BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.257 of 2018
Date of Instt. 12.06.2018
Date of Decision: 05.08.2019
Chander Bhushan Aggarwal aged about 42 years S/o Late Sh. Ravi Bhushan Aggarwal, R/o NK-250 A, Charanjit Pura, Jalandhar.
..........Complainant
Versus
1. Religare Health Insurance Company Ltd., (registered office), 5th Floor, 18 Chawla House Nehru Place, New Delhi-110019, through its Managing Director/Manager/Authorized Representative.
2. Religare Health Insurance Company Ltd., 2nd Floor, SCO-4, Puda Complex, Opposite District Administration Complex, Jalandhar, Punjab 144001, through its Branch Manager.
3. Poonam Kochhar, Agency code 20038646, Religare Health Insurance Company Ltd., 2nd Floor, SCO-4, Puda Complex, Opposite District Administration Complex, Jalandhar.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Sh. K. K. Gupta, Adv. Counsel for the Complainant.
Sh. R. K. Sharma, Adv. Counsel for the OPs No.1 and 2.
OP No.3 exparte.
Order
Karnail Singh (President)
1. This complaint has been filed by the complainant, wherein alleged that in the month of March, 2017, the complainant received a phone call from the OP No.3, with the intention to trap the complainant in her illegal design, she informed the complainant that she is calling from the office of the OP No.2, which is Health Insurance Company and she is providing Health insurance plans under the name and style of M/s Religare Health Insurance Company Ltd. and having their office at Delhi, Gurugram and also having a branch office at Jalandhar. The OP No.3 also informed the complainant that the OPs No.1 and 2 has launched a Health Insurance plan in which the company will cover the whole family of the insured persons and in case of any health problem occurs to the insured person or his family member, then they will cover and bear all the expenditure of medical treatment, medicine etc. under their above said health plan, on very low premium amount. After that the complainant disclosed that he and his all the family members are already covered with a good health insurance plan of National Insurance Co. from 2010-11 to 19.04.2017, then the OP No.3 started pressuring the complainant to port his above said policy from National Insurance Company to their company. The OP No.3 also offered a better health insurance plan for a heavy sum assured of Rs.15,00,000/- to the complainant with the premium of Rs.28,467/- and also assured that their company will also cover all types of pre existing health problems/diseases in this case. On the inducement, assurances and representations made by the OP No.3, the complainant gave consent and became ready to port his Health Insurance Plan with OPs No.1 and 2. Then the OP No.3 with another employee of OPs No.1 & 2 visited the office of the complainant to collect required documents, previous policies and cheque of Rs.28,467/-. The complainant handed over all the documents to employee of OPs No.1 and 2 and who assured the complainant that the validity of the policy valid from 22.04.2017 to 21.04.2018. Thereafter, the OP No.3 asked few questions about health of the complainant and accordingly, the complainant shown all the old medical test reports and orally disclosed his and other family member’s health status and OP No.3 assured the complainant that now their company will cover all the pre-existing diseases surely on the basis of long previous policy term and no claim status.
2. Then in the month of August, 2017, the complainant undergone a surgery pertaining to Fistula in Anus and thereafter, discharged from Batra Hospital, Mission Compound, Jalandhar. After that the complainant contacted the OP No.3 and demanded his original policy to file medical claim, then the OP No.3 visited the office of the complainant and demanded relevant bill, medical test reports and medicine bills etc., instead of giving his original policy documents, on the demand of the OP, the complainant handed over all the documents, including discharge card, hospital bills, medicine bills etc. The complainant has filed his medical claim for a sum of Rs.62,058/- and thereafter, the complainant number to times contacted the OP for clearing the medical insurance bill, but the same was lingering on the one pretext or the other and ultimately, in the month of March, 2018, the complainant received a letter, whereby the insurance claim of the complainant was rejected on the ground, Non Disclosure-Ankylosing Spondylitis since 3 years, which is not disclosed during port. Non Disclosure. Even after receiving the rejection letter, the complainant again requested the OP, but they did not ready to listen the complainant and ultimately, a legal notice was served to the OP, but all in vain. The act and conduct of the OPs tantamount to unfair trade practice and deficient in service and accordingly, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay Rs.62,058/- as medical claim amount, and be also directed to pay Rs.2,00,000/- as loss of no claim bonus and be also directed to pay compensation of Rs.50,000/- and litigation expenses of Rs.15,000/- with interest @ 18% per annum.
3. Notice of the complaint was given to the OPs, but despite service OP No.3 did not come present and ultimately, OP No.3 was proceeded against exparte, whereas OPs No.1 and 2 appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that the instant complaint is not maintainable against the answering OPs. The complainant himself is guilty of non-disclosure of material facts at the time of taking/porting policy, as such, the complaint is liable to be dismissed. It is further submitted that the complainant was issued insurance policy bearing No.11238569 for the period 22.04.2017 to 21.04.2018 subject to terms and conditions of the insurance policy by the OP No.2 insuring spouse, two sons and himself for a sum insured of Rs.15,00,000/-. It is further alleged that the complainant was admitted from 25.08.2017 till 30.08.2017 at Batra Hospital and filed for reimbursement claim. On receipt of the claim papers and scrutiny thereof, the answering OPs came up-front with the fact that the insured was suffering from Ankylosing Spondylitis prior to the policy and the same was not disclosed by the insured at the time of taking policy. Since, there was non-disclosure on the part of the insured, the respondent company rejected the claim of the insured vide letter dated 27.12.2017 on the basis of Clause 7.1 of the policy terms and conditions i.e. non-disclosure of material information at the time of policy inception. It is evident from the treatment record issued by the i-MED Hospital, Mohali dated 25 July, 2017 that the complainant Chander Bhushan was suffering from the Lower Back Ache from last more than 2 years and was also suffering from Ankylosing Spondylitis from 3 years. The treatment record of the aforesaid hospital is dated 25.07.2017, placed on the file. It is further submitted that if the insured would have disclosed the previous history of Ankylosing Spondylitis, as per under writing guidelines, the respondent company would have not issued the policy to the insured. On merits, it is admitted that the complainant got insurance policy and also submitted a medical insurance claim and the same was considered, but there was fault on the part of the complainant for non-disclosing of previous disease and as such, the same was rejected legally and rightly. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
4. The complainant filed Rejoinder of the written reply and whereby reasserted the entire facts as detailed in the complaint and denied those of the written statement.
5. In order to prove the case of the complainant, counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA alongwith some documents Ex.C-1 to Ex.C-21 and closed the evidence.
6. Similarly, counsel for the OPs No.1 and 2 tendered into evidence affidavit of Sh. Ankit Shekhar Bhardwaj as Ex.O-A alongwith some documents Ex.O-1 to Ex.O-11 and closed the evidence.
7. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.
8. From the argument of both the counsel for the parties, it reveals that the complainant has established on the file that he was taking insurance policy since 2010 from National Insurance Company and insurance certificate placed on the file by the complainant are Ex.C-3 to Ex.C-9 and thereafter, the complainant submitted that he got insurance policy from OPs by porting the previous policy and these facts have not denied by the OP in Para No.2 of the written statement on merits, if so, then the complainant is insured since 2010 and if any proposal form filled by the complainant is to be taken into consideration, the first proposal form furnished in the year 2010 and if in that proposal form the complainant concealed any pre-existing disease, then the complainant is bound by the terms and conditions of the OP i.e. terms and conditions Ex.O-2, but in the instant case, the OP has repudiated the claim of the complainant, vide repudiation letter Ex.C-12 dated 15.03.2018 on the ground that the complainant has concealed pre-existing disease i.e. ‘Ankylosing Spondylitis’ since 3 years, but the complainant has never got treatment of this disease, the complainant alleged that he got admitted himself in Batra Hospital, Jalandhar for getting a treatment of Fistula in Anus and this fact is very much clear from the Discharge Slip Ex.C-11 and further the OP has not brought on the file any document i.e. a report or prescription slip issued by any hospital or doctor, which shows that the complainant was ever taking treatment of ‘Ankylosing Spondylitis’ for the last 3 years, if so, then the plea taken by the OP for rejection of the claim, is not established rather it shows that the claim of the complainant has been wrongly and illegally rejected by the OP, vide letter dated 15.03.2018.
9. Apart from above, the complainant categorically alleged that he never signed the proposal form produced on the file by the OP i.e. Ex.O-6 dated 20.04.2017, when a specific plea has been taken by the complainant, then it is bounded duty of the OP to get compare the signature on the proposal form Ex.O-6 with the admitted signature of the complainant, but for the best known reason, the OP remained silent, which itself speaks that the said proposal form Ex.O-6, is not signed by the complainant. Even if we see with the naked eyes the signature on the proposal form Ex.O-6 and then compare with the signature on the complaint, then we can say without any hesitation that the same are not one and the same person and as such, we find that the insurance claim of the complainant has been wrongly and illegally rejected by the OPs without any reason and rhyme, whereas the complainant is entitled for the relief claimed.
10. In the light of above detailed discussion, the complaint of the complainant is partly accepted and OPs are directed to reimburse the medical insurance claim of Rs.62,058/- to the complainant with interest @ 12% per annum from the date of repudiation of the claim i.e. 15.03.2018, till its realization and further OPs are directed to pay a compensation, to tune of Rs.15,000/- and litigation expenses of Rs.7000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
11. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Karnail Singh
05.08.2019 Member President
