BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 693 of 2019
Date of Institution : 28.11.2019
Date of Decision : 26.09.2023.
Sanjay Kumar, aged 48 years, son of Shri Radha Krishan, resident of Gali No.6, Kirti Nagar, Sirsa, Tehsil and District Sirsa.
……Complainant.
Versus.
1. Religare Health Insurance Company Ltd., IndusInd Bank, Dabwali Road, Sirsa, Tehsil and District Sirsa, through its Branch Manager.
2. Religare Health Insurance Company Ltd., Regd. Office: 5th Floor, 9, Chawla House, Nehru Palace, New Delhi- 110019, through its Manager/ Authorized Signatory.
...…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
Argued by: Sh. JBL Garg, Advocate for the complainant.
Sh. Rajeev Kumar, Advocate for opposite party no.2.
Opposite party no.1 already given up.
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 through online complainant had purchased a medi claim policy from ops bearing No. 12509497, cover type floater for the period w.e.f. 28.05.2018 to 27.05.2019 and paid a sum of Rs.27,886/- as insurance premium which was paid by him through his bank account with ICICI Bank Ltd. Sirsa branch. That on 29.07.2018 complainant had developed fever and he got himself medically checked up from Sanjivani Hospital, Sirsa and he was diagnosed with Dengue fever. The complainant remained admitted as indoor patient in said hospital w.e.f. 29.07.2018 to 1.8.2018 and a sum of Rs.28,171/- was incurred by complainant on his treatment. The complainant had lodged his claim with the ops for said medical expenses and ops had remitted said amount of Rs.28,171/- to the complainant being cashless policy claim.
3. It is further averred that thereafter complainant developed jaundice and thus on 05.02.2019 the complainant was taken to SPS Hospital, Sirsa and got himself checked in OPD and paid a sum of Rs.300/- as OPD charges. That few tests were conducted and complainant incurred a sum of Rs.3280/- on the same. Again on 18.2.2019 complainant further got himself checked up from SPS Hospital, Sirsa and paid a sum of Rs.300/- as OPD fee. Thereafter, the complainant remained admitted as an indoor patient with Medicity Hospital, Sirsa w.e.f. 26.02.2019 to 28.02.2019 and a sum of Rs.32,500/- was charged from him. Thereafter, he was got admitted in Sanjivani Hospital, Sirsa from 06.03.2019 to 10.03.2019 and a sum of Rs.42,500/- was charged from him. In this manner, the complainant incurred a sum of Rs.82,000/- on his said treatment. It is further averred that complainant lodged his claim with the ops and supplied all the required documents and information for the settlement of claim, but however, the ops have repudiated the claim of complainant vide letter dated 27.06.2019 on the ground that “ (i) Rejected : Deficiency not replied as First consultation paper of chronic liver disease and (ii) Deficiency not replied.” That complainant was shocked to know the repudiation of his claim due to above imaginary reason because the complainant had no chronic liver disease rather the same was suffered by him after purchase of the policy and moreover, the ops had already reimbursed the medical claim of Rs.28,171/- to the complainant for Dengue Fever and it appears that ops found false excuse to repudiate the claim of complainant and thereby to wriggle out of their liability to indemnify the complainant. The complainant is entitled to claim amount alongwith interest from the date of lodging of claim till realization of the same. That complainant has approached the ops and requested them to settle and pay his claim but the ops did not pay any heed to the same and ultimately complainant got served a legal notice upon ops on 21.08.2019 but of no use. Hence, this complaint.
4. Notice of the complainant was issued to the ops. Notice issued to op no.1 could not be served for want of correct address and ultimately op no.1 was given up by learned counsel for complainant.
5. Op no.2 appeared and filed written statement raising certain preliminary objections. It is submitted that there is no dispute with regard to first claim lodged by complainant which was approved after some deductions. It is further submitted that complainant approached the ops’ company with a cashless request with respect to his hospitalization w.e.f. 25.02.2019 at Medicity Hospital, Sirsa for Anorexia, anxiety and pain in abdomen since seven days. On perusal of the documents, the ops’ company came to know that complainant is a known case of Chronic Liver Disease, Pulmonary Hypertension (PHTN) and patient has habit of alcohol. As per the discharge summary of Medicity Hospital, he was diagnosed with CLD at SPS Hospital, Sirsa. Accordingly the ops’ company raised query letter dated 25.02.2019 and 26.02.2019 to seek details as under:-
* Complete indoor case papers with admission notes, history
sheet, doctor’s notes, nursing notes and vital chart.
* Exact duration and past history of present ailment with first
consultation paper and all past treatment records.
* Pre hospitalization OPD treatment record.
* Treating doctor’s certificate for etiology of present ailment
* Pre hospitalization OPD treatment record.
6. It is further submitted that since the ops’ company did not receive the requisite documents from the side of complainant, it raised two reminders letters dated 27.2.2019, 28.2.2019 thereby reminding the complainant to provide the above said requisite documents. Since the ops did not receive the requisite documents, the claim was closed on the ground “Deficiency not replied”. It is further submitted that post denial of the cashless request, the complainant approached the ops’ company with a reimbursement claim with respect to his hospitalization w.e.f. 26.2.2019 till 28.2.2019 at Medicity Hospital, Sirsa. The complainant was diagnosed of chronic liver disease, pulmonary hypertension, jaundice. On perusal of the documents, the ops’ company came to know as under:-
* As per the Consultation paper of SPS Hospital, complainant is a known case of chronic liver disease, pulmonary hypertension (PHTN) and patient has habit of alcohol habit.
* As per the discharge summary of Medicity Hospital, he was
diagnosed with CLD at SPS Hospital, Sirsa.
* As per the history sheet of Medicity Hospital, Sirsa, it was
specified that the complainant was diagnosed with CLD at SPS Hospital on 5.2.2019.
* As per the USG report of whole abdomen as done by Riddhi
Siddhi diagnostic centre, the complainant was given an
opinion of Coarsen & altered echotexture liver with
splenomegaly & dilated portal vein large ascites. S/O CLD.
* As per the USG Abdomen Report dated 30th July, 2018 he
was suffering from Liver Parenchymal Disease with Portal
Hypertension, Splenomagly, Left renal calculi.
7. It is further submitted that since the complainant did not provide the requisite documents, accordingly the ops’ company sent two reminders letters dated 30.3.2019 and 9.4.2019 to seek above said details as under:-
* Exact duration and past history of present ailment with 1st consultation paper and all past treatment records related to chronic liver disease.
* Pre hospitalization OPD treatment record.
8. It is further submitted that complainant had provided the USG report dated Feb,2019 which specified that “Coarsen & altered echotexture liver with splenomegaly & dilated portal vein large ascites. However, the ops’ company came to know that as per the USG abdomen report dated 30.7.2018, he was suffering from Liver Parenchymal disease with portal hypertension, splenomagaly, left renal calculi. Since the query was pending at the complainant’s end, to appropriately analyze the claim, the ops’ company rejected the claim vide letter dated 27.6.2019. It is further submitted that further cashless request of complainant with respect of his hospitalization with effect from 6.3.2019 at Sanjivani Hospital, Sirsa was rejected for want of above said above said medical record and reports. The claim was denied vide letters dated 8.3.2019 and 9.3.2019 on the ground that as per submitted documents pre existing nature of ailment could not be ruled out, hence liability of insured could not be taken at present juncture and cashless facility is being denied and he was suggested for filing reimbursement claim with all supportive documents. However, as the complainant did not provide the documents despite reminder letters dated 30.3.2019, 9.4.2019, 15.4.2019 and 25.04.2019 the reimbursement claim lodged by complainant was also denied vide letter dated 22.5.2019 on the ground “Deficieny not replied as even after multiple reminder, appointment detail not shared.” It is also submitted that complainant had the opportunity to disclose about his Chronic liver disease, PHTN at the time of filing of proposal form. However, no correct such disclosures were made by the complainant. The complainant to the specific question put to him that does he has any pre existing disease answered as ‘NO’. Thus, the complainant is not only acting in breach of the policy terms and conditions governing the policy, but also has acted in blatant violation of the principles and regulations of IRDAI. It is further submitted that op no.2 has repudiated the claim of complainant as per terms and conditions of the policy. On merits, it is also submitted that the subsequent requests for cashless facility and reimbursement claims were rejected for deficiency not replied for chronic liver disease. The complainant is not providing the first consultation of chronic liver disease and the same is needed to rule out the possibility of pre existing disease. It is further submitted that op no.2 did not come to know that complainant is a known case of chronic liver disease. Also the current diagnosis is related to chronic liver disease and dengue is not related to chronic liver disease. With these averments, dismissal of complaint prayed for.
9. The complainant in evidence has tendered his affidavit Ex. CW1/A and copies of documents Ex.C1 to Ex.C36.
10. On the other hand, op no.2 has tendered copies of documents Ex.R1 to Ex.R19.
11. We have heard learned counsel for the parties and have gone through the case file carefully. We have also gone through the written arguments filed on behalf of ops in which all the pleas of written statement have been reiterated. We have also gone through the authorities cited by learned counsel for ops.
12. There is no dispute of the fact that complainant had purchased health insurance policy from the company of op no.2 for the period 28.05.2018 to 27.5.2019 for the sum insured amount of Rs.5,00,000/- which fact is also evident from policy certificate Ex.C1. Through this health insurance policy, the complainant himself, his wife Geeta Devi and sons Himanshu Vedi and Yash Vedi were insured. It is also proved on record that during the period of said policy, the complainant was treated for Dengue fever in Sanjivani Hospital from 29.07.2018 to 01.08.2018 and claim lodged by complainant was duly paid by op no.2 after some deductions. It is also proved on record that thereafter on 5.2.2019 complainant was taken to SPS Hospital, Sirsa as is evident from prescription slip Ex.C3 and he was diagnosed with CLD (chronic liver disease) and Pulmonary Hypertension (PHTN). Thereafter complainant was admitted in Medicity Hospital, Sirsa from 26.02.2019 to 28.02.2019 and was diagnosed with CLD, PHT, Jaundice as is evident from indoor file of that hospital Ex.C14. According to the complainant he has spent an amount of Rs.32,500/- on his admission and treatment in the Medicity Hospital, Sirsa and also spent another amount of Rs.42,500/- for his admission and treatment for the above said disease in Sanjivani Hospital, Sirsa but his cashless request as well as request for reimbursement of above said total claim amount of Rs.82,000/- have been denied and rejected by the op no.2 on the ground “Deficiency not replied” and that complainant did not provide exact duration and past history of present ailment with first consultation paper and all past treatment records, pre hospitalization OPD treatment record despite various reminders and letters. In this regard op no.2 has also placed on file copies of reminders and letters written to the complainant as Ex.R9, Ex.R16, Ex.R17. The op no.2 has also denied the cashless request of complainant on the grounds that as per submitted documents pre existing nature of ailment could not be ruled out, hence liability of insured could not be taken at present juncture and thereafter the claim of complainant has been rejected on the ground that deficiency not replied as even after multiple reminder, appointment detail not shared. However, we are of the considered view that op no.2 has wrongly and illegally denied the cashless request as well as claim amount to the complainant. The complainant has claimed that he lodged his claim with the ops and supplied all the required documents and information and also observed all the required formalities for settlement of claim and in this regard complainant has also placed on file all his treatment record including prescription slip of SPS Hospital dated 05.02.2019 i.e. first consultation papers. The complainant suffered said disease only after purchasing of the policy in question from op no.2 and it cannot be said that it is a pre existing disease. Moreover, onus to prove any pre existing to the complainant was on the op no.2 which is alleging the same but op no.2 has failed to prove on record through any cogent and convincing evidence that complainant was having pre existing disease or that he was ever treated before 05.02.2019 or prior to purchasing of the policy in question for said liver disease. The op no.2 has not placed on file any affidavit of the treating doctor to prove that complainant was having any pre existing disease prior to the purchase of policy in question and that he has concealed true and material fact regarding his health from ops at the time of filling of proposal form. Although all the documents regarding treatment of complainant have been placed on file by complainant and have also been supplied to the op no.2 but even if it is presumed that complainant did not supply the required documents i.e. first consultation paper etc. to op no.2, the op no.2 could arrange the said documents from the hospital itself. It is also proved on record from prescription slip of SPS Hospital, Sirsa dated 05.02.2019 that after examination of complainant, alcohol was absent from his body and doctor of Sanjivani Hospital, Sirsa has also given his certificate to the effect that no chronic alcoholism evidence found in physical examination of the patient i.e. complainant. So, it is proved on record by complainant that repudiation of claim of complainant by op no.2 is on imaginary reason and complainant had no chronic liver disease prior to the purchase of the policy in question and he suffered the said disease after purchase of the policy in question and it also appears that op no.2 found false ground to repudiate the genuine claim of complainant and has caused unnecessary harassment to the complainant who was already under mental trauma. It is also proved on record by complainant through bills and receipts that he has spent total amount of Rs.82,000/- on his above said treatment in the above said hospitals and as such he is entitled to reimbursement of this amount of Rs.82,000/- from the op no.2 besides compensation for harassment and litigation expenses. The judgment of the Hon’ble Supreme Court in case titled as Satwant Kaur Sandhu Versus New India Assurance Company Ltd. CA No. 2776 of 2002 decided on 10.7.2009 as well as judgment of Hon’ble National Commission in case titled as Life Insurance Corporation of India Versus Smt. Neelam Sharma, RP No. 967 of 2008 decided on 30.9.2014 relied upon by learned counsel for op no.2 are not applicable to the fact and circumstances of present case since op no.2 has failed to prove on record that complainant was having any pre existing disease.
13. In view of our above discussion, we allow the present complaint against the opposite party no.2 and direct the op no.2 to pay above said claim amount of Rs.82,000/- to the complainant within a period of 45 days from the date of receipt of copy of this order, failing which complainant will be entitled to receive the above said amount of Rs.82,000/- alongwith interest at the rate of @6% per annum from the date of this order till actual realization. We also direct the op no.2 to further pay a sum of Rs.10,000/- as compensation for harassment and also to pay another sum of Rs.10,000/- as litigation expenses to the complainant within above said stipulated period. 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: 26.09.2023. District Consumer Disputes
Redressal Commission, Sirsa.
