Chandigarh

StateCommission

CC/19/2019

Sanjay Aggarwal - Complainant(s)

Versus

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

Vaibhav Sharma, Viraj Gandhi, Salina Chalana Adv.

24 May 2021

ORDER

 STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

Complaint case No.	:	19 of 2019
Date of Institution	:	22.01.2019
Date of Decision	:	24.05.2021

 

Sanjay Aggarwal S/o Sh.Ram Swaroop Aggarwal, R/o House No.3054, Sector 28-D, Chandigarh 160018.

……Complainant

V e r s u s

Religare Health Insurance Company Limited, SCO 56-57-58, 2^nd Floor, Sector 9-D, Chandigarh-160017.

….Opposite Party

BEFORE:       JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT.

                      MRS. PADMA PANDEY, MEMBER.

                      MR. RAJESH K. ARYA, MEMBER.

 

Present through Video Conferencing:     

                      Sh.Adarsh Dubey, Advocate proxy for Sh.Viraj Gandhi, Advocate for the complainant.

None for the opposite party

PER RAJESH K. ARYA, MEMBER

                   It is the case of the complainant that in order to secure his as well as health of his family members consisting of his wife, son and daughter, he had purchased medical health insurance policy bearing no.10175700, from the opposite party, on 11.12.2014. It has been stated that the said policy was issued after thorough medical examination of the complainant being done by the doctors of the opposite party, at the relevant time. He kept on renewing the said policy, from time to time. The policy in dispute, was lastly got renewed by him, which was valid for the period from 22.12.2017 to 21.12.2018. In the first week of June 2018, son of the complainant namely Mr.Pranav Aggarwal suffered trauma in his chest, while playing football and complained breathlessness and difficulty in swallowing food. He was taken to the PGIMER, Chandigarh, on 16.06.2018 and after conducting various tests, it was found that he was having a large lobulated mass in his superior and anterior mediastinum (Tumor in the chest cavity, Non-Hodgkin’s Lymphoma). He remained admitted in the said hospital for the period from 17.06.2018 to 21.06.2018, for proper diagnosis. Thereafter, in order to undertake best treatment, he was taken to S.L. Raheja Hospital, Mumbai, where he took treatment for the period from 22.06.2018 to 06.07.2018. It has been stated that since the complainant and his family members were covered under the said policy, as such, in the first instance, cashless facility was approved by the opposite party but on 05.07.2018 (Annexure C-4)  the same was declined by it on the ground that since the complainant was a known case of hypertension, which fact was not disclosed by him at the time of obtaining the said insurance policy, as such, his son is not entitled to get any claim out of the treatment taken by him. It has been further stated that thereafter the son of the complainant underwent another treatment in the same hospital for the period from 17.07.2018 to 23.07.2018 for which an amount of Rs.1,98,426/- was spent on him, yet the same was also refused to be paid by the opposite party.  Hence this complaint.

2.           On notice being issued, the opposite party while admitting the factual matrix of the case with regard to purchase of the policy in question and the treatment taken by the son of the complainant  pleaded in its written reply that since the claim amount sought for by the complainant is only Rs.4 lacs and the remaining amount is towards compensation etc. as such, this Commission is not vested with pecuniary jurisdiction; that on receipt of documents for cashless facility, investigator was appointed to assess the authenticity of the claim, whereupon it was found that as per the history provided to the hospital concerned, the complainant and his father has a family history of hypertension, which fact was concealed by the complainant at the time of obtaining the policy in question; that since the complainant was having hypertension for the last 10 years which fact was not disclosed by him, as such, the claim of his son was rightly repudiated, as per terms and conditions of the policy in question; that since there was non-disclosure of material information by the complainant as such the policy in question was cancelled. Pleading that there is no deficiency in service on its part, a prayer for dismissal of the complaint has been made.
3.           In the rejoinder filed, the complainant reiterated all the averments contained in his complaint and controverted those contained in the written reply filed by opposite party. 
4.           This Commission has afforded adequate opportunities to the parties to adduce evidence in support of their respective contentions, by way of filing affidavit. In pursuance thereof, they have adduced evidence by way of affidavits and also produced numerous documents including written arguments by the parties.  
5.           Since none put in appearance on behalf of the opposite party, on the day when this case was fixed for arguments, as such, we have heard Counsel for the complainant and have also gone through the record of the case including the written arguments, very carefully.
6.           The first question which needs consideration is with regard to pecuniary jurisdiction; it may be stated here that if the total value of the relief sought i.e. restoration of the policy in question for the sum assured of Rs.5 lacs; claim amount plus other reliefs claimed i.e. interest on the claim amount and compensation for mental agony and harassment etc., are clubbed together, the same exceeds Rs.20 lacs and fell below Rs.1 crore. Thus, this Commission has got pecuniary Jurisdiction to entertain and decide this complaint, as per CPA 1986, under which this complaint has been filed. Thus, the objection taken in this regard, stands rejected.
7.           Since the facts with regard to purchase of the policy in question by the complainant for him and his family members in the year 2014; payment of premium in respect of the same; renewal thereof from time to time till 2018 are not in dispute, as such, the only question which needs to be decided in this complaint is, as to whether, the opposite party was justified in repudiating the claim filed by the complainant against the treatment taken by his son for the aforesaid disease or not. It may be stated here that though the claim raised by the complainant was with regard to the amount spent by him for the treatment aforesaid, taken by his son, yet, the same was repudiated by the opposite party on the ground that in the ‘Admission History and Assessment Form’- Annexure R-2, it has been mentioned by the doctor concerned that the father and grandfather of the patient (son of the complainant) i.e. the complainant and father of the complainant were having hypertension, which fact had been concealed by the complainant at the time of obtaining the insurance policy in question. In the reply filed also, the opposite party has tried its level best to strengthen its case, on this sole ground only.  
8.           Under above circumstance, to come to any definite conclusion, this Commission is required to find out, as to whether, there was any concealment of facts on the part of the complainant with regard to the fact that he was allegedly suffering from hypertension at the time of obtaining insurance policy in question in 2014 or not. It may be stated here that it is the definite case of the complainant that it was only after his thorough medical examination having been conducted by the doctors of the opposite party that the policy in question was issued in his favour. This has been averred by the complainant in para no.3 of his complaint, relevant part whereof is reproduced hereunder:-

 

“…It is further stated that it was only after thorough medical examination of me by the doctors of the Opposite Party-Insurance Company, the policy was issued to me”.

 

On the other hand, the opposite party in reply to this para, has stated as; “That the contents of Para no.3 is a matter of record, hence no reply”. Thus, under these circumstances, when the doctors of the opposite party have medically examined the complainant, thoroughly, and thereafter only issued the policy in question, which fact has been admitted by the opposite party in para no.3 of its written reply, as such, now it cannot be heard to say that the complainant has concealed at the time of obtaining the insurance policy in question that he was suffering from hypertension.

9.           Thus, in the face of candid admission of the opposite party to the effect that its doctor had medically examined the complainant, thoroughly, and thereafter only  the company had issued the policy in question, reliance placed by it on  ‘Admission History and Assessment Form’- Annexure R-2, wherein it has been mentioned by the doctor concerned that the father and grandfather of the patient (son of the complainant) i.e. the complainant and father of the complainant were having hypertension, is misplaced. Besides this, no evidence has been placed on record by the opposite party to prove that the said information was supplied by the insured or any of his attendants, at the time of initial assessment of his case. The said document bears no signatures of the patient or any of his family members. No affidavit of the doctor concerned or other credible evidence has been placed on the record to establish that the complainant or his father was suffering from hypertension prior to obtaining of the insurance policy and the same has a direct nexus to the treatment given to the son of the complainant. The Hon’ble Supreme Court in Mithoo Lal Nayak Vs. LIC of India - AIR 1962 SC 814 as also in Satwant Kaur Sandhu Vs. New India Assurance Co. Ltd.- (2009) 8 SCC 316 has held that the test to determine is as to what is a material fact, and whether that fact has any bearing on the risk undertaken by the insurer. If the fact has any bearing, it is a material fact and if not, it is not material.
10.           Recently also, a similar question fell for determination before the Hon’ble National Commission in New India Assurance Co. Ltd. Vs. Surinder Singh, Revision Petition No.1246 of 2014, decided on 10.07.2020, which was decided in favour of the insured, while holding as under:-

“A perusal of the discharge summary of the complainant would show that he was hospitalized for the treatment of a coronary disease  and his angioplasty was done at PGI Chandigarh. Therefore the reimbursement which he sought from the insurer was for the expenses which he incurred on his angioplasty. As per the discharge summary this was an old case of hypertension and inferior wall myocardial infraction. The said summary does not show how old the coronary ailment was. There is no evidence to prove that the complainant was suffering from any coronary ailment at the time the insurance policy was taken by him. No evidence was produced by the insurer to prove that the complainant was suffering from coronary ailment at the time the policy was initially taken by him in the year 2011. The possibility of the coronary ailment having been discovered by the complainant after taking the policy but before his admission in the hospital therefore cannot be ruled out. Hence, it is not proved to be a pre existing disease at the time the insurance policy was taken. Though, there is evidence to prove that the complainant was suffering from hypertension 4/5 years before taking the policy, the reimbursement he sought was not for treatment of hypertension but was for the angioplasty which was done in PGI Chandigarh. No evidence was led by insurer to prove that that the blood pressure of the complainant was uncontrolled and had led to the coronary ailment for removal of which angioplasty had to be done by at PGI Chandigarh. No doubt hypertension may be one or more causes of someone developing a coronary artery disease if the hypertension is not under control but it is not necessary that even a controlled hypertension would lead to the patient to a coronary artery disease. Therefore, I am unable to accept the contention that the disease of complainant  was covered under clause 4.1 of the terms and condition attached to the policy. As far as class 4.3 is concerned coronary artery disease is not one of the ailments for which cooling off period of 2 years is prescribed in the insurance policy. Therefore, the case is also not covered under class 4.3 of the policy. It is true that hypertension has been concealed by the complainant while obtaining the insurance policy, he having replied in negative when asked whether he was suffering from hypertension. But, a perusal  of the repudiation letter would show that the aforesaid concealment was not a ground for repudiation of the claim. As held by the Hon’ble Supreme Court in GALADA POWER AND TELECOMMUNICATION LTD Vs. UNITED INDIA INSURANCE CO. LTD. AND ANOTHER  IV (2016) CPJ 5 (SC) the insurer cannot be allowed to travel beyond the ground taken in the repudiation letter issued by it while rejecting the claim. Therefore, the aforesaid concealment cannot be a ground for dismissing the complaint, the same not being one of the grounds for repudiating the claim”.        

11.           It is pertinent to mention here that during pendency of this complaint, sensing that it is at fault, the opposite party on 28.05.2019 through its Counsel stated that let the complainant submit all medical bills of which reimbursement is claimed and that efforts will be made to approve the claim raised. Thereafter on 03.09.2019, the opposite party offered an amount of Rs.1,87,425/- vide cheque dated 03.08.2019, which the complainant refused to accept on the ground that the same is on the lesser side. This exercise of the opposite party, in itself, is sufficient to prove the case of the complainant that it was deficient in providing service and also negligent in repudiating his claim on bald grounds.
12.           In view of the facts and circumstances of this case, it is held that the complainant was not suffering from any pre-existing diseases such like hypertension etc. yet, the claim filed by him for the amount spent towards treatment of his son was repudiated by the opposite party on flimsy grounds, just with a view to escape from its liability, which act amounts to deficiency in providing service, negligence and adoption of unfair trade practice. The complainant is thus held entitled to get the amount spent by him on the treatment of his son, upto the extent of the sum assured under the policy in question.
13.           For the reasons recorded above, this complaint is partly accepted with costs and the opposite party is directed as under:-

1. To restore the policy in question from the date when the same was cancelled by it, giving it a retrospective effect and is at liberty to receive the amount of premium due if any, till date, from the complainant, without charging any interest or late fees. 
2. To reimburse the amount spent by the complainant on the treatment of his son, which shall not exceed the sum assured vide the policy in question, alongwith interest @9% p.a. starting from 01.01.2019, within a period of 30 days, from the date of receipt of a certified copy of this order, failing which, thereafter, the said amount shall carry 3% penal interest i.e. 12% p.a. (9% p.a. plus (+) 3% p.a.), from the date of passing of this order, till realization.
3. To pay compensation for causing mental agony and harassment and also cost of litigation, in lumpsum, to the tune of Rs.50,000/-, to the complainant, within a period of 30 days, from the date of receipt of a certified copy of this order, failing which, the said amount of Rs.50,000/-, shall carry interest @9% p.a. from the date of passing of this order, till realization.

14.           Certified Copies of this order be sent to the parties, free of charge.
15.           The file be consigned to Record Room, after completion.

 

Pronounced

24.05.2021

 

Sd/-

[JUSTICE RAJ SHEKHAR ATTRI]

PRESIDENT

 

 

Sd/-

 (PADMA PANDEY)

          MEMBER

 

 

Sd/-

 (RAJESH K. ARYA)

MEMBER

 Rg.