Chandigarh

DF-II

CC/574/2015

Vinay Kumar Saini - Complainant(s)

Versus

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

Ravi Inder SinghAdv

18 May 2016

ORDER

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

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Consumer Complaint  No	:	574 of 2015
Date  of  Institution	:	7.10.2015
Date   of   Decision	:	18.5.2016

 

 

 

 

 

Vinay Kumar  Saini s/o late Sh. Hukmi Ram Saini r/o flat No.451, Jeevan Adhaar Society, Sector 48-A, Chandigarh.

                …..Complainant

Versus

 

Religare Health Insurance company Ltd. through its authorized representative SCO No.28, First floor Sector 20, Chandigarh.

….. Opposite Party

 

BEFORE:  SH.RAJAN DEWAN                 PRESIDENT

         SH.JASWINDER SINGH SIDHU       MEMBER

         MRS.PRITI MALHOTRA             MEMBER

 

 

For complainant(s)      :     Sh. Ravi Inder Adv.  

 

For OP                  :     Sh. Sahil Abhi, Adv.

       

 

 

PER PRITI MALHOTRA, MEMBER

 

 

          As per the case, the complainant purchased a health insurance from the Opposite Party  for a sum insured Rs.8 lacs commencing from 20.8.2015 to 19.8.2016 by paying a premium of Rs.19,334/- and accordingly insurance certificate was issued to the complainant Annexure C-1 (colly). On 26.9.2015 the complainant was admitted in silver oaks hospital Moahli for fever, body ache/headache, Nausea/vomiting and was discharged on 2.10.2015. The hospital raised a bill of Rs.41,960/- and Rs.6451/- was charged by the chemist for the medicines prescribed. During his hospitalization the complainant informed the hospital that he is insured with OP and accordingly a request to Opposite Party for cashless hospitalization was made by filing a form duly signed by the complainant alongwith requisite documents. It is alleged that the Opposite Party vide letter dated 1.10.2015 rejected the claim of the complainant for cashless hospitalization on the ground of concealment of material facts stating that the complainant is having history of depression and he did not disclose the same to the Opposite Party at the time of policy.   It is pleaded that the complainant had never been in depression and had been hospitalized for depression ever. Alleging deficiency in rendering service for the aforesaid act of repudiation of the claim by the Opposite Party the instant complaint has been filed with prayer to direct the Opposite Party to reimburse Rs.48,411/- alongwith interest @18% p.a., to pay Rs.1.00 lac as compensation for deficiency in service and causing mental agony and physical harassment and Rs.50,000/- as costs of litigation.

 

2.     The Opposite Party while admitting the factual matrix of the case stated that the cashless request of the complainant was declined on the ground that the complainant is a known case of having history of depression for which he had similar episode in 2012 which was also not disclosed at the time of policy  inception. Since these past medical history facts were not disclosed in the proposal form submitted by the complainant at the time of obtaining the insurance policy from the Opposite Party, the cashless request was declined on ground of non-disclosure of material facts/pre-existing ailments at the time of proposal based on clause 9 of the policy terms and conditions which has been inadvertently mentioned as clause 6.1 in the rejection letter dated 1.10.2015.  It is further stated that the rejection of claim of the complainant is legal and as per terms and conditions of the contract of insurance being  enforceable under the eyes of law. Pleading no deficiency in service and denying rest of the allegations, it is prayed that the complaint be dismissed.
3.     The Complainant also filed rejoinder thereby reiterating the averments as made in complaint and controverting that of the Opposite Party made in the reply.
4.     Parties led evidence in support of their contentions.
5.     We have heard the ld. Counsel for the parties and have also perused the record.

    There is no dispute qua issuance of policy to the complainant by the Opposite Party  for the period from 20.8.2015 to 19.8.2016. There is also no dispute qua hospitalization of the complainant and the treatment taken for the period from 26.9.2015 to 2.10.2015. It is not disputed that for availing the said treatment the complainant incurred Rs.48,411/- in toto.  It is admitted by the Opposite Party that the complainant applied for cashless hospitalization to the Opposite Party but it declined the same vide letter dated 1.10.2015 in view of clause 9 of the policy which  inadvertently got mentioned as clause 6.2 in the repudiation letter of the Opposite Party. According to the complainant the repudiation of the claim by the Opposite Party is arbitrary and illegal.

6.     The only defense of Opposite Party in rejecting the claim relates to suppression of certain facts which it claimed to be material. It is claimed by the Opposite Party that the complainant is guilty of non disclosure of his previous ailment that he is having history of depression which had similar episode in 2012 and thus not entitled for the claim in question.
7.     It is gathered from the record that the complainant denied the factum of suffering from depression and also denied any hospitalization on that account and at the same time the Opposite Party has not placed on record any cogent and independent evidence to prove the fact that the complainant remained a patient of depression in the year 2012 and had also been hospitalized for the same. No. hospitalization  record pertaining to that period has been placed on record by the Opposite Party. There is no evidence on record to show what efforts the Opposite Party made to confirm the factum  of previous treatment availed by the complainant  in the year 2012 in order to fortify their repudiation.  
8.      It is well proved on record that before issuance of policy in question the complainant undergone all the medical tests as required by the Opposite Party and it is only after thorough medical examination as well as examination of the medical reports and other documents the complainant was issued the present policy. Thus it is suffice to say that the present policy was issued to the complainant after thorough verification of all the aspects including the health status  of the proposor in question. The Opposite Party was when approached for the cashless benefit under the given policy they enquired from the hospital about the medical status of the complainant as well as about the previous medical history of the complainant. Record reveals that no where it was disclosed by the hospital concerned that the complainant had history of depression or is being treated for the same. It is observed that the Opposite Party had placed reliance on the statement mentioned in column 9 of the questionnaire claimed to have been answered by the insured which is placed on record by the Opposite Party at page 86 of the paper book of its written statement, which has categorically been denied by the complainant in his replication. It has been pleaded by the complainant in his replication that the statement given in the above said questionnaire is not of the complainant and the same has been tampered by the Opposite Party because the Opposite Party got the said form duly filled in from the complainant and got the signatures of the complainant on the bottom of the page leaving space in between the signatures and filled box. The record on file is enough to state that the Opposite Party did not try to elucidate the truth of treatment taken by the complainant in the year 2012 and found it easy to just rely upon the aforementioned statement mentioned in column 9 of the questionnaire of the insured, which otherwise the complainant completely denied. Thus in our opinion the ground of rejection of the claim is altogether illegal and not tenable in the eyes of law and the Opposite Party unnecessarily caused mental agony and physical harassment to the complainant by rejecting his rightful claim. Reliance is placed on the various judgments placed on record by the complainant  i.e. United India Insurance Co. LTd. and anr. Vs. S.K. Gandhi decided on 5.1.2015, Life Insruance Corporation of India Vs. Priya Sharma and ors decided on 2.11.2012, Bajaj Allianz life Insruanace Company Ltd. Vs. Sowbhagyalaxmi and Ors. decided on 2.11.2012and   New India Assurance Co. LTd. Vs. Arun Krishan Puri decided on 4.3.2009 decided by the Hon’ble National Commission wherein it has been held that onus is on the Opposite Party to prove that the insured was suffering from pre-existing disease.  The aforesaid judgments are fully applicable in the instant case as the OP in this case failed to prove that the complainant was suffering from pre-existing disease.  As such we find merit in the complaint and the same deserves to be allowed.
9.     In view of the above discussion, we are of the opinion that deficiency in service on the part of the Opposite Party is proved and the present complaint deserves to be allowed.  Accordingly, the complaint is allowed and the Opposite Party is directed as under;

        

a]  To reimburse the expenses incurred by the complainant for his treatment amounting to Rs.48,411/-.

 

b]  To pay Rs.10,000/- as compensation to the complainant for deficient service rendered by the Opposite Party.

C]  To pay Rs.5,000/- towards litigation expenses.

 

         The above said order shall be complied with by the Opposite Parties within 45 days of its receipt, failing which they shall be liable to pay interest on the above awarded amounts at (a)  and (b) @12% p.a. from the date of this order till it is paid, besides paying litigation expenses.

 

         The certified copy of this order be sent to the parties free of charge, after which the file be consigned.

Announced

18.5.2016

                                                                                       Sd/-

 (RAJAN DEWAN)

PRESIDENT

 

 

Sd/-

 (JASWINDER SINGH SIDHU)

MEMBER

 

Sd/-

(PRITI MALHOTRA)

MEMBER