Haryana

Karnal

CC/224/2017

Smt. Balwinder Kaur - Complainant(s)

Versus

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

Ram Lal Bilam

27 Mar 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                          Complaint No. 224 of 2017

                                                          Date of instt. 17.07.2017

                                                          Date of Decision 27.03.2019

 

Smt. Balwinder Kaur wife of Shri Sukha Singh resident of house no.162, Behind Jai Hind Public School, Nagla Megha, Karnal.

 

                                                                       …….Complainant

                                        Versus

Religare Health Insurance Company Limited, SCO no.214 First Floor, Sector-12, Karnal through its Branch Manager.

 

                                                                      …..Opposite Party.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

      Sh.Vineet Kaushik ………..Member

                Dr. Rekha Chaudhary…….Member

 

 Present:  Shri Munish Lather Advocate for complainant.

                  Shri Rohit Gupta Advocate for opposite party.

 

                   (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 complainant purchased a group policy bearing no.10087119, valid upto 26.11.2017. The sum insured of the policy was Rs.6,00,000/-. The complainant starting suffering from fever, chills, body ache etc. in the last week of September, 2016 and she took the treatment of the same from Kalyani Hospital, Sector-45, CHD city Karnal and the concerned doctor after examining her, diagnosed the disease “Sepsis with ARDS (Brucellosis) and advised the complainant to admit in the said hospital as the said disease cannot be treated as OPD patient due to the nature of the same. On the advice of the doctor complainant admitted in the abovesaid hospital from 3.10.2016 to 21.10.2016 and got the treatment and spent approximately Rs.6,00,000/- on her treatment. After getting discharge from the hospital complainant lodged her claim with the OP for releasing the said amount to the complainant and submitted all the bills etc. and completed other formalities and the OP assured the complainant that the claim amount would be released to her within a short span of time. Thereafter, the complainant contacted the OP several times to pay the claim amount to her but OP postponed the matter on one pretext or the other. Then complainant sent a legal notice dated 3.6.2017 to the OP in this regard but it also did not yield any result. In this way there was deficiency in service on the part of the OP. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OP, who appeared and filed written version raising preliminary objections with regard to territorial jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the complainant was issued policy of insurance bearing Group Policy no.10106147, vide certificate of insurance no.10166581 for a period from 20.11.2014 to 19.11.2015 and renewed till 26.11.2017 for a sum insured of Rs.6,00,000/- for insuring the complainant subject to the policy terms and conditions. It is further pleaded that the complainant has filed a Reimbursement Claim with the OP for Hospitalization but it was repudiated on the ground of Non-Disclosure of Diabetes since 2012 and Arthritis since 2013. It is denied that the complainant was not suffering from any disease and she was hale and hearty at the time of purchasing the policy. Hence there is no deficiency in service on the part of the OP. The other allegations made in the complaint have been denied by the OP and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence her affidavit Ex. CW1/A and documents Ex.C1 to Ex.C8 and closed the evidence on 14.11.2016.

4.             On the other hand, OP tendered into evidence affidavit Ex.RW1/A and documents Ex.R1 to Ex.R12, Ex.R5/A, Ex.R6/A and Ex.R11/A and closed the evidence on 31.01.2019.

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

7.             The case of the complainant is that she purchased a Group policy on 20.11.2014 from OP, valid upto 26.11.2017 for sum insured of Rs.6,00,000/-. In the month of September, 2016 she had taken the treatment from Kalyani Hospital, Sector 45, CHD City Karnal and concerned doctor after examining her, diagnosed the disease “Sepsis with ARDS (Brucellosis). On the advice of doctor complainant admitted in the said hospital from 3.10.2016 to 2.10.2016 and spent approximately Rs.6,00,000/-. Complainant lodged her claim with OP for releasing the amount but OP did not release the said amount and repudiated the claim on the ground that the complainant has a history of pre-existing disease.

8.             On the other hand, the case of the OP is that complainant was issued policy of insurance bearing Group Policy no.10106147, vide certificate of insurance no.10166581 for a period from 20.11.2014 to 19.11.2015 and renewed till 26.11.2017 for a sum insured of Rs.6,00,000/- for insuring the complainant subject to the policy terms and conditions. In the present case the proposer by not disclosing her correct health status has breached the concept of uberrima fides or utmost good faith. As per the questionnaire dated 14.12.2016 administered to the complainant by the investigator, complainant mentioned that she is suffering from diabetes Miletus from the last 4 years back and also suffering from Arthritis since 2013. Moreover, discharge summary dated 21.10.2016 issued by the treating hospital of the complainant is mentioned to be known case of type 2, Diabetes Miletus and OHA. But this fact was not disclosed by the complainant at the time of inception of policy. The claim was rejected for non-disclosure of material facts of Diabetes Miletus since 4 years and Arthritis since 3 years. Claim rejection was intimated to the complainant on 10.04.2017.

9.             Admittedly, the complainant was issued policy of insurance bearing group policy no.10106147 for a period from 20 November, 2014 to 19 November, 2015 and renewed till 26 November, 2017 for a sum insured of Rs.6,00,000/- by the OP. It is also admitted that the complainant had taken the treatment from Kalyani Hospital, Sector 45, CHD City Karnal during the subsistence of the policy. It is also admitted with regard to serving of legal notice dated 3 June, 2017, reply to the legal notice sent by OP on 21 June, 2017 and repudiation of the claim on the grounds of Non-Disclosure of Diabetes and Arthritis. The learned counsel of OP relied upon the authorities Satwant Kaur Sandhu Versus New India Assurance company IV (2009) 8 SCC 316 and Life Insurance Corporation of India Vs. Smt. Neelam Sharma pronounced by the National Commission on 30^th September, 2014

10.            We have gone through the documents on record and it has been found that except questionnaire for the insured dated 14 December, 2016 Ex.R2, discharge summary Ex.R3, history sheet Ex.R4 prepared by the concerned hospital, when after treatment of the complainant was discharged from the Hospital, continuation sheet Ex.R5 and OPD slip Ex.R6. there no number, there is no other evidence on the record to prove that the complainant was suffering from any disease, as alleged.

11.            It is admitted that the complainant took the health insurance policy from OP in the year 2014. The policy was valid upto 26.11.2017. The  complainant also covered in the said policy and sum insured was of Rs.6,00,000/-. Ex.R1 is the copy of that policy. Ex.R3 is the discharge summary of the complainant which proves that she was diagnosed of Sepsis with ARDS cause Brucellosis. As per the past history sheet, complainant is mentioned to be known case of type 2 Diabetes Miletus. Ex.R7 is the denial of claim access to the complainant by the OP and operative part of the same reads as under:-

        “Non-disclosure of material facts pre-existing ailments at the time of proposal”

Thus, it is proved that the claim of the complainant was denied on account of diabetes and its related complication and it is mentioned that there was diabetes since 4 years which is pre-existing in nature. Thus, we are the view that the burden was on the OP to prove that the complainant had concealed material fact of pre-existing disease at the time of taking the policy. There is no other document on record except Ex.R2 Questionnaire for the insured and Ex.R4 issued by the concerned hospital, where she was admitted and remained under treatment. OP has failed to produce on record any document to show that the complainant was suffering from diabetes from the last 4 years. The OP has to failed to get further information from the hospitals as to whether the doctors who recorded past history, recorded the said information on the basis of the information given by the patient or her relative or some medical prescription were consulted. It was the duty of the OP to verify who supply this information to the hospital. It is also the duty of the OP to conduct a thorough enquiry about the previous treatment of diabetes obtained by the patient. However, no such enquiry was conducted. Even the affidavit of the doctor who recorded the past history has not been produced on record. So, merely on the basis of past history mentioned in Doctor’s record in Ex.R4, it cannot be said that the patient was suffering diabetes at the time of taking the policy and she was intentionally concealed the said material fact.

12.            In United India Insurance Co. Ltd. & Anr. Versus S.K. Gandhi, 2015 (2) CLT 71 (NC)  the insurance company had not placed on record either the discharge summery of the complainant or any medical document signed by the doctors who treated him in Bhatnagar Eye Centre, Karnal and Arpana Hospital, Madhuban to show that the complainant when he was admitted to the said hospital, had himself stated that he was suffering from hypertension from last 8 years. In that case it was held that it is quite possible that the complainant, despite suffering from diabetes was not actually aware of the same and he cannot be accused of mis-statement or concealment. Onus was upon the insurance company to prove that he had made a mis-representation while obtaining the insurance policy and since the insurance policy failed, it was held that it was liable to pay to the complainant to the extent a sum insured by it. In Satish Chander Madan Vs. M/s Bajaj Allianz General Insurance Co. Ltd. 2016(1) CPJ 613 (NC) it was held that diabetes 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. It was further held that treatment for heart problem cannot be termed as claim in respect of pre-existing disease and the insurance company was held liable. In Oriental Insurance Co. Ltd. Vs. Naresh Sharma & Ors 2015 (2) PLR 75 the Hon’ble Punjab and Haryana High Court held that the exclusion clause has to be read to the benefit of patient in genuine circumstances. Where respondent was admitted in hospital suffering from headache, giddiness and hypertension, his claim cannot be rejected on the basis of exclusion clause.

13.            So, in the present case the OP has failed to produce cogent evidence to prove that prior to the date of taking the policy, the complainant was suffering from diabetes and was getting any treatment and that fact was in the knowledge of the complainant and she intentionally concealed the same. There is no dispute with regard to the law laid down in the judgment referred by learned counsel for the OP but the same are not applicable to the facts of the present case because in the present case the OP has failed to produce cogent evidence to the effect that the complainant had knowledge of diabetes and had intentionally concealed the treatment. It is pertinent to mention here that except the Ex.R6, there is no other evidence on record that the complainant was getting the treatment of diabetes at the time of taking the policy.  Moreover, complainant had taken the policy on 20 November, 2014 but Ex.R6 issued on 12.03.2015 after inception the policy. Even otherwise, there is no proof on the record as to who disclosed to the doctor about the diabetes being suffered by the complainant.

14.            OP has failed to prove that the complainant has suppressed material facts while obtaining the policy. As such OP was not justified in repudiating the claim of the complainant. The complainant has placed on record  Ex. C4 which is the copy of detail of bill making the payment to the Kalyani Hospital, CHD City, Karnal in the tune of Rs.4,60,000/-. The complainant claimed the amount of Rs.6,00,000/- for treatment and she placed on the record bill only Rs.4,60,000/-. So she is entitled only bill amount. As such OP is liable to reimburse the amount of Rs.4,60,000/- to the complainant. The complainant is also entitled to compensation because of denial of her rightful claim by the OP.

15.            It was rightly said that the doctor who had recorded past history qua alleged disease suffered by the complainant had not seen any medical prescription to support the above finding recorded. History of getting any treatment before issuance of insurance policy, has also not been brought on record. It was also rightly stated that there is nothing on record to prove that complainant had knowledge of suffer from the disease like diabetes.

16.            It has come on record that the age of the complainant when mediclaim insurance policy was issued in her favour was more than 45 years.  This fact was proved vide certificate of Insurance Ex.R1 in which date of birth of complainant is mentioned as 11 February, 1967. In that event, as per instructions issued by Insurance Regulatory & Development Authority of India (IRDA), it was duty of the OP to put the complainant thorough medical examination. In the case of National Insurance Company Ltd. Versus Harbirinder Singh appeal no.220 of 2016 decided on 30.09.2016. State Commission U.T. Chandigarh has nothing abovesaid fact and failure on the part of the insurance company to get thorough medical examination of the insured before issuance of mediclaim insurance policy, dismissed appeal filed by the insurance company by observing as under:-

        “To deny claim raised by the complainant, reliance has been placed upon self declaration form R-2 (page 74 of the original paper book). The said declaration form has been signed by Saranbir Kaur on 5.2.2013. There is nothing on record to show that policy was issued to the complainant and his wife on the said date, by believing above document. The policy infact was issued on 13.02.2013. The appellants have failed to co-relate the said declaration form with the policy (C2) referred above. A note is appended on the said declaration form that it needs to be filled up if the age of the member is above 45 years. The complainant and his wife both are older than the said age. There is nothing on record to show that before insurance policy was issued to them, the appellants got them medically examined, which as per instructions issued by Insurance Regularly & Development Authority of India (IRDA) is must in such like cases. 

17.            Similar view was taken by Hon’ble Chandigarh State Commission in case of M/s Max Bupa Health Insurance Co.Ltd. Vs. Rakesh Walia, appeal no.191 of 2016 decided on 18.08.2016  wherein it was also stated that if contrary to the instructions issued by IRDA, an insured above the age of 45 years, was not put to through medical examination, claim raised after issuance of insurance of policy cannot be rejected on account of non-disclosure of the fact of pre-existing disease when policy was obtained.

18.            Thus, as a sequel to above discussion, we allow the present complaint and direct the OP to pay Rs.4,60,000/- to the complainant with 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 on account of mental agony and harassment suffered by her and for the litigation expense. This order shall be complied 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:27.03.2019

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

 

               

        (Vineet Kaushik)          (Dr. Rekha Chaudhary)

            Member                         Member