Chandigarh

DF-II

CC/631/2017

Mr. Vipul Jain - Complainant(s)

Versus

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

D.K. Singal Adv. & Ammish Goel Adv.

31 Aug 2018

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	631 of 2017
Date  of  Institution	:	22.08.2017
Date   of   Decision	:	31.08.2018

 

 

 

 

Vipul Jain, r/o House No.A-901, Vrindavan Garden Society, Zirakpur, District Mohali 140603 Punjab  

 

             ……..Complainant

Versus

 

1]  Religare Health Insurance Company Limited, through its Managing Director, having its registered Office at D-3, District Centre Saket, New Delhi

 

    2^nd Address:-

Vipul Tech Square, Tower-C, 3^rd Floor,     Sector 43, Golf Course Road, Gurgaon 122009

3^rd Address:-

GYS Global, Plot No.A-3, A-4,A-5, Sector 125, Noida, Uttar Pardesh 201301

 

2]  Religare Health Insurance Company Limited, through its Branch Manager, Top Floor, SCO No.56-58, Sector 9-D, Chandigarh 160017

 

………. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

SMT.PRITI MALHOTRA        MEMBER

            SH.RAVINDER SINGH         MEMBER

 

Argued By: Sh.Ammish Goel, Adv. for complainant.

Sh.Sachin Ohri, Adv. for OPs.

 

 

PER RAVINDER SINGH, MEMBER

 

         The case of the complainant, in brief is that, he subscribed a cashless Health Insurance Policy of OPs in Nov., 2015 and got it renewed from 16.11.2016 to 15.11.2017 vide Policy No.10423735 (Ann.C-1).  Under the said policy, the wife and son of the complainant was also covered with sum insured of Rs.5 lacs.  It is averred that the complainant suddenly felt pain in abdomen and on check-up and endoscopy test on 7.1.2017, stone of 4.4mm had been found in his gall bladder (Ann.c-3 & c-4). The matter was reported to OPs, whose representative visited the complainant and noted down that the complainant is suffering from bronchial asthma since his childhood and has been taking inhaler for the same.  However, the representative assured the complainant that he would be entitled for claim benefits, but despite that the pre-approval was rejected by the OPs.  Ultimately, the complainant was admitted in Alchemist Hospital on 24.1.2017 for surgery of removal of stone and discharged on 25.1.2017 (Ann.C-5) after paying all the expenses. Thereafter a claim was lodged with the OPs, but the same was rejected by the OPs on the ground of non-disclosure of material facts/pre-existing ailments at the time of proposal.  It is submitted that the bronchial asthma is not a persistent problem with the complainant and he rarely used the inhaler specially once or twice in a year, but the representative of the OPs mis-guided the complainant and pressurized him to give writing that the same had been using the inhaler since his childhood.  It is also submitted that bronchial asthma & the use of inhaler and surgery of gall bladder have no co-relation in any manner nor bronchial asthma was the reason of development of stone in gall bladder.  Therefore, alleging the said repudiation of claim as illegal and an act of deficiency in service on the part of OPs, this complaint has been filed.

 

2]       The OPs have filed joint reply and while admitting the factual matrix of the case, stated that the cashless facility request of the complainant for the treatment undertaken by him was denied on 22.1.2017 for non-disclosure of pre-existing ailment while proposing for the policy as per terms & conditions thereof.  It is stated that the hospitalization of complainant at Alchemist Hospital from 24.1.2017 to 25.1.2017 was for the treatment of Gall Intestine Stone disease and Chronic Gastritis and after perusal of medical documents submitted by the complainant & investigation, it was observed that the complainant had a history of Bronchial Asthma since childhood and use inhaler for the same and is suffering Cholelithiasis since May, 2015, which was not disclosed by the complainant while proposing for the policy and as such breached the principle of utmost good faith.  It is submitted that the claim of the complainant was rightly rejected for non-disclosure of pre-existing ailment at the time of taking the policy.  Pleading no deficiency in service and denying all other allegations, the OPs have prayed for dismissal of the complaint.  

 

3]       Complainant also filed rejoinder thereby reiterating the assertions made in the complaint.

 

4]      Parties led evidence in support of their contentions.

5]       We have heard the ld.Counsel for the parties and have also perused the record.

 

6]       The complainant had Medical Insurance Policy from Apollo Munich Health Insurance Company w.e.f. 15.11.2014 to 14.11.2015 (Ann.R-1).  Later on the said insurance policy was ported to Religare Health Insurance Company and the policy was issued in his favour w.e.f. 15.11.2015 to 14.4.2016, which was further renewed upto 15.11.2017.  As per policy, the complainant was entitled for reimbursement of pre-hospitalization medical expenses upto 30 days and post-hospitalization medical expenses upto 60 days after hospitalization.

 

7]       The complainant suffered from Gall Bladder Stone disease and was admitted in Alchemist Hospital on 24.1.2017 for treatment and after needful surgery, discharged on 25.1.2017 (Ann.C-5).  As per terms & conditions of the policy, the medical expenses incurred by the complainant with effect from 23.12.2016 to 26.3.2017 for an amount of Rs.76,709/-  were admissible for payment as claimed for. 

 

8]       The Opposite Parties have declined the claim of the complainant on pretext of allegation of concealment of pre-existing disease of Asthma vide letter dated 12.6.2017 (Ann.C-11).

 

9]       The complainant has stated that he does not suffer from any disease of bronchial asthma.  He has stated to have used inhaler very occasionally only when he feels little suffocated on account of seasonal change.  Dr.Vinay Verma, MBBS, MD (Medicine) Consultant physical & Cardiologist vide certificate Ann.C-13 has certified as under:-

“Sh.Vipula Jain does not suffer from Bronchial Asthma at this time. His PFT is normal.  He however gives history that he occasionally gets some seasonal allergy once or twice a year from which he takes/uses inhaler on his own. It is further certified that Bronchial asthma does not lead to Gall Bladder stones & the two problem are not related to each other in any way.”   

 

10]      The Opposite Parties have not produced any cogent, reliable defense in rebuttal to the opinion of Dr.Vinay Verma. 

11]      The contentions raised by the OPs in their written statement regarding concealment of pre-existing disease of Cholelithiasis since May, 2015 by the complainant, are vague and hypothetical too.  The CT Scan abdomen and pelvis dated 20.5.2016 (Ann.R-4) only indicate impression:-

1. Diffuse Fatty change in the Liver.
2. Cholelithiasis

         The term Cholelithiasis may refer to the presence of gall stones.  The gall stones tend to be asymptomatic.  People though having stones in their body, did not have an iota of feeling of presence of such stones in their body till the same is detected by way of medical investigations/X-ray/scan etc. The mere impression of Cholelithiasis on 20.5.2016 in CT Scan Report (Ann.R-4) does not indicate the same within the knowledge of the complainant till that time. There is no intentional or willful suppression of any fact by the complainant, prejudicial to the terms & conditions of the policy. The complainant has taken the Health Insurance Policy from Opposite Parties w.e.f. 14.11.2015 much prior to CT Scan dated 20.5.2016.    

 

12]      The Opposite Parties without any valid & legal reasons have illegally repudiated the claim of the complainant for reimbursement of medical expenses, which tantamounts to unfair trade practice on their part. 

        

 

13]      Keeping into consideration the facts & circumstances of the case, as discussed in the preceding paragraphs, the present complaint is allowed with directions to the Opposite Parties to repay an amount of Rs.76,709/- to the complainant along with interest @9% per annum from the date of filing this complaint i.e. 22.8.2017. The Opposite Parties are also directed to pay a compensatory cost of Rs.10,000/- and litigation cost of Rs.5000/- to the complainant.

         This order shall be complied with by the Opposite Parties within a period of 30 days from the date of receipt of copy of this order, failing which they shall be liable to pay additional compensatory cost of Rs.5,000/- to the complainant apart from the above relief.

         Certified copy of this order be sent to the parties, free of cost. File be consigned to record room.

Announced

31^st August, 2018                                                  Sd/-

 (RAJAN DEWAN)

PRESIDENT

                                                                                               

Sd/-

                                                                    (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER