Chandigarh

DF-II

CC/427/2018

Ranjit Minhas - Complainant(s)

Versus

Religare Health Insurance Company Ltd., - Opp.Party(s)

Adv. Harsh Garg and Adv. Pulkit Goyal

21 Nov 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Consumer Complaint  No	:	427 of 2018
Date  of  Institution	:	01.08.2018
Date   of   Decision	:	21.11.2019

 

 

 

 

Ranjit Minhas, aged about 60 years, wife of Sh.Avaninder Singh Minhas, resident of House No.324, Sector 21-A, Chandigarh.     

             ……..Complainant

 

Versus

 

1]  Religare Health Insurance Company Ltd., Vipul Tech Square, Tower C, 3^rd Floor, Sector 43, Golf Course Road, Gurgaon, through its Managing Director.

 

2]  Religare Health Insurance Company Ltd., SCO 56-57-58, Sector 9-D, Chandigarh through its Branch Manager.

 

………. Opposite Parties

 

BEFORE:  SH.RAJAN DEWAN        PRESIDENT

SMT.PRITI MALHOTRA    MEMBER

           

 

Argued By:

Sh.Harsh Garg, Adv. for the complainant.

Sh.Sachin Ohri, Adv. for Opposite Parties.

 

PER PRITI MALHOTRA, MEMBER

         Briefly stated, the complainant took an Insurance Policy No.10009753 from Opposite Parties on 8.1.2013 (Ann.C-1) effective from 8.1.2013 to 7.1.2014 and got it renewed from year to year and lastly the policy was renewed from 8.1.2016 to 7.1.2017 (Ann.C-2 colly).  It is averred that the complainant in Nov., 2016 visited Dr.Sangeeta Singh of Sangeeta Nursing Home, with a lump in his breast and thereafter, started taking treatment from PGI, Chandigarh.  It is averred that vide report dated 17.12.2016 of PGI, Chandigarh, she was diagnosed with ‘Lymph Node’ in her right breast, which is a type of Carcinoma (Ann.C-4).  It is averred that the husband of the complainant, who is also beneficiary under the policy, duly informed the Opposite Parties regarding the illness of the complainant in order to obtain medical insurance (Ann.C-5) & also informed about the treatment so taken from PGI, Chandigarh (Ann.C-6).  However, the OPs rejected the claim of the complainant vide letter dated 4.10.2017 on the ground of her suffering from a pre-existing disease i.e. diabetes mellitus (Ann.C-7).  Alleging the said repudiation of claim as illegal and a deficient act on the part of OPs, hence this complaint has been filed. 

 

2]       The Opposite Parties have filed joint reply and while admitting the factual matrix of the case, stated that the liability of the Opposite Parties under the insurance policy in question is strictly as per its terms & conditions. It is submitted that the complainant has admitted in the questionnaire form that she was suffering from Diabetes Mellitus since 2012 and Hypothyroidism since 2002 and even as per Out Patient Record of PGIMER, the complainant was suffering from Hypothyroidism since 10 years. It is stated that the claim of the complainant was rightly rejected as per terms & conditions of the policy.  It is further submitted that the insured had not disclosed the pre-existing illness of Diabetes Mellitus and Hypothyroidism at the time of filling up the proposal form before taking of the policy with the OPs.  That the said misrepresentation on the part of the complainant is a breach of terms & conditions of the Policy and therefore, the claim was rightly rejected for non-disclosure of pre-existing ailment at the time of taking the policy and there is no deficiency in service on the part of Opposite Parties. Pleading no deficiency in service and denying all other allegations, the OPs have prayed for dismissal of the complaint.

 

3]       Rejoinder has been filed by the complainant thereby controverting the assertions of Opposite Party.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the parties and have also perused the entire record.

 

6]       It has duly been admitted in the reply of the Opposite Parties & well proved on record that the complainant for the first time took the Health Insurance Policy valid from 8.1.2013 to 7.1.2014 for sum insured upto Rs.5 lacs from OPs which further got renewed on yearly basis till 2018.  It is gathered from the record that no dispute ever arisen between the parties since 2013 till Sept., 2017 and it is only the rejection of the claim lodged with the Opposite Parties for reimbursement vide letter dated 4.10.2017 (Ann.C-7) that forced the complainant to file the present complaint.

 

7]       The record further reveals that during the subsistence of the insurance coverage period from 8.1.2016 to 7.1.2017, the complainant/insured was diagnosed with Lymph Node in her right breast (Carcinoma right breast) and was thereafter treated for the same at PGIMER, Chandigarh. Thereafter, the complainant lodged claim with the Opposite Parties for reimbursement of the amount incurred by her on the said treatment, which the Opposite Parties declined vide letter dated 4.10.2017 on the ground of non-disclosure of material facts/pre-existing ailment at the time of proposal. Also in the written statement, the Opposite Parties claimed that the claim of the complainant was rejected as she is a known patient of Diabetes Mellitus and is suffering from Hypothyroidism, which she failed to disclose while proposing for the policy in question.

 

8]       However, the Opposite Parties failed to brought on record any cogent documentary evidence which also states so that at the time of taking the policy, the complainant was suffering from Diabetes Mellitus and Hypothyroidism.  No investigations have been conducted by them for establishing their stand qua alleged Diabetes Mellitus being suffered by the complainant at the time of proposing for the policy in question.  Rather the record before us, at Page No.78 of the Opposite Parties, reveals that at the time of taking the policy in question for the first time in the year 2013, the complainant’s medical examination got conducted at the behest of the OPs and it is only then she was issued policy being found fit.

 

 

9]       The grounds for the rejection, relied upon by the OPs, have not been substantiated by any independent documentary evidence.  The complainant has denied of having been suffering from Diabetes Mellitus at the time of availing the policy in the year 2013.  It has further been submitted that her husband Sh.Avaninder Singh Minhas, who is also insured under the said policy, very fairly disclosed about having been suffered from Diabetes at the time of availing the policy for the first time in the year 2013.  The policy document at Page No.21 also records/mention the same.  The bona-fide of the policyholder can very well be circumscribed from the fact that the husband of the complainant duly disclosed about his suffering from Diabetes in the proposal form, which also later on find place in the policy document.  So no doubt can be raised on the integrity of the complainant for concealing any facts qua her suffering from Diabetes Mellitus at the time of taking the policy in the year 2013, as alleged by the Opposite Parties.  She may have developed such disease during the currency of subsequent policy periods as the policy taken in the year 2013, was renewed admittedly till 2018.  The thorough perusal of the policy document reveals that under the Clause ‘benefits in the Policy’, the OPs were under obligation to get conducted the medical check-up of the insured once a year, which they failed.  Had the insured been called for the health check-up, it could have been detected that the complainant during the currency of the insurance policy developed Diabetes Mellitus.

 

10]      It is suffice to reiterate that there is no record revealing that the complainant was suffering from Diabetes Mellitus at the time of availing the policy, as alleged by the OPs.

 

11]      After having considered the objection of the Opposite Parties qua alleged non-disclosure, it is turn to enquire that the disease for which the complainant has been diagnosed and has been treated for during the subsistence of the policy coverage, is a pre-existing disease, as alleged to have not been covered under the policy.  The record is evident of the fact that the complainant has been diagnosed with Lymph Node (Carcinoma right breast) vide Report dated 17.12.2016 (Ann.C-4) and she took treatment for the same at PGIMER, Chandigarh.  Again there is no record showing that the complainant has ever been diagnosed or suffered for the disease, which she developed during the policy coverage only.  Thus, it cannot be termed as a pre-existing disease and also does not fall under the definition of pre-existing disease, as given in the policy terms & conditions.

 

12]      For further clarification, we would like to reproduce the definition of Pre-Existing Disease, as given in the Policy Terms & Conditions along with Exclusion Clause for pre-existing diseases as mentioned in the Policy Clause No.4.1(c):-

“1.36 Pre-existing Disease means any condition, ailment or injury or related condition for which the Insured Person had sign or symptoms, and/or were diagnosed, and/or received Medical Advice/treatment within 48 months prior to the first Policy issued by the Company.

 

Exclusions

4.1(c)

Pre-existing Disease Claims will not be admissible for any Medical Expenses incurred as Hospitalization Expenses for diagnosis/treatment of any Pre-existing Disease until 48 months of continuous coverage has elapsed since the inception of the first Policy with the Company.”

 

13]      After going through the above discussion & findings and the definition of pre-existing disease in specific, it is very well clear that the claim of the complainant does not fall under the Exclusions of Pre-Existing Disease as the Carcinoma disease, which complainant developed during the policy period, was not a pre-existing disease.  Therefore, the expenses incurred on the treatment of the complainant, which is not pre-existing disease, is well covered under the policy and thus payable. By rejecting the genuine claim of the complainant and adding pain to her sufferance already undergone during the treatment of carcinoma, the Opposite Parties have committed serious breach of duty, which they own under the policy in question. 

 

14]      From the entire facts & circumstances of the case, discussion and findings, as made in the preceding paragraphs, it is proved that the Opposite Parties No.1 & 2 not only remained grossly deficient in rendering proper service to the complainant, but also indulged into unfair trade practice. Therefore, the present complaint is allowed against Opposite Parties NO.1 & 2 with following directions:-

         

1. To reimburse an amount of Rs.1,84,323/- to the complainant (Ann.C-9 Colly. & C-10 Colly.), along with interest @12% p.a. from the date of repudiation i.e. 4.10.2017 till payment;

 

2. To pay a compensation amount of Rs.25,000/- to the complainant for causing immense mental agony, harassment due to deficient act of the Opposite Party No.1 & 2 coupled with unfair trade practice;

 

c)  To pay litigation cost of Rs.10,000/-;

 

         This order shall be complied with by Opposite Parties No.1 & 2 within a period of 30 days from the date of receipt of copy of this order, failing which they shall be liable to pay additional compensatory cost of Rs.15,000/- apart from the above relief.   

 

        Certified copy of this order be sent to the parties, free of cost. File be consigned to record room.

Announced

21^st November, 2019                                                               Sd/-

                                                                   (RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

                                                                    (PRITI MALHOTRA)

MEMBER