Haryana

Karnal

CC/393/2017

Sanjay - Complainant(s)

Versus

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

Amish Goel

07 Feb 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                          Complaint No.393 of 2017

                                                         Date of instt. 29.11.2017

                                                         Date of decision:07.02.2019

Sanjay aged about 46 years son of Shri Ram Chand, resident of House no.102-A, Gali no.3, Raiv Puram, Phoosgarh Road, Karnal.

                                                                         …….Complainant

                                        Versus

1. Religare Health Insurance Company Limited, Mughal Canal, Karnal through its Branch Manager.

2. Religare Health Insurance Company Limited, having its registered office 5^th floor, 19 Chawla House, Nehru Place, New Delhi, through its Managing Director/Chief Executive Officer/Authorized signatory.

3. Religare Health Insurance Company Limited, heaving its Corresp. Office at Vipul Tech Square Tower C, 3^rd floor, Golf Course Road, Sector-43, Gurugram.

                                                                      …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act.    

       

Before   Sh. Jaswant Singh……President.       

              Sh. Vineet Kaushik………Member

              Dr. Rekha Chaudhary……Member

 

 Present:  Shri Amish Goyal Advocate for complainant.

                Shri Akshat Sharma Advocate for OPs.

                               

                (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that on 12.12.2012 the complainant had purchased a “Family Health Optima Insurance Policy,” from Star Health & Allied Insurance Company Ltd., which continued year by year upto 4 years and thereafter on 12.12.2016 the complainant ported his health cover with the complainant of OPs i.e. Religare Health Insurance Company Ltd., vide policy no.#10900943 without any break w.e.f. 12.12.2016 to 11.12.2019 for three years. The complainant felt the problem of nasal bleeding on 26^th April 2017, then the complainant approached to Fortis Hospital, Faridabad and met to Dr. Sanjeev Chawla and admitted there in Hospital on 27^th April, 2017. During investigation medical problem diagnosed “Liver Parenchymal Disease and Epistaxis,” as mentioned in the medical report. After completion of medical treatment the total payable bill of the complainant was of Rs.97,410/-. The complainant lodged the Medical Claim with the OPs, vide claim no.90341176 and requested the OPs to proceed in the aforesaid ‘Medi Claim’ and he disbursed the amount of the claim. The complainant also submitted the medical treatment record, all medical reports, bills etc. with the OPs. Thereafter, complainant requested the OPs so many times for reimbursement of the claim but OPs did not pay any heed to his request and ultimately repudiated the claim of the complainant vide letter dated 26.05.2017 on the ground that “the claim is 4 years waiting period for treatment of pre-existing disease and its complications.” 

                It is further alleged that complainant again felt ill and admitted in Virk Hospital Pvt. Ltd. Karnal on 15.07.2017, vide IPD no.26612/17 and taken treatment from there and discharged form said hospital on 21.07.2017 and had spent an amount of Rs.50,000/- for the said treatment. Thereafter, complainant received a letter dated 13.09.2017 sent by the OPs, vide which the OPs alleged that “While verifying the claim documents, submitted by you against the captioned policy, we have noticed that there has been Non-Disclosure of Material facts/pre-existing ailment at the time of proposal, you had a history/known case of Epitaxis since November, 2016. However, this fact was not disclosed at the time of taking policy. In accordance with the policy terms and conditions, we hereby serve you a notice of 15 days, from the date of this letter, within which you should furnish correct facts supported by valid documentary proof, in case you dispute the same, failing which we would be entitled to cancel the policy as per policy terms and conditions.”  Thereafter, complainant on 21.09.2017 sent reply to the abovesaid letter dated 13.09.2017 and requested to continue the policy. Thereafter, complainant complained the matter to the Secretary, Bima Lok Pal, Chandigarh twice and requested for settling the claim but no action has ever been taken in this matter. Further, OPs cancelled the said policy which is upto 11.12.2019 without any reason and are not paying the claim amount. 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 version raising preliminary objections with regard to maintainability; jurisdiction; locus standi; cause of action and complainant is estopped by his own act and conduct from filing the present complaint. On merits, it is pleaded that the OP company had issued an Health Insurance Policy vide policy no.10900943 covering the complainant and his son with effect from 12.12.2016 to 11.12.2019 for a sum insured of Rs.5,00,000/- subject to policy terms and conditions. The complainant approached the OPs with a cashless claim request with respect to the hospitalization of the complainant in Fortis Escorts Hospital, Faridabad for Epistaxis (Nasal Bleeding) from 27.4.2017. The OP company on reception of the cashless request initiated an investigation in order to further check the veracity of the claim. As per investigation done and documents appended thereof it was found that complainant has not disclosed the true and material facts regarding his health at the time of inception of the policy. Hence the claim of the complainant was rejected vide letter dated 26.5.2017 on the ground of non-disclosure of material facts/pre-existing ailments of Epistaxis (Nasal Bleeding) as well as Acute Liver Disease at the time of proposal. It is further pleaded that complainant was again admitted on 15.07.2017 to 21.07.2017 at Virk Hospital, Karnal for the treatment of acute gastritis, APD acute pancreatitis. However, the re-imbursement claim was rejected under the clause 7.1 for non-disclosure of material facts/pre-existing ailments at the time of proposal that is episodes of nasal bleeding and liver Parenchymal Disease with alcoholism. The said information was duly communicated to the complainant, vide claim rejection dated 11.01.2018.  Hence there is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C25 and closed the evidence on 8.8.2018.

4.             On the other hand, OPs tendered into evidence affidavit of Annapurna Manager Ex.RW1/A and documents Ex.R1 to Ex.R8 and closed the evidence on 30.11.2018.

5.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

 

6.             The case of the complainant is that on 12.12.2012 complainant purchased a “Family Health Optima Insurance Policy” from Star Health and Allied Insurance Co. Ltd. which continued year by year upto 4 years and thereafter on 12.12.2016, the complainant ported his health cover with the OPs i.e. Religare Health Insurance Co. Ltd., vide policy no.#10900943 without any break w.e.f.12.12.2016 to 11.12.2019 for three years. Complainant felt the problem of nasal bleeding on 26.04.2017, then the complainant admitted to Fortis Hospital, Faridabad on 27.04.2017. During investigation medical problem diagnosed “Liver Parenchymal Disease and Epistaxis” and complainant incurred Rs.97,410/- for his medical treatment.

7.             It is further case of the complainant is that he was admitted in Virk Hospital Pvt. Ltd. Karnal on 15.07.2017 and discharged on 21.07.2017 and had spent Rs.50,000/- for his treatment.

8.             Further, complainant lodged his medical claim with the OPs and submitted all the required medical records. The claim of the complainant was repudiated on 26.05.2017 by the OPs without any cogent reason.

9.             On the other hand, case of OPs is that OPs issued an health insurance policy covering the complainant and his son w.e.f.12.12.2016 to 11.12.2019 for a sum assured of Rs.5 lakhs subject to the policy terms and conditions. The complainant approached the OPs with a cashless claim request with respect to the hospitalization in Fortis Escorts Hospital, Faridabad. As per investigation and document appended thereof, the following facts came at the forefront:-

        #As per the statement given by the complainant’s son dated 1.5.2017, the complainant’s son mentioned the face that the complainant is having Epistaxis (Nsal Bleeding) since 6 months, that is prior to the inception of the policy period.

# As per the Prescription Note dated 29.11.2016 (prior to policy inception) issued by Virk Hospital, Karnal the complainant is also duly mentioned to have Acute Liver Disease (ALD) and has been prescribed medicine for the same. It is pertinent to note here that the said ailment was also not disclosed by the complainant to the respondent company as well at the time of filling of the Proposal Forum. The complainant has been taking subsequent consultation for same ailment from the above mentioned hospital as is depicted din Prescription Note dated 09.12.2016.

10.           Further, in the light of Non-Disclosure of the material facts/ pre-existing Ailments of the Epistaxis (Nasal Bleeding) as well as Acute Liver Disease at the time of proposal, the Cashless claim request of the complainant was duly rejected on 01.05.2017. The complainant was again admitted on 15.07.2017 to 21.07.2017 at Virk Hospital, Karnal for the treatment of acute gastritis, APD acute pancreatitis.

11.           Admittedly, complainant purchased Ported Health Insurance Policy w.e.f. 12.12.2016 to 11.12.2019 for a sum assured of Rs.5 lakhs. Complainant admitted in Fortis Escort Hospital, Faridabad on 27.04.2017 and spent Rs.97,410/- for his treatment. The claim of the complainant was repudiated on the ground of non-disclosure of material facts/Pre-Existing Ailment of the Epistaxis (Nasal Bleeding) as well as Acute Liver Disease at the time of proposal. The complainant had purchased a “Family Health Optima Insurance Policy” from Star Health and Allied Insurance Co. Ltd. which continued year by year upto 4 years and thereafter on 12.12.2016, the complainant ported his health cover with the OPs i.e. Religare Health Insurance Co.Ltd., vide policy no.#10900943 without any break w.e.f.12.12.2016 to 11.12.2019 for three years.

12.           As per the statement (Ex.R2) given by the complainant’s son dated 01.05.2017, the complainant’s son mentioned the fact that the complainant is having Epistaxis (Nasal Bleeding) since 6 month and as per the Prescription Note dated 29.11.2016 (prior to policy inception) issued by Virk Hospital, Karnal the complainant is also duly mentioned to have Acute Liver Disease (ALD) and has been prescribed medicine for the same. But complainant purchased the health policy on 12.12.2016 from Star Health and Allied Insurance Co. Ltd. and same was ported in the month of December,2016. The complainant had taken treatment from Virk Hospital, Karnal firstly in the year 2016 and admitted in Fortis Hospital Faridabad in the month of April, 2017. There is no record on the file to prove that complainant had concealed the true and material facts at the time of purchasing the health insurance policy from OPs as complainant had already taken the medical policy in the year of 2012 and same was ported in the year of 2016 with the OPs. The policy in question is not a new policy. The plea taken by the Os is not sustainable. Thus, we are of the considered view that act and conduct of the OPs is amount to a deficient in service. The complainant spent total Rs.1,47,410/- on his treatment. Rs.97410/- in Fortis Hospital, Faridabad and Rs.50,000/- in Virk Hospital, Karnal. Hence complainant is entitled for the said amount.

13.           Thus, as a sequel to above discussion, we allow the present complaint and direct the OPs to pay Rs.1,47,410/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OP to pay Rs.20,000/-to the complainant for mental agony, harassment and towards litigation expenses. This order shall be complied with within 30 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: 07.02.2019

                                                                        President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

 

 

                     (Vineet Kaushik)     (Dr. Rekha Chaudhary) 

                        Member                       Member