Chandigarh

DF-II

CC/1093/2019

Inder Kaur - Complainant(s)

Versus

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

Gaganpreet Singh Adv.

05 Jan 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-II,

U.T. CHANDIGARH

 

Consumer Complaint  No	:	1093 of 2019
Date  of  Institution	:	06.11.2019
Date   of   Decision	:	05.01.2024

 

 

 

 

Inder Kaur w/o Late Sh.Hardit Singh Bhasin, R/o # 1161, Sector 15-B, Chandigarh

... Complainant

Versus

1]  Religare Health Insurance Company Limited, SCO 56-58, Sector 9-D, Top Floor, Chandigarh through its Branch Manager.

 

2]  Religare Health Insurance Company Limited, Regd. Office at 5^th floor, 19, Chawla House, Nehru Palace, New Delhi, through its Chairman cum Managing Director.

    ….. Opposite Parties

 

BEFORE:  MR.AMRINDER SINGH SIDHU,       PRESIDENT

                    MR.B.M.SHARMA,                 MEMBER

                               

Argued by  :    Sh.A.S.Parmar, Counsel for the complainant

Ms.Niharika Goel, Adv. proxy for Sh.P.M.Goyal, Counsel for OPs No.1 & 2.

 

ORDER BY AMRINDER SINGH SIDHU, M.A.(Eng.),LLM,PRESIDENT

 

         The complainant has filed the present complaint pleading that she took the Health Insurance Policy bearing No.10585471 from the OPs valid from 17.3.2016 to 17.3.2018 and the same was renewed from time to time by paying the due premiums upto 16.3.2020 (Ann.C-1 to C-4).  It is stated that during the policy coverage period, the complainant was taken to Fortis Hospital as she was having two episode of syncope associate with vomiting since evening on 12.8.2019, she was admitted there on 12.8.2019 and discharged after treatment on 14.8.2019 upon which she incurred expenditure to the tune of Rs.1,08,282/- (Ann.C-6 & C-7).  However, the cashless facility under the policy was denied by the OPs at the time of discharge from the hospital on 14.8.2019. Thereafter, the complainant filed the claim form with the OPs for reimbursement of the said medical expenses.  However, the OPs vide letter dated 6.9.2019 rejected the claim of the complainant on the ground that since the ailment i.e. abnormalities of heart beat for which insured took treatment is suffering from hypertension prior to policy inception.  Hence, this complaint has been filed alleging the said repudiation of claim as illegal and deficiency in service with a prayer to direct the OPs to reimburse the medical expenses incurred on her treatment along with interest and to pay compensation as well as litigation cost. 

 

2]       After notice of the complaint, the OPs have put in appearance and filed written version.  The OPs while admitting the factual matrix of the case about treatment taken by the complainant-insured during the policy period stated that the complainant was on beta blockers (nebiprolol) because of which her current diagnosis was triggered i.e. Drug Induced Junctional Bradycardia.  It is submitted that after scrutinizing the documents and discharge summary of the complainant, the company came to know that the complainant’s provisional diagnosis – Drug Induced Junctional Bradycardia i.e. Decrease in rate of heartbeat is related to Hypertension (Pre-Existing Disease) and its complication.  It is also submitted that the complainant’s claim was rejected as the treatment occurring because of Pre-Existing disease and its complication is covered only after 48 months since the policy inception date. Lastly denying all other allegations, the OPs have prayed to dismiss the complaint with cost.

 

4]       Parties led evidence in support of their contentions.

 

5]       We have heard the ld.Counsel for the contesting parties and perused the entire documents on record including written arguments.

 

6]       The question to be decided whether there is deficiency in service or unfair trade practice on the part of the OPs in repudiating the medi-claim of the complainant on the ground of pre-existing disease of hypertension or not ?

 

7]       To find out answer to this issue, it is important to take into consideration the following facts and circumstances of the present complaint:-

         The OPs have admittedly rejected the medi-claim of the complainant/insured on the ground that she was treated for Drug Induced Junctional Bradycardia i.e. Decrease in rate of heartbeat, which related to Hypertension, a Pre-existing Disease, which was covered only after 48 months since the policy inception date, as per the terms and conditions of the insurance policy.

8]       However, the complainant has placed on record the Certificate dated 12-10-2019 issued by the treating doctor i.e. Dr.G.S.Kalra, MD, DM(Cardiology), Director Department of Cardiology, Fortis Hospital, Mohali who certified that:-

“Mrs.Inder Kaur Age 92 Yrs/Female UHID1963865 was admitted at Fortis Hospital, Mohali on 12/08/2019. This junctional bradycardia may not be because of hypertension.

This junctional bradycardia might be because of heperkalemia sick sinus syndrome.  At the time of admission B.P.110/60. She was discharged on 14/08/2019.”

 

9]       It is observed that from the above referred certificate issued by the treating doctor of the complainant i.e. Dr.G.S.Kalra, MD, DM(Cardiology), Director Department of Cardiology, Fortis Hospital, Mohali, it is clear that the ailment suffered by the complainant was not because of hypertension and it might be because of heperkalemia sick sinus syndrome.  Therefore, the stand of the OPs that the ailment suffered by the complainant was solely due to hypertension (pre-existing disease) is unjustified, hence it is held that the claim of the complainant has wrongly been rejected by the OPs.

10]           The Hon’ble National Consumer Disputes Redressal Commission, New Delhi in Revision Petition No.3619 of 2013 – Satish Chander Madan Vs. M/s. Bajaj Allianz General Insurance Co. Ltd., decided on 11.1.2016 has held that “Hypertension is a common ailment and it can be controlled by medication – Claim was wrongly repudiated.”  

 

11]       Further, we draw support from Life Insurance Corporation of India Vs. Sushma Sharma II (2008) CPJ 213 wherein Hon'ble Punjab State Commission has held as under:-

“So far as hypertension is concerned, no doubt, it is a disease but it is not a material disease. In these days of fast life, majority of the people suffer from hypertension. It may be only the labour class who work manually and take the food without caring for its calories that they do not suffer from hypertension or diabetes. Out of the literate and educated people particularly who have the white collar jobs, majority of them suffer from hypertension or diabetes or both. If the Life Insurance Companies are so sensitive that they consider hypertension and diabetes as material diseases then they should wind up their business and stop accepting premium. If these diseases had been material Nand Lal insured would not have survived for 10 years after he started suffering from these medical problems. Like hypertension ,diabetes has also infected a majority of the Indian population but the people who suffer from diabetes and continue managing it under the medical advice, they survive for number of years and none of these diseases is fatal and as discussed above, if these diseases had been material deceased Nand Lal insured would not have survived for 10 years.”.

 

12]     We further draw support from Life Insurance Corporation of India Vs. Sudha Jain II (2007) CPJ 452 wherein Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has held that “maladies like diabetes, hypertensions being normal wear and tear of life, cannot be termed as concealment of pre-existing disease”.

13]      In such a situation, the repudiation made by the OPs-Insurance Company regarding genuine claim of the complainant have been made without application of mind. It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sorts of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation.  This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. 

14]      It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-

    “It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.  The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.

15]      Taking into consideration the above discussion & findings, it can be safely concluded that OP Insurance Company has committed deficiency in service by wrongly and illegally rejecting the genuine claim of the complainant. Therefore, the present complaint deserves to be partly allowed and the same is accordingly allowed against OP No.1 & 2.  The OP No.1 & 2 are directed to reimburse an amount of Rs.1,08,282/- along with interest @9% per annum from the date of payment-14.08.2019 till its actual payment to the complainant.

         This order be complied with by the OP No.1 & 2 within 90 days from the date of receipt of its certified copy.

16]      Pending application(s) if any, stands disposed of accordingly.

        The Office is directed to send certified copy of this order to the parties, free of cost, as per rules & law under The Consumer Protection Rules & Act accordingly. After compliance file be consigned to record room.

Announced

05.01.2024                                                                    Sd/-

                                                            (AMRINDER SINGH SIDHU)

PRESIDENT

 

 

Sd/-

(B.M.SHARMA)

MEMBER