BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 271 of 2019
Date of Institution : 21.05.2019
Date of Decision : 23.02.2024.
Ram Niwas Goyal (aged about 65 years) son of Sh. Kundal Lal, resident of 37- Main Gali, RSD Colony, Sirsa.
……Complainant.
Versus.
1. Religare Health Insurance Company Ltd., 5th Floor, 19 Chawla House, Nehru Palace, New Delhi- 110019 through its Divisional/ Senior Manager/ Authorized signatory.
2. Religare Health Insurance Company Ltd., Vipul Tech Square, Tower-C, 3rd Floor, Golf Course Road, Sec. 43, Gurugram- 122009, Haryana through itjs Corporate Manager/ Senior Manager/ Authorized Signatory.
3. Punjab National Bank, Main Branch, Rori Bazar, Sirsa through its Senior Manager.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. PADAM SINGH THAKUR ……………PRESIDENT.
SMT. SUKHDEEP KAUR…………….…….MEMBER
SH. OM PARKASH TUTEJA……………..MEMBER
Present: Sh. Rishab Goyal, Advocate for the complainant.
Sh. H.S. Raghav, Advocate for opposite parties no.1 and 2.
Sh. M.S. Sethi, Advocate for opposite party no.3.
ORDER
The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 (after amendment u/s 35 of C.P. Act, 2019) against the opposite parties (hereinafter referred as OPs).
2. In brief, the case of the complainant is that complainant is a senior citizen and is an old account holder of op no.3. The Manager of the bank advised him to purchase a Family Health Care Insurance Policy known as Ab Health Hamesha from Religare Health Insurance Company. That accordingly complainant insurance policy with the specification i.e. Group Policy Holder bearing policy no. 11561922 and certificate of insurance No. 13067738 was allotted to him under the plan name Group Care. The wife of complainant was also insured under the policy. The ops issued certificate of insurance in this regard shown to be commencing from 29.09.2018 to 28.09.2019 and complainant had paid premium of Rs.15,391/- to the ops no.1 and 2. It is further averred that under the column detail of insured in pre existing disease, it was specifically mentioned that complainant is a patient of Diabetes and despite having knowledge of all these facts, the complainant was insured by the ops and the risk/ sum insured of the policy was up to Rs. five lacs. That thereafter, the ops issued an Identity Card under the Policy No. 13067738 in the name of complainant and his wife. In this manner, the complainant without concealing any material facts purchased the policy by entering into contract offered by the ops. The complainant had also accepted the same and paid the premium for securing his health to the extent of Rs. five lacs. It is further averred that on 16.11.2018 complainant felt less urine output problem and he had immediately contacted with Dr. Kapil Singla, MBBS DNB Surgery, DNV Urology. The doctor after clinically and closely examining him advised for PSA test. That complainant got conducted Prostate Specific Antigen Serem from SRL Diagnostic Laboratory on 24.11.2018 and as per the report, the frequency of Prostate Specific Antigen was shown as 17.100 which was on higher side, so the doctor advised for one month medicine and further advised to repeat the PSA test after one month of medicines. That complainant again conducted PSA test on 01.01.2019 and surprisingly the level of PSA was shown as 17.900 i.e. higher than the previous report. It is further averred that complainant was advised for conducting MRI which was done on 16.01.2019 and as per the report Dr. Pankaj Garg MD Radiologist observed “Likely Malignant”. That however as the doctor was not satisfied, so he further advised for Biopsy test from higher hospital in Metro City. The complainant went to Medanta Hospital, Gurugram and under the clinical supervision of Dr. Rajiv Yadav, the biopsy test was conducted on 25.01.2019 and the concerned doctor for the first time observed Cancer and mentioned the detail in the report. It is further averred that complainant for inquiring the detail history of the disease shown in report dated 25.01.2019 preferred to go for further investigation and contacted with Dr. Hari Goyal of Artemis Hospital, Gurugram who is known as a specialist for conducting PSA PET Scan. The concerned doctor after carefully examining and preparing the report confirmed the Cancer Disease and advised Harmon Therapy Treatment and he is still under the treatment of Dr. Hari Goyal. That complainant upon coming to know the final finding immediately informed to the ops and one of the authorized agent of ops came to the premises of complainant at Sirsa and requested for supplying the treatment detail record of complainant. The said agent came with claim form and received entire treatment record on 22.02.2019 and on his second visit on 07.03.2019 he had informed that their claim has been settled and ops have decided to release the entire expenses and also decided to cover the risks till commencement. That said agent made a request to furnish an affidavit which was got prepared and handed over to him on 07.03.2019 and he informed to the complainant that his case had been thoroughly scrutinized and approved by the company and just after submitting this affidavit he shall be entitled for pending claim. It is further averred that complainant informed to the agent that the doctors concerned have advised for Radiotherapy followed by the surgical operation for the prostate which requires Rs. four lacs. That complainant was shocked to receive the letter dated 30.03.2019 whereby ops denied the claim of complainant on the hyper technical reasons and the reason of denial mentioned in the letter are self contradictory, liable to be quashed and set aside and pending claim of Rs.91,664/- is to be released forthwith alongwith interest and the ops have caused unnecessary harassment and deficiency in service towards the complainant. Hence, this complaint seeking direction to the ops to release the amount of Rs.91,664/- and other expenses alongwith interest and to provide all the benefits of insurance Group Policy No.11561922 commencing from 20.09.2018 to 28.09.2019 up to the sum assured amount of Rs. five lacs and also to pay Rs.20,000/- as compensation for harassment and also to pay litigation expenses.
3. On notice, ops no.1 and 2 appeared and filed written version raising certain preliminary objections. It is submitted that complainant applied for a cashless request for a planned hospitalization, through its treating hospital i.e. Medanta Medicity, Gurgaon for TRUS guided biopsy. That on receipt of the cashless request, the ops’ company in order to get more clarity of the matter sought additional documents vide query letter dated 25.01.2019 and company also triggered a claim investigation. It is further submitted that upon receiving the query reply and on investigation, it came to light that complainant had a history of hypertension prior to policy inception and the same was not disclosed by the complainant at the time of taking the policy. That as per the statement of the son of complainant taken at the time of investigation, he has certified the fact that complainant has a history of HTN since 2015 i.e. prior to policy inception with the ops’ company. Hence, the cashless request was denied by ops’ company as per clause 5.2 Disclosure to Information Norm of the policy terms and conditions. That complainant thereafter approached the ops’ company with the reimbursement claim vide claim No. 90862482 for an amount of Rs.73004 ( including pre and post hospitalization expenses) with respect to his hospitalization on 25.01.2019 at Medanta Medicity, Gurgaon and said claim form was received on 22.02.2019. After the receipt of the reimbursement request, the ops’ company sent a query letter dated 02.03.2019 and required documents i.e. detailed original final bill, bill of claimed amount of Rs.21,720/-, exact duration and past history of present ailment with first consultation paper and all past treatment records, personalized cancelled cheque in the name of proposer/ primary member or NEFT mandate form signed and stamped by bank authorities and first consultation paper immediately after incident. It is further submitted that complainant failed to provide the reply to the above mentioned query, therefore, the ops’ company rejected the claim of complainant vide claim denial letter dated 30.03.2019 with the observation that as per query reply not received yet from insured, hence is rejected under deficiency not replied. It is further submitted that as per the judgment of the Hon’ble Supreme Court in the Export Credit Guarantee Corp of India Ltd. versus M/s Garg Sons International the insured cannot claim anything more than what is covered by the insurance policy and the terms of the contract have to be construed strictly without altering the nature of the contract as the same may affect the interests of the parties adversely and the clauses of an insurance policy have to be read as they are and consequently the terms of the insurance policy that fix the responsibility of the insurance company. On merits, it is also submitted that complainant violated the terms and conditions of the insurance policy and complaint is liable to be rejected on this score alone. All other contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
4. Op no.3 also appeared and filed written statement raising certain preliminary objections. It is submitted that Branch Manager has never advised to complainant for insurance and answering op has never explained to the complainant about terms and condition of insurance policy. The matter of insurance and its term is between the insurance company and complainant and answering op has no concern whatsoever in the insurance policy. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint qua op no.3 made.
5. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C31.
6. On the other hand, op no.3 has tendered affidavit of Branch Manager as Ex.R1. Ops no.1 and 2 have tendered documents Exz.R2 to Ex.R18, affidavit of Sh. Lakshay Juneja, Manager Legal as Ex.R19 and documents Ex.R20 to Ex.R26.
7. We have heard learned counsel for the parties and have gone through the case file.
8. Admittedly the complainant had purchased health insurance policy bearing No. 11561922 from the ops no.1 and 2 for the period 20.09.2018 to 28.09.2019 vide which complainant and his wife were insured and the sum insured amount under the policy was Rs. five lacs and said fact is also proved from policy documents Ex.C3 to Ex.C6. It is also not in dispute that in the month of January, 2019 i.e. during the period of policy, the disease of cancer was detected to the complainant and according to complainant he has spent Rs. 91,664/- in Medanta Hospital, Gurgaon, Artemis Hospital, Gurgaon and has placed on file receipts and bills as Ex.C13 to Ex.C25. The claim of the complainant has been denied by the ops no.1 and 2 on the ground that complainant failed to provide the documents demanded through query letter dated 02.03.2019 and also on the ground of non disclosure of pre existing ailment of hypertension at the time of purchasing of policy in question. But however we are of the considered opinion that ops no.1 and 2 have wrongly and illegally repudiated the claim of complainant because complainant at the time of purchasing the policy in question had disclosed to the ops no.1 and 2 that he is suffering from disease of diabetes and therefore, it is not possible that he had concealed the disease of hypertension from them. Moreover, the disease of hypertension is a common and lifestyle disease and claim cannot be rejected on the ground of concealment of this type of disease. The complainant also submitted all the documents to the ops for getting his claim amount. The complainant has spent amount of Rs.91,664/- on the disease of cancer and not on the disease of hypertension and same has no concern with the disease of cancer and as such repudiation of the claim of the complainant is on hyper technical ground. As such complainant is entitled to reimbursement of the amount of Rs.91,664/- from ops no.1 and 2 and ops no.1 and 2 are also liable to provide all the benefits of the policy in question to the complainant. The ops no.1 and 2 are also liable to pay compensation and litigation expenses to the complainant for causing unnecessary harassment and deficiency in service to the complainant.
9. In view of our above discussion, we allow the present complaint qua ops no.1 and 2 and direct the opposite parties no.1 and 2 to pay the claim amount of Rs.91,664/- to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 21.05.2019 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops no.1 and 2 to further provide all the benefits of the policy in question to the complainant within above said period. We further direct the ops no.1 and 2 to pay a sum of Rs.15,000/- as compensation for harassment and Rs.10,000/- as litigation expenses to the complainant within above said stipulated period. However, complaint qua op no.3 stands dismissed. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced: Member Member President,
Dated: 23.02.2024. District Consumer Disputes
Redressal Commission, Sirsa.
