BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.340 of 2017
Date of Instt. 15.09.2017
Date of Decision: 29.10.2019
- Sorabh Tayal S/o Shri Ashok Kumar
- Seema Tayal W/o Shri Sorabh Tayal
Both R/o H.No. 5-C, Aman Nagar, Jalandhar, Punjab.
..........Complainants
Versus
1. Religare Health Insurance Company Ltd., PUDA Complex, Near OBC Bank, Near LIC Building, Jalandhar – 144001 through its Chairman/ Directors/ Branch Manager/ Principal Officer.
2. Star Health and Allied Insurance Company Ltd., EH 198, Second Floor, Nirmal Complex, G.T. Road, Jalandhar. Through its Chairman/ Directors/ Branch Manager/ Principal Officer.
….….. Opposite Parties
Complaint Under Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Sh. Atul Malhotra, Adv. Counsel for the Complainant.
Sh. Raman Kumar Sharma, Adv. Counsel for the OP No.1
Sh. Nitish Arora & Sh. A.K. Arora Advocates Counsel for OP No.2
Order
Karnail Singh (President)
1. The instant complaint has been filed by the complainant, wherein alleged that complainants are consumers of the insurance services provided by opposite parties. After receiving due premium of Rs. 10,584/- from complainants at Jalandhar, OP No.1 issued an insurance policy bearing No. 10131575 for a sum of Rs. 5,00,000/- to complainants at Jalandhar which was valid from 3/8/2014 to 2/8/2015. Just before the conclusion of above said policy on 2/8/2015, complainant ported the insurance policy from OP No.1 to OP No.2. Complainant got issued another insurance policy in continuation to the above said insurance policy from OP No.2. OP No.2 after receiving the due premium of Rs. 9,462/- from complainants at Jalandhar issued a Policy No. P/161125/01/2016/001103 valid from 3/8/2015 to 2/8/2016 along with recharge benefit of Rs. 1,50,000/-. The said policy was issued by OP No.2 under portability from earlier insurance policy and in continuation of earlier insurance policy of complainants. The premium was received and accepted by OP No.2 on 29/7/2015 through their agent namely Lakshya Saini at Jalandhar.
2. That at the time of portability, making the payment of premium and at the time of issuing said insurance policy from OP No.2. Complainants had informed the OP No.2 and their agent namely Lakshya Saini about cough of complainant No.2 though complainants never knew about the actual problem and it looked to be minor coughing and congestion. But despite providing the information about the coughing of complainant No.2, OP No.2 and its agent did not feel the requirement to get complainant No.2 medically examined from their panel of doctors and accepted the premium and issued the policy. Moreover, the agent of OP No.2 and OP No.2 had assured themselves that it is only minor problem of cough. Thereafter complainant No.2 felt persistent coughing problem and approached the doctors at Central Hospital and Maternity Home on 23/7/2015 for the first time. The doctors diagnosed as simple coughing and congestion and advised steam from seven days. Thereafter when the problem persisted and complainant No.2 could not get any relief for seven days, complainant No.2 again approached the doctor Yash Sharma in the said hospital on 31/7/2015. On 31/7/2015, the doctor advised complainants to get X ray and CT scan. In the mean time, complainants had completed formalities for getting insurance policy ported from OP No.1 to OP No.2 and OP No.2 had accepted premium on 29/7/2015. Thereafter complainant No.2 got X ray and CT scan conducted on 1/8/2015 from Super Scanning and Diagnostic Pvt. Ltd., Jalandhar. At this stage, complainants for the first time came to know that complainant No.2 is suffering from some problem in the throat as informed by the doctors after perusing the X ray and CT scan. Then complainants consulted doctors who advised complainant No.2 to get the surgery conducted. On the advice of doctors, complainant No.2 was referred to Fortis Hospital, Ludhiana. Complainant No.2 was admitted in Fortis Hospital, Ludhiana on 11/8/2015 and was discharged on 14/8/2015. Complainants had to spend about Rs. 3,00,000/- on the operation, special diet. Moreover complainant No.2 is not healed up fully till date and still needs medical treatment. Complainants are not satisfied with the treatment of Fortis Hospital, Ludhiana and now Fortis Hospital, Ludhiana and its doctors have referred complainant No.2 to AIIMS, New Delhi for further treatment. Complainants had informed OP No.2 about the problem and had raised the claim with OP No.2 immediately without any delay and had submitted all the required documents as and when demanded by the OP No.2. But initially, OP No.2 illegally and arbitrarily refused to make the payment of cashless insurance claim to complainants.
3. That thereafter on 4/11/2015, OP No.2 illegally, arbitrarily repudiated the claim of complainants vide letter dated 4/11/2015. Complainants have been pursuing the claim before OP No.2 initially because the operation and other expenditures were made during the pendency of insurance policy issued by OP No.2. Moreover complainants were under the impression that the claim was to be filed with OP No.2 only.
4. Thereafter complainants also raised claim with OP No.1 since as per the policy terms and conditions. Complainants could raise their claim with OP No.1 also. Complainant had sent a notice under registered post to OP No.1 along with all documents and raised claim for Rs. 5,00,000/-. But even after the receipt of the said notice, OP No.1 has failed to give any reply of the said notice. As such, both the OPs are liable to make payment of the claim of the complainants. Thereafter complainants had also filed another claim with OP No.2 which was also denied and repudiated the claim of the complainant vide letter dated 13/5/2016. The act and conduct of both the opposite parties tantamount to deficiency in service and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay Rs. 9,00,000/- to complainants for deficiency in services, negligence, unfair trade practice and restrictive trade practices on the part of the OPs due to which the complainants suffered mental tension, harassment and further OPs be directed to pay litigation expenses of Rs. 11,000/- and further any other relief for which the complainants are entitled.
5. Notice of the complaint was given to the OPs and accordingly, OP No.1 appeared through its counsel and filed written reply whereby contested the complaint by taking preliminary objections that the present complaint is not maintainable against the answering OP No.1 as the period of treatment of the complainant No.2 was for the period 11/8/2015 to 14/8/2015. However, the complainant No.2 was insured with this answering respondent from 3/8/2014 to 2/8/2015 which did not cover the period of hospitalization. Hence the complaint against the answering OP No.1 is liable to be dismissed and further alleged that complainants were fully aware that treatment of the complainant was taken during the subsistence of insurance policy issued by OP NO.2 Star Health and Allied Insurance Co. Ltd. and consequently claim arose during the subsistence of insurance policy issued by OP No.2 and claim was lodged with OP No.2 and only after repudiation of the claim of the complainants by OP No.2, the complainants lodged the claim with the answering OP No.1 and further submitted that claim of the complainant with OP No.1 was not maintainable as it did not fall in the policy period, as such the claim of the complainant No.2 was rightly repudiated and further aware that there is no deficiency in service or negligence on the part of answering OP No.1. On merits, it is admitted that complainants took insurance policy from the answering OP but treatment period of complainant No.2 was after the expiry of insurance policy taken from OP No.1. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
6. OP No.2 filed its separate reply and contested the complaint by taking preliminary objections that complainant No.2 was admitted in Fortis Hospital, Ludhiana with complaint of breathing difficulty & change of voice i.e. treatment of emergency tracheostomy with diagnostic laryngoscopy. The claim of the complainant No.2 amounting to Rs. 12,994/- was reported on the 9th day of inception of the policy. Further the complainants submitted the inpatient history and physical record in response to the query letter dated 13/8/2015 of the answering OP which stated that that patient was suffering from breathlessness since one and half months i.e. prior to the inception of the policy and was unable to do anything. The discharge summary of the said hospital also disclosed that the complainant developed the problem of breathlessness at rest two months back. It was further revealed that insured had consulted Central Hospital & Maternity Home on 23/7/2015 for stridor and on the advised of doctor to undergo Citi Scan. It is further alleged that complainant had never disclosed the aforesaid facts in the proposal form while porting his policy from OP No.1 on 3/8/2015. Moreover, the CT report which clearly showed that the complainant has subglottic stenosis is dated 1/8/2015 but this was not disclosed to the answering OP. The non-disclosure of these material facts at the time of taking of insurance policy from the answering opposite party amounts to misrepresentation by the complainant therefore, the claim of the complainant was rightly repudiated by the answering opposite party and was communicated to the insured. On merits, it is admitted that complainants purchased insurance policy from OP No.1 and further admitted by the parties that said policy was got ported by the complainant from OP No.1 to OP No.2 and also admitted that insurance claim of the complainant was repudiated according to rules and regulations of the insurance policy but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
7. Rejoinder not filed. In order to prove the case of the complainant, counsel for complainant tendered into evidence affidavit of complainant Ex.CA and some documents Ex.C-1 to Ex.C-95 and closed his evidence.
8. Similarly, counsel for the OP No.1 tendered into evidence affidavit Ex.OP1/A along with some documents Ex.O-1/A to Ex.O-3/A and closed the evidence. Counsel for OP No.2 tendered into evidence affidavit Ex. OP2/A along with some documents Ex. OP-1 to Ex. OP-18 and closed the evidence.
9. We bestowed our thoughtful consideration to the argument put forth by the learned counsel for the respective parties and also scanned the written arguments submitted by learned counsel for the complainant as well as learned counsel for the OP No.2.
10. After considering the overall circumstances put before us by the respective counsel for the parties and whereby we find that the factum in regard to purchase of insurance policy by the complainant from OP No.1 regarding period 3/8/2014 to 2/8/2015 is not denied and it is further admitted by the parties that said policy was got ported by the complainant from OP No.1 to OP No.2 for the further period 3/8/2015 to 2/8/2016. It is also not denied by either of the parties that complainant No.2 got treatment from different hospitals and submitted insurance claim bill firstly with OP No.2 and then OP No.1 and both the OPs repudiated the said insurance claim of the complainant No.2, after considering the same and then complainant came to this Forum and filed the instant complaint.
11. Now, first of all, we have to consider the liability of OP No.1, who issued the insurance policy to the complainant for the period 3/8/2014 to 2/8/2015. It reveals from the discharge summary Ex. OP-11, that complainant admitted in the hospital on 11/8/2015 and the policy issued by OP No.1 was expired on 2/8/2015 means much prior to the date of admission in the hospital i.e. 11/8/2015. So as per settled principle of law, complainant can claim only insurance claim for the period of the insurance policy but can’t claim any insurance after the expiry of the insurance policy and admittedly in this case, the claim in regard to admission in hospital is after the expiry of the insurance policy issued by OP No.1 and therefore, we are of the considered opinion that claim of the complainant have been rightly repudiated by OP No.1.
12. Coming to the case of the complainant qua OP No.2. OP No.2 also repudiated the claim of the complainant vide repudiation letter Ex. C60 dated 4/11/2015 wherein the OP No.2 while rejecting the claim as under:-
“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of emergency tracheostomy with diagnostic laryngoscopy.
It is observed from the indoor case records of the above hospital that the insured patient is having breathlessness i.e. symptomatic of the above disease for the past 1 ½ months which is prior to our policy. The CT report dated 1/8/2015 shows subglottic stenosis. These finding confirm the insured patient has the above disease prior to policy.
You have earlier taken medical insurance policy from Religare Health Insurance for the period from 3/8/2014 to 2/8/2015 and subsequently taken policy from our company from 3/8/2015 to 2/8/2016 under portability.
At the time of portability, you have not disclosed the above mentioned medical history/ health details of the insured-person in the proposal form and other documents which amounts to misrepresentation/ non-disclosure of material facts”.
13. If we analyze the above observation of the OP No.2 while repudiating the claim of the complainant, then we can say without any hesitation that complainant No.2 virtually concealed the disease which is persistent two months prior to inception of the policy and this fact is very well within the knowledge of the complainant No.2. Complainants themselves stated in Para No.5 of the complaint that complainant No.2 approached the doctors at Central Hospital and Maternity Home on 23/7/2015 for the first time and after diagnosing of the complainant No.2, doctors told it as simple coughing and congestion and advised steam for seven days and then complainant consulted at other doctor Yash Sharma on 31/7/2015 who advised to complainant No.2 to get X ray and CT scan. Thereafter complainant got CT scan conducted on 1/8/2015, this fact has been mentioned in Para No.6 of the complaint. So from these pleadings, we observed that complainant was well aware about his disease much prior to inception of the policy from OP No.2 i.e. 3/8/2015. The pleadings of the complainant is further fortified with other documentary evidence that treatment taken from Central Hospital and Maternity Home on 23/7/2015 and its description slip Ex. C3 and CT Scan report Ex. C4 dated 1/8/2015 and further discharge summary Ex. O-2/A established that complainant got himself admitted in the hospital on 11/8/2015 wherein doctor categorically mentioned that “patient was apparently well 2 months back when she developed complaints of breathlessness at rest which increased with work”. The said discharge summary is Ex. O-11/A and further report of the Fortis Hospital Ex. OP9 established that complainant was having the same problem for the last 1 ½ months but despite knowing that the complainant was having some breathlessness problem but the complainant intentionally did not disclose to OP No.2 while filing proposal form Ex. O17. So from all angles, the complainant has concealed the pre-existing disease and as per terms and conditions of the insurance policy, if any insured misrepresent to the insurance company then company is not liable to make any payment or compensation. So in these circumstances, the rulings referred by learned counsel for the complainant in his written arguments are not applicable in the present case.
14. In view of the above detailed discussion, complaint of the complainant fails and accordingly same is dismissed with no order as to costs. Parties will bear their own costs. This complaint could not be decided within stipulated time frame due to rush of work.
15. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Karnail Singh
29.10.2019 Member President
