Haryana

Karnal

CC/10/2017

Harpal Singh - Complainant(s)

Versus

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

Sh. Jaswant Singh

26 Mar 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                          Complaint No. 10 of 2017

                                                          Date of instt. 04.01.2017

                                                          Date of Decision 26.03.2019

 

Harpal Singh son of Shri Virender Singh son of Shri Phool Singh resident of house no.399, village Uchana, 60 Karnal Lake, Karnal.

 

                                                                       …….Complainant

                                        Versus

 

1. Religare Health Insurance Company Limited, registered office at D-3, P3B, District Center, Saket, New Delhi-110017, Correspondence Address-GYS Global plot no.A3, A4, A5, 125 Noida, UP-201301 through its Chief Executive Officer.

2. Indusind BankLtd. Sector-12, Urban Estate, Karnal through its Branch Manager/authorized signatory.

 

                                                                      …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

      Sh.Vineet Kaushik ………..Member

                Dr. Rekha Chaudhary…….Member

 

 Present:  Shri Joginder Singh Advocate for complainant.

                  Shri Rohit Gupta Advocate for OP no.1.

                  Opposite party no.2 exparte.

 

                   (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant’s father purchased a Medi-Claim Health Insurance Policy bearing no.10691479 on 18.06.2016 from opposite party no.1 (OP no.1), in the sum of Rs.4,00,000/- which is valid upto 17.06.2017. In the said policy the father of the complainant made nominee to the complainant. The father of the complainant had undergone a complete medical checkup by the doctor nominated by the company and there was no pre-existing disease and there was no report of his illness and bad health. Thereafter, the father of the complainant had paid a premium of the policy amounting to Rs.14,716/- to the official of the OPs against the insured amount of Rs.4 lac and risk of the disease as well as injuries caused in accident were covered and all the expenses of hospitalization and medical expenses were covered under the policy. The father of the complainant met with a Road Side Accident on 2.8.2016 at about 3.00 p.m. with Buffalo Travel Abandoned and patient was taken to Arvind Bhai Hospital, Karnal and he was evaluated and treated with head injury ad blunt trauma and patient was referred to Max Mohali view of drowsiness and shock and thereafter the father of the complainant was treated in Max Hospital, Mohali, Punjab and treated there upto 13.08.2016 and due to the serious injuries occurred in accident died on 14.08.2016. The complainant had spent more than Rs.10 lacs on the treatment of his father and tried his best to save his life but inspite of his best efforts, the complainant could not save the precious life of his father. The complainant made request alongwith documents for his claim in the office of OP no.1 for the reimbursement of the amount of claim no.90248878 under the said health Insurance Policy. Thereafter, the claim has been rejected by the OP no.1 on 29.09.2016 on the ground of non-disclosure of material facts/pre-existing ailments at the time of proposal and as per document dated 20.05.2015, the patient is K/C/O Hypertension and Diabetes, by mentioning the false and vexatious grounds. In fact, the insured was not died due to the reason mentioned in the repudiation letter and there was no nexus between diabetes and injuries caused in the accident. So, the claim cannot be repudiated/cancelled on the ground of disease and the repudiation report is totally unjustified and unreasonable. Thereafter, the complainant visited the office of OP no.1 several times to get Health Insurance Claim but the official of the OP no.1 always did not bother the request of the complainant. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, OP no.1 appeared and filed written version raising preliminary objections with regard to territorial jurisdiction; maintainability; cause of action and concealment of true and material facts. On merits, it is pleaded that a policy bearing no.10087119 for the period from 18.06.2016 to 17.06.2017 was issued by the OP no.1 in the name of the insured Virender Singh on receipt of Insurance premium of Rs.14,716/- for a sum insured of Rs.4,00,000/- subject to the policy terms and conditions and the complainant made nominee in the said policy and OP no.1 had issued client ID no.54020715 in the name of the insured Virender Singh. It is further pleaded that any pre-policy medical examination is subject to the disclosure made by the applicant in the proposal form. Depending upon the disclosure made by the insured at the time of proposal, plan opted and sum insured, certain sets of medical examinations are conducted by the company. Based upon the results of such medical tests, and the disclosures in the pre-policy medical examination form the company decides whether to accept the risk and provide the policy to the customer or not. It is the duty of the insured to disclose correct and accurate information about his current health status at the time of proposal so that correct set of medical examination could be conducted for the accurate assessment of risk. It is further pleaded that if the patient Viender Singh was on medication, then the company even after pre-policy medicals, cannot measure the actual readings of blood pressure, diabetes. Hence, the contract of insurance puts weight on the notion of utmost good faith-uberrimae fides under which it is the responsibility of the insured to disclose all the material facts at the time of proposal for the insurance. Had the correct health status of the proposed life to be insured been disclosed to the OP company, the company would not have issued the policy. It is further pleaded that complainant approached the OP no.1 via cashless claim facility i.e. request for pre-authorization of cashless hospitalization bearing no.80083213 for the hospitalization of the insured Virender Singh for the treatment of Grade-II Liver injury and Grade-I Renal Injury due to the Road Traffic Accident at Max Healthcare, Mohali on 2.8.2016. It is further pleaded that the request of complainant regarding cashless facility denied, vide letter dated 3.8.2016 under the clause 9 of the policy terms and conditions for non-disclosure of material facts/pre-existing ailment at the time of proposal as patient Virender Singh is known case of Hypertension, Diabetes Mellitus and Chronic Liver Disease and the same was not disclosed by the patient at the time of inception of the policy. Hence there is no deficiency in service on the part of the OP no.1. The other allegations made in the complaint have been denied by the OP and prayed for dismissal of the complaint.

3.             OP no.2 did not appear and proceeded against exparte by the order of this Forum dated 10.11.2017.

4.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C9 and closed the evidence on 11.07.2018.

5.             On the other hand, OP no.1 tendered into evidence affidavit Ex.RW1/A and documents Ex.OP1 to Ex.OP16 and closed the evidence on 04.12.2018.

6.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

7.             The case of the complainant is that the father of the complainant purchased a Mediclaim Health Insurance Policy on 18.06.2016 for the sum assured of Rs.4,00,000/-, which is valid upto 17.06.2017. The father of the complainant made nominee to the complainant. The father of the complainant had undergone a complete checkup by the doctor nominated by the company and there was no pre-existing disease at the time of purchased a policy. On 2.8.2016, father of the complainant met with a Road Side Accident, insured was taken to Arvind Bhai Hospital Karnal and thereafter father of complainant was referred to Max Hospital Mohali, where he admitted/treated upto 13.08.2016 and due to serious injuries occurred in accident insured died on 14.08.2016. The complainant had spent more than an amount of Rs.10 Lakhs. The complainant submitted his claim with OP no.1 for reimbursement of the amount of claim. But OP rejected the claim on the ground of non-disclosure of material facts/pre-existing ailments at the time of proposal and as per document dated 20.05.2015, the patient is K/C/O Hypertension and diabetes, by mentioning the false and vexatious grounds. In fact, the insured was not died due to the reason mentioned in the repudiation report and there is no nexus between diabetes and injuries caused in the accident.

8.             On the other hand, the case of the OP no.1 is that group policy no.10087119 issued in favour of insured commencing w.e.f.18 June, 2016 to 17 June, 2017 for the sum assured of Rs.4 lakhs. The OP o.1 on the basis of the documents received from the patient Virender Singh and the concerned hospital authorities, denied the cashless facility request vide letter dated 3.8.2016, under the clause 9 of the policy terms and conditions for non-disclosure of material facts/pre-existing ailment at the time of inception as policy. As per the discharge summary dated 25.05.2015 issued by Max Hospital, Mohali the patient is mentioned to be hypertension and has H/O of diabetes alongwith H/O of CLD. It is also mentioned that the patient had a history of Upper GI Bleeding 4-5 years back.

.  As per the discharge summary dated 25^th May, 2015 issued by Max Hospital, Mohali the patient is mentioned to be Hypertensive & has H/O of Diabetes alongwith H/O of CLD. It is also mentioned that the patient had a history of Upper GI Bleeding 4-5 years back.

 

. As per the progress Note dated 25^th May, 2015 issued by Max Hospital, Mohali the patient is mentioned to be Hypertensive & has H/O of Diabetes alongwith H/O of CLD. It is also mentioned that the patient had a history of Upper GI Bleeding 4-5 years back.

. As per the Discharge Summary dated 29^th March, 2016 issued by Max Hospital, Mohali the patient is mentioned to be Hypertensive and Diabetic, K/O/C cirrhotic liver disease with H/O Grade 2 hepatic encephalopathy in May 15 and also had H/O UGI bleed post banding in 2011.

 . As per the Progress Note dated 27^th March, 2016 to 29^th March 2015 issued by Max Hospital the patient is mentioned to be Hypertensive and Diabetic, K/O/C cirrhotic liver disease with H/O Grade 2 hepatic encephalopathy in May 15 and also had H/O UGI bleed post banding since 6-7 years.

. As per the Discharge Summary dated 13^th August, 2016 issued by Max Hospital, Mohali the patient is mentioned to be K/C/O Cirrhotic Liver with portal hypertension (Non-Alcoholic Fatty Liver Disease)/Hypertension/DM type II.

. Statement of the Doctor to investigator At the time of investigation, our Investigator visited the hospital Max Healthcare, Mohali and procured a statement of Dr. Onkar Gupta (treating doctor as per Discharge summary) and he vide his Questionnaire statement dated 2^nd August, 2016 confirmed that “Patient is having history of HTN since 1 year and H/O Liver disease due to NAFLD in May, 2015. 

 

 Repudiation of claim for reimbursement was justified stating that non-disclosure of factum of pre-existing disease in proposal form would amount to violation of terms and conditions of the policy. The learned counsel of OP no.1 relied upon the authorities Satwant Kaur Sandhu Versus New India Assurance company IV (2009) 8 SCC 316 and Life Insurance Corporation of India Vs. Smt. Neelam Sharma pronounced by the National Commission on 30^th September, 2014

9.             We have gone through the documents on record and it has been found that except discharge summary dated 20.05.2015 (Ex.OP6), discharge summary dated 27.03.2016 (Ex.OP7), discharge summary dated 2.8.2016 (Ex.OP8) and Questionnaire for the doctor Ex.OP9, there is no other evidence on the record to prove that father of the complainant was suffering from any disease, as alleged.

10.            It is admitted that the father of complainant took the health insurance policy from OPs in the year 2016. The policy was valid upto 17.06.2017. The sum insured was of Rs.4 lakhs. Ex.OP1 is the copy of that policy and Ex.OP2 is scheme for Indusind Bank customer. Ex.OP6 to Ex.OP8  are the discharge summary of the father of the complainant which proves that he was diagnosed K/C/O Hypertension and diabetes.  As per the past history, there is mention of K/C/O Hypertension and diabetes. Ex.OP10 is the denial of claim access to the father of the complainant by the OP no.1 and operative part of the same reads as under:-

        “Non-disclosure of material facts pre-existing ailments at the time of proposal is k/c/o hypertension and diabetes and CLD before inception of the policy.

Thus, it is proved that the claim of the father of the complainant was denied on account of hypertension and diabetes and its related complication and it is mentioned that there was diabetes and hypertension before inception of the policy, which is pre-existing in nature. Thus, we are the view that the burden was on the OP no.1 to prove that father of the complainant had concealed material fact of pre-existing disease at the time of taking the policy. There is no other document on record except the Ex.OP6 to Ex.OP8 (discharge summaries) issued by the concerned hospital, where he was admitted and remained under treatment. OP no.1 has failed to produce on record any document to show that the father of the complainant was suffering from hypertension and diabetes before the inception of the policy. The OP no.1 has to failed to get further information from the hospitals as to whether the doctors who recorded past history, recorded the said information on the basis of the information given by the patient or his relative or some medical prescription were consulted. It was the duty of the OP who supply this information to the hospital. It is also the duty of the OP to conduct a thorough enquiry about the previous treatment of hypertension and diabetes obtained by the patient. However, no such enquiry was conducted. Even the affidavit of the doctor who recorded the past history has not been produced on record. So, merely on the basis of past history mentioned in Doctor’s record slips (Ex.OP6 to Ex.OP8), it cannot be said that the patient was suffering from hypertension and diabetes at the time of taking the policy and he was intentionally concealed the said material fact.

11.            Moreover, the father of the complainant met with an accident and due to grievous injuries suffered in accident he expired during treatment. Insured was not died due to any pre-existing disease and there is no nexus between pre-existing disease and cause of death.

12.            In United India Insurance Co. Ltd. & Anr. Versus S.K. Gandhi, 2015 (2) CLT 71 (NC)  the insurance company had not placed on record either the discharge summery of the complainant or any medical document signed by the doctors who treated him in Bhatnagar Eye Centre, Karnal and Arpana Hospital, Madhuban to show that the complainant when he was admitted to the said hospital, had himself stated that he was suffering from hypertension from last 8 years. In that case it was held that it is quite possible that the complainant, despite suffering from diabetes was not actually aware of the same and he cannot be accused of mis-statement or concealment. Onus was upon the insurance company to prove that he had made a mis-representation while obtaining the insurance policy and since the insurance policy failed, it was held that it was liable to pay to the complainant to the extent a sum insured by it. In Satish Chander Madan Vs. M/s Bajaj Allianz General Insurance Co. Ltd. 2016(1) CPJ 613 (NC) it was held that diabetes is a common ailment and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack. It was further held that treatment for heart problem cannot be termed as claim in respect of pre-existing disease and the insurance company was held liable. In Oriental Insurance Co. Ltd. Vs. Naresh Sharma & Ors 2015 (2) PLR 75 the Hon’ble Punjab and Haryana High Court held that the exclusion clause has to be read to the benefit of patient in genuine circumstances. Where respondent was admitted in hospital suffering from headache, giddiness and hypertension, his claim cannot be rejected on the basis of exclusion clause.

13.            So, in the present case the OP no.1 has failed to produce cogent evidence to prove that prior to the date of taking the policy, the complainant’s father was suffering from hypertension and diabetes and was getting any treatment and that fact was in the knowledge of the complainant and he intentionally concealed the same. There is no dispute with regard to the law laid down in the judgment referred by learned counsel for the OP no.1 but the same are not applicable to the facts of the present case because in the present case the OP no.1 has failed to produce cogent evidence to the effect that the complainant had knowledge of diabetes and had intentionally concealed the treatment. It is pertinent to mention here that except the discharge summary Ex.OP6 to Ex.OP8, there is no other evidence on record that the father of complainant was getting the treatment of hypertension and diabetes at the time of taking the policy. Even otherwise, there is no proof on the record as to who disclosed to the doctor about the diabetes being suffered by the father of the complainant before purchasing the policy.

14.            OP no.1 has failed to prove that the father of complainant has suppressed material facts while obtaining the policy. As such OP no.1 was not justified in repudiating the claim of the complainant. The complainant has placed on record Ex.C9 which is copy of bills making the payment to the concerned hospital in the tune of Rs.5,78,000/-. As such OP no.1 is liable to reimburse the amount of Rs.4,00,000/- to the complainant because the father of the complainant was insured only for Rs.4,00,000/-. The complainant is also entitled to compensation because of denial of his rightful claim by the OP no.1.

15.            It was rightly said that the doctor who had recorded past history qua alleged disease suffered by the complainant had not seen any medical prescription to support the above finding recorded. History of getting any treatment before issuance of insurance policy, has also not been brought on record. It was also rightly stated that there is nothing on record to prove that complainant had knowledge of suffer from the disease like diabetes.

16.            It has come on record that the age of the father of the complainant when mediclaim insurance policy was issued in his favour was more than 45 years. This fact is proved, vide Health Insurance Policy Ex.OP1 in which date of birth is mentioned as 13.06.1959. In that event, as per instructions issued by Insurance Regulatory & Development Authority of India (IRDA), it was duty of the OP to put the father of the complainant thorough medical examination. In the case of National Insurance Company Ltd. Versus Harbirinder Singh appeal no.220 of 2016 decided on 30.09.2016. State Commission U.T. Chandigarh has nothing abovesaid fact and failure on the part of the insurance company to get thorough medical examination of the insured before issuance of mediclaim insurance policy, dismissed appeal filed by the insurance company by observing as under:-

        “To deny claim raised by the complainant, reliance has been placed upon self declaration form R-2 (page 74 of the original paper book). The said declaration form has been signed by Saranbir Kaur on 5.2.2013. There is nothing on record to show that policy was issued to the complainant and his wife on the said date, by believing above document. The policy infact was issued on 13.02.2013. The appellants have failed to co-relate the said declaration form with the policy (C2) referred above. A note is appended on the said declaration form that it needs to be filled up if the age of the member is above 45 years. The complainant and his wife both are older than the said age. There is nothing on record to show that before insurance policy was issued to them, the appellants got them medically examined, which as per instructions issued by Insurance Regularly & Development Authority of India (IRDA) is must in such like cases. 

17.            Similar view was taken by Hon’ble Chandigarh State Commission in case of M/s Max Bupa Health Insurance Co.Ltd. Vs. Rakesh Walia, appeal no.191 of 2016 decided on 18.08.2016  wherein it was also stated that if contrary to the instructions issued by IRDA, an insured above the age of 45 years, was not put to through medical examination, claim raised after issuance of insurance of policy cannot be rejected on account of non-disclosure of the fact of pre-existing disease when policy was obtained.

17.            Thus, as a sequel to above discussion, we allow the present complaint and direct the OP no.1 to pay Rs.4,00,000/- i.e. sum insured amount to the complainant with interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OP no.1 to pay Rs.20,000/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expense. This order shall be complied within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:26.03.2019                                                                       

                                                                         President,

                                                                District Consumer Disputes

                                                                Redressal Forum, Karnal      

        (Vineet Kaushik)          (Dr. Rekha Chaudhary)

            Member                               Member