Chandigarh

DF-II

CC/229/2018

Smt. Nisha Mehta - Complainant(s)

Versus

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

Dhiraj Chawla Adv.

30 Aug 2018

ORDER

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

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Consumer Complaint  No	:	229 of 2018
Date  of  Institution	:	23.04.2018
Date   of   Decision	:	30.08.2018

 

 

 

 

Nisha Mehta wife of Yogesh Mehta, aged 61 years, H.No.3169, Industrialist Cooperative House Building Society Ltd., Plot No.7, Sector 51-D, Chandigarh  

 

             ……..Complainant

Versus

 

1]  Religare Health Insurance Company Ltd., SCO No.56-58, 2^nd Floor, Sector 9-D, Chandigarh through its Branch Manager.

 

2]  Religare Health Insurance Company Ltd., through its Managing Director, 5^th Floor, 19 Chawla House, Nehru Palace, New Delhi 110019

 

………. Opposite Parties

 

 

BEFORE:  SH.RAJAN DEWAN            PRESIDENT

SMT.PRITI MALHOTRA        MEMBER

            SH.RAVINDER SINGH         MEMBER

 

Argued By: Sh.Ashutosh Gupta, Adv. for Sh.Dhiraj Chawla, Adv. for complainant

Sh.Sachin Ohri, Adv. for OPs.

 

 

PER RAVINDER SINGH, MEMBER

 

         The case of the complainant, in brief is that, she availed medical insurance policy from OPs for cashless hospitalization on 19.11.2015 for sum insured of Rs.10 lakh. It is averred that the complainant while taking policy had specifically mentioned in the proposal form that she was having hypertension/High Blood Pressure since May, 2015 (Ann.C-1). Accordingly, the OPs issued the policy on 19.11.2015 and the same was got renewed till 18.11.2018 (Ann.C-2). 

         It is submitted that the complainant was diagnosed with Osteoarthritis and was recommended total Knew Replacement (TKR) of both legs by Orthopedics Surgeon Dr.Harsimran Singh, Fortis Hospital, Mohali on 22.2.2018.  However, the Opposite Parties rejected the cashless hospitalization request of the complainant for the said treatment.  It is also submitted that since the complainant was suffering from regular pain, she got herself operated for total knee replacement from Fortis Hospital, Mohali from 6.3.2018 to 13.3.2018 and incurred an expenditure of Rs.3,99,093/- from her own pocket. It is alleged that the OPs illegally and wrongly rejected the cashless hospitalization request of the complainant, which amounts to deficiency in service and unfair trade practice 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 as per Pre Anesthesia checkup record and statement of husband, the complainant is found to be suffering from Hypertension since 25 years.  It is stated that before issuance of the policy and at the time of submitting the proposal form, the complainant intentionally did not disclose the correct duration of Hypertension since 25 years and due to said non-disclosure of the fact, the cashless request of the complainant was rejected on 1.3.2018 (Ann.R-4).  It is stated that the claim of the complainant was rightly rejected.  Pleading no deficiency in service or unfair trade practice on the part of Opposite Parties, it is prayed that the complaint be dismissed.

 

3]      Parties led evidence in support of their contentions.

 

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

 

5]       The complainant was insured vide Religare Health Insurance Policy No.10451088 with effect from 19.11.2015 to 18.11.2016, which was renewed upto 18.11.2018 (Ann.C-1 & C-2 Page 13 & 49) for sum insured of Rs.10 lakh.  The complainant while filling-up the proposal form (Ann.C-1 Page 43-45) disclosed having suffering from hypertension since 2005. The complainant’s disclosure of her being suffering from hypertension for the last 10 years has no bearing on the claim lodged by her for reimbursement of the medical expenses incurred on the treatment of her knees replacement on 6.3.2018 at Fortis Hospital, Mohali. The knee replacement has been done on 6.3.2018 i.e. after lapse of specific waiting period of 24 consecutive months of coverage of the insured person, as envisaged in Clause No.4.1 of the insurance policy (Page 25 Ann.C-1). 

 

6]       The Hon’ble National Consumer Disputes Redressal Commission, New Delhi in Revision Petition No.3619 of 2013 – Satish Cahnder Madan Vs. M/s. Bajaj Allianz General Insurance Co. Ltd., decided on 11.1.2016 has held that “Hypertension 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 – Treatment for heart problem cannot be termed as claim in respect of pre-existing disease – Claim was wrongly repudiated.” 

 

7]       The case of hypertension has little relevance or rather has no nexus with knee replacement undertaken by the complainant on the advice of the doctors.  Moreover, she has already disclosed this fact of her having hypertension since 2005 in the proposal form, which was duly accepted by the OPs and consequent thereto only, the policy was issued and renewed twice till 18.11.2018. 

 

8]       The contention raised by the ld.Counsel for the OPs regarding concealment of pre-existing disease of hypertension for the last 25 years is without basis and record.  The Opposite Parties have not produced any reliable and cogent document or medical record in proof of its allegations.

 

9]       Keeping in view the facts, as discussed in the preceding paragraphs, the claim of the complainant for medical reimbursement of Rs.3,99,093/- is found to be genuine and admissible under the terms & conditions of the insurance policy.  The Opposite Parties are found to have indulged into unfair trade practice and deficient in their service too by repudiating the genuine medical claim of the complainant on flimsy grounds. 

 

10]      In view of the above findings, the complaint is allowed with directions to the OPs to jointly & severally reimburse an amount of Rs.3,99,093/- to the complainant with interest @12% p.a. from the date of payment i.e. 13.3.2018 along with litigation cost of Rs.5000/-. 

         The complainant has preferred her private treatment in Fortis Hospital, Mohali, which is expensive, leaving aside Govt. Hospital.  She could have get this treatment from PGI, Chandigarh at half of the cost, which she has spent in private Fortis Hospital.  Hence, this Forum not deem it fit to award any compensatory cost in this matter.  

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

Announced

30^th August, 2018                                                                   Sd/-    

 (RAJAN DEWAN)

PRESIDENT

                                                                                               

Sd/-

                                                                    (PRITI MALHOTRA)

MEMBER

 

Sd/-

(RAVINDER SINGH)

MEMBER