Chandigarh

DF-II

CC/375/2017

Mrs. Asha Rani Mehta - Complainant(s)

Versus

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

Anju Arora Adv.

28 Dec 2018

ORDER

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

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Consumer Complaint  No	:	375 of 2017
Date  of  Institution	:	27.04.2017
Date   of   Decision	:	28.12.2018

 

 

 

 

 

Asha Rani Mehta w/o Sh.S.C.Mehta, through legal heirs:-

1]  Subhash Chander Mehta, aged 70 years, son of Chander Bhan, R/o 2647, Sector 47-C, Chandigarh.

2]  Yukta Mehta aged 43 years D/o Subhash Chander Mehta, R/o 213, MDC, Sector 4, Panchkula.

3]  Nidhi Mehta, aged 37 years, D/o Subhash Chander Mehta, R/o 2647, Sector 47-C, Chandigarh.

4]  Harsh Mehta s/o Subhash Chander Mehta, R/o 2647, Sector 47-C, Chandigarh.

 

             ……..Complainants

 

Versus

 

1]  Religare Health Insurance Company Limited, through its Managing Director, GYS Global, Plot No.A3, A4, A5, Sector 125, Noida, UP 201301 having its registered office Religare Health Insurance, D-3, District Centre, Saket New Delhi 17, through its Authorised Signatory.

 

2]  Jai Laxmi Corporative Services, Intermediary  RM Code HARSWARUP c/o GYS Global, Plot No.A3, A4, A5, Sector 125, Noida, UP 201301 having its registered office Religare Health Insurance, D-3, District Centre, Saket New Delhi 17, through its Authorised Signatory. 

 

3]  Branch Manager, Religare Health Insurance Company Limited, SCO No.28, 2^nd Floor, Sector 20-D, Chandigarh through its authorised Signatory.

 

………. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

SMT.PRITI MALHOTRA        MEMBER

            SH.RAVINDER SINGH         MEMBER

 

Argued By: Ms.Anju Arora, Adv. for complainant.

Sh.Sachin Ohri, Adv. for OPs No.1 & 3

OP No.2 exparte.

 

 

PER PRITI MALHOTRA, MEMBER

 

         The complainant Asha Rani Mehta had expired during the pendency of the present compliant and as such, her legal heirs, as mentioned in headnote, have been brought on record.

         The case of the complainant (since deceased), in brief is that, she obtained a Health Insurance Mediclaim Policy – “Care” from OPs on paying the premium amount of Rs.18,220/-, which was commenced from 25.1.2015 to 24.1.2016 (Ann.C-1).  It is averred that the OPs issued the said insurance policy to the complainant after conducting thorough medical examination.   

         It is stated that the complainant was diagnosed - Colon biopsy-Aden Carcinoma moderately differentiated - by PGIMER, Chandigarh vide Biopsy Report dated 10.8.2015 and was advised surgery of Sigmoida1CA during first week of Sept., 2015 (Ann.C-3).  It is stated that on 31.8.2015, the complainant was admitted in Fortis Hospital, Mohali for her treatment and was operated on 1.9.2015.  The cashless request made to Opposite Party No.1 was declined by it on the ground that the complainant is a known case of hypertension since 7-8 years, which was not disclosed at the time of proposal (Ann.C-4) and further stated that she is suffering from depression and is getting treatment from PGI, therefore, has concealed the fact of pre-existing disease and hence the claim was rejected.  Against the said repudiation, the complainant filed Consumer Complaint NO.644 of 2015 before District Forum, UT, Chandigarh, which was decided in her favour and even the appeal filed by the Opposite Parties was also dismissed.  It is submitted that during the pendency of the said consumer complaint, when entire medical history of the complainant was available with the Opposite Parties, the OPs renewed the Health Insurance Policy against premium of Rs.23,209/- (Ann.C-8).  It is also submitted that the Opposite Parties have further mentioned in their renewal office letter dated 16.11.2015 “No Claim” Bonus of Rs.40,000/- and the claim status was mentioned as ‘NO’ when they knew that the complaint is pending before the District Forum, UT, Chandigarh and entire medical record was with them.

         It is stated that the complainant is getting treatment at PGI Chandigarh and submitted her bills to OPs, but the same were rejected on the ground that the pre-hospitalization is not covered under the policy, whereas in the policy the same is covered.  It is also stated that the complainant underwent surgery at PGI and remained admitted there from 5.6.2016 to 22.6.2016 and then submitted her bills to OPs for reimbursement, but that too were rejected by them stating – Depression since 4 to 5 years and   non-disclosure of material facts/pre-existing disease at the time of proposal.  It is further stated that the question of concealment of fact or any disease can not arise at all as entire medical history is available with the OPs.  Alleging the said repudiation as illegal and deficiency in service, hence this complaint has been filed.

 

2]       The OPs No.1 to 3 have filed joint reply and while admitting the factual matrix of the case, stated that the earlier claim of the complainant was rightly rejected for non-disclosure of material information at the time of proposing for the policy.  It is stated that when the matter went to National Commission, after decision from Fora below, both the parties agreed to settle the claim upto 50% of the claim amount and hence the claim of the complainant was settled as per non-standard basis.  It is stated that now the complainant has filed the present complaint under policy No.10198938 valid from 25.1.2016 to 24.1.2017.  It is also stated that the claim of Rs.50,709/- lodged by the complainant under the current policy stating that she was admitted on 5.6.2016 to 22.6.2016 for cancer of sigmoid colon, the same was rejected on 25.1.2017 for non-disclosure of pre-existing disease.  The complainant also filed another claim of Rs.13,800/- for treatment taken on 4.3.2016, which was rejected as out-patient treatment is a permanent exclusion as per policy terms & conditions.   It is submitted that the policy was renewed because matter was sub judice before Hon’ble Commission.  It is also submitted that the policy was renewed with terms & conditions of earlier policy in continuation.  It is further submitted that the claims lodged by the complainant under present policy has rightly been rejected.  Pleading no deficiency in service and denying other allegations, the OPs have prayed for dismissal of the complaint. 

 

3]       Replication has also been filed by the complainant thereby reiterating the assertions as made in the complaint and controverting that of Opposite Parties made in their reply.

 

4]       Parties led evidence in support of their contentions.

 

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

 

6]       The chronology of the events narrates that the complainant, now deceased (herein referred to as deceased insured) availed the Health Insurance Mediclaim Policy – “Care” from Opposite Parties for the first time in the year 2015 and was insured vide Policy No.10198938, which was valid from 25.1.2015 to 24.1.2016 for sum insured of Rs.4.00 lacs.  It has earlier been observed that unfortunately the deceased insured was diagnosed as a case of Colon Biopsy-Aden Carcinoma moderately differentiated on 10.8.2015 and thereafter underwent surgery as per the advice of the doctors and being covered under the policy, mentioned above, requested for cashless approval, which was denied by the Opposite Parties. Admittedly, the said matter was challenged before the District Forum, UT, Chandigarh vide Consumer Complaint No.644 of 2015, which was allowed in favour of the complainant and the appeal filed thereof by the Opposite Parties was dismissed by the Hon’ble State Commission. The Opposite Parties further filed revision petition before the Hon’ble National Commission, where the matter was settled between the parties and the claim was settled upto 50% of the claimed amount.

 

7]       In this background of the previous facts, we are diverting towards the matter in dispute in the present complaint. 

 

8]       It is the case of the complainant/deceased insured that during the pendency of the earlier  complaint, the OPs have renewed the policy availed by her for further period from 25.1.2016 to 24.1.2017.  It is evident that during the currency of that insurance cover, the deceased insured remained hospitalized and was treated for the earlier diagnosed disease of Colon Biopsy-Aden Carcinoma moderately differentiated and the claims filed for the reimbursement of the expenses incurred in the treatment were repudiated, which results in the filing of the present complaint. 

 

9]       In the reply, the Opposite Parties justified their stand for repudiating the claim stating that since the deceased insured failed to disclose about her pre-existing ailment qua hypertension since past 7/8 years and also depression since 4/5 years, is guilty of suppression of material facts.  It is also claimed that the complainant was under obligation to furnish the correct information as per Clause 19(4) of the IRDA (Protection of Policyholder’s Interest) Regulations, 2017, which was violated and thus, they rightly repudiated the claim for non-disclosure about the pre-existing disease. 

 

10]      The thorough perusal of the record reveals that at the time of getting the policy renewed, the complainant duly submitted the ‘Change  Request  Form’ dated 20.1.2016  (Annexure C-12) wherein it has specifically been mentioned in affirmative by the complainant against the Clause i.e.:–

 

Health Status Declaration :

    Post commencement of your insurance policy with us, did you suffer from or are currently suffering from or have any disease/illness/injury or accidental/ medical condition other than common cold or fever .   Yes.

 

         Besides disclosing other particulars, she also gave specific note on this form to the effect “All relevant documents & details are with the Company already sent.”  On the basis of this very form, the complainant’s policy was renewed with all benefits under the policy with specific note that “Renewal of this policy does not change or alter the Policy Terms and Conditions of “Care”.   The Opposite Parties in their reply have not objected to the filing of the said ‘Change Request Form’ containing the note and also of the renewal of the policy on the basis of said form having due reference about the existing health status and regarding the submission of the documents.

 

11]      The OPs cannot deny the factum that the policy in question, vide which the claims have been repudiated, was duly renewed during the pendency of the previous claim under the previous year policy and while renewing the same, were well aware about the health status of the complainant; also were aware about the alleged non-disclosure made by the complainant in the proposal form filled while getting the policy for the first time in the year 2015.  Admittedly, the complaint earlier filed was allowed in favour of the deceased insured and the appeal thereof filed by the OPs got dismissed and matter when was challenged before the Hon’ble National Commission, New Delhi, was settled between the parties vide order dated 17.3.2017 (Ann.C-17) as reproduced below:-

         “Dated: 17.03.2017

                                                          ORDER

After some arguments, it has been agreed that the amount which the petitioner company had deposited with District Forum shall be refunded to the complainant alongwith interest which may have accrued on that amount in full and final settlement of the claim.  Ordered accordingly.  The revision petition also stands disposed of.

                                                                   Sd/-

                                                          ……………………

                                                          (V.K.Jain, J.)

                                                PRESIDING MEMBER”

 

         It is further pertinent to mention that the OPs kept the status of the policy intact and had never cancelled the renewed policy by refunding any premium amount on prorate basis.

 

12]      In the given factual position, the OPs cannot refrain to admit that the renewal of the policy was issued to the complainant even having full knowledge about the deceased insured’s health status, non-disclosure as well as claim lodged by her in the initial policy.  Thus the renewal of the policy having full knowledge clearly establish that the OPs being fully aware undertook to indemnify the deceased insured by receiving the due premium for the sum insured of Rs.4.00 lacs.  Astonishingly the Renewal Policy document (Ann.C-7) reveals that there is a mention of ‘No Claim Bonus’ to the tune of Rs.40,000/- and the claim status has been recorded as Negative (whereas already earlier filed claim was sub-judice).  In our considered opinion, when once the OPs have undertaken to indemnify the claim, despite having full knowledge about the true facts, they must honour their commitment, which they made by renewing the policy for further period from 25.1.2016 to 24.1.2017 and must pay the claim raised upto the extent of sum insured.  

         It has specifically been observed that the defective functioning of the OPs Company might have cause immense pain & mental harassment to the deceased insured, who already was fighting against the deadly disease and unfortunately failed to won battle for life.  In our opinion, such claims under the policy should be dealt in a painstaking manner.  

 

13]      From the above discussion, it is held that the Opposite Parties have wrongly & illegally rejected the claims of the deceased insured, which clearly amounts to gross deficiency in service.  Therefore, the present complaint is allowed against the Opposite Parties with following directions:-

1. To reimburse an amount of Rs.2,80,736/- (Rs.52057+228679) (Page-94 & 95 Ann.C-13);
2. To pay an amount of Rs.30,000/- as compensation on account of deficient services;
3. To pay an amount of Rs.10,000/- towards litigation expenses.

 

         This order be complied with by the OPs within a period of 30 days from the date of receipt of its certified copy, failing which they shall also be liable to pay additional cost of Rs.25,000/- apart from the above relief.

 

         The above decreetal amount shall be paid to the legal heirs of the complainant, as mentioned in the headnote of the order, in equal shares.

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

28^th December, 2018                                                              Sd/-

                                                                   (RAJAN DEWAN)

PRESIDENT

 

Sd/-

 (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER