Haryana

Karnal

CC/612/2021

Sonia Sharma - Complainant(s)

Versus

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

P.K. Bhandari

08 Nov 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No. 612 of 2021

                                                        Date of instt.29.10.2021

                                                        Date of Decision:08.11.2023

 

Sonia Sharma widow of Shri Umesh Sharma, resident of H.No.1290/13, Urban Estate, Karnal, (age about 46 years) (Aadhar Card No.7102 9583 2085). 

 

                                               …….Complainant.

                                              Versus

 

1.     Religare Health Insurance Company Limited, SCO No.214, Mughal Canal, Karnal, through its Branch Manager.

 

2.     Bharat Bhatia, Agent, Religare, Health Insurance Company Limited C/o Religare Health Insurance Company Limited, SCO No.214, Mughal Canal, Karnal. 

 

                                                              …..Opposite Parties.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

      Dr. Suman Singh……Member

          

 Argued by: Shri Deepak Kumar, counsel for the complainant.

                    Shri Ashwani Popli, counsel for the OP.

 

                    (Jaswant Singh President)

ORDER:   

                

                The complainant has filed the present complaint Under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that Shri Umesh Sharma, during his lifetime had taken a health policy from Star Health and Allied Insurance Company Limited on 13.01.2018 vide policy No.P/211114/01/2018/007363 with policy coverage of Rs.5,00,000/- for a period from 13.01.2018 to 12.01.2019. Thereafter, Op No.2 contacted Shri Umesh Sharma telephonically and allured him to take the policy of OP No.1. He convinced Shri Umesh Sharma that the policy which he had taken from Star Health covers only limit upto Rs.5,00,000/- at the annual premium of Rs.12,955/- and further convinced him that it will cover almost double of medical coverage on the meager amount of Rs.10,467/- per annum. He also stated that the OP No.1 will further give benefit of earlier period of policy which he had taken from Star Health Insurance Co. Ltd. Thus, under the undue influence and misrepresentation of OP No.2, Shri Umesh Sharma, became ready to take the policy of OP No.1. Prior to issuing of policy, OP No.1 got medically examined Shri Umesh Sharma alongwith other family members from the doctors on its panel. Thereafter, issued a health insurance policy on 21.12.2018, valid upto 20.12.2019 in which the complainant has been mentioned/shown as “Nominee”. The OP no.1 also issued medical card because the said policy was a cashless policy, on which the names of family members were mentioned. On 05.12.2018, Shri Umesh Sharma, felt a problem in his stomach, as such, he approached Dr.Ajay Gupta, Sarvodaya Multi Speciality Hospital, Karnal and after examination, he had given the prescription slip and also advised him to conduct certain tests i.e. ECG etc and suspected IBS and marked “question mark” on the prescription slip. After taking treatment, he got relief, then again on 10.03.2019, Shri Umesh Sharma again felt some problem in his stomach and again approached the said hospital who diagnosed as chronic diarrhea and ruled out the possibility of IBS. Then h advised to get conducted the colonoscopy and other tests. Carcinoma rectum mentioned and further advised for the biopsies from H/P because from the tests as well as from prescription slips of the doctor, it was not actually diagnosed that under what disease the patient was suffering. On the advised of Dr.Ajay Gupta, Shri Umesh Sharma had gone to Rajiv Gandhi Cancer Institute and Research Centre, Delhi and there he was examined by the competent doctors i.e. Dr.Ullas Batra who had conducted the Biopsy and report to the same was received on 19.3.2019 and colne cancer was diagnosed. In order to make the payment of concerned hospital, cashless card of the OP No.1 was used, however, payment was declined by the OP No.1 and ultimately, Shri Umesh Sharma had to make payment from his account. In the meanwhile, the complainant approached to the OP No.1 to know the reason of declining, they had issued a denial letter on 18.3.2020, thereby giving the reason that “Denial –Non disclosure of material facts/pre-existing ailments at time of proposal. K/C/O IBS teachycardia and related symptoms prior to policy; non disclosure of material facts/pre-existing ailments at time of proposal”. Shri Umesh Sharma, approached to Dr.Ajay Gupta and asked him whether he was ever suffering from IBS, then Dr.Ajay Gupta had issued a certificate on 02.04.2019 in which he mentioned that he was a suspect of IBS only but later on, on the evaluation by biopsy and colonoscopy report, the actual disease of colone cancer deducted. It is pertinent to mention here that the policy was taken on 21.12.2018 and by that time, the problem of colone cancer was not diagnosed and the doctors were conducted the different tests to diagnose the actual disease. The actual problem was diagnosed at Rajiv Gandhi Cancer Institute and Research Centre Delhi on 19.03.2019. After obtaining certificate from Dr.Ajay Gupta, Shri Umesh Sharma again approached OP No.1 and requested to reconsider his claim but the OP No.2 assured that he will definitely able to get cleared all the outstanding as the Op No.1 has wrongly declined the claim. Shri Umesh Sharma, had to undergo Chemotherapy from time to time and remained admitted in Rajiv Gandhi Cancer Institute and Research Centre Delhi from 04.04.2019 to 05.12.2019 and during the admission in the said hospital, Shri Umesh Sharma used the cashless card but all the time the cashless card was declined by the OP No.1. The OP No.2 advised Shri Umesh Sharma to submit his entire treatment bills for reimbursement after his complete treatment. After getting the treatment as mentioned above on different dates, the bills were submitted with the OP No.1 but each and every time, the same were declined with the same reason. The OP No.1 has not given any reasoning why they are not considering the certificate issued by Dr.Ajay Gupta. Shri Umesh Sharma, also took treatment from AIIMS, Delhi as entire funds of Shri Umesh Sharma were exhausted and even the loan amount which he had raised from different persons for his treatment was also exhausted, as such, he had left with no other alterative but to take treatment from AIIMS Delhi and he had taken treatment since 21.12.2019 to 13.10.2020. Due to lack of funds, Shri Umesh Sharma, could not continue his treatment from Rajiv Gandhi Cancer Institute and ultimately on 24.01.2020, Shri Umesh Sharma expired due to the above said disease and lack of funds. Even after the death of Shri Umesh Sharma, the complainant being nominee of Shri Umesh Sharma, submitted the claim for reimbursement of the bills for the treatment of Shri Umesh Sharma, however, the OP No.1 declined the medi-claim of the late Shri Umesh Sharma on 07.11.2020. The complainant is continuing to deposit the premium of the abovesaid policy each and every year even after the death of Shri Umesh Sharma, for three members i.e. complainant and her two daughters. The medi-claim of the complainant has been declined by the OP No.1 knowingly, deliberately, intentionally and wrongly. A total amount of Rs.13,00,000/- were spent on the treatment of Shri Umesh Sharma and approx Rs.2,00,000/- were spent on the transportation.  The act and conduct of the OP amounts to deficiency in service and unfair trade practice. Hence, prayed for allowing the complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the insured had undergone several hospitalizations for the treatment of cancer and raised several claims on the same date i.e. 30.09.2020; however all the claims have been rejected by the company on the ground of non-disclosure of material facts. As per the doctor consultation paper dated 05.12.2018, prepared by Sarvodaya Multispeciality Hospital, Karnal, the complainant was known case for IBS and Tachycardia i.e. prior to policy inception with the OP company. The complainant was under an obligation to disclose all the material facts at the time of filing of proposal. The OP has on the basis of disclosures made in the proposal form issued the policy to the complainant in good faith. Thus, the complainant is not only acting in breach of the policy terms and conditions but also has acted in blatant violation of the terms and conditions of the policy. So in view of the terms and conditions of the policy as well as legal aspects, the complaint is liable to be dismissed. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.C1, copy of death certificate Ex.C2, copy of claim denial letter Ex.C3, copy of insurance policy Ex.C4, copy of acknowledgement Ex.C5, copy of confirmation letter Ex.C6, copy of star health policy Ex.C7, copy of star health card Ex.C8, copies of receipts Ex.C9 to Ex.C11, copy of colonoscopy report Ex.C12, copy of denial letters Ex.C13 and Ex.C14, copy of reports Ex.C16 to Ex.C17, copy of treatment summary Ex.C18, copies of cash bills/memos Ex.C20 to Ex.C36, copies of discharge summary Ex.C37, copy of appointment slip Ex.C38, copies of cash memos Ex.C39 to Ex.C42, copy of summary bill Ex.C43, copy of retail invoice Ex.C44, copy of cash memos/bills Ex.C45 to Ex.C51, copy of discharge summary Ex.C52, copies of cash memos Ex.C53 to C55, copy of discharge summary Ex.C56, copy of final bill Ex.C57, copy of biopsy Ex.C58, copy of discharge summary Ex.C59, copy of final bill Ex.C60, copy of discharge summary Ex.C61, copy of final bill Ex.C62, copy of report Ex.C63, copy of discharge summary Ex.C64, copy of final bill Ex.C65, copy of discharge summary Ex.C66, copy of final bill Ex.C67, copy of bills and final bills Ex.C68 to Ex.C71 and closed the evidence on 16.02.2023 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Saurav, Manager-Legal at Care Health Insurance Limited as Ex.OP1/A and copy of terms and conditions as Ex.OP1, copy of prescription slip of Dr.Ajay Gupta Ex.OP2, copy of claim denial letter dated 08.10.2020 Ex.OP3, copy of application form Ex.OP4 and closed the evidence on 26.04.2023 by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant had purchased a health insurance from the OP No.1. On 05.12.2018, Shri Umesh Sharma, felt a problem in his stomach, as such, he approached Dr.Ajay Gupta, Sarvodaya Multi Specialty Hospital, Karnal and after examination, he had given the prescription slip and also advised him to conduct certain tests i.e. ECG etc and suspected IBS and marked “question mark” on the prescription slip. After taking treatment, he got relief, then again on 10.03.2019, Shri Umesh Sharma again felt some problem in his stomach and again approached the said hospital who diagnosed as chronic diarrhea and ruled out the possibility of IBS. On the advised of Dr.Ajay Gupta, Shri Umesh Sharma had gone to Rajiv Gandhi Cancer Institute and Research Centre, Delhi and there he was examined by Dr.Ullas Batra who had conducted the Biopsy and report to the same was received on 19.3.2019 and colne cancer was diagnosed. In order to make the payment of concerned hospital, cashless card of the OP No.1 was used, however, payment was declined by the OP No.1. In the meanwhile, the complainant approached to the OP No.1 to know the reason of declining, they had issued a denial letter on 18.3.2020, thereby giving the reason that “Denial –Non disclosure of material facts/pre-existing ailments at time of proposal. The actual problem was diagnosed at Rajiv Gandhi Cancer Institute and Research Centre Delhi on 19.03.2019. Shri Umesh Sharma, had to undergo Chemotherapy from time to time and remained admitted in Rajiv Gandhi Cancer Institute and Research Centre Delhi from 04.04.2019 to 05.12.2019 and during the admission in the said hospital, Shri Umesh Sharma used the cashless card but all the time the cashless card was declined by the OP No.1. The OP No.2 advised Shri Umesh Sharma to submit his entire treatment bills for reimbursement after his complete treatment. After getting the treatment as mentioned above on different dates, the bills were submitted with the OP No.1 but each and every time, the same were declined with the same reason. The OP No.1 has not given any reasoning why they are not considering the certificate issued by Dr.Ajay Gupta. Shri Umesh Sharma, also took treatment from AIIMS, Delhi as entire funds of Shri Umesh Sharma were exhausted and even the loan amount which he had raised from different persons for his treatment was also exhausted, as such, he had left with no other alterative but to take treatment from AIIMS Delhi and he had taken treatment since 21.12.2019 to 13.10.2020. Due to lack of funds, Shri Umesh Sharma, could not continue his treatment from Rajiv Gandhi Cancer Institute and ultimately on 24.01.2020, Shri Umesh Sharma expired due to the above said disease and lack of funds. Thereafter, the complainant being nominee, submitted the claim for reimbursement of the bills for the treatment of Shri Umesh Sharma, however, the OP No.1 declined the medi-claim of the late Shri Umesh Sharma on 07.11.2020. The complainant requested the OPs several times for reimbursement of claim amount but OPs did not pay the claim amount and repudiated the same on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that the complainant approached the OPs for reimbursement of the claim for his hospitalization. As per medical documents and discharge summary, complainant has a history of cancer prior to obtaining the insurance policy. Hence, the claim of the complainant has been repudiated by the OPs, vide letters dated 18.10.2020 Ex.C3,  dated 15.04.2019 Ex.C13, dated 03.11.2020 Ex.C14 and 08.10.2020 Ex.OP3 and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant has availed the health insurance policy from the OP No.1. It is also admitted that during the subsistence of the insurance policy complainant has taken a treatment in from the Rajiv Gandhi Cancer Institute, Delhi and AIIMS Delhi, Karnal and died. It is also admitted that the complainant being the nominee in the insurance policy has applied for reimbursement of claim. It is also admitted that the sum insured in the insurance policy was Rs.10,00,000/-.  

11.           The claim of the complainant has been repudiated by the OP No.1, vide repudiation letter dated 18.10.2020 Ex.C3, dated 15.04.2019 Ex.C13, dated 03.11.2020 Ex.C14 and 08.10.2020 Ex.OP3, on the ground, which reproduced as under:-

“Denial-Non disclosure of material facts/pre-existing ailments at the time of proposal K/C/O IBS Tachycardia and Related Symptoms Prior to policy.

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

 

12.           The onus to prove its case lies upon the OPs, but OPs have miserably failed to prove the same by leading any cogent and convincing evidence. The case of the OPs is based upon treatment record/prescription slip Ex.OP2 dated 05.12.2018, issued by Dr.Ajay Gupta’s Sarvodaya Multispeciality, Hospital, Karnal. Neither the said doctor who have issued the said treatment record were examined nor his affidavit was tendered into evidence by the OPs to prove its version. Moreover, said treatment record is only photocopy and same is not admissible in the eyes of law. Furthermore, for the purpose of clarification of the document Ex.OP2, the same doctor i.e. Dr.Ajay Gupta’s, Sarvodaya Multispeciality Hospital, Karnal, has issued a certificate, which is reproduced as under:-

                                TO WHOM IT MAY CONCERN

It is certified that Mr.Umesh Sharma son of Brij Bhushan Sharma, was initially used as a suspect case of IBS but on evaluation it was used as a case of colonel.

 

13.           From the said certificate Ex.C11, it is clear that the husband of the complainant was not suffering from IBS, rather he was only a suspect. Thus, the case of pre-existing disease does not arise at all. 

14.           Further, for the sake of arguments, if it is presumed that the complainant was suffering from cancer at the time of obtaining the insurance policy, in that case also the claim of the complainant cannot be repudiated on the said ground, because the cancer was detected in the year 2019 and this fact is clearly proved from the documents Ex.C17 dated 19.03.2019 and treatment summary Ex.C18. If the complainant was in the knowledge that he was suffering from cancer then as to why he has not taken the treatment earlier, since he was acquiring the insurance policy from the year 2018. No prudent person can take the risk of his life and kept mum for a long time from the year 2018 to 2019. From this it is clear that the husband of the complainant was not acquiring the knowledge of pre-existing disease at the time of purchasing of the policy. Furthermore,

15.           Further 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.

16.  

It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.

 17.          Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OP while repudiating the claim of the complainant amounts to deficiency, which is otherwise proved genuine one. 

16 .          The complainant has spent Rs.13,00,000/- on the treatment of his husband and in this regard he has placed on record medical bills Ex.C19 to C36, C39 to Ex.C42, Ex.C45 to Ex.C51, Ex.C53 to Ex.C55, Ex.C57, Ex.C60, Ex.C62, Ex.C65, Ex.C67 to Ex.C71. The said bills have not been rebutted by the OP.  However, the sum insured of the husband of the complainant was to the tune of Rs.10,00,000/-. Hence, the complainant is entitled for an amount of Rs.10,00,000/- alongwith interest, compensation for mental harassment and litigation expenses etc.

17.           Thus, as a sequel to abovesaid discussion, we partly allow the present complaint and direct the OP No.1 to pay Rs.10,00,000/- (Rs. Ten lacs only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OP No.1 to pay Rs.50,000/- to the complainant on account of mental agony and harassment and Rs.22,000/- towards the litigation expenses.  This order shall be complied with within 45 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:08.11.2023                               

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 (Vineet Kaushik)       (Dr. Suman Singh)

                          Member                           Member