Chandigarh

DF-II

CC/693/2018

Ram Sarup - Complainant(s)

Versus

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

Mohit Singla Adv.

25 Jun 2019

ORDER

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

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Consumer Complaint  No	:	693 of 2018
Date  of  Institution	:	07.12.2018
Date   of   Decision	:	25.06.2019

 

 

 

 

Ram Sarup Aged about 61 years s/o Sh.Manohar Lal, Resident of # 3390, Sector 47-D, Chandigarh          

 

             ……..Complainant

 

Versus

 

1]  Religare Health Insurance Company Limited, Registered Office 5^th Floor, 19 Chawla House, Nehru Place, New Delhi 110019, through its Chairman/Managing Director/Director.

 

2]  Religare Health Insurance Company Limited, Vipul Tech Square, Tower-C, 3^rd Floor, Sector 43, Golf Course Road, Gurgaon 122009, through its Branch Manager/Office Incharge.  

 

3]  Religare Health Insurance Company Limited, SCO 56-58, 2^nd Floor, Sector 9, Chandigarh 160017, through its Branch Manager/Office Incharge.

 

………. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN        PRESIDENT

SMT.PRITI MALHOTRA    MEMBER

         SH.RAVINDER SINGH     MEMBER

 

 

Argued By:       Sh.Mohit Singla, Adv. for complainant

Sh.Gaurav Bhardwaj, Adv. for Opposite Party.

 

PER PRITI MALHOTRA, MEMBER

 

                                The case of the complainant in brief is that he took Health Insurance Policy from OPs on 14.5.2015 and got it renewed from time to time till the period 27.6.2018 to 26.6.2019 (Ann.C-1 to C-2).  It is averred that the complainant was operated for knee surgery on 22.10.2018 at Max Super Specialty Hospital, Mohali while remained admitted there from 21.10.2018 to 27.10.2018.  It is averred that the pre-authorization request of cashless Hospitalization of the complainant was denied by the OPs on 22.10.2018 on flimsy ground of non-disclosure of material facts/pre-existing disease, whereas he was covered under cashless health insurance policy issued by them. As such, the complainant, when discharged on 27.10.2018, had to make the payment of Rs.2,91,354/- (Annexure C-10) to the Hospital towards his medical treatment bill.  It is submitted that the complainant thereafter requested the Opposite Parties many a times to pay his claim, but they did not pay any heed.  Hence, this complaint has been filed alleging deficiency in service on the part of Opposite Parties.

 

2]       The Opposite Parties have filed joint reply and while admitting the factual matrix of the case, stated that after going through the documents supplied by the complainant, it transpired that he suppressed material facts from the company at the time of taking the policy as the complainant at the time of pre-anesthesia check-up, disclosed that he is suffering from hypertension for past five years and is on regular medication and further suffering from diabetes T-II DM for the past 8 to 10 years and is under regular checkup (Ann.OP-3). However, the complainant never disclosed about his suffering from hypertension and diabetes as pre-existing ailment at the time of proposing for the policy or thereafter.  It is submitted that the complainant has suppressed the material information about his pre-existing disease from the OPs, therefore, his claim was rightly repudiated.  Pleading no deficiency in service and denying all other allegations, the Opposite Parties have prayed for dismissal of the complaint.

 

3]      Parties led evidence in support of their contentions.

 

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

 

5]       Being not disputed and otherwise also proved on record that the complainant availed Health Insurance Policy from the Opposite Parties for the first time in the year 2015 and get the same renewed for further period from 14.5.2016 to 13.5.2017 (Annexure C-1).  Policy document  Ann.C-2 placed on record shows that the complainant after the expiry of previous coverage again availed the Health Insurance Policy from the Opposite Parties for the period from 27.6.2018 to 26.6.2019 and during the currency period of that policy, he availed treatment for his ailing knees and as per doctor’s advice, he undergo knee transplant and thereby incurred expense of Rs.2,91,354/-.  The claim lodged for the reimbursement under the policy was declined by the OPs, raising cause of action in favour of the complainant to file the present complaint.

 

6]       As per the rejection letter dated 22.10.2018 (Ann.C-8), the claim was rejected due to non-disclosure of the fact that the complainant is a K/C/O hypertension and Diabetes Mellitus-II.  The rejection of the present claim for the assigned reason is highly technical and in our considered opinion is not sustainable for the reasons recorded hereunder.

 

7]       It have been observed that the complainant in the year 2015 filled the proposal form for obtaining the Health Insurance Policy and the age of the complainant at that time was 59 years (10.10.1956) and the OPs without going into the verification of the disclosures made in the proposal form, just issued the policy after obtaining premium for the same.  The Opposite Parties at that juncture before receiving the premium amount did not even thought of getting the medical examination conducted to find out the truth of the disclosures made in the proposal form.  Even at the time of renewal of the said policy, again there was no requirement from the OPs for getting the medical examination conducted.  It is further observed that the complainant had availed the present policy after a gap of 13-14 days for the period 27.6.2018 to 26.6.2019 whereas the earlier policy, which the complainant previously got renewed was availed for the period 14.5.2017 to 13.5.2018 i.e. the coverage expired on 13.5.2018.  The OPs even at the time of issuing the policy for the period from 27.6.2018 to 26.6.2019 again forego to enquire about the medical status of the complainant and only showed their readiness to collect the premium.  In our opinion, the Opposite Parties, who have their own investigating agency and in-house panel doctors to investigate the claims raised under the policy, never consulted them while issuing the policy to a person aged more than 60 years where the degeneration changes are bound to occur and definitely the gravity of the same varies from person to person.

 

8]       It is considered that once the Opposite Parties open heartedly accepted the premium of the complainant paid under the policies availed, must also honour the claim if raised during the policy currency period.  Once they committed to indemnify the claim, if any, without going into the requisite enquiries, then they shall not be allowed to shun of their responsibility to indemnify the claim raised during the coverage period.

 

9]       Besides, there is no independent report placed on record by the Opposite Parties revealing that the complainant is a K/C/O Hypertension & D.M.-II and it had just relied upon the alleged Pre Anesthesia Check-up form recorded by Hospital dated 15.10.2018 (Ann.C-4), the authenticity of the same is also doubtful. In our opinion, the repudiation of genuine claim of the complainant is totally unsustainable against the established law as laid down by Hon’ble Supreme Court as well as National Consumer Disputes Redressal Commission. 

 

10]      The Hon’ble Supreme Court in the case Biman Krishna Bose Vs. United India Insurance Company, civil Appeal No.3438 of 1995, has held that that if a person is suffering from hypertension, the insurance claim of the legal heirs of such a person cannot be repudiated on the ground that the life assured had suppressed this information from the Insurance Company. Moreover hypertension is not a material disease which is fatal in itself.

 

11]     The Hon’ble National Consumer Disputes Redressal Commission, New Delhi in Revision Petition No.3619 of 2013 – Satish Cahnder Madan Vs. M/s. Bajaj Allianz General Insurance Co. Ltd., decided on 11.1.2016 has held that “Hypertension is a common ailment and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack – Treatment for heart problem cannot be termed as claim in respect of pre-existing disease – Claim was wrongly repudiated.” 

 

12]      The Hon’ble Mr.Justice P.S.Dhaliwal, State Consumer Disputes Redressal Commission, Punjab, in FA No.769 of 2016 – Bajaj Allianz Life Insurance Co. Ltd. Vs. Pashmina Rani, decided on 25.5.2017, relying upon the judgments ibid of Hon’ble Supreme Court & Hon’ble National Commission, while considering the issue identical with the facts, as alleged in the present complaint, has held the insured entitled for medical reimbursement claim.

 

13]      The complainant was not chronic patient of Hypertension, as alleged.  There is nothing on record to prove that he was under treatment for ailment of Hypertension prior to 15.10.2018 or 21.10.2018, before his admission in Max Super Specialty Hospital, Mohali.  Moreover, there is no nexus between the treatment taken by the complainant i.e. knee surgery and hypertension & DM-II. 

 

14]      The Hon’ble Supreme Court as well as Hon’ble National Consumer Disputes Redressal Commission, while adjudicating the matter on this substantial issue of repudiation of claim merely on the basis of suffering from Hypertension of insured person, has categorically ruled that Hypertension is not a material disease and is manageable by medication/meditation, change of life style etc. and as such, cannot be a ground for rejection of genuine claims.  The Opposite Parties, despite settled law laid down by the Hon’ble Supreme Court as well as Hon’ble National Consumer Disputes Redressal Commission, have still dared to ignore the law of the land and indulged in unfair trade practice on its part by refusing to pay the claim of the complainant. The Opposite Parties/Religare Health Insurance Company Limited, treated itself to be above law by not complying the dictate of the Hon’ble Apex Court and as such warrants severe admonishing and deterrent compensatory cost.  The callous attitude on the part of Insurance Companies open floodgates for such litigations which is otherwise avoidable.

 

15]      we are also guided by the judgment of Hon’ble Justice Ranjit Singh, in case Oriental Insurance Company Limited, Chandigarh Vs. Khursheed and another, Civil Writ Petition No.3996 of 2011 of Hon’ble Punjab & Haryana High Court, decided on 22.3.2011, wherein it has been held that :-

 

“…Insurance Companies are charging hefty premium for insuring the vehicles. Once the question of liability arises, the companies resort to one technical objection and the other.  These Companies really chase people and literally promise everything at the time of selling policy.  It is usual to see people struggle to run after agents and surveyors to get their rightful claims.  Such agents then look other way and make insurers to make rounds to Company offices.  Insurers are then made to approach the Courts and are even dragged to this Court on one technical plea or the other.  No one really is made to read the terms while making him to sign on the printed forms for selling policies.  This attitude must change. At least, the Courts should not be burdened with this uncalled for litigation”

 

16]      Keeping in view the facts and settled position of law, as discussed in the preceding paragraphs, the claim of the complainant for medical reimbursement of Rs.2,91,354/- is found to be genuine and admissible under the terms & conditions of the insurance policy.  The Opposite Parties are found to have indulged into unfair trade practice and deficient in their service too by repudiating the genuine medical claim of the complainant on flimsy grounds. 

 

17]      In view of the above findings, the complaint is allowed with directions to the Opposite Parties to reimburse an amount of Rs.2,91,354/- to the complainant with interest @12% p.a. from the date of repudiation i.e. 22.10.2018 till payment, along with litigation cost of Rs.10,000/-. 

         The Opposite Parties/Religare Health Insurance Company is also imposed with compensatory cost of Rs.2.00 lacs on account of their misdemeanor, which shall be deposited with Department of Cardiology, Advanced Cardiac Centre, PGIMER (Post Graduate Institute of Medical Education & Research), Chandigarh, Through its Head of Department, for use on treatment of needy patients. 

 

18]     This order shall be complied with by the Opposite Parties in toto within the period of 30 days.

         Certified copy of this order be sent to the parties as well as to The Head of Department, Department of Cardiology, Advanced Cardiac Centre, PGIMER (Post Graduate Institute of Medical Education & Research), Chandigarh, free of cost. File be consigned to record room.

Announced

25^th June, 2019            

                                                                                       Sd/-

 (RAJAN DEWAN)

PRESIDENT

                                                                                               

Sd/-

                                                                    (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER