Punjab

Ludhiana

CC/19/187

Manoj Kumar - Complainant(s)

Versus

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

Tirath S.Grewal

04 Aug 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 187 dated 12.04.2019.                                                        Date of decision: 04.08.2022.

 

1. Manoj Kumar Dhingra aged about 45 years,
2. Anju aged 42 years wife of Shri Manoj Kumar Dhingra, both residents of House No.13, Model Gram Extension, Ludhiana.                                                                                                              ..…Complainants
3.  

1. Religare  Health Insurance Co. Ltd., Regd. Office: D3, P3B, District Centre, Saket, New Delhi-110017, through its Director/M.D.
2. Religare Health Insurance Co. Ltd., Corporate Office: Vipul Tech Square, Tower C, 3^rd Floor, Gold Course Road, Sector 43, Gurgaon-122009, through its Officer Incharge.
3. Religare Health Insurance Co. Ltd., 1^st Floor, Golden Plaza Mall, The Mall Road, Near Fountain Chowk, Ludhiana-141001, through its Branch Manager.                                                                                                                                                                       …..Opposite parties 

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

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainants            :         Sh. Tirath Singh Grewal, Advocate.

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

 

 

 

 

 

ORDER

PER K.K. KAREER, PRESIDENT

1.                In brief, the case of the complainants is that they obtained Family Floater Health Optima Insurance Policy from Star Health & Allied Insurance Co. Ltd which was valid from 10.06.2011 to 09.06.2012 with a sum assured of Rs.2,00,000/-. The policy was renewed from time to time till 08.07.2017 without any break. Thereafter, the complainants got the said policy ported with the OPs w.e.f. 09.07.2017 to 08.07.2018 and paid a premium of Rs.10,337/-. At the time of porting of the policy, a proposal form was got signed by an agent of the OPs namely Anuj Kapoor. The entire treatment record of complainant No.2 pertaining to kidney stone treatment was supplied to the agent of the OPs. The complainant had also availed a claim regarding kidney stone treatment from M/s. Star Health and Allied Insurance Co. Ltd.

2.                It is further alleged that after the policy was ported with the OPs, the policy No.11443279 was issued to the complainants which was valid from 09.07.2017 to 08.07.2018. However, no terms and conditions of the policy were supplied to the complainants. During the currency of the policy, complainant No.2 was hospitalized from March 2018 to November 2018 as a lump was detected in her right breast and a sum of Rs.6,16,605/- approximately was spent on her treatment. On 26.03.2018, complainant No.2 was taken to Suman Hospital where she was advised mammography and the report was found positive. Thereafter, complainant No.2 was taken to Deep Hospital on 30.03.2018 and then to  Chhabra Hospital on 31.03.2018. Subsequently, complainant No.2 was taken to a hospital at Chandigarh and then to Ludhiana Mediways Hospital on 05.04.2018. On 06.04.2018, complainant No.2 was admitted in Ludhiana Mediways Hospital where she remained admitted up to 10.04.2018. During this period, she was operated upon and further process of chemotherapy was started and the chemotherapy was performed on 26.04.2018, 18.05.2018, 08.06.2018, 29.06.2018, 26.07.2018 and 10.08.2018. Even after 10.08.2018, the treatment of complainant No.2 continued.

3.                It is further alleged that the complainant lodged a claim with the OPs in respect of the hospitalization period from 09.07.2017 to 08.07.2018 and 09.07.2018 to 08.07.2019 for a sum of Rs.6,16,605/-. All the requisite documents in original were submitted with the OPs along with the claim. However, the OPs repudiated the claim vide letter dated 02.08.2018 on the ground of non-disclosure of solitary kidney before taking the policy. According to the complainant, the repudiation of the claim is illegal and arbitrary. The complainants have availed the medi-claim policy since the year 2011 and with the passage of time, all the pre-existing diseases, if any, were impliedly covered under the policy. Moreover, the factum of solitary kidney had nothing to do with the ailment of the complainant for which the claim was lodged. Thus, the repudiation of the claim cannot be justified and clearly amounts to deficiency of service and un-fair trade practice on the part of the OPs. The complainant got served a legal notice dated 27.12.2018 but despite that the claim was not given. Hence the complaint whereby it has been requested that the OPs be directed to pay the claim of Rs.6,16,605/- along with interest @12% per annum and further the OPs be made to pay a compensation of Rs.1,00,000/- and litigation expenses of Rs.20,000/-.

4.                The complaint has been resisted by the OPs. In the written statement filed on behalf of the OPs, it has been, inter alia, pleaded that the complaint is not maintainable. According to the OPs, the policy No.11443279 valid from 09.07.2017 to 08.07.2018 was issued on the basis of the proposal form submitted by the complainants. The sum assured for the policy was Rs.3,00,000/- . The policy was renewed from 09.07.2018 to 08.07.2019. The OPs have further pleaded that on the receipt of the claim in respect of the hospitalization with Mediways Hospital, Ludhiana, the same was scrutinized. A query letter dated 08.06.2018 was sent to the complainants asking for the exact duration and past history of the present ailment and a personalized cancelled cheque of the proposer. On receipt of the documents sent by the complainant, the claim was rejected vide letter dated 02.08.2018. Thereafter, the complainant again applied for reimbursement of hospitalization expenses following which query letter dated 08.06.2018 was issued to the complainants for providing investigation report supporting diagnosis with original detailed discharge summary. After the receipt of the documents, the claim was rejected vide letter dated 24.07.2018 on the ground of non-disclosure of solitary kidney before taking the policy.

5.                It is further alleged that the complainant again applied for the reimbursement of the hospitalization and again a query dated 18.07.2018 was issued asking the complainants to provide all the previous treatment record of 2010. After the documents were sent by the complainants with the claim form, the claim was rejected vide letter dated 03.08.2018 on the ground of non-disclosure of solitary kidney at the time of taking the policy. Thereafter, the complainant again applied for reimbursement of the hospitalization expenses and this time, query letter dated 17.07.2018 was issued and thereafter, the claim was rejected vide letter dated 03.08.2018 due to non-disclosure of solitary kidney before taking the policy. It has further been pleaded that as per the ultrasound report of upper abdomen of the complainant dated 04.11.2016, complainant No.2 was found to be a known case of solitary kidney since before the inception of the policy. As per discharge summary dated 10.04.2018, complainant No.2 was also found having a history of hypothyroidism and choldithiasis. However, contrary to this, the complainants did not disclose all these facts in the proposal form. Thus, the complainants have deliberately concealed the actual health history whereas as per clause 7.1 of the policy, the complainants were bound to disclose the correct health history. Therefore, the claim has been rightly repudiated. The other allegations made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

6.                In evidence, the complainant submitted his affidavit Ex. CA along with documents Ex. C1 to Ex. C195 and closed the evidence.

7.                On the other hand, learned counsel for the OPs tendered affidavit Ex. RA of Sh. Tejinder Singh, Manager (Legal) of the OPs along with documents Ex. R1 to Ex. R17 and closed the evidence.

8.                We have gone through the record and heard the arguments advanced by the counsel for the parties and also gone through the written arguments submitted by the complainant.

9.                During the course of arguments, the counsel for the complainants has argued that the OPs have wrongly repudiated the claim lodged by the complainant despite the fact that the policy was originally obtained from Star Health and Allied Insurance Co Ltd. in the year 2011. The policy was renewed from time to time without any break. The counsel for the complainants has further contended that even after the policy was ported with the OPs in the year 2017, the benefits accrued under the policy from 2011 onwards cannot be denied to the complainants. The counsel for the complainants has further contended that even in the year 2016, the claim for hospitalization of complainant NO.2 for gall bladder surgery was duly reimbursed by M/s. Star Health and Allied Insurance Co. Ltd. The counsel for the complainant has further contended that the instant claim, which has been wrongly repudiated by the OPs, pertains to hospitalization of complainant No.2 in respect of treatment of upper chest cancer which was not a pre-existing disease. The claim has been repudiated on the ground that the complainant No.2 did not disclose that he was having only solitary kidney and this fact was not disclosed in the proposal form. The counsel for the complainant has further referred to the Insurance Regulatory and Development Authority of India Notification dated 12.07.2016 which clearly defines ‘Portability’ means the right accorded to an individual health insurance policyholder (including family cover), to transfer the credit gained for pre-existing conditions and time bound exclusions, from one insurer to another or from one plan to another plan of the same insurer. The counsel for the complainant has referred to ultrasound report Ex. R13 of Suman Hospital wherein it is mentioned that the right kidney is normal in size while left kidney is not visualized. According to the counsel for the complainants, from the report ex. R13, it cannot be categorically stated that complainant No.2 is having just one kidney as the report simply says that the left kidney is not visualized. Even otherwise, the ground of repudiation that the factum of solitary kidney was not disclosed does not have any nexus whatsoever with the disease i.e. upper chest cancer and that being so, the ground of repudiation cannot be sustained in the eyes of law considering the fact that the date of inception of the policy is admittedly 10.06.2011 and, therefore, the waiting period of all pre-existing disease had already expired by time the claim in question was lodged. Therefore, the repudiation of the claim cannot be justified at all.     

10.              On the other hand, the counsel for the OPs has argued that it is a clear cut case of concealment of the material facts by the complainants with regard to the health conditions of complainant No.2 and it was not disclosed in the proposal form that complainant No.2 was having only one kidney. The counsel for the OPs has further contended that had the fact of solitary kidney was disclosed by the complainants at the time of porting the policy with the OPs, the OPs would have considered not to issue the policy to the complainants considering her to be a case of solitary kidney. Since this material fact was not disclosed, the repudiation of the claim cannot be said to be unjustified.

11.              We have weighed the contentions raised by the counsel for the parties and have gone through the record.

12.              Admittedly, the claims lodged by the complainants in respect of the treatment of complainant No.2 was in respect of the ailment of upper chest cancer. No evidence has been led by the OPs that complainant No.2 was suffering from this disease prior to taking the policy in the year 2011 or even prior to porting of the policy with the OPs on 09.07.2017. The claim seems to have been repudiated on the ground that the factum of complainant No.2 having solitary kidney was not disclosed in the proposal form. In this regard, the counsel for the OPs has relied upon ultrasound report Ex. R13 in which it is stated that the left kidney cannot be visualized. However from the report Ex. R13, it cannot be conclusively stated that complainant No.2 was having just one kidney. However, even if it is presumed for the sake of arguments that complainant No.2 is having just one kidney, it could not have been made the basis of repudiating the claim. In this regard, it is pertinent to mention that no evidence has been led by the OPs that one kidney of complainant No.2 was removed at any point of time. In the absence of any such evidence at the most, it could be presumed that complainant No.2 was born with just one kidney. In such cases where people are born with just one kidney are known to be a case of renal agenesis in the field of medical science. In such cases, usually one kidney is missing. As per information available on the internet, people simply having solitary kidney can also lead a normal life provide that one kidney is normal. Even if complainant No.2 is treated to be a case of renal agenesis with one healthy kidney, she has been living normal life as no evidence has been led by the OPs that due to solitary kidney, complainant No.2 had been having health problems. In addition to this, the OPs have further not led evidence that the disease of upper chest cancer had any connection or nexus with the fact that complainant No.2 was having just one kidney. In these circumstances, when complainant No.2 has not been having any renal problems despite having just one kidney, in the absence of any evidence of nexus with the upper chest cancer, the claim for treatment of chest cancer cannot be said to have been rightly repudiated on the ground of non-disclosure of renal agenesis by complainant No.2 in the proposal form. In the given circumstances, in our considered view, it would be just and proper if the OPs are directed to consider and reimburse the claim of hospitalization of the complainant with Ludhiana Mediways Hospital from 06.04.2018 to 10.04.2018 along with follow up treatment of chemotherapy between 26.04.2018 to 10.08.2018 strictly in accordance with terms and conditions of the policy and keeping in view the sum assured under the policy within a period of 30 day from the date of receipt of copy of order along with a composite costs and compensation of Rs.5,000/-.

13.              As a result of above discussion, the complaint is partly allowed with direction to OPs to consider and reimburse the claim of hospitalization of the complainant with Ludhiana Mediways Hospital from 06.04.2018 to 10.04.2018 along with follow up treatment of chemotherapy between 26.04.2018 to 10.08.2018 strictly in accordance with terms and conditions of the policy and keeping in view the sum assured under the policy within 30 days from the date of receipt of copy of the order. The OPs are further made to pay composite costs and compensation of Ps.5,000/- (Rupees Five Thousand only) to the complainant within period of 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.

14.              Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:04.08.2022.

Gobind Ram.

Manoj Kumar Vs Religare Health Insurance Co.                       CC/19/187 

Present:       Sh. Tirath Singh Grewal, Advocate for complainants.

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

 

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with direction to OPs to consider and reimburse the claim of hospitalization of the complainant with Ludhiana Mediways Hospital from 06.04.2018 to 10.04.2018 along with follow up treatment of chemotherapy between 26.04.2018 to 10.08.2018 strictly in accordance with terms and conditions of the policy and keeping in view the sum assured under the policy within 30 days from the date of receipt of copy of the order. The OPs are further made to pay composite costs and compensation of Ps.5,000/- (Rupees Five Thousand only) to the complainant within period of 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.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:04.08.2022.

Gobind Ram.