Haryana

Karnal

CC/85/2020

Jaskaran Singh - Complainant(s)

Versus

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

Parshant Pahwa

06 Jul 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No. 85 of 2020

                                                        Date of instt.07.02.2020

                                                        Date of Decision:06.07.2023

 

Jaskaran Singh aged about 22 years son of Richpal Singh, resident of village Taraori, Tehsil Nilokheri, District Karnal.

                                               …….Complainant.

                                              Versus

 

1.     Religare Health Insurance Company Ltd. Registered office at 5^th floor, 19, Chawla House, Nehru Place, New Delhi-19, through its Managing Director.

 

2.     Religare Health Insurance Company Ltd. Branch office at SCO no.214, 1^st floor Sector-12, Karnal through its Branch Manager.

 

                                                                      …..Opposite Parties.

 

Complaint Under Section 12 of the Consumer Protection Act, 1986 and after amendment Under Section 35 of Consumer Protection Act, 2019.

 

 

Before   Sh. Jaswant Singh……President.

              Sh. Vineet Kaushik……Member 

      Dr. Rekha Chaudhary……Member

          

 Argued by: Shri Parshant Pahwa, counsel for the complainant.

                    Shri Rohit Gupta, counsel for the OPs.

 

                    (Jaswant Singh President)

ORDER:   

          

                 The complainant has filed the present complaint Under Section 12 of the Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant has purchased a medical claim insurance policy from the OPs, vide insurance policy no.13242693 for an amount of Rs.5 lakhs. The said policy is of Care Plan and was having validity from 31.10.2018 to 30.10.2019.

2.             On 18.05.2019, the complainant was working in the kitchen of his house at once in the LPG fire extinguish due to which he was caught hold by the fire and was badly burnt and immediately after the occurrence he was shifted to Shri Hari Hospital, Karnal where he remained admitted from 18.05.2019 to 06.06.2019. The intimation was sent to the OPs. The OPs asked the complainant to make the payment of the bills of hospital and that OPs will reimburse the same. Accordingly, complainant paid the total bills of Rs.2,49,448/- (i.e.Rs.152500/- paid as hospital charges and Rs.96948/- as bills of medicines etc.). The condition of the complainant was very critical hence he on 29.06.2019 was admitted in Balaji Hospital, Minar Road, Karnal where he remained admitted uptill 08.07.2019. The complainant has paid an amount of Rs.165262/-( i.e. Rs.1,11,400 to the said hospital and Rs.53,862/- as medicines expenses). Thus, in all the complainant has submitted total amount of Rs.4,14,710/-. Still the treatment of complainant is going on. After discharge from the hospital, complainant lodged the claim with the OP no.2 for reimbursement of the abovesaid amount and completed all the formalities as desired by the OPs. Thereafter, complainant visited the office of the OPs so many times and requested to settle the claim but OPs did not pay any heed to the request of complainant and lingered the matter on one pretext or the other and lastly repudiated the claim of complainant, vide letter dated 10.10.2019 on the false and frivolous grounds. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

3.             On notice, OPs appeared and filed its written version, raising preliminary objections with regard to maintainability; cause of action; locus standi; jurisdiction and concealment of true and material facts. On merits, it is pleaded that OPs have issued a Health Insurance Policy with Product “CARE” individual bearing policy no.13242693 covering the complainant w.e.f. 31.10.2018 till 30.10.2019, for a sum insured of Rs.5,00,000/- subject to the policy terms and conditions. The complainant filed a reimbursement claim with the OPs. The complainant was admitted at Shri Hari Hospital, Karnal w.e.f. 18.05.2019 till 29.05.2019 for the complaints of burn injuries in kitchen. Upon receipt of the claim the OP company raised query, vide query letter dated 18.07.2019 and reminders dated 28.07.2019 in order to properly assess the claim and asked for the following documents;

1.     Detail original discharge summary.

2.     Detail narration of injury with exact date and time.

3.     Original cash paid receipt against final bill.

4.     Copy of MLC/FIR.

5.     Recent passport size photographs of proposer/nominee.

6.     Treating Doctor’s certificate for alcohol/Any other drug abuse.

7.     Complete indoor case papers with admission notes, history sheet, doctor’s notes, nursing notes and vital chart.

8.     1^st consultation paper immediately after incident.

 

It is further pleaded that OPs triggered a claim investigation in order to properly analyze the claim. The complainant did not provide the requisite documents even after repeated reminders. The complainant, vide letter dated 28.08.2019 asked for refund of all the documents submitted by him, therefore, OP denied the claim, vide claim denial letter dated 08.09.2019 with the following observation;

Claim withdrawn by complainant;

The complainant filed a reimbursement claim with the OPs. The complainant/insured was admitted at Balaji Hospital, Karnal w.e.f. 29 June-2019 till 08.07.2019 for further management and was operated for Post Burn RA. On perusal of the documents received from investigation, OPs came to know that the complainant is Bhuki and Opium addicted. The same was also not informed to the company at the time of disclosure. The consumption of which is explicitly disallowed as per the policy terms and conditions. Hence, OPs rejected the claim, vide letter dated 10.10.2019 with the following observation:

Clause no.17.7 (A) non-disclosure of material facts/pre-existing ailment at the time of proposal, smack inhalation prior to policy inception. Clause no.2.4.1(23) permanent exclusion: condition caused by suicide or substance abuse/intoxication.

.       Non disclosure

.       Permanent exclusion: condition caused by suicide or substance abuse/intoxication.

The evidence supporting the rejection is a follows:

.       As per the Indoor case papers, Doctor’s initial Assessment sheet, he had personal history of addiction of Bhuki and Opium.

.       As per Doctor’s Progress sheet dated 18.05.2019, 20.05.2019, 21.05.2019, 22.05.2019, 23.05.2019, 24.05.2019, 25.05.2019, 27.05.2019, 28.05.2019, 29.05.2019 he is a Bhuki and Opium addicted. It was confirmed that he had history of smack inhalation since 3-4 years and daily dose was 0.5gm 1 gm. He was intoxicated at the time of accident.

.       As per the Doctor’s questionnaire, the doctor asked the question.

        Please specify if patient was under the influence of Alcohol or other toxicants at the time of Accident?

        The Doctor answered, “the patient was drug addict, opium, Irritable, withdrawal symptoms after 3-4 days of admission”.

The relevant clause pertaining to non-disclosure, permanent exclusion is as follows:

Clause 7.1 Disclosure to Information Norm

If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description of non-disclosure of any material particulars or any material information having been withheld or if a claim is fraudulently made of any fraudulent means or devices are used by the policy holder or the insured person or any one acting on his/their behalf, the company shall have no liability to make payment of any claims and the premiums paid shall be forfeited ab initio to the company.

Clause 4.2 Permanent Exclusion-

23)   Act of self-destruction or self-inflicted injury, attempted suicide or suicide while sane or insane or illness or injury attributable to consumption, use, misuse or abuse of intoxicating drug, alcohol and hallucinogens.

It is further pleaded that as per the IRDAI rules, it is duty of the insured to disclose all the material facts to the insurer in order to assess the risk as per its capacity but in the present case complainant is not acting as per the policy terms and conditions. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

4.             Parties then led their respective evidence.

5.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of claim denial letter dated 10.10.2019 Ex.C1, copy of insurance policy letter Ex.C2, copy of policy certificate Ex.C3, copy of medical bills and hospital charges Ex.C4 to Ex.C65 and closed the evidence on 22.07.2022 by suffering separate statement.

6.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Prabhjyot Singh Manager Ex.OP1/A, copy of insurance policy alongwith terms and conditions Ex.OP1, copy of claim form Ex.OP2, copy of discharge summary Ex.OP3, copy of query letters dated 18.07.2019, 28.07.2019, 07.08.2019 Ex.OP4, copy of denial letter dated 08.09.2019 Ex.OP5, copy of letter dated 28.08.2019 Ex.OP6, copy of claim form Ex.OP7, copy of discharge summary Ex.OP8, copy of denial letter dated 10.10.2017 Ex.OP9, copy of doctor’s initial assessment Ex.OP10, copy of proposal form Ex.OP11, copy of case law Ex.OP12 and closed the evidence on 20.04.2023 by suffering separate statement.

7.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

8.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant has purchased a medical claim insurance policy from the OPs. On 18.05.2019, the complainant was burnt due to LPG fire while he was working in the kitchen. He was shifted to Shri Hari Hospital, Karnal where he remained admitted from 18.05.2019 to 06.06.2019. The intimation was sent to the OPs. The complainant has spent an amount of Rs.2,49,448/- on his treatment in the said hospital. Due to critical condition on 29.06.2019, he was admitted in Balaji Hospital, Minar Road, Karnal where he remained admitted uptill 08.07.2019. The complainant has paid an amount of Rs.165262/- on his treatment in the said hospital. After discharge from the hospital, complainant has submitted the claim of Rs.4,14,710/- with the OPs for reimbursement of the same and completed all the formalities. Complainant requested the OPs so many times to settle the claim but the claim of complainant has been repudiated, vide letter dated 10.10.2019 on the false and frivolous grounds and prayed for allowing the complaint.

9.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that complainant filed a reimbursement claim with the OPs for the complaints of burn injuries in kitchen. Upon receipt of the claim the OPs company raised query and demanded requisite documents but complainant did not provide the same even after repeated reminders. OPs have rightly rejected the claim of complainant, vide letter dated 10.10.2019 because the complainant is Bhuki and Opium addicted and the same was not disclosed to the OPs at the time of obtaining the insurance policy and lastly prayed for dismissal of the complaint.

10.           We have duly considered the rival contentions of the parties.

11.           Admittedly, complainant has purchased the mediclaim policy from the OPs for sum insured of Rs.5 lakhs. He has suffered burn injury during the subsistence of the insurance policy.

12.           The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.C1/Ex.OP9 dated 10.10.2019 on the grounds, which are reproduced as under:-

“We have reviewed the claim filed by you pertaining to Health Insurance Policy and hereby inform you that the claim is not payable as per policy terms and conditions listed below:

.       Clause no.1 7.7 (A) non-disclosure of material facts/pre-existing ailment at the time of proposal: Smack inhalation prior to policy inception. Clause no.2.41 (23) permanent exclusion condition caused by suicide or substance abuse/intoxication.

.       Permanent exclusion: condition caused by suicide or substance abuse/intoxication”.

 

13.           The claim of the complainant has been repudiated by the OPs on the above mentioned grounds.

14.           The onus to prove its case lies upon the OPs, but OPs have miserably failed to prove the same by leading any cogent and convincing evidence. The case of the OPs is based upon the Doctor’s Initial Assessment Ex.OP10 dated 18.05.2019 issued by Shri Hari Hospital, Karnal. The said Initial Assessment Ex.OP10 is a photocopy. Except that document there is no other opinion/ documents on the file to ascertain that the complainant was Bhuki and Opium addicted. Thus, the repudiation of claim of complainant is only on the basis of presumption and assumption and furthermore OPs have neither examined the said doctor nor tendered his affidavit in its evidence. Thus, the said document has no weightage in the eyes of law. In this regard, we are fortified with the observation of Hon’ble National Commission in case titled as Sucha Singh Versus Head Branch Office, HDFC Life and another 2022 CJ 201 (NC)  wherein it is held that there is nothing on record to show that deceased was suffering from chronic alcoholic condition and was suffering with chronic liver disease and that he submitted fake documents at the time of obtaining original policy. State Commission had adopted wrong approach while rejecting complaint- respondent shall pay to complainant assured amount alongwith 9% interest. Further, in case SBI Life Insurance Co. Ltd. Versus Lakshmiben Naginbhai Chauhan and others 2020 CJ 110 (NC) Hon’ble National Commission has held that repudiation of death claim on ground of concealment of pre-existing disease-complaint allowed by For a below-Both District Forum and State Commission had reached  to the conclusion after going through all documents that medical papers have not been properly proved since neither doctor has been duly examined nor his affidavit has been furnished-National Commission is not expected and required to re-appreciate and re-assess evidences-where on the basis of evidences Fora Below have reached to a conclusion which is a possible conclusion, then such conclusion need not be disturbed in Revision Petition-Revision Petition dismissed.

15.           Furthermore, if for the sake of arguments, it is presumed that complainant was Bhuki and Opium addicted, however, there is no nexus between the treatment taken by the complainant for burn injuries and intoxication. No previous history has been placed on file by the OPs to prove that complainant was Bhuki and Opium addicted. Complainant was 21 years old at the time of taking the policy and during the tenure of the policy, complainant has not taken any treatment.  Hence, plea taken by the OPs has no force.

16.           Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

 17.          Keeping in view, the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, we are of the considered view that act of the OP while repudiating the claim of the complainant amounts to deficiency and unfair trade practice.

18.           The complainant has spent Rs.4,14,710 on his  treatment and in this regard he has placed on file medical bills and receipts Ex.C4 to Ex.C65/-. The said bills have not been rebutted by the OPs.

Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

19.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.4,14,710/- (Rs. four lakhs fourteen thousand seven hundred ten only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OPs to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs.5500/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:06.07.2023

                                                                President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

      

(Vineet Kaushik)        (Dr. Rekha Chaudhary)

Member                         Member