Punjab

Sangrur

CC/508/2018

Sikander Singh - Complainant(s)

Versus

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

Sh.S.S.Mann

02 Nov 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .

                                                                         Complaint No. 508

 Instituted on:   04.12.2018

                                                                         Decided on:     02.11.2021

 

Sikander Singh Boparai son of Late Sher Singh, resident of Dhaler Kalan (Ahmedpur) PO Jhuner, Tehsil Malerkotla, District Sangrur.

                                                          …. Complainant.     

                                                 Versus

1.             Religare Health Insurance Company Ltd. 5^th Floor, 19-Chawla House, Nehru Place, New Delhi-110019 through its Managing Director.

2.             Religare Health Insurance Company Ltd. SCO-13, 3^rd Floor, Shanghai Tower, Feroze Gandhi Market, Ludhiana 141001 through its Branch Manager.

             ….Opposite parties 

 

For the complainant    : Shri S.S.Mann, Adv.              

For OPs                    : Shri Jatinder Verma, Adv.

 

Quorum                                           

S.P. Sood, President

Vinod Kumar Gulati, Member

Sarita Garg, Member

 

 

ORDER BY:     

S.P. Sood, President.

1.             Complainant Shri Sikander Singh Boparai (hereinafter referred as complainant) has filed this complaint alleging inter-alia that he is simpleton villager and is into farming. In the month of March,2018 respondent/Executive of the OP Religare Health Insurance Company Limited sued through its Managing Director and its Branch Manager approached him at his village Dhaler Kalan and explained the benefits of the health insurance policy  offered by the OPs despite the fact complainant had already opted for the similar policy from L&T Insurance and Apollo Munich Health Insurance etc.  This is how at the instance of the said representative/Executive of the OPs complainant agreed to shift and buy health insurance policy from OPs whereby the said insurance company committed to bear health expenditure to the extent of Rs.5.00 Lacs on treatment.  At that occasion, the said representative/Executive filled the proposal form and accepted a sum of Rs.20,000/- in lieu of providing health insurance to the complainant and his wife Smt. Balwinder Kaur and finally policy bearing number 12234234. ‘Floater’ type was issued  with validity from 15.3.2018 to 14.3.2019. However, in the month of May, 2018 complainant suffered chest pain and got himself medically checked and found that he was suffering from CAS-Double vessel disease, PTCA and stenting to LAD & RCA was done whereby stents were implanted during his treatment at Fortis Hospital Ludhiana on 14.5.2018.  During this exercise, complainant incurred a total expenditure of Rs.3,30,348.33 which he paid of his own and later on submitted his claim for reimbursement of the same. However, what to talk of allowing the said claim, OPs appointed investigator who was instrumental in getting the investigations form filled from complainant’s daughter and mischievously got mentioned in the same that the complainant used to suffer from hypertension and was taking Tablet Telma 40mg. However, the fact of the matter was that complainant never suffered any pre- existing disease rather above said entry was mischievously incorporated in the claim form from the daughter of the complainant that he was is suffering from hypertension whereas complainant never suffered from hypertension. Even otherwise also hypertension is not a major ailment rather the same can well be controlled with medicine. Continuing further the complainant alleged that on the basis of above said procured record by the concerned officials, OPs repudiated his claim on the basis of non disclosure of material fact of pre-existing ailment at the time of proposal but the above said act and conduct of the OPs was palpably bad and completely unlawful which clearly amounts to unfair trade practice. Faced with this situation, the complainant shot off a letter to Ombudsman of Insurance on 17.10.2018 but again when he did not hear anything from it then he was constrained to file the present complaint. In the end, complainant sought directions to OPs for reimbursing the entire expenditure of Rs.3,30,348.33 along with interest  @ 18% per annum along with a sum of Rs.50,000/- as compensation on account of mental agony, harassment and another sum of Rs.50,000/- as litigation expenses.

2.             Upon notice, OPs contested this claim on the grounds of maintainability, cause of action, locus standi and estoppel and jurisdiction of this Commission was also assailed.  Along with this OPs have also blamed complainant to have filed this complaint with malafide intention on account of his concealing material facts from this Commission.  Besides the above said legal objections, OPs have also averred that every person who applies for any scheme to buy any insurance policy, he has to make a proposal for the same by means of an application in the customized proposal form wherein the said proposer is required to disclose material information as demanded therein. The same procedure was followed in this case also when answering OP/respondent company received a duly filled online proposal form complainant to avail health insurance scheme seeking coverage to himself and his spouse.  After believing the said information and details provided by the complainant to be true and authenticated including the medical history as disclosed in the said form to be correct in all respects, respondent company issued insurance policy number 12234234 insuring for a sum of Rs.5,00,000/- for the period of one year from 15.3.2018 to 14.3.2019 subject to the terms and conditions enshrined in the policy itself. The copy of schedule bearing relevant details of the policy along with policy bond with terms and conditions were duly sent to the proposer and no assurance was given to the complainant beyond the terms and conditions of the said policy.  Further it was alleged that the policy kit comprising of all the relevant documents was duly delivered to the complainant periodically thereby giving an opportunity to the complainant to verify and examine the benefits and other incidental terms and conditions of the policy purchased by him and even in response thereof complainant never approached the OPs objecting that the information given in the policy schedule was incorrect.  Further OPs also alleged that complainant approached them for cashless claim facility request (AL-80176547) for hospitalization at Fortis Hospital from 12.5.2018 to 15.5.2018 due to complaint of chest pain radiating to left arm with uneasiness following which complainant was diagnosed  with CAS/ACS and underwent CAS. However, the cashless claim request was closed as the complainant did not avail cashless facility. However, afterwards complainant approached OPs for reimbursement of the expenses incurred by the complainant in the above said hospitalization and on receipt of the claim form officials of the OPs dispatched its query letter dated 23.7.2018 to the complainant asking for exact duration and past history of present ailment with first consultation paper and other past treatment record of hypertension. While all this was under process the company also triggered its investigation to check the veracity of the claim during which it came to their knowledge that complainant was a known case of hypertension since one year because in the questionnaire form dated 20.7.2018 duly filled and signed by the daughter of the complainant it was disclosed that her father was suffering from hypertension from 2017 and was taking Tab. Telma 40mg.  Even in the discharge summary dated 15.5.2018 from Fortis Hospital, Ludhiana again the complainant was also advised to take Tab Avas 40 mg HS, Tab Metolar XR 25 mg and Tab Pinorm 20 mg for treatment of hypertension which he had not disclosed at the time of filling up the proposal form. It was in the light of non-disclosure of material facts and pre- existing disease of hypertension since one year his claim was rejected under clause 7.1 of the policy terms and conditions and it was informed to the complainant vide letter of 2.8.2018.  This is how complainant was found to be guilty of breach of principles of utmost good faith which formed the basis of contract of insurance by not furnishing correct and accurate information at the time of proposal for the referred policy. In fact the complainant has not disclosed his actual correct health condition and had the complainant disclosed his real and actual health condition at the time of purchasing the policy the OPs would have offered the policy to complainant on different terms and conditions.  So virtually for all these reasons, since complainant’s claim does not fall in the ambit of policy so there was no deficiency in service on the part of the OPs so present complaint deserves to be dismissed. 

3.             After completion of the proceedings both the parties were called upon to lead their evidence and during this process the complainant relied upon premium acknowledgement showing of his having paid a sum of Rs.19,862/- on 14.3.2018 Ex.C-1, discharge summary from Fortis Hospital dated 15.5.2018 Ex.C-2 comprising of 11 pages, sworn affidavit of the complainant Ex.C-3 whereby he reiterated contents of his complaint, various policies which complainant had obtained from L&T Insurance, Apollo Munich Health Insurance were proved as Ex.C-4 for the year 2013-2014, 2014-2015, 2015-2016 and another health insurance policy pertaining to the year 2012-2013 Ex.C-5, written request by the complainant addressed to Insurance Ombudsman on 17.10.2018 as Ex.C-6, bill issued to him in lieu of the procedure laid down by the Fortis Hospital Ex.C-7, repudiation of claim by the OP Ex.C-8 and closed his evidence.

4.             On the other hand, OPs have relied upon Ex.OP-1 as the policy kit running into 25 pages, request for cashless hospitalization for medical insurance policy Ex.OP-2, claim form Ex.OP-3, investigation form Ex.OP-4, discharge summary Ex.OP-5 and claim repudiation letter Ex.OP-6 (Ex.C-7) and proposal form submitted by complainant Ex.OP-7 and sworn affidavit of one Ms. Tanya Kapoor, authorized signatory Ex.OP-8 and closed its evidence.

5.             Along with this the learned counsel representing the complainant also relied upon what was observed by the Hon’ble National Commission while deciding Revision Petition No.3619 of 2013, decided on 11.1.2016 titled Satish Chander Madan versus M/s. Bajaj Allianz General Insurance Co. Ltd. and another order of Hon’ble Punjab State Consumer Disputes Redressal Commission in First Appeal No.836 of 2016, decided on 26.4.2017 titled Religare Health Insurance Company Ltd. versus Subhash Chander Aggarwal, wherein the observations of Hon’ble National Commission as referred above was also followed.  It is also pertinent to mention here that OP did not choose to rely upon any such observation in support of its contention.

6.             Now if we look into the pleadings putforth by both the parties, we find that there is no dispute so far as complainant having availed health insurance cover from OPs in lieu of premium of Rs.19,862/- and  consequently OPhad issued policy number 12234234 valid from 15.3.2018 to 14.3.2019 is concerned.  It has also not been categorically denied by the OPs that before shifting to their company the complainant had availed health insurance cover from Apollo Munich Insurance Co. and thereafter from L&T Insurance from 2012 onwards till 2016 vide policies brought on record as Ex.C-5 and Ex.C-4, respectively, and thereafter the complainant availed another policy from OPs for the period of 15.3.2018 to 14.3.2019 which has been proved as Ex.C-1. Likewise, there is no variance between the parties that some how or the other complainant remained admitted in Fortis Hospital Ludhiana between 12.5.2018 to 15.5.2018 and incurred an expense to the tune of Rs.3,30,348.33 as he underwent angioplasty on 14.5.2018 after he complained of chest pain radiating towards his left arm.  With all these admitted facts acting in the background, we find that after complainant got himself discharged from the hospital after paying the bill from his own pocket raised the claim before OPs which of course was repudiated vide claim denial letter Ex.C-8 also relied upon by OPs as Ex.OP-6disclosing that his claim is not payable due to non disclosure of pre existing ailment at the time of proposal.  Even, if we further dig into this aspect or if we go deep to ascertain as to what had actually weighed with the OPs to deny his claim happen to be the report submitted by one of their investigator was appraised who happened to be told by none other but the daughter of the complaint, that her father used to suffer from hypertension for almost one year and he used to take Tablet Telma 40mg for the same and as this fact was not disclosed at the time of making the proposal online which stands corroborated  from Ex.OP-7, therefore, on account of non disclosure of this fact by the complainant the claim case raised by the complainant happened to be covered under the exclusion clause 7.1 of the policy terms and conditions.  This primarily was the reason for which OPs repudiated his claim.  However, if we look into the medical record prepared and maintained by hospital where the complainant underwent this procedure ever since he approached them with the complaint of chest pain, we don’t find any such thing that the complainant had a history of hypertension prior to the above said occasion and further more we are unable to reconcile with the fact that what the hill prevented OP to subject the complainant to medical examination before accepting his proposal to buy the health insurance cover that is not understandable. Moreover if we go through the observation relied upon by the complaint rendered by Hon’ble National Consumer Disputes Redressal Commission, New Delhi also brings out that in fact hypertension is being treated to be a common ailment which can easily be controlled by medication and it is not at all necessary that a person suffering from hypertension would always suffer a heart attack.  Even if it was also observed by the Hon’ble Commission that treatment for the heart problem cannot be termed as a claim in respect of pre-existing disease.   If we go into the details of the respective pleadings of the above said case seized with the Hon’ble National Commission, we find that complainant in the said case Shri Satish Chander Madaan had purchased an overseas travel insurance policy from the respondent/OP.  Thereafter the said complainant had reached London on 28.05.2010 but a few days later, during the subsistence of the insurance policy, the complainant developed chest pain following which he consulted a doctor and was admitted in hospital in London itself and underwent Coronary bypass graft surgery at Wellington Hospital, London.  Thereafter he was discharged after he tendered the hospital bill from his own side and thereafter the claim for the said amount was repudiated and as such the complainant was constrained to approach the Consumer Forum/Commission.  Even thereafter his plea was accepted and the complaint was allowed. However, aggrieved by the said decision, the Op went into First Appeal which was also allowed.  Aggrieved by the said outcome, complainant preferred the said Revision Petition before the Hon’ble National Consumer Commission wherein the above said observation was made.  Even if we further go through the facts of the case, we find that even in the said case, complainant had previous medical history showing of his suffering from hypercholestremia Ischaemic heart disease as well as that of hypertension also and i.e. why his claim was refused.  While allowing the revision petition, Hon’ble National Commission had also observed that the conclusion made by the OPs was on the basis of presumptions.  Even if the complainant had previous history of hypertension and he used to take blood pressure medicine mere this thing in itself does not lead to the conclusion that the petitioner was also having the previous history of heart problem.  So for that reasons the repudiation of the claim by the insurance company was not found to be justified. Even it was also observed by the Hon’ble Commission that the hypertension is a common life style ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack and as such the contention raised by OPs was too far fetched and has in any way rejected.

7.             Even the above said observation rendered by the Hon’ble National Commission reported in 2016(1) CPJ 613 was also relied upon by the Hon’ble State Commission Punjab while deciding First Appeal No.836 of 2016, decided on 26.4.2017 titled  Religare Health Insurance Company Limited versus Subhash Chander Aggarwal.

8.             While dismissing the first appeal Hon’ble State Commission had observed that even if complainant failed to disclose in the proposal form regarding his already suffering from hypertension but as the above said problem is a common disease which can easily be controlled by medication and that it is not for sure that the person suffering from hypertension would also suffer heart attack so repudiation on account of pre- existing disease was not justified, therefore, when no material information was concealed by the insured at the time of taking the policy,  so the claim denied by the OPs was not tenable as such appeal was dismissed with costs.  Now guided by the above said observations recorded by Hon’ble Commissions, we find that in the instant case also even if hospital people did not find anything disclosed by the complainant or by any of his family members when he got himself admitted in Fortis Hospital, Ludhiana rather what compelled him to approach the said health care institute was the complaint of chest pain radiating to his left arm, it was only after check up that his case was found to be that of unstable angina and relevant investigation revealed him to be suffering from CAG.  Added thereto, if we refer to the investigation form, wherein it was disclosed by Ms. Harmandeep Kaur daughter of the complainant that his father used to be suffering from hypertension but it has already been observed that hypertension is more or less a life style disease of any individual and it can easily be managed by the medication so repudiation of claim was not justified.  No further effort was found to be made by the investigator as to on whose advise the complainant used to take tablet Telma 40 MG atleast if the complainant used to take the above said tablet as per the advice of some local doctor then the concerned Medical Practitioner could have been easily approached and enquired about his health and fitness,  to further strengthen the view that in fact the complainant was a chronic patient of hypertension which he deliberately concealed at the time of submitting the proposal form while shifting to the OPs for health insurance in March, 2018.  So, for all these reasons, the claim refused by the OPs can well said to be the result of unfair trade practice adopted by the OPs, so the repudiation letter was palpably unreasonable and unjustified.  As such, present complaint is found to have merit and hence same stands allowed and we direct OPs to reimburse a sum of Rs.3,30,348.33 to the complainant within two months along with interest @ 6% per annum from the date of order till realization.  We further direct the OPs to pay to the complainant an amount of Rs.10,000/- as compensation for mental tension, agony and harassment and further an amount of Rs.5,000/- on account of litigation expenses.

9.             A certified copy of this order be issued to the parties free of cost as per rules. File be consigned to records.

                                Pronounced.

 

                                November 2, 2021.

 

              (Sarita Garg)  (Vinod Kumar Gulati)     (S.P. Sood)

                   Member              Member           President