                Upon notice, opposite parties No.1 to 3 appeared and filed joint written statement by taking preliminary objections that the complaint is not maintainable; lack of cause of action; concealment of facts etc. Opposite parties No.1 to 3 stated that the complainant had filed the present complaint with respect to his son's hospitalization. The complainant in his complaint had claimed that he had applied for the cashless request on 28.05.2018 as his son Master Ram Jaiswal was at Fortis Hospital, Ludhiana. However, the opposite parties have not received any such documents pertaining to said claim. Moreover, the policy of the complainant was already cancelled by them in accordance with Policy Terms and Conditions vide  Cancellation letter dated 06.05. 2017 and the same was also communicated to the complainant vide letter dated 14.05.2017. According to opposite parties No.1 to 3, all insurance policies have been regularized by the terms and conditions of the policies. The complainant approached the opposite parties for health insurance policy subject to policy terms and conditions to him. After understanding the same, the complainant filled the proposal form with the true and correct information and decided to take the policy and the opposite parties believing the information to be true, issued and supplied complete booklet along with policy bearing No. 10647356 to the complainant, his wife and his 2 sons for the sum insured of Rs.3,00,000/- for the period of 10.05.2016 till 09.05.2019 subject to the policy terms and conditions. Thereafter, the Complainant applied for the cashless facility request vide Claim no.80093889 for his hospitalization with effect from 14.10.2016 at Fortis Hospital, Ludhiana for an amount of Rs.59,200/- for the treatment of Fever, Abdominal Heaviness & Pain and Vomiting. On receipt of pre-authorization request, opposite party No.1 to 3 sent a Query Letter dated 15.10.2016 to the hospital and asked for the documents, which is reproduced as under:-

• Kindly provide initial assessment sheet with detail line of treatment with vital charts.
• Kindly provide all investigation reports related to ailment.
• Kindly provide OPD treatment record before hospitalization.

The opposite parties also triggered an investigation after the said cashless request and on reception of reply, the opposite parties sent a query letter dated 17.10.2016 to the hospital asking for the documents, reproduced as under:-

• Kindly provide all previous investigation and prescription papers in relation to Diabetes Mellitus as patient is K/C/O of DM.
• Kindly provide first consultation paper when DM was diagnosed.
• Kindly provide exact duration of DM.

The opposite parties again sent a query letter dated 17.10.2016 to the hospital and asked for the following documents:-

• Kindly provide a previous investigation and prescription papers in relation to Diabetes Mellitus as patient is K/C/O of DM.
• Kindly provide first consultation paper when DM was diagnosed.
• Kindly provide exact duration of DM. Still awaited.

On receipt of the documents, opposite parties No.1 to 3 reviewed the claim documents and rejected the cashless claim request vide denial letter dated 18.10.2016 with the following observation:-

• Non disclosure of material facts/pre-existing ailments at the time of proposal (K/C/O DM since 6-7 months).

Opposite party No.1 to 3 further stated that as per Indoor Case Papers at Triage History Physical Sheet, the Complainant is mentioned to known case of DM. The discharge summary of Fortis Hospital dated 17.10.2016 wherein it is clearly mentioned in the Past History that the Complainant has Diabetes Mellitus- II. As per Doctor's Certificate dated 18.10.2016, it mentioned by the Doctor that the Complainant is a known case of Diabetes Mellitus for 6-7 months i.e. before policy inception. Moreover, as per complainant he suffered from DM since 6-7 months. According to opposite party No.1 to 3, the complainant had an opportunity to declare that the Insured is a known case of Diabetes Mellitus at the time of filing Proposal Form, however, the complainant intentionally did not disclose the same to them. In the proposal form the insured made declaration to the questions which are reproduced as under:-

          "Health & Lifestyle information"

 

Has anyone been diagnosed hospitalized or under any treatment for any illness injury during the last 48 months or is suffering from any illness/ disease?

Answer- No.

Diabetes- Yes No.

Answer- N.

Further the complainant gave the following declarations in the Proposal Form:

"I/ We hereby declare on my behalf and on behalf of all persons proposed to be insured, that the above statements, answers and/or particulars given by me are true and complete in all respects to the best of my knowledge and that I/We am are authorized to propose on behalf of these other persons.”

Opposite parties further stated that the complainant had deliberately tried to conceal his actual health history by not disclosing that he is a known case of Diabetes Mellitus. According to Clause 7.1 of Policy Terms & Conditions, the complainant was bound to disclose the correct health history of the Insured to the insurer at the time of inception of policy but by not disclosing the material information pertaining to Insured's health, the complainant has violated Clause 7.1 of Policy Terms & Conditions. Further the opposite parties mentioned IRDAI Regulations 2017 as well as Cause 7.1 and 7.13 of the insurance policy.

                   The opposite parties further stated that they sent a notice of cancellation of policy dated 22.02.2017 to the complainant to furnish correct facts along with documentary proof but due to non-receipt of any reply or response from the complainant, the policy was cancelled vide letter dated 06.05.2017.

                   On merits, opposite parties No.1 to 3 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.                During pendency of the complaint, opposite parties No.1 to 3 filed application for deleting name of OP4 from the array of parties, which was allowed  vide order dated 15.11.2019 and the name of OP4 was ordered to be deleted from the array of the opposite parties.

4.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents i.e. Ex. C1 is the copy of policy certificate, Ex. C2 is the copy of premium acknowledgement and policy documents, Ex. C3 to Ex. C11 are the copies of outpatient receipt/bills issued by Fortis Hospital, Ludhiana, Ex. C12 is the copy of email dated 28.05.2018, Ex. C13 is the copy of legal notice dated 02.03.2019, Ex. C14 is the copy of reply to legal notice, Ex. C15 is the copy of health insurance card of Ram Jaiswal and closed the evidence.

5.                On the other hand, counsel for opposite parties No.1 to 3 tendered affidavit Ex. RA of Sh. Tejinder Singh, Manager-Legal at Religare Health Insurance Co. Ltd., having its office at Vipul Tech Square, Tower-C, 3^rd Floor, Sector-43, Gurgaon-122009 along with documents Ex. R1 is the copy  of welcome letter dated 13.05.2016, Ex. R2 is the copy of request for cashless hospitalization, Ex. R3 is the copy of query letter dated 15.10.2016, Ex. R4 and Ex. R5 are the copies of query letter dated 17.10.2016, Ex. R6 is the copy of letter dated 18.10.2016 written to Fortis Hospital by the insurance company regarding denial of cashless treatment, Ex. R7 is the copies of treatment record. Ex. R8 is the copy of discharge summary, Ex. R9 is the copy of proposal form, Ex. R10 is the copy of policy terms and conditions, Ex. R11 is the copy of IRDA regulations, 2017, Ex. R12 is the copy of the notice of cancellation of policy, Ex. R13 is the copy of legal notice dated 02.03.2019 as well as reply to the legal notice, Ex. R14 is the copies of judgment  in case titled Satwant Kaur Sandhu Vs new India Assurance Co. Ltd.; judgment in case titled LIC of India Vs Neelam Sharma, copy of judgment in case titled Export Credit Guarantee Corp. Vs M/s. Garg Sons International and closed the evidence.

6.                After closing their evidence, opposite parties No.1 to 3 filed an application for leading Additional evidence, which was allowed vide order dated 01.03.2013 and as such, opposite parties No.1 to 3 tendered affidavit of Dr. Ashish as Ex. RB and closed the additional evidence.

                   In rebuttal to additional evidence, the complainant tendered his affidavit as Ex. CB and closed the rebuttal evidence.

7.                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.

8.                Admittedly, the complainant purchased medi-claim Floater policy Ex. C1=Ex. R1 under Care Plan having policy No.10647356 from opposite parties No.1 to 3 having validity from 10.05.2016 to 09.05.2016 i.e. for three years having sum assured of  Rs.3,00,000/- with coverage of the complainant, his wife Amarjit Kaur, sons namely Kamaljit Singh and Ram Jaiswal. During the subsistence of coverage of said policy, son of complainant Ram Jasiwal remained hospitalized from 28.05.2018 to 04.06.2018 with complaint of vomiting, abdominal pain, abdominal fullness for 2-3 days and fever for 8-10 days.  An amount of Rs.68,350/- Ex. C6 to Ex. C11 were incurred on his treatment. The cashless authorization request (Ex. R2was declined on 18.10.2016 vide letter Ex. R6 on the following grounds:-

• Non disclosure of material facts/pre-existing ailments at the time of proposal (K/C/O DM since 6-7 months).

9.                The main basis of repudiation of the claim by the opposite parties is that the complainant was a known case of Diabetes Mellitus for the last 6-7 months. 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 6-7 months. Even the report or affidavit of any investigator has not been brought on record to substantiate its claim. However, opposite parties No.1 to 3 have submitted certificate Ex. RB  issued by Dr. Ashish of Fortis Hospital, Ludhiana certifying that the patient Lakhvir Singh is diabetic mellitus since 6-7 months but Dr. Ashish never treated either complainant Lakhvir Singh or his son Ram Jaiswal for diabetes mellitus-II.

10.              The counsel for the complainant has referred to the extract of the discharge summary Ex. R8 of Fortis Hospital, Ludhiana vide which the complainant was diagnosed of Acute Febrile Illness Acute Gastroenteritis and  under the column of chief complaints of Fever for 2 days, abdominal pain for 2 days, abdominal fullness for 2 days. The discharge summary Ex. R7, when read as a whole clearly spells out that necessity arose for his admission in the hospital due to above said reason.  The complainant was managed with IV fluids, PPI’s, multivitamins, antipyretics, thrombocytopenic precautions and other supportive measures. Patient responded to treatment and his platelets as on 15.09.2016 were 133. The patient was discharged in stable condition with follow up advise in OPD. So it appears that prima facie there was a strong case for the admission of the complainant in the hospital. The claim has been repudiated on the premise that the complainant is diabetic mellitus since 6-7 months.  Pertinently, the main basis of repudiation of the claim is that factum of the complainant suffering from diabetic mellitus since 6-7 months was not disclosed and its non-disclosure amounts to suppression of material facts. The opposite parties have not produced any evidence of medical record with regard to diagnosis, procedure and treatment of the said pre-existing disease. In fact, the complainant has submitted cashless claim with respect of hospitalization of his son Ram Jaiswal with Fortis Hospital, Ludhiana since 28.05.2018 to 04.06.2018 where he was treated for abdomen infection and the opposite parties could not establish that the so diagnosed disease had a direct nexus with the alleged pre-existing disease of the complainant. Apart from this, in the discharge summary Ex. R8, the diagnosis is only Acute Febrile Illness, Acute Gastroenteritis. The said diseases do not appear to have any direct nexus with the so called pre-existing disease of diabetes mellitus-II which is more or less common disease, would definitely suffer from the disease of Acute Febrile Illness, Acute Gastroenteritis nor any evidence has been d by the opposite parties to prove any nexus between the disease of diabetes mellitus-II with the other disease. As such, none of the conditions, the complainant was diagnosed with, has any nexus or connection with the disease of diabetes mellitus. 

11.              In this regard, reference can be made to III (2023) CPJ 62 (Har.) in United India Insurance Company Limited and ANR. Vs Reetu Goel & Another whereby the Hon’ble State Consumer Disputes Redressal Commission, Panchkula has held that Consumer Protection Act, 1986 – Sections 2(1)(g), 14(1) (d), 15 – Insurance (Mediclaim) – Medical reimbursement – Repudiation of claim – Deficiency in service – Complainant has been successful to establish that she was not suffering from diabetes mellitus for last 4/5 years rather it was for 3/4 months – Even if it is taken that complainant was suffering from diabetes mellitus for last 3/4 years, same had no relation with rheumatic heart disease – Impugned order of District Consumer Forum of allowing complaint is upheld.  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.

12.              Perusal of notice of cancellation of policy No.10647356 dated 22.02.217 and policy cancellation dated 06.05.2017 Ex. R12 also shows that the policy was also cancelled by the opposite parties. It appears to be unilateral decision of the opposite parties and no reasonable opportunity of being heard was afforded either to the insured or to the complainant before cancelling the policy. It is a gross violation of principle of natural justice. So the cancellation of the policy is hereby revoked and it will be deemed to be in operation for all intends and purposes during the period of its validity.

13.              In the light of above said facts and circumstances, opposite party No.1 to 3 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 opposite party No.1 to 3 are directed to settle and reimburse the claim of the complainant in terms of policy terms and conditions. Opposite party No.1 to 3 are also burdened with composite costs of Rs.10,000/-.

14.              As a result of above discussion, the complaint is partly allowed with an order that the cancellation of the policy is hereby revoked and it will be deemed to be in operation for all intended purpose during the period of its validity. Opposite parties No.1 to 3 are further directed to settle and reimburse the claim to the complainant as per terms and conditions of the policy within 30 days from the date of receipt of copy of order. Opposite party No.1 to 3 shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the complainant 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.

 

 

 

15.              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:11.08.2023.

Gobind Ram.

 

 

Lakhvir Singh Vs Religare Health Insurance Co.                      CC/19/212

Present:       Sh. Roshan Lal Rana, Advocate for the complainant.

                    Sh. Gurjeet Singh Kalyan, Advocate for the OP1 to OP3.

                   Name of OP4 already deleted vide order dated 15.11.2019.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with an order that the cancellation of the policy is hereby revoked and it will be deemed to be in operation for all intended purpose during the period of its validity. Opposite parties No.1 to 3 are further directed to settle and reimburse the claim to the complainant as per terms and conditions of the policy within 30 days from the date of receipt of copy of order. Opposite party No.1 to 3 shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the complainant 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:11.08.2023.

Gobind Ram.