Haryana

Karnal

CC/33/2015

lalita Rani W/o Om Parkash - Complainant(s)

Versus

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

J.B. Rohilla

15 Dec 2017

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No.33 of 2015

                                                         Date of instt. 03.03.2015

                                                         Date of decision:15.12.2017

 

Smt. Lalita Rani wife of Shri Om Parkash, resident of House no.85-A, Bahadur Chand Colony, Gali no.1, Hansi Road, Karnal.

                                                                                               

                                                                        …….Complainant.      

                                        Versus

 

1. Religare Health Insurance Company Limited GYS Global plot no.A-3, A4, A5, Sector-125 Noida UP through its Authorized Signatory.

2. The Branch Manager, Religare Health Insurance Company Limited, Sector-12 U.E. Karnal-132001.

                                         

                                                                     …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act.            

 

Before   Sh. Jagmal Singh……President.

              Sh. Anil Sharma……….Member

      Ms. Veena Rani ………..Member.

             

 

 Present  Shri J.B.Rohilla Advocate for complainant.

               Shri  Rohit Gupta Adv. for opposite parties.

               

 

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that she purchased the policy bearing no.10067973 under Plan no. Care Cover Type Individual by paying the premium amount of Rs.4513. The said policy was valid from January 2014 to January 13, 2015 covering the medical claim of Rs.2,00,000/- and she herself was insured for hospitalization expenses, pre-hospitalization and hospitalization expenses, ambulance cover, organ donor cover, domiciliary hospitalization, health check-up, recharge of sum insured, daily allowance. She was medico legally examined by the OP at the time of issuance of said policy. On 1.8.2014 she all of sudden felt some problem and she was taken to Shri Ram Chand Memorial Hospital, Karnal where she was examined by the doctors and she was found a patient of high blood pressure. On 12.8.2014 she suffered from acute headache and on examination she was found high blood pressure and doctors on examination diagnosed the disease as allergic bronchitis and K/C/O. She being treated as indoor patient and she remained admitted in the abovesaid hospital upto 19.8.2014. She spent Rs.80,200/- on her treatment and she also spent Rs.30,000/- towards medicines purchased from the market. Thereafter, she contacted with the OPs and lodged the claim bearing no.90060234 and at the time of submitting the claim, she submitted all the required documents and treatment record and OPs assured her that the claimed amount would be remitted to him as early as possible. She visited the office of OPs several times and requested for reimbursement of the amount, but OPs did not pay any heed to her request and lastly repudiated her claim, vide letter dated 6.12.2014 on the ground that Vertigo was caused due to change in pressure in ear, hence claim stand denied. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written statement raising preliminary objections with regard to territorial jurisdiction; locus standi and cause of action; deficiency in service and concealments of true and material facts. On merits, it has been submitted that the OPs issued a policy no.10067973, Plan Name Care, Cover type Individual to the complainant providing a coverage upto Rs.2 lakhs for Hospitalization Expenses (conditions for Medical expenses-upto Rs.2,00,000/- i. Room Rent= 1% of Benefit/ Sum Insured per day, ii ICU charges= 2% of Benefit/Sum Insured per day),  pre-hospitalization & Post-hospitalization Expenses, Ambulance cover, organ Donor Cover, domiciliary hospitalization, health check-up, recharge of sum insured, daily allowance and No Claims Bonus on payment of Rs.4513/- as insurance premium and was valid from 14.1.2014 to 13.1.2015 subject to the Policy Terms and Conditions. Complainant lodged the claim with the OP and submitted required document. The claim of the complainant has been repudiated on the grounds of Non-disclosure of pre-existing ailments at the time of proposal and patient is hypertensive since 10 years on regular treatment as mentioned in the claim denial letters. However, the alleged certificate on the letter head of Shri Ram Chand Memorial Hospital where it is mentioned that Lalita Rani was not suffering from HTN but she is taking medication for HTN but not on regular treatment, which was contradictory. Hence there was no deficiency on the part of the OPs in repudiating the claim of the complainant. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence her affidavit Ex.CW1/A and documents Ex.C1 to Ex.C8 and closed the evidence on 3.10.2016.

4.             On the other hand, OPs tendered into evidence affidavit of Prashant Singh Manager Ex.OP1/A and documents Ex.OP1 to Ex.OP7 and closed the evidence on 5.4.2017.

5.             We have heard the learned counsel for both the parties and perused the case file carefully and have also gone through the evidence led by the parties.

6.             From the pleadings of the case, it is clear that there is no dispute between the parties that complainant had purchased the policy no.10067973, plan name CARE, cover type Individual, single premium of Rs.4513/- valid from 14.1.2014 to 13.1.2015 for a sum insured of Rs.2 lakh. On 1.8.2014, the complainant felt some problem and she was taken to Shri Ram Chand Memorial Hospital, Karnal (hereinafter referred as SRCM), where she was found patient of High Blood Pressure and medicine were prescribed. Again on 12.8.2014, the complainant suffered from acute headache and she was admitted in aforesaid hospital, where she diagnosed the disease as allergic bronchitis and K/C/O HTN. She remain admitted upto 19.8.2014 and the hospital charged Rs.80,200/- and Rs.30,000/- as medicines purchased from market. The complainant made the claim with the OP, which was earlier rejected, vide letter dated 21.11.2014 Ex.O-5 and finally rejected, vide letter dated 6.12.2014 on the ground that Virtigo was caused due to change in pressure in ear, hence the claim stands denied on below mentioned clause “CARE 6.1: NON-DISCLOSURE OF PRE-EXISTING AILMENTS AT TIME OF PROPOSAL. PATIENT IS HYPERTENSIVE SINCE 10 YEARS ON REGULAR TREATMENT”

7.             According to the complainant, the OP has wrongly repudiated her claim whereas according to OP, the insured was hypertensive since 10 years as regular treatment and the complainant has not disclosed the same at the time of taking the policy, so the claim was rightly repudiated.

8.             As is clear from the record of the case that the OP has repudiated the claim on the ground of suppression of pre-existing disease, therefore, the onus to prove the same is on the OP. To prove its contention, the OP produced in its evidence affidavit Ex.OP1/A and documents O-1 to Ex.O-7. The document Ex.O-1 is photo copy of letter dated 13.1.2014, vide which policy was issued including the terms and conditions of the policy. Ex.O-2 to Ex.O-4 are the photocopies of the record from SRCM hospital. Ex.O-5 is the photo copy of the repudiation letters dated 21.11.2014. Ex.O-6 is the photo copy of computerized copy of application and Ex.O-7 is the photocopy of cancellation letter dated 8.1.2015. To prove the allegation that the complainant has suppressed the pre-existing ailment, it was necessary to produce on the file, the proposal form bearing the signature of the complainant or the certified/attested copy of the same. But the OP has not produced the same on the file, the reason are best known to the OP. It is pertinent to mention here that the OP has alleged in para no.4 of the preliminary objections of its reply that proposal form is annexed as Annexure-4 but Annexure-4 is the photocopy of the medical record of the complainant issued by the aforesaid hospital. No doubt the OP has placed in his evidence, photo copy of the computerized copy of application as Ex.O-6 but the same did not bear the signature of the complainant. So from this document it is not proved that the same was executed by the complainant. As already stated above, the OP has not produced the proposal form signed by the complainant or its attested copy on the file, therefore, it cannot be said that the OP has proved on the file that the complainant has suppressed the pre-existing ailment while filling up her proposal form. The OP has produced on the file, the photo copies of medical record of the complainant as Ex.O-2 to Ex.O-4. All these documents were issued after taking of the policy in question and these documents are unattested photocopies of the treatment record, therefore, the same are not admissible in evidence. In this regard we can rely upon the authority cited in 2017 (3) CLT 526 (NC) titled as Birla Sun Life Insurance Co. Ltd. & Anr. Versus Arvind Kaur wherein it is held that mere production of the same unattested, unverified and unauthenticated photocopies, could not have been the basis of holding that the deceased was an alcoholic and was diagnosed with alcohol liver disease and its complications. This authority is fully applicable to the facts of the present case. Keeping in view the above facts and circumstances of the case, we are of the opinion that OP has failed to prove that the complainant had suppressed the fact of her pre-existing ailment at the time of taking the policy. Hence the OP has wrongly repudiated the claim of the complainant and is deficient in providing services to the complainant.

9.             The complainant alleged that the hospital has charged Rs.80,200/- and she spent Rs.30,000/- on medicines from market. But the complainant has placed on the file, photocopy of bill Ex.C3 for Rs.80,200/- only. Regarding the original bill, the learned counsel for complainant stated at the time of argument that the same (original bill) was given to the OP alongwith the claim. This contention of complainant has force and moreover the same has not been denied by the OP which means admitted by the OP. Hence in our view the complainant is entitled for this amount of Rs.80,200/-.

9.             Thus, as a sequel of above discussions, we allow the complaint and direct the OPs to pay Rs.80,200/- to the complainant.  We further direct the OPs to pay Rs.5500/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied within 30 days from the date of this order failing which the abovesaid amount will carry interest at the rate of 8% per annum from the date of order till its realization. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 08.12.2017

                                                                       

                                                                   President,

                                                          District Consumer Disputes

                                                          Redressal Forum, Karnal.

 

                     (Veena Rani)       (Anil Sharma)

                          Member                Member