Dt. of filing- 05/03/2018
Dt. of Judgement- 21/08/2019
Mrs. Sashi Kala Basu, Hon’ble President.
This complaint is filed under Section 12 of the Consumer Protection Act, 1986 by the complainant Amit Majumdar against Opposite Party namely Religare Health Insurance Co. Ltd. alleging deficiency in service on its part.
Case of the complainant in short is that complainant is the Policy Holder of the OP being Policy Number 10308676 and during the validity period of Policy, his wife was admitted in the Vision Care Hospital on 11.05.2017 due to severe stomach pain and was discharged from the hospital on 15.05.2017. Complainant paid a total sum of Rs.101900/- towards medical bill. But when complainant claimed the said amount from the OP, OP refused on the ground of “nondisclosure at the time of policy inception (psychometric disorder )”. Complainant again wrote to OP stating that the health insurance policy was taken in the month of June , 2015 but the psychiatric advice for his wife namely Debjani Majumder from Dr. Abir Mukherjee was given on 11.08.2016 and 25.08.2016 and his wife was not affiliated with any sort of psychometric disorder at the time of inception of the said health insurance on 06.07.2015. On 20.06.2017 complainant again wrote to the OP that the said claim is for acute pancreatitis as diagnosed by the hospital. He also sent a notice through his Ld. Advocate but OP did not Pay the amount and thus present complaint is filed praying for directing OP to pay mediclaim amount of Rs. 101900/-with interest @ 18%, to pay Rs. 30,000/- compensation and litigation cost.
Complainant has annexed with the complaint petition, copy of medical bills including prescription and discharge summary, copy of letters exchanged between the parties and copy of notice dt. 19.12.2017 sent by the complainant through his Ld. Advocate.
Opposite Party has contested the case by filing of written version denying and disputing the allegations contending inter alia that as per discharge summary dated 10.05.2017, insured is also mentioned to have a history of “ some psychiatric illness on medication”. As per prescription note of Dr. Abir Mukherjee (Psychiatrist) dated 11.08.2016, the insured is mentioned to have history of “Insomnia second to Anxiety( Psychatric Disorder ) for more than 10 years”, which is before the inception of the Policy Period. So, for such non-disclosure as per Clause 6.1 of the Policy’s terms and conditions, company shall have no liability to make payment of any claim and premium paid is liable to be forfeited by the company. Thus the OP has prayed for dismissal of the case.
During the course of the evidence, both parties have filed their respective evidence followed by filing of questionnaire and reply thereto. Ultimately written notes of arguments have also been filed by both the parties and they have also advanced their argument.
So, following points require to be determined:-
- Whether there has been any deficiency in service on the part of OP ?
- Whether the complainant is entitled to the reliefs as prayed ?
Decision with reason
Both the points are taken up together for a comprehensive discussions.
The claim of the complainant that he is a Policy Holder of health insurance being Policy No 10308676 and the said policy was firstly incepted on 06.07.2015 and ended on 05.07.2016 and thereafter it renewed from 06.07.2016 to till 05.07.2017, is not a disputed fact. It is also an admitted fact that policy also covered wife of the complainant and his daughter. There is also no dispute that the wife of the complainant namely Debjani Majumder was admitted in the Vision Care Hospital on 11.05.2017 and was discharged on 15.05.2017. Complainant has also filed the discharge summary along with prescription and final medical bills.
Only contention which has been raised by the OP is that they rejected the claim in view of Clause 6.1 of the Policy’s terms and conditions. Clause 6.1 of the policy specifies that –
“ If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particulars or any material information having been withheld or if a claim is fraudulently made or any fraudulent means or devices are used by the policy holder or is insured person or any one acting on his/her behalf, the company shall have no liability to make payment of any claim and the premium paid shall be forfeited to the company”.
According to OP, complainant did not disclose about the history of some psychiatric illness and that his wife i.e. the insured had history of “Insomnia second to Anxiety ( Psychiatric disorder ) for more than 10 years”.
On perusal of discharge summary issued on 15.05.2017, it appears that the patient was admitted for pain in the Left Lower Abdomen for one day, vomiting several times. Discharge diagnosis is stated “Acute Pancritities”suggesting that she was diagnosed and treated for acute Pancreatitis. However, in the column past history it is stated in the discharge summary “ history of some psychiatric illness on medication”. The OPD prescription dated 11.08.2016 filed by the OP indicates that Dr. Abir Mukherjee who examined the patient on 11.08.2016 has mentioned history of “Insomnia most probably second to anxiety for 10 years has been suffering disorder ( now 2 mg of Alprazolm ) +zolpide ( 1mg) for few years”.
On the date of admission at Vision Care Hospital i.e. on 11.05.2017 also towards caption history of present illness it has been stated “history of some psychiatric illness”. These medical prescription has not been disputed by the complainant but has only contended that on the date of inception of the policy in 2015, there is no document of phscriatric illness of his wife and has urged that the relevant prescription are dated 11.08.2016 and 11.05.2017. So, the question is whether there has been non-disclosure and mis-representation as per Clause 6.1 of the Policy ? It is apparent that history has been stated either by the patient or by the patient party accompanying her. If that be so, than OPD prescription referred to above makes it very clear that the wife of the complainant was suffering from Insomnia for 10 years and disorder since few years. She had been taking tablets namely Alprazolam ( 2 mg) and Zolpidem for Insomnia and disorder as stated in the OPD prescription. So the claim of the complainant that at the time of inception of policy, patient did not have any such illness of disorder, cannot be accepted. In such a situation as per terms and conditions in the Clause 6.1 of the policy, since complainant did not disclose the fact of his wife suffering from Insomnia and disorder at the time of taking the policy, OP’s refusal to pay the amount towards treatment, cannot be termed as unfair trade practice or deficiency in service. If the complainant had disclosed, his wife was suffering from Insomnia and disorder and was under medication, OP might not have entered into contract with the complainant. In such view of the matter, complaint is liable to be dismissed.
Hence,
Ordered
CC/100/2018 is dismissed on contest.
