District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No. 620/2019.
Date of Institution:16.12.2019.
Date of Order: 17.02.2023.
Mohit Malhotra S/o Shri Jogesh Kumar Malhotra, House No. 284, Near Holy child School, Sector-29, Faridabad, Haryana.
…….Complainant……..
Versus
Religare Health Insurance Company Limited, Regd. Office: 5th floor, 19 Chawla House, Nehru Place, New Delhi – 110 019.
Also at
Corresp. Office – Vipul Tech Square, Tower C, 3rd floor, Golf Course Road, Secto-43, Gurugram – 122009.
…Opposite parties……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana………….Member.
PRESENT: Sh. Ganesh Chand Sharma, counsel for the complainant.
Sh. P.L.Garg, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant on believing the version of the opposite party and under the influence of the facilities to be provided by the opposite party took the mediclaim policy and the same was issued to the complainant on 11.01.2017. The details of the policy are:
Policy No. : 10946302.
Client ID of policy Holder : 55084806
Client ID of policy insured : 55084807
Pre-existing disease : None
Sum insured : Rs.5,00,000/-
Tenure : 06.01.2017 – 05.01.2018.
While issuing the policy and to insure the father of the complainant the opposite party duly conducted the medical examination of the father of the complainant and taken on record the full body check up vide Accesssion NO. 0071QA000852 dated 08.01.20917 from SRL Diagnostics. On 08.01.2017 Dr. Sidharth Bawa of opposite party conducted the medical examination of the insured i.e. the father of the policy holder complainant herein. The medical examiner gave its comments on Electro Cardio Gram (ECG) as normal. The opposite party duly conduct the medical examination of the insured father of the complainant and found all parameters normal. Before the renewal of the aforesaid policy in the month of December 2017 the agent of the opposite party approached the policy holder and lured the policy holder for increasing the sum insured of the policy by quoting that “aapke father ki age jyada hai kabhi bhi kuch medical problem hui to 2 lack kaaur benefit ho sakta hai bas thoda aur jyada premium lagega”. The complainant believed the version of the opposite paprty agreed to the proposal and paid total premium of Rs.20,503/- for the total sum insured to the tune of Rs.7,00,000/-. On 17.12.2018 the father of the complainant and the insured in the policy got admitted at Asian Institute of Medical Sciences at Faridabad with the complaint of “anorexia, constipation, breathing difficulty, pedal edema on and off since one month and walking difficulty since 2 month.” After the diagnosis the father of the complainant diagnosed with Rapidly Progressive Glomerulonephritis (CANCA +ve/CRESENTIC GN (PAUCI – IMMUNE), Hypertension and anemia. The patient had not suffering from any kind of illness and any pre existing disease when he got insured by the opposite party. It was further submitted that the opposite party conducted the complete medical examination upto their satisfaction and issued the mediclaim policy with all benefits as per the policy. On 18.12.2018 the complainant applied for the cashless benefit of the policy issued by the opposite party but the opposite party sent a denial letter dated 18.12.2018 with remarks “Non disclosure of material facts/pre existing ailments at time of proposal (H/o of the medicalim policy to the policy holder had done complete medical check up of the insured the father of the policy holder and did not find any symptom related to hypertension. After a span of almost 2 years since the insurance of the first mediclaim policy the father of the complainant suddenly suffered from the aforementioned complaints and the same was not at all present at the time of the issuance of the mediclaim policy. After the discharge of the father of the complainant on 28.12.2018 the total bill of the said treatment was Rs. 3,07,130/- and the insured sum of the mediclaim policy was Rs.7,00,000/-. It was submitted that the opposite party with fraudulent intention to cheat the policy holder did not discharge its liability to pay the medical bills and expenses covered under the policy cover rather denied the payment by citing the frivolous reason of non – disclosure which was completely vague and unscrupulous. The patient fortunately having another mediclaim policy and got his bills by the said policy but cheated and deceived by the opposite party after extorting premium twice from the complainant by making false promise and statements. Opposite party then again lured the complainant that he pay the premium this time and the issue would not raise again and make the complainant to pay a further premium of Rs.231,358/- for mediclaim policy for the period of 04.02.2019 to 03.02.2020 and a policy certificate was issued and in the same also the pre existing disease was marked as none. It was evinced from the policy certificate dated 03.02.2019 that the opposite party had deliberately denied the claim of the insured and just extorting the money of the innocent people. On 20.01.2019 the complainant wrote an email to the opposite party seeking clarification on two points as under:
i) As the policy renewal date was elapsed i.e. 05.01.2019 and running under grace period. What would be the impact of his false interpretation of hypertension mentioned in his denial letter on this policy henceforth. It should be appraised to him what would nbe the impact of this on any future claim, if anyt arises in future year. (Please provide him detailed reply alongwith referring the policy clauses).
ii) The same fact was put to the company customer care executive but he wasn’t able to help neither with regard to further renewal decision nor with regard to impact of the denial letter facts on the policy henceforth. Based on his reply to above mentioned query the decision with regard to the renewal would be taken. The opposite party then admitted their fault and asked the complainant to file the reimbursement claim vide email dated 01.02.2019 on which the complainant sent reply vide email dated 01.02.2019 for taking informed decision for renewal of policy. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) pay Rs. 9,00,000/- as compensation for causing mental agony and harassment .
b) disclose the status of the existing mediclaim policy NO. 10946302 going to be expired on 03.02.2020 with client ID 55024807 of the insured with all benefits and complete details in the interest of justice.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the complainant had taken a Health insu8rance Policy bearing No. 10946302 covering the complainant’s father Jogesh Kumar w.e.f. 6.1.2017 to 5.1.2018 for the insured sum of Rs.5,00,000/-. The said policy was further renewed on annual basis till 3.2.2021. The sum insured was enhanced to Rs.7,00,000/-. The complainant through its treating hospital applied for a cashless request vide claim No. 80233457 with respect to the hospitalization of the insured namely Jogesh Kumar w.e.f 17.12.2018 at Asian Institute of medical Sciences Faridabad for an expected amount of Rs.40,000/- as per the cashless request form, the hospitalization was for the treatment of provisional diagnoses of Urosepsis, AKI Pedal Edema. The opposite party company in receipt of the claim sent a deficiency letter dated 17.12.2018 to the hospital to provide the following documents necessary for proper assessment of the claim:
i) Exact duration and past history of present ailment with Ist consultation paper and all past treatment records.
ii) Investigation report supporting diagnosis.
iii) Pre hospitalization OPD treatment record.
The hospital/complainant sent the documents with the quarry reply. After perusal of the documents submitted by the hospital, the opposite party company rejected the claim of the complainant vide denial letter dated 18.12.2018 with the following observation:
Non disclosure of material facts/pre-existing ailments at the time of proposal (H/o Hypertension since prior to policy inception).
Non disclosure
The following documents establish non disclosure of material facts on the part of the complainant:
a) As per the cashless form, insured was mentioned to have history of hypertension.
b) As per the history sheet of the Asian Hospital dated17.12.2018, the insured was mentioned to have history of HTN since 1 and half years.
c) As per the AVR recording the insured mentions that insured was taking treatment from care well Hospital since 3-4 years back for HTN and was on medication of Tab Telma.
Accordingly, the cashless was denied and same was informed to the complainant vide letter dated 18.12.2018.
The complainant had an opportunity to declare his history of pre-existing ailments of hypertension at the time of filing online proposal form, but the complainant intentionally did not disclose the same to the opposite party company in the proposal form, the following mis-declaration was made by the complainant/policy holder:
Does any person(s) to be insured had any pre-existing disease
Insured-1 – No.
Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite party– Religare Health Insurance Company Limited with the prayer to: a) pay Rs. 9,00,000/- as compensation for causing mental agony and harassment .b)
disclose the status of the existing mediclaim policy NO. 10946302 going to be expired on 03.02.2020 with client ID 55024807 of the insured with all benefits and complete details in the interest of justice.
To establish his case the complainant has led in his evidence, Ex.CW1/A – affidavit of Mohit Malhotra, Annx.C-1 – policy, Annexure C-2 – Test Report Status,, Annexue C3 – Medical Examination Form, Annx.C4 – policy certificate, Annexure C-5 – Discharge summary, Anneaxue C6 – Denial letter, Annexure C-7 – Finall Bill Summary, Annexue C8 - letter dated 3.2.2019, Annexue C9 – email, Annexure C-10 & 11.
On the other hand counsel for the opposite party strongly agitated and
opposed. As per the evidence of the opposite party Ex.RW1/A – affidavit of Shri Ravi Boolchandani, Manager-Lega; M/s. Care Health Insurance Ltd. (formerly known as M/s. Religare Health Insurance co. Ltd.) Care Health Insurance Limited, Vipul Tech Square, Tower C, 3rd floor,, Sector-43, Golf Course Road, Gurgaon, Ex.R-1 – Policy certificate, Ex.R-2 – Request for Cashless Hospitalizaiton for Medical Insurance Policy, Ex.R-3 – Deficiency letter dated 17.12.2018, Ex.R-4 – denial letter dated 18.12.2018, Ex.R-5 – TPA Declaration of patient/attandent, Ex.R-7 - affidavit under section 65-D of the Indian Evidence at, 1872, Ex.R-8 – proposal form “Care”, Ex.R-9 – email dated 01.02.2019.
6. In this complaint, the complaint was filed by the complainant with the prayer to a) pay Rs. 9,00,000/- as compensation for causing mental agony and harassment b)disclose the status of the existing mediclaim policy NO. 10946302 going to be expired on 03.02.2020 with client ID 55024807 of the insured with all benefits and complete details in the interest of justice.
7. As per complaint, the complainant has got two mediclaim policies one from Religare health Insurance Company Limited and other from other company. During the course of arguments, the counsel for the complainant has argued at length and stated at Bar that he is only pressing the litigation and harassment because opposite party has denied their cashless vide letter dated 18.12.2018 on the ground that (i)“Non Disclosure of material facts/pre-existing ailments at the time of proposal (H/O Hypertension since prior to policy inception. (ii) Non Disclosure, vide Ex.R-4. The complainant has been reimbursed his mediclaim bill from the other carrier i.e Bajaj Allianz because he has got two mediclaim policies.
8. After going through the evidence led by the complainant, no doubt there was denial letter dated 18.04.2018 vide Ex.R-4 on the ground that due to hypertension which was not disclosed by the complainant at the time of getting the insurance medicalim policy form the opposite party. It is evident from proposal Form vide Ex,R-8 in which it has been mentioned in Additional Details column :
A. Does any person(s) to be insured has any pre-existing disease?
Insured 1 (No)
B. Have any of the person(s) to be insured ever filed a claim with their current/previous insurer?
Insured 1 (no)
C. Has any proposal for Health Insurance been declined cancelled or charged a higher premium?
Insured 1 (No)
D. Is any of the person(s) to be insured, already covered under any other health insurance policy of Religare Health Insurance?
Insured 1 (No)
As per Cashless form Vide Ex.R2 insured is mentioned to have history of Hypertension – Yes. As per TPA Declaration of patient/attendant vide Ex.R-5 that insured is mentioned to have history of Hypertension since 1 and half years. It shows that there is no deficiency in service on the part of opposite party to repudiate the cashless on non disclosure and misrepresentation done by the complainant.
9. Keeping in view of the above submission, the Commission is of the opinion that no deficiency in service on the part of the opposite party has been proved. Resultantly, the complaint is dismissed. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 17.02.2023 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
