Date of filing: 07/02/2020
Date of Judgment: 19/07/2023
Mrs. Sashi Kala Basu, Hon’ble President.
This complaint is filed under section 35 of the Consumer Protection Act, 2019 by Sri Saibal Saha against opposite parties (referred as OPs hereinafter) namely (1) Religare Health Insurance Co. Ltd., (2) Smt. Rashmi Saluja, (3) Smt. Asha Nair, (4) Sri Sham Lal Mohan (5) Smt. Anju Gulati, (6) Shamsher Singh Mehta (7) Siddarth Dinesh Mehta (8) Daljit Singh and (9) Malay Kumar Sinha (OP 2 to 8 are the Directors of OP 1) alleging deficiency in service on the part of OPs.
Case of the complainant in short is that he purchased a Health Insurance Policy in the name of his father Satya Gopal Saha on 15.12.2016 for the period from 15.12.2016 to 14.12.2017 and Nominee / Proposer name is complainant Saibal Saha. He has been renewing the health insurance policy by making premium regularly. Prior to selling the policy OP got medical examination conducted and health check up of the complainant’s father through their medical team and on being satisfied issued the policy finding complainant’s father to be fit. Complainant’s father fell ill on 06.03.2019 and was admitted to Woodland Multi Speciality Hospital Ltd. and discharged on 14.03.2019. Attending doctor diagnosed that the complainant’s father had “Chovi Obstructive Pulmonary Disease” for last one year. Soon after the father of the complainant was discharged, complainant approached for the reimbursement of hospital bill and on being asked by the OP, complainant submitted all the necessary document in which some of the documents were original. Thereafter complainant received intimation from the OP that the claim has been declined on the ground that the father of the complainant had pre-existing disease. But complainant’s father had no pre-existing disease. So a demand notice was sent but OP did not respond to the notice. Thus present complaint is filed to direct the OPs to pay the legitimate claim of Rs. 1,14,338/-, to pay compensation of Rs. 3,00,000/- and to pay litigation cost of Rs. 50,000/-
OPs have contested the case by filing written version denying allegations made in the complaint contending inter-alia that a pre-auth cashless request was received from the hospital. So for checking the veracity of the claim, OP initiated investigation and had raised query vide their letter dated 07.03.2019 asking for required documents and on receiving the same, OP insurance found that as per doctor’s continuation sheet dated 07.03.2019 of woodland hospital patient was K/C/O OAD since 10-15 years and as per doctor’s continuation sheet dated 06.03.2019 patient / insured was K/C/O/ HTN/DM/Hyperthyroid / COPD. So OP rejected the cashless request on the ground of non-disclosure of material facts / pre-existing ailments at the time of inception of policy. Complainant thereafter lodged the claim for reimbursement of expenses to the tune of Rs; 1,14,338/-. OP thus asked for documents namely (1) Treating doctor’s certificate justifying the prolonged need of hospitalisation, (2) Treating doctor’s certificate for Alcohol / any other Drug Abuse, (3) Pre-hospitalisation OPD treatment Record and (4) complete indoor case papers with admission notes. But no reply was received from the complainant in spite of reminder sent. So OP rejected the reimbursement claim, vide letter dated 11.05.2019 as per the terms and conditions of the policy, on the ground of non-disclosure of obstructive Air way disease at the time of policy inception. It is contended by the OP that the father of the complainant was suffering from OAD since 10-15 years i.e. before the inception of policy which was suppressed. So the OPs have prayed for dismissal of the complaint with cost.
During the course of evidence, both parties have filed their respective examination-in-chief followed by filing of questionnaires and reply thereto. Ultimately argument has been heard of both sides. Both parties have also filed brief notes of arguments
OPs have referred some of the decisions of Hon’ble NCDRC & of Hon’ble Supreme Court, in BNA filed by them is support of their contention that non-disclosure of pre-existing disease entitles the insurer to repudiate the claim.
So the following points require to be determined:
- Whether there has been any suppression of material facts / non-disclosure of pre-existing disease by the complainant?
- Whether there has been any deficiency in service on the part of the OPs?
- Whether the complainant is entitled to the reliefs as prayed for?
DECISION WITH REASONS
All the points being co-related are taken up together for discussion to avoid repetition.
At the very outset it may be pertinent to point out that this is an admitted fact that complainant had taken health insurance policy of the OP for the insurance coverage of his father Sri Satya Gopal Saha commencing from 15.12.2016 to 14.12.2017. Sum Insured was Rs. 4,00,000/-. Policy was renewed every year. There is also no denial that the insured Satya Gopal Saha was hospitalised at Woodland Hospital for the period from 06.03.2019 to till 14.03.2019 and he was diagnosed and treated for Chovi Obstructive Pulmonary Disease (COPD). Complainant has filed the medical bill wherefrom it appears that hospital raised bill of Rs. 1,14,338/- towards the treatment of his father. However OP had refused the cashless treatment initially and subsequently also refused to reimburse the said amount to the complainant.
According to the specific contention of the OP reimbursement of the claim was rejected as “there is non-disclosure of obstructive Airway disease” at the time of policy inception. OP has filed copy of the proposal form submitted by the complainant. It is evident from the said proposal form that the complainant had stated ‘NO’ against the question whether the proposer has “Any respiratory disease / disease of lungs, pleura and airway (including but not limited to Asthama / Tuberculosis / Pleural effusion / Bronchitis / Emphysema). So the question to be considered is whether the complainant had suppressed the pre-existing obstructive airway disease?
In this case, not only complainant had stated that insured did not suffer from any such ailment of obstructive airway disease in his proposal form but the same answer has also been recorded by the doctor / medical team of the OP insurance Co. who had conducted the medical test of complainant’s father before issuance of policy. OPs have filed the said medical examination form wherefrom it appears that under caption “Respiratory System” it has been stated in the following manner:-
“Have you ever suffered from or diagnosed with Asthama Bronchitis Pneumonia Tuberculosis COPD Sarcoidosis pleurisy coughing of blood any breathing problem any other respiratory disorder please provide details - NO
Examinations
Is the chest symmetrical? If not provide details of – asymmetry – Yes
Any Abnormality breath sounds – No
Respiratory Rate – 14 / minute”.
In the written version filed by the OPs, OPs sought to suggest that medical examination of the insured was conducted based on the information provided and disclosure made in the proposal form. Had such material facts been disclosed at the time of proposal, different set of tests would have been conducted. But it is evident from the medical examination form that at first information of the insured was taken by the doctor / medical team of the OP insurance co. and than the doctor himself examined the insured and gave his observation / finding. It is already highlighted above that doctor on examination did not find any ailment relating to respiratory system and ultimately on conclusion of the examination, doctor has not only given declaration to the effect that he carefully had examined the proposed life to be insured but also categorically stated that in his opinion there was nothing about the examined person’s health, life style, character or mode of life which might affect the insurability. In other words there was nothing negative found by the doctor on examination regarding medical condition of the complainant’s father. It may be pointed out that medical tests are conducted to determine current health status of a potential policy holder and knowing the health status helps the insurance company to provide insurance coverage. So there cannot be any denial that insurance co. conducts the pre-medical test / examination as they want to assess the prospective policy holder’s medical condition as to whether he is fit for issuing policy. If OP insurance co. had to rely upon the declaration made by the insured than no medical examination was necessary because proposal form was already submitted stating all the queries therein. In such a situation, contention of the OPs that the medical examination of the insured was conducted based on the information provided and disclosure made in the proposal form, cannot be accepted and the same appears to be an afterthought and only for the purpose of this case. Thus as there is no material before this commission to suggest that there was any suppression of material facts or non-disclosure of pre-existing Obstructive Airway disease, complainant is entitled to the claim amount and also compensation in the form of interest.
Hence
ORDERED
CC/44/2020 is allowed on contest. Opposite parties are directed to pay Rs. 1,14,338/- to the complainant along with interest on the said sum @ 7% P.A. from 23.04.2019 (the date of submission of claim form) to till this date within 45 days from the date of this order. OPs are further directed to pay Rs. 10,000/- as litigation cost within the aforesaid period of 45 days. In default of payment entire sum shall carry interest @ 7% till realisation.
