Punjab

Fatehgarh Sahib

RBT/CC/319/2018

Ashwani Kumar Pathak - Complainant(s)

Versus

Religare Health Insurance Comopany Limited - Opp.Party(s)

In person

13 Sep 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, FATEHGARH SAHIB.     

RBT/319/2018

CC No. 319 of 2018

                                                                             Date of Institution: 16.03.2018

                                                                             Date of Decision: 13.09.2022

 

Ashwani Kumar Pathak, aged 71 years, S/o Late Sh. Lalit Kumar Pathak, R/o Flat No.106, Windcross Society, Tehsil Road, Zirakpur-140603, Mohali.

         

                                                                                                   ……….Complainant(s)                                              

                                                Versus

1. Religare Health Insurance Company Limited. Register Post, 5^th Floor, 19 Chawla House, Nehru Place, New Delhi, 110019 through its Director
2. Religare Health Insurance Company Ltd., SCO 56-58, 2^nd Floor, Sec 9-D, Chandigarh, 160017, through its Director.

……....Opposite Party(s)

 

Complaint under Section 12of the Consumer Protection Act

Quorum

Sh. Pushvinder Singh, President

Ms. Shivani Bhargava, Member

Sh. Manjit Singh Bhinder, Member

 

Present:Complainant in person.

          Sh. Sahil Abhi, counsel for OP.

 

Order by

Pushvinder Singh, President

 

1.              This complaint has been filed by the complainant(hereinafter referred to as CC) for directing the opposite parties(hereinafter referred to as OPs) to refund the amount paid by him along with interest @ 14% per annum and CC is also seeking compensation of Rs.2,00,000/- for mental and physical harassment and any other relief.
2.               The CC has alleged that he is insured for health claims with the OPs for Rs.5,00,000/- and has paid premium amount. He was medically examined before giving health policy. CC who is an old man of age 71 years, developed urinary problems in 2016 and after consultation with Dr. A.S. Bawa, CC was advised for a laser operation urgently and he was operated upon. The claim of CC was disallowed for cashless hospitalization and he was advised to file claim subsequently. Fortis hospital raised a bill for Rs.1,40,138/- and the amount was paid by the CC. The claim of CC was rejected by the OPs only on the basis of one ground that CC was taking treatment for anxiety since 2002 and this fact was not disclosed at the time of taking policy, so, OPs rejected his claim on this single ground.
3.                Upon notice OPs appeared through counsel Sh. Sahil Abhi and filed reply/version stating that the present complaint is not maintainable before this Commission and further submitted that OPs denied the cashless facility request vide letter dated 20.11.2017 for non-disclosure of pre-existing ailments at the time of proposal in accordance to Clause 7.1 of the policy terms and conditions obtained by the CC i.e. treatment of anxiety, diabetes and hypertension since 2002. OPs further prayed that the complaint be dismissed with costs.
4.                In evidence, the CC furnished her affidavit reiterating the contents of the complaint as Ex.CW-1/A and also proved copies of billsas Ex.C-1 to Ex.C-7, copy of policy as Ex.C-8, Policy Cancellation Notice as Ex.C-9. On the other hand, OPs have furnished reply-cum-affidavit as Ex.OP.1/1, copy of policy certificate and policy ID Card as Ex.OP-1.
5.                We have heard the counsels for the parties and have gone through the file carefully.
6.                  The CC has filed this complaint for refund of medical expenses stating that the claim has been arbitrarily and illegally rejected by the OPs. The CC has also sought interest, compensation and litigation expenses.Admittedly the CC was insured for health claims with the OPs for Rs.5,00,000/- and he paid the premium. The CC developed urinary problem in 2016 and consulted various doctors and finally on 08.11.2017 Dr. A.S. Bawa Senior Consultant Urology Fortis Hospital, Mohali advised for a laser operation urgently and he was operated upon. The claim of CC was disallowed for cashless hospitalization and he was advised to file claim subsequently. Fortis hospital raised a bill for Rs.1,40,138/- and the amount was paid by the CC. It is also not disputed that the claim of CC was rejected only on the basis of one ground as mentioned below: -

         “There has been non-disclosure of Material Facts/Pre-existing ailments at the time of proposal. Patient Mr. Ashwani Kumar Pathak had a history/known case of taking treatment for anxiety since 2002, however this fact was not disclosed at the time of taking policy.”

7.                 In the reply/version also the OPs have alleged that the claim of CC was repudiated only on the ground of non-disclosure of treatment of anxiety since 2002.
8.                 The CC who is an old man forcefully contended that at the time of proposal he was not suffering from anxiety and the anxiety is not such type of disease which can be considered as a permanent disease and required to be disclosed to the Insurance Company. The CC used to take Alprex tablet occasionally whenever he felt anxiety. The CC was never the patient of depression. We after gone through the record find that the claim of CC was repudiated only on single ground that the CC did not disclose that he was suffering from anxiety since 2002. We agree with the CC that the anxiety is not a permanent disease and in fact is a mindset due to positive or negative circumstance. We are also of the view that anxiety is not such a disease which must have been disclosed at the time of taking the insurance policy. In the present complaint it was alleged by the CC that he used to take tablet Alprex tablet occasionally. Even otherwise, earlier the CC was operated upon and his gallbladder was removed in September, 2016 at Dharm Hospital, Chandigarh and his claim was accepted and the OPs refund the amount of claim and at that time no objection was raised by the OPs. So, we are of the considered opinion that the claim of the claimant has been wrongly repudiated by the OPs.  In fact, the CC is entitled to receive claim amount which has been paid to the Fortis Hospital.
9.                    In view of our aforesaid discussions, the present complaint is allowed partly and the OPs are directed to refund the amount paid by the CC to Fortis Hosptial, Mohali for his treatment as per the bills produced by the CC, subject to the terms and condition of the policy. The claimant is also entitled to the interest from the OPs on the said amount and in our considered opinion interest @ 8% shall be the reasonable rate of interest from the date of payment made by the CC till the realization of the claim amount. The CC has also suffered physical and mental harassment being an old man and he must be compensated for the same. So, OPs are directed to pay Rs.20,000/- for mental & physical harassment and also directed to pay Rs.10,000/- for litigation expenses. The compliance of this order be made by the OPs within a period of 45 days on receipt of certified copy of this order. Copy of this order be provided to the CC and the OPs as per rules.This complaint could not be decided within a specific period as provided by the statute due to rush of work and large pendency.  File be returned back to the District Consumer Commission, Mohali for consignment.
10.  
11.                                                     (Pushvinder Singh)

                                                                                     President

 

 

    (Manjit Singh Bhinder)

                                                                                                     Member

 

               

                                                                            (Shivani Bhargava)

   Member