Chandigarh

DF-II

CC/903/2019

Brij Mohan Arora - Complainant(s)

Versus

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

Sandeep Gupta Adv., Jatin Parkash Adv. & Jasbir Singh Adv.

20 Jul 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II

U.T. CHANDIGARH

 

Consumer Complaint No.	:	903/2019
Date of Institution	:	06.09.2019
Date of Decision	:	20.07.2022

 

                     

            

 

Brij Mohan Arora aged about 55 years s/o Sh.Hajari Lal r/o H-551, Phase-1, Mohali.

                 ...  Complainant.

Versus

 

1.  Religare Health Insurance Company Ltd., SCO 56-58, 2^nd Floor, Sector 9-D, Chandigarh -160017.

 

2.  Cheema Medical Complex, Phase-4, Near Telephone Exchange, Mohali.

 

…. Opposite Parties

 

BEFORE:
	SMT.SURJEET KAUR,	PRESIDING MEMBER
	SHRI B.M.SHARMA	MEMBER
Argued by:-
	Sh.Jatin Parkash, Adv. for the complainant
	None for OP No.1 Sh.G.D.Goyal, Adv. for OP No.2

 

 

PER B.M.SHARMA,MEMBER

1.     Briefly stated, the complainant took Cashless Insurance Policy No.12515947 from OP No.1 for himself and his family members (Annexure C-1). On 13.04.2019, the complainant visited to OP No.2 for medical check-up and advised some tests. On receipt of the reports, the complainant was advised to undergo surgery for hernia. On 15.04.2019, OP No.2 sent pre-approval for claim before surgery to OP No.1 and he received a message regarding approval of the same on 16.04.2019. The complainant operated in the said hospital on 17.04.2019 and on 18.04.2019, discharge summary was sent by OP No.2 to OP No.1 for getting the payment transferred but the claim was denied. On enquiry, the complainant came to know that the Hospital inadvertently mentioned the past history of COPD.  Thereafter, OP No.2 sent a letter to OP No.1 for clarifying the mistake that the previous history of COPD was written inadvertently and the complainant had no previous history of COPD but OP No.1 did not pay any heed. The complainant paid the hospital expenses to the tune of Rs.45,971/- from his own pocket. The complainant also requested OP No.1 to reimburse the claim but to no effect. Alleging that the aforesaid acts of omission and commission on the part of the OPs amount to deficiency in service and unfair trade practice, the complainant has filed the instant complaint. 
2.     In its written statement, OP No.1 while admitting the factual matrix of the case has stated that on receipt of the cashless claim request w.e.f. 17.04.2019, it sent a query letter dated 15.04.2019 to the hospital and on receipt of the reply to the query, they initially authorized the payment upto Rs.40,000/- vide authorization letter dated 16.04.2019. On investigation of the documents and as per the findings of the investigation, the complainant was found to be suffering from COPD and therefore, the claim was rejected vide letter dated 18.04.2019. The cashless request was rejected on the ground of non-disclosure of the material facts reading the pre-existing ailment of K/C/O COPD prior to the policy inception, as per the terms and conditions of the insurance policy. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service on their part, a prayer for dismissal of the complaint has been made.
3.     In its separate written statement, OP No.2 has stated that the claim of the complainant was wrongly rejected and without any basis. It has further been pleaded that they have clarified the mistake vide letter (Annexure A-6) and the complainant had no history of COPD.  It has been admitted that the complainant had paid the treatment charges. The remaining allegations have been denied, being false. Pleading that there is no deficiency in service on its part, a prayer for dismissal of the complaint has been made.
4.     The complainant filed separate rejoinders to the written replies of the OPs controverting their stand and reiterating his own.
5.     The complainant filed rejoinder to the written reply of the Opposite Parties controverting their stand and reiterating his own.
6.     We have heard the Counsel for the contesting parties and have gone through the documents on record as well as written submissions.
7.     From the perusal of the documentary evidence and the pleadings of the parties, it is evident that the complainant, who is having cashless insurance policy (Annexure C-1) of the OP No.1, took treatment in OP No.2-Hospital on 17.04.2019 during the existence of the said policy and incurred Rs.45,971/- towards his treatment against receipt dated 18.04.2019 (Annexure C-7). 
8.     The main ground of the repudiation of the claim by OP No.1 in its letter dated 18.04.2019 is that the complainant is a known case of COPD before the inception of the insurance policy. However, the factum with regard to the COPD has been clarified by OP No.2 to OP No.1 vide letter dated 18.04.2019 (Annexure C-6) wherein it was specifically mentioned that by mistake, while printing they had mentioned the patient’s past history of COPD which was found ‘Nil’ while they cross-checked.  The receipt of the aforesaid letter has not been denied by the Insurance Company.
9.       In  P. Vankat Naidu Vs. Life Insurance Corporation of India and Anr. 2011(4) CLT Supreme Court 494= IV (2011) CPJ 6 (SC), it was held that it was for the Opposite Parties, who had come out with the case, that the insured did not disclose the correct facts, relating to his/her illness, to produce cogent evidence, to prove the allegation.  In New India Assurance Co. Ltd. Vs. Arun Krishan Puri, III(2009) CPJ 6 (NC), it was held that onus to prove the pre-existing disease of the insured at the time of taking the policy lay on the insurer.
10.     In the instant case, OP No.1-Insurer has not been able to place on record any reliable and documentary evidence in the form of medical record of the complainant to show that he is known case of pre-existing disease i.e. COPD before the inspection of the insurance policy, but he failed to disclose the same at the time of obtaining the insurance policy. Further in the absence of verification of discharge summary by the doctor, who treated/issued the same, no reliance can be placed on it. In the absence of such evidence, the repudiation of the claim by OP No.1 cannot held to be justified. Thus, OP No.1 has committed deficiency in service by rejecting the genuine claim of the complainant.
11.     In view of the above discussion, the present complaint deserves to be allowed and the same is accordingly allowed. OP No.1 is directed as under:-

[a]    To pay the claim of Rs.45,971/- to the Complainant;

 

[b]    To pay Rs.5,500/-on account of deficiency in service and causing mental and physical harassment to the Complainant; 

 

[c]    To pay Rs.7,000/- as cost of litigation;

 

12.     This order be complied with by OP No.1, within 45 days from the date of receipt of its certified copy, failing which the amount at Sr.No.(i) and (ii) shall carry interest @9% per annum from the date of this order till actual payment besides payment of litigation costs.
13.     Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

 

Announced 20/07/2022
	Sd/- (SURJEET KAUR) PRESIDING MEMBER
	Sd/- (B.M.SHARMA) MEMBER