Haryana

Kurukshetra

CC/219/2020

Sanjay Walia S/o GIan Chand - Complainant(s)

Versus

Religare Health Insurance Company - Opp.Party(s)

Shekhar Thakur

23 Dec 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL  COMMISSION, KURUKSHETRA.

 

          Complaint No.219 of 2020

Date of Instt. 15.07.2020.

Date of Decision:23.12.2021.

 

Sanjay Walia son of Sh.Gian Chand Walia, resident of house No.2128 Ward/Sector 5, Choitta Bazar, Thanesar District Kurukshetra.

                                                                        …….Complainant.                                              Versus

1.Religare Health Insurance Company Limited, Corporate office at Vipul Tech Square Tower-C, 3ard Floor, Golf Course Road, Sector -43, Gurugram – 122009  (Haryana) through its Managing Director.

 

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

 

3. PNB Bank Ground Floor, Mini Secretariat  New Building, District Kurukshetra through its Branch Manager.

                ….…Opposite parties.

 

                Complaint under Section  35 of Consumer Protection Act.

 

Before       Smt. Neelam Kashyap, President.    

                   Shri Issam Singh Sagwal, Member.

                   Ms.Neelam Member.

                 

Present:     Sh.Shekhar Thakur Advocate for the complainant.

                 Sh.Rajesh Kaushik Advocate for the OP No.1 and 2.

                 Sh.Lovekesh Machhal Advocate for the OP No.3.

 

                 This is a complaint under Section 35 of the Consumer Protection Act, 1986 moved by Sanjay Walia against Religare Health Insurance etc.-Opposite Parties.

 

2.             As per the present complaint, the complainant took a policy No.12735375 dated 24.7.2018 bearing client ID61411334  having coverage of  all family members i.e. complainant, Preeti Walia, Gravita Walia, Adamya Walia from the OP No.2’s branch , i.e. Religare Health Insurance Company limited Service Branch office Top “Floor,SCO -56-58 Sector 9-D, Chandigarh and such policy was got renewed by the complainant for the period 24.7.2019 to 23.7.2020.  It is submitted that during the period of renewal policy, the complainant suffered with restrosteral chest pain with radiation of bilateral arms and diaphoresis on and off for last three days since 22.8.2019. The complainant approached SIMSS Hospital, Sector 32, Sushant City near Shani Mandir , Kurukshetra who after admitted the complainant for one day, referred to higher c entre for medical procedure of CABG (Coronary Artery  Bye Pass Graft). The complainant paid Rs.1400/- for hospital expenses  with advance payment of Rs.5000/-, Rs.9150/- for body test i.e. Angiography, KF.T. HIV, HCV, HB & AAg and Rs.4223/- for medicines etc.  The complainant approached the Forties Hospital Mohali where concerned doctor i.e. T.S.Mahant and others after preliminary examination  performed surgery/operation of Coronary Artery Bypass Grafting (CABAX3-LIMA TO LAD, SVG TO PDA, SVG TO OM) ON 27.8.2019and discharged on 2.9.2020. The complainant spent about Rs.19050/- as total cost for operation procedure as well as Rs.8390/- as cost of allied medicine etc. The cashless request of the complainant has been denied by the OPs ON THE GROUND OF DIABETES AND HYPERTENSION EXISTING PRIOR TO INCEPTION OF THE POLICY VIDE E-MAIL DATED 23.8.2019. Thus, the complainant spent about Rs.19773/- under SIMSS Kurukshetra andRs.20742/- under FORTIS Mohali. The complainant submitted the claim papers to the OP vide claim No.80311066 but the Ops denied the claim as mentioned above vide letter dated 27.4.2020.The Ops are completely deficient in providing service to the complainant qua his medi claim and the complainant got his reimbursement of medical schemes under government scheme relating  with the department of his wife, therefore, the complainant is entitled to the compensation of Rs.4.00 lacs. Thus, the complainant has filed the present complaint alleging deficiency in services on the part of the Ops and prayed  for payment of compensation alongwith litigation expenses.

 

3.             Notice of the complaint was given to the Ops. OP No.1 and 2 filed their joint written statement disputing the claim of the complainant. It is submitted that the complainant is claiming expenses for mental agony  and he has been paid medical expenses under government  medical scheme from his wife’s deptt. The complaint is not maintainable as the company had denied the request because the complainant failed to disclose his history of diabetes since 7 days and hypertension since five years. The present complaint has only been filed to harass the company. The OP issued a policy namely Group Care (PNB) as mentioned in the complaint.  The said policy was further renewed upto 23.7.2020.  Thus, the complainant has not disclosed about the pre existing disease like diabetes and hypertension and his claim has been rightly denied. Thus, it is submitted that there is no deficiency in services on the part of answering Ops and has prayed for dismissal of the present complaint.

 

4.             The OP No.3 has filed its separate written statement disputing the claim of the complainant. It is submitted that the present complaint is nothing but bundle of lie which deserves dismissal qua the answering OP. Thus, it is prayed that there is no deficiency in services on the part of the OP and prayed for dismissal of lthe present complaint.

 

5.             The complainant in support of his case has filed his affidavit Ex.CW1/A and tendered documents Ex.C-1  to Ex.C-6 and closed his evidence.

 

6.             The OP No.1 and 1 in support of their case have filed affidavit Ex.RW1/A and tendered documents Ex.R-1 to Ex.R-8 and closed their evidence.

 

7.             The learned counsel for OP No.3 has made a statement that written statement filed by OP No.3 be read as evidence on behalf of OP No.3.

8.             We have heard the learned counsel for the parties and have gone through the material available on the case file.

 

9.             The learned counsel for the complainant while asserting the averments made in the complaint has argued that complainant took a policy No.12735375 dated 24.7.2018 bearing client ID61411334  having coverage of  all family members i.e. complainant, Preeti Walia, Gravita Walia, Adamya Walia from the OP No.2’s branch and such policy was got renewed by the complainant for the period 24.7.2019 to 23.7.2020.  It is argued that during the period of renewal policy, the complainant suffered with restrosteral chest pain with radiation of bilateral arms and diaphoresis on  and off for last three days since 22.8.2019. The complainant approached SIMSS Hospital,   Kurukshetra who after admitted the complainant for one day, referred to higher centre for medical procedure of CABG (Coronary Artery  Bye Pass Graft). The complainant paid  Rs.1400/-  for hospital expenses  with advance payment of Rs.5000/-, Rs.9150/- for body test i.e. Angiography, KF.T. HIV, HCV, HB & AAg and Rs.4223/- for medicines etc.  The complainant approached the Forties Hospital Mohali where concerned doctor i.e. T.S.Mahant and others after preliminary examination  performed surgery/operation of Coronary Artery Bypass Grafting (CABAX3-LIMA TO LAD, SVG TO PDA, SVG TO OM) ON 27.8.2019 and discharged on 2.9.2020. The complainant spent about Rs.19050/- as total cost for operation procedure as well as Rs.8390/- as cost of allied medicine etc. The cashless request of the complainant has been denied by the OPs ON THE GROUND OF DIABETES AND HYPERTENSION EXISTING PRIOR TO INCEPTION OF THE POLICY VIDE E-MAIL DATED 23.8.2019. Thus, the complainant spent about Rs.19773/- under SIMSS Kurukshetra andRs.20742/- under FORTIS  Mohali. The complainant submitted the claim papers to the OP vide claim No.80311066 but the Ops denied the claim as mentioned above vide letter dated 27.4.2020.The Ops are completely deficient in providing service to the complainant qua his medi claim and the complainant got his reimbursement of medical schemes under government scheme relating  with the department of his wife, therefore, the complainant is entitled to the compensation of Rs.4.00 lacs.The learned counsel for the complainant has placed reliance on the authority cited as Manivasagam Versus NIC Limited and another decided on 30.01.2014 by Hon’ble Madras High Court.

 

10.            On the other hand, learned counsel for the Ops while reiterating the contentions made in their written statements have argued  that the complainant is claiming expenses for mental agony  and he has been paid medical expenses under government  medical scheme from his wife’s deptt. The complaint is not maintainable as the company had denied the request because the complainant failed to disclose his history of diabetes since 7 days and hypertension since five years. The present complaint has only been filed to harass the company. The OP issued a policy namely Group Care (PNB) as mentioned in the complaint.  The said policy was further renewed upto 23.7.2020.  Thus, the complainant has not disclosed about the pre existing disease like diabetes and hypertension and his claim has been rightly denied.

11.            The contention of the learned counsel for the Ops that complainant has not disclosed about the pre existing disease like diabetes and hypertension and his claim has been rightly denied, is devoid of any force. Hon’ble Madras High court in the cited authority has held as under:

 

                “ It is admitted case of the petitioner that he is suffering from hypertension and diabetes. If the treatment is relating to hypertension and diabetics, then it is pre existing disease and no claim can be made. However, in the report, it is stated that the petitioner was suffering from Coronary Artery Disease and surgery was done. Coronary Artery Disease is not a pre-existing disease at the time when the policy was issued. Therefore, the claim apparently is rejected on the misconception. The authority cannot read something more into the terms and conditions of the policy and come to the inference that one disease is relatable to other disease and therefore, medi claim is rejected.”

 

12.            In the case in hand, the petitioner took the treatment of Coronary Artery Bypass Grafting (CABAX3-LIMA TO LAD, SVG TO PDA, SVG TO OM) ON 27.8.2019and discharged on 2.9.2020 and not that of diabetes and hypertension, therefore, the claim of the complainant has been rejected by the Ops illegally and the complainant was entitled to medi claim from the Ops. Though, the claim of the complainant has been paid by the department of his wife being a spouse yet by not paying the claim by the Ops, the complainant  has been harassed by the Ops and on this account there was deficiency in services  and unfair trade practice on the part of the Ops and the present complaint is liable to be accepted for awarding adequate compensation to the complainant. The authority cited on behalf of the complainant is fully applicable to the facts and circumstances of the present case.

13.            For the reasons recorded above, we accept the present complaint and direct the Ops No.1 and 2 to pay the compensation of Rs.50,000/- to the complainant for the  mental agony and harassment caused to him. The OP No.1 and 2 are further directed to pay the sum of Rs.5000/- to the compensation for the litigation expenses. The OP no.1 and 2 are  also directed to make the compliance of this order within a period of 30 days from the date of receipt of the copy of this order failing which the complainant shall be at liberty to initiate proceeding u/s 71 of the Consumer Protection Act. The complaint qua OP No.3 stands dismissed. Certified copy of this order be sent to the parties concerned as per rules and the file be consigned to the record room after due compliance.

 

Announced in the Open Commission.

Dated 23.12.2021.                                               President.

 

                        Member             Member.