District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.640/2019.
Date of Institution: 24.12.2019.
Date of Order: 02.08.2022.
Vinod Grover S/o Mehar Chand R/o House No. 3C-185, near Police Post, NH-3, Faridabad, Haryana, Aged 60 years.
Anmol Grover S/o Vinod Grover R/o House No. 3C-185, Near Police Post, NH-3, Faridabad, Haryana, aged 24 years,
…….Complainants……..
Versus
1. Religare Health Insurance Company, U nit No. 604-607, 6th floor, Tower-C, Unitech Cyber Park, Sector-39, Gurugram-122001.
2. The New India Assurance Co. Ltd., NH-5-R/2, NEAR Badshah Khan Chowk, NIT, Faridabad, Haryana – 121001.
3. Policy Bazar Insurance Web Aggregator Pvt. Ltd. Plot NO. 119, Sector-44, Gurugrma, Haryana.
…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.
PRESENT: Sh. Dharmender Dagar, counsel for the Complainant.
Sh. N.K.Garg, counsel for opposite party No.1.
Sh. D.K.Gosain, counsel for opposite party No.2.
Sh. Saurabh Gupta, counsel for opposite party No.3.
ORDER:
The facts in brief of the complaint are that the complainant was a member of floater cashless medical health policy bearing policy No. 14056096 from 21st April 2019 – 20th march 2020 against the premium amount of Rs.27,645/- already paid from the opposite party No.1. The complainant and his family previously was the consumer and was insured with floater medical health policy of the opposite party No.2 since the year 2006 and the same policy had been renewed every year consecutively till 20th April 2019. In the month of April 2019 opposite party NO.2 approached the complainant to port his floater medical plan of the New India Assurance Co. Ltd. No floater medical plan of Religare Health Insurance Company which would give him extra medical cover than prior health insurance plan and the opposite party No.3 served as an intermediary to this present policy bearing policy No. 14056096 with the opposite party No.1. On account of this the complainant ported his medical floater policy in April 2019. The medical policy under which the complainant had been insured since 2006 had not been ended but ported to a different company for the like services alongwith the cumulative bonus added to the cashless floater policy all these years. Which nonetheless means that the policy and he benefits attached to it which commenced in the year 2006 did not terminate in March 2019 but continued and just the provider had been changed not the policy and benefits attach to the policy. On 09.05.2019 the complainant NO.2 had been diagnosed with the minute disease (Sinus) for the very first time. On 11.05.2019 complainant No.2 again went to the hospital for further investigation and blood reports. Also, the PAC (pre anesthetic checkup) was also done on 11.5.2019. After the said investigation doctor suggested for surgery. After the detection of sinus the complainant No.2 applied for cashless hospitalization of the
complainant through Asian Institute of medical science the same was denied by opposite party NO.1 vide letter dated 15.05.2019 stating that there had been on disclosure of material facts/pre-existing ailment at the time of propose the same was being appended herewith as Annexure A17. The complainant NO.2 went through a minor surgery on 18.05.2019 and was discharged the very same day as it was a minute surgery and hospitalization was not required. The expenses of the same was beard by the complainants. The complainant No.2 visited the Asian hospital on 20.05.2019 for follow up and removal of pack. The expenses of the same was beard by the complainants. The document stating that the Sinus had been detected on 09.05.2019 on the letter head of Asian Institute of medical Science written itself by Medical Superintendent was being appended herewith as Annx.A18. However, the complainants went through a minor surgery on 18.05.2019 and the amount was paid in cash to the Asian Institute of medical science which was Rs.60,569/-. Aongwith the expenditure of medical surgery the medicines were also purchased by the complainants during and after the surgery which was of total amount of Rs.9280/-. Opposite party No.1 had not only denied the medical claim of the complainant but also cancelled the medical floater policy purchased by the complainants. Which in itself shows the fraud of the opposite party No.1 companies like opposite parties charges heavy amount of premium and at the time of giving benefits in times of need/emergency denies the same and did not perform their part of the contract. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainants have prayed for directions to the opposite party to:
a) the complainant be granted the amount of Rs.69849/- which was spent by the complainant onto the surgery and medicine bills alongwith 12% interest.
b) Alternatively, the amount of premium paid Rs.1,37,000/- to the opposite parties be granted to the complainant alongwith this 12% on the said amount per annum.
c) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 20,000 /-as litigation expenses.
2. Opposite party No..1 put in appearance through counsel and filed written statement wherein Opposite party No.1 refuted claim of the complainant and submitted that the complainant Vinod Grover had taken a Care Floater Policy bearing No. 140556096 with insurance coverage to the complainant Vinod Grover, his spouse namely Praveen Grove and his son namely Anmol Grover Grover for a sum insured of Rs.5,00,000/- w.e.f 21.4.2019 to 20.4.2020. The policy issuance was subject to policy terms and conditions governing the policy. The said policy was ported form the New India Assurance Co. Ltd. The complainant approached the cashless request facility vide claim NO. 80275175 for the hospitalization of his son namely Anmol Grover in Asian Institute of Medical Sciences, Faridabad on 11.5.2019 for complaint of facial pain and Nasal bleeding. On the basis of investigation conducted and documents so received with the cashless form, the opposite party company rejected the cashless claim of the complainant vide denial letter dated 14.5.2019 on the following grounds:
Non disclosure of material facts/pre-existing ailments at the time of proposal. Patient having symptomatic prior to inception of policy with them.
Proof of non-disclosure
As per the declaration made by the complainant, it was being stated that the insured had history of similar complaint sfor 4-5 months which was before the policy inception.
Therefore, in the light of the non-disclosure of material facts/pre existing disease, the cashless claim of the complainant was rejected and the same was intimated to
the complainant vide letter dated 14.5.2019 under clause 7.1 of the policy terms & condition.
Re-imbursement Claim No. 90970372
Post denial of cashless, the complainant approached the opposite party Company with a re-imbursement claim vide claim No. 90970372 w.r.t the aforesaid hospitalization of the insured Anmol Grover for Endoscopic Surgery for Deviated Nasal Septum Sinusitis at Asian Institute of Medical Sciences. The insured was admitted to the hospital for a day from 18.05.2018 and discharged the same day. The said claim form was received with the opposite party company on 1.6.2019.
i) Upon receipt of re-imbursement claim, an investigation was triggered by the opposite party company to insure the veracity of the claim.
ii) Upon perusal of the documents received with the claim form, the opposite party company raised a query vide query letter dated 17.6.2019 and asked for the following documents:
- Exact duration and past history of present ailment with Ist consultation paper and all past treatment records:
Deviated Nasal Spetum
- Pre hospitalization OPD treatment record;
Including the investigation reports when diagnosed for the first time. Since, the opposite party company did not receive any reply to the query letter dated 17.6.2019, reminder letter dated 2.7.2019 was sent to the complainant.
The complainant replied to the above mentioned quarry.
The opposite party rejected the reimbursement claim vide denial letter dated 6.7.2019 on the following grounds:
Claim rejected: Deficiency not replied.
Reason for seeking documents:
a) As per the casualty card of Asian Hospital dated 2.6.2019, the insured was stated to be K/C/O deviated nasal septum and sinusitis.
b) As per the statement of the complainant, it was stated that the insured was facing problem of sinus for last five months. This means that the complainant had this problem before policy inception and did not disclose the same while filing the proposal form as a pre existing ailment.
Policy Cancellation:
Since there was non disclosure on the part of the complainant at the time of proposal as the insured having a history of Sinus, therefore, a notice regarding exclusion and cancellation of policy dated 27.5.2019 was sent to the complainant. It was also stated therein that disease of Sinuskitis/RElaed Disorders (Dns) would be marked as pre-existing and the same would be excluded for first 4 years of continuous coverage as per the underwriting guidelines. Later , the policy was cancelled by the opposite party vide policy cancellation letter dated 3.10.2019 on the ground of misrepresentation of material information at the time of proposal.
Online proposal Form
The complainant had an opportunity to declare that the insured had a history of Sinus at the time of filing of online proposal form; however, the complainant
intentionally did not disclose the same to the opposite party co. The declaration made by the insured to the following questions asked in the proposal form is as under:
A. Does any person(s) to be insured has any pre-existing disease?
Answer to the above question was marked as “No.”.
However, the complainant did not disclose the pre-existing ailment of Sinus of the insured, for which he was suffering from last 4-5 months i.e. before the policy inception. Opposite party No.1 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. Opposite party No..2 put in appearance through counsel and filed written statement wherein Opposite party No.2 refuted claim of the complainant and submitted that the complainants had neither any cause of action nor locus standi to file the present complaint. The complaint had been filed by the complainant in respect of policy No. 14056096 obtained by him form opposite party No.1 and opposite party No.1 and the complainant No.2 took treatment during the validity period of the said policy. Further no claim was ever lodged with opposite party No.2 in respect of which the present complaint had been filed. Opposite party No.2 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
4. Opposite party No..3 put in appearance through counsel and filed written statement wherein Opposite party No.3 refuted claim of the complainant and submitted that so far as the only allegation made by the complainant against opposite party No.3 in paragraph 1 of the complaint was concerned, it was vehemently denied that in April 2019 opposite party No.3 approached the
complainant to port his floater medical plan to opposite party No.2 into Floater medical plan of opposite party No.1. As a matter of fact, the complainant visited the website of Opposite party NO.3 viz, “policy azaar.com and compared various insurance policies on the basis of his requirements as filled up by it on the aforesaid website. The comparison of the insurance policies over the aforesaid website was based on the imputs provided by the visitor on the website and the veracity of the said inputs cannot be checked by opposite party No.3. It was submitted that the complainant, out of his own violation, opted for availing the insurance from opposite party No.3 as per his own needs and requirements. It was submitted that opposite party No.3 operates by facilitating comparison of various products of different insurers on its web portal – “policybazaar.com” and thereby providing its customers with an opportunity to view, compare and then decide as to what product/policy suits their requirements. Opposite party No.3 only acts as an intermediary between the policyholder and insurance company. The complainant admittedly purchased the insurance policy from opposite party No.1 and paid the premium amount of the policy to it. The complainant never paid any amount to the opposite party No.3. The terms and conditions of the policy were agreed upon between the complainant and the opposite party No.1. It was submitted that the opposite party NO.3 had nothing to do with the settlement or repudiation of the claim raised by the complainant as it was a matter between the insurer and the insured. Opposite party No.3 denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
5. The parties led evidence in support of their respective versions.
6. We have heard learned counsel for the parties and have gone through the record on the file.
7. In this case the complaint was filed by the complainant against opposite parties– Religare Health Insurance Co. Ltd. with the prayer to : a) the complainant be granted the amount of Rs.69849/- which was spent by the complainant onto the surgery and medicine bills alongwith 12% interest. b) Alternatively, the amount of premium paid Rs.1,37,000/- to the opposite parties be granted to the complainant alongwith this 12% on the said amount per annum. c) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
After availing several effective opportunities, learned counsel for the complainant failed to file evidence on behalf of the complainant. Hence, evidence on behalf of the complainant was hereby closed by court order vide order 2.3.2022.
On the other hand counsel for the opposite party No.1 strongly
agitated and opposed. As per the evidence of the opposite party No.1 Exx.RW1/A – affidavit of Shri Lakshay Juneja of Care Health Insurance Ltd. (Religare Health Insurance Co. Ltd.), Ex.R-1 – policy ported from New India Assurance Co. ltd. Ex.R-2 – Cashless request, Ex.R-3(colly) querry letters, Ex.R-4 – denial letter dated 14.5.2019, Ex.R-5 - declaration made by the complainant, it is being stated that the insured has history of similar complaints for 4-5 months which is before the policy inception, Ex. R-6 – claim form, Ex.R-7 – query letter dated 17.6.2019, Ex.R-8 –reminder letter, Ex.R-9 – claim denial letter, Ex.R-10 – Casualty card, Ex.C-11, as per the statement of the complainant that the insured is facing problem of sinus for last five months. Ex.R-12 – letter dated 27.05 2019 regarding cancellation of policy, Ex.R-13 - cancellation letter dated 3.10.2019, Ex.R-14 – proposal form.
As per evidence of opposite party No.2, Ex.RW2/A – affidavit of Shashi Praksh – Sr. Divisional Manager, New India Assurance Company Limited, NH-5-R/2, NIT Faridabad, EX.RX – New India floater Mediclaim schedule..
As per evidence of opposite party No.3 Ex.OP3/A – affidavit of Shri Rohit Kumar S/o Shri Akhil Kumar having office address at Plot No. 119, sector-44, Gurgaon, Ex.OP3/1 – Resolution letter, Ex.OP3/2 – deficiency letter , Ex.OP3/3 - CD.
8. It is evident from insurance policy that the complainant Vinod Grover had taken a Care Floater policy bearing No. 140556096 with insurance coverage to the complainant Vinod Grover his spouse namely Praveen Grover and his son namely Anmol Grover for a sum of insured of Rs.5,00,000/- w.e.f 21.4.2019 to 20.4.2020. The complainant approached the cashless request facility vide claim NO. 80275175 for the hospitalization of his son namely Anmol Grover in Asian Institute of Medical Sciences, Faridabad on 11.5.2019 for complaint of facial pain and Nasal bleeding vide Ex.R-2. It is evident from denial letter dated 14.5.2019 vide Ex.R-4 on the ground that “ Non disclosure of material facts/pre-existing ailments at the time of proposal. Patient having symptomatic prior to inception of policy with us.”
As per the declaration made by the complainant, it is being stated that the insured has history of similar complaints for 4-5 months which is before the policy inception vide Ex.R-5. It is evident from Casualty card of Asian Hospital dated 2.6.2019 vide Ex.R-10 that the insured is stated to be K/C/O deviated nasal septum and sinusitis. As per the statement of complainant vide Ex.R-11 that the insured is facing problem of sinus for last five months This means that the complainant had this problem before policy inception and did not disclose the same while filing the proposal form as a pre-existing ailment. As per the proposal form vide Ex.R-14 in which the declaration made by the insured to the following questions asked in the proposal form is as under:
A. Does any person(s) to be insured has any pre-existing disease?
Answer to the above question was marked as “No.”.
However, the complainant did not disclose the pre-existing ailment of Sinus of the insured, for which he was suffering from last 4-5 months i.e. before the policy inception.
Counsel for the opposite party has placed on reliance in case titled Manmohan Nanda Vs. United India Assurance co. Ltd. and Another passed by the Hon’ble Supreme court of India in Civil Appeal No. 8386/2015 Decided on December 6,2021.
Ratio of the above authority is applicable to the facts of the present case.
9. After going through the evidence led by the parties, the Commission is of the opinion that no deficiency in service on the part of the opposite parties have been proved. Resultantly, the complaint is dismissed. Copy of this order be given to the parties free of costs and file be consigned to record room.
Announced on: 02.08.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
