Punjab

Ludhiana

CC/19/462

Raj Kumar - Complainant(s)

Versus

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

N.P.Singh Adv.

08 Jun 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 462 dated 27.09.2019                        

                                 Date of decision: 08.06.2022. 

 

1.Raj Kumar Jain son of late Shri Gora Lal Jain resident of HL-138, Jamalpur Colony, Near Gurudwara, Ludhiana, Punjab-141010.

2.Sarita Jain wife of Raj Kumar Jain son of late Shri Gora Lal Jain resident of HL-138, Jamalpur Colony, Near Gurudwara, Ludhiana, Punjab-141010.                                                                                             ..…Complainants

                                                Versus

1.Religare Health Insurance Company Limited having its registered office at 5^th Floor, 19, Chawla House, Nehru Palace, New Delhi-110019 having its correspondence addressed: Vipul Tech Square, Tower C, 3^rd Floor, Gold Course Road, Sector 43, Gurgaon-12200.

2.Religare Health Insurance Company Limited., San Plaza Building, SCO 13, 3^rd, Feroze Gandhi Market, Ludhiana, Punjab-141001 through its Manager Director.

                                                                                      …..Opposite parties

              Complaint under Section 12 of Consumer Protection Act.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH.JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainants           :         Sh.Amritpal Singh, Advocate

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

 

ORDER

PER K.K. KAREER, PRESIDENT

1.                In brief, the case of the complainants is that the complainant no.1 along with his wife and children’s purchased health insurance policy bearing No.10769862 from the OPs on payment of premium of Rs.23,703/-. During the currency of the policy, the complainant no.2 was admitted in Fortis Hospital, Ludhiana for treatment of epigastria hernia. She remained admitted in the said hospital from 17.05.2019 to 20.05.2019 and the doctors conducted laparoscopic repair of ventral hernia with mesh on 18.05.2019. A sum of Rs.2,03,313/- was incurred on the treatment of the complainant no.2. The claim in respect of the said amount was lodged with the OPs. However, the OPs vide letter dated 07.06.2019 repudiated the claim due to discrepancies in the record submitted by the complainant. Thereafter, another letter dated 25.06.2019 was sent by the OPs regarding cancellation of the policy on the ground that there was non-disclosure of pre-existing ailments at the time of taking the policy. It was mentioned in the notice that the complainant no.2 had a history of hypertension but this fact was not disclosed. As a matter of fact, the complainant no.2 remained admitted in Fortis Hospital, Ludhiana from 09.03.2018 to 12.03.2018 and in the discharge summary of the said period, there was no mention of the fact that the complainant no.2 was a patient of hypertension. Thus, the repudiation of claim and notice of cancellation of the policy are arbitrary and illegal and amounts to deficiency of service on the part of the OPs. In the end, it has been requested that the OPs be directed to reimburse the claim amount of Rs.2,13,313/- and the OPs be further made to pay damages of Rs.50,000/- to the complainant.

2.                The complaint has been resisted by the OPs. In the written statement filed on behalf of OPs, it has been, interalia, pleaded that the complaint is not maintainable. According to the OPs, the complainant lodged a cashless claim in respect of hospitalization of the complainant no.2 with Fortis Hospital, Ludhiana for Epigastric Hernia with effect from 15.05.2019. The OPs initially approved the cashless claim for an amount of Rs.1 lac vide letter dated 17.05.2019. The said approval, however, is conditional in nature and was subject to the submission of all the claim related documents and proper verification in accordance with the terms and conditions of the policy. Simultaneously the OPs raised a query vide letters dated 17.05.2019 and 20.05.2019 whereby the complainant was asked to provide the relevant documents. On perusal of the claim, it was found that as per the pre anesthesia report dated 17.05.2019, the insured was having the history of hypertension since 3-4 years i.e. prior to the inception of the policy. Thus the complainant was found to be a case of hypertension prior to the inception of the policy. Therefore, the cashless claim was denied vide clause 7.1 of the policy terms and conditions. Thereafter, the complainant lodged a claim of Rs.2,03,522/- for the hospitalization of the complainant no.2 from 17.05.2019 to 20.05.2019 and also submitted a certificate issued by the treating doctor stating that the complainant no.2 does not have the history of hypertension. However, the said certificate is against the medical history recorded in the pre anesthesia note and, therefore, the certificate could not be relied upon. In the light of the contradictions and discrepancies in the documents, the claim of the complainant was rejected in accordance with the clause 7.1 of the policy terms and conditions. The rest of the averments made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

3.                In evidence, complainant no.1 submitted his affidavit Ex.CA along with documents Ex.C1 to Ex.C23 and closed the evidence.

4.                 On the other hand, OPs submitted affidavit Ex.RA of Sh.Kashif Nazki, Manager(Legal) of OPs along with documents Ex.R1 to Ex.R9 and closed the evidence.

5.                We have heard the counsel for the parties and have also gone through records.

6.                During the course of arguments, counsel for the complainants has argued that the claim has been wrongly rejected invoking clause 7.1 of the policy terms and conditions and on the ground that the complainant no.2 had a past history of hypertension and the factum of hypertension was not disclosed in the proposal form at the time of inception of the policy. Counsel for the complainant has further contended that as a matter of fact the complainant no.2 never suffered from hypertension. The complainant no.2 was previously hospitalized with Fortis Hospital, Ludhiana from 09.03.2018 to 12.03.2018 and in the discharge summary of the said period of hospitalization, the blood pressure of the complainant no.2 was normal and she never suffered from hypertension. Therefore, the rejection of the claim is totally arbitrary.

7.                On the other hand, counsel for the OPs has argued that the complaint is without any merit as the claim has been rejected on legal and valid ground of non-disclosure of material facts at the time of taking the policy. Counsel for the OPs has referred to Preanaesthesia Checkup (PAC) Record Ex.R3 wherein it is clearly mentioned that the complainant was suffering from hypertension for the last 3-4 years whereas this fact was not disclosed in the proposal form at the time of taking the policy. Thus there is deliberate concealment of facts which justified the repudiation of the claim.

8.                We have weighed the rival contentions raised by counsel for the parties.

9.                In this case, the date of inception of the policy is 26.08.2016. The claim in question was lodged in respect of hospitalization of the complainant no.2 from 17.05.2019 to 20.05.2019 with Fortis Hospital, Ludhiana. In the discharge summary Ex.C14, the diagnosis mentioned as Epigastric Hernia and in the column of past history, it is mentioned that the complainant had a history of Hypothyroidism. The claim has been rejected on the ground that the complainant did not disclose in the proposal form at the time of taking the policy that she was suffering from hypertension. In this regard, counsel for the complainants has referred to the discharge summary Ex.C2 in respect of the hospitalization of the complainant no.2 from 09.03.2018 to 12.03.2018. In the said discharge summary Ex.C2, the diagnosis is mentioned as Hypothyroidism and Acute Gastroenteritis and in the column of past history, it is mentioned that the complainant had a history of Hypothyroidism. It is further mentioned in the column of physical examination that the complainant no.2 had blood pressure of 110/68 mm Hg which is supposed to be a normal range of blood pressure. If the discharge summary Ex.C2 is taken into account, it can definitely be said that in the month of March 2018 the complainant was not suffering from hypertension. Even otherwise the disease of hypertension is of a common disease and apparently hypertension does not appear to have any nexus with the disease of epigastric hernia. In these circumstances, considering the fact that at the time of her previous hospitalization in the year 2018, the complainant no.2 was not suffering from epigastric hernia and the disease of epigastric hernia has no nexus with the hypertension, in our considered view, the rejection of claim on the ground that the complainant was suffering from a pre-existing of hypertension or that same was not disclosed in the proposal form at the time of taking the policy cannot be said to be justified. In these circumstances, in our considered view, it would be just and proper if the OPs are directed to consider and reimburse the claim in respect of hospitalization of complainant no.2 from 17.05.2019 to 20.05.2019 with Fortis Hospital, Ludhiana strictly in accordance with the terms and conditions of the policy.

10.           As a result of above discussion, the complaint is allowed with an order that the OPs shall consider and reimburse the claim in respect of the hospitalization of the complainant no.2 from 17.05.2019 to 20.05.2019 with Fortis Hospital, Ludhiana strictly in accordance with the terms and conditions of the policy. Further, the OPs shall pay the composite compensation and litigation cost of Rs.5000/-(Rupees Five Thousand Only) to the complainant. Compliance of order 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.         

11.              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:08.06.2022.

Gurpreet Sharma