Haryana

Karnal

CC/305/2017

Jangsher Singh Rana - Complainant(s)

Versus

Religare Health Insurance Complany Limited - Opp.Party(s)

Joginder Singh Rana

18 Mar 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                          Complaint No. 305 of 2017

                                                          Date of instt. 15.06.2017

                                                          Date of Decision 18.03.2019

 

Jangsher Singh Rana son of Shri Shishpal Singh resident of House no.159, Sector-7, Urban Estate, Karnal.

                                                                       …….Complainant

                                        Versus

1. Religare Health Insurance Company Limited, through its Divisional Manager, Registered office, D-3, P3B, District Centre, Saket, New Delhi-110017.

2.  Religare Health Insurance Company Limited, through its Branch Manager, Vipul Square,Tower C, 3^rd floor, Sector-43, Golf Course Road, Gurugram, 122009.

3. Religare Health Insurance Company Limited, through its Branch Manager, SCO-124, 1^st floor, sector-12, Karnal.

 

                                                                      …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

      Sh.Vineet Kaushik ………..Member

           

 

 Present:  Shri Joginder Singh Advocate for complainant.

                  Shri Rohit Gupta Advocate for OP.

 

                   (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 took a policy from opposite party no.1 (OP no.1), vide policy no.10133633 firstly on 10.08.2014 to 09.08.2015 and the premium for the said period was paid to the tune of Rs.14,51/- then on 08.09.2015 to 07.09.2016 and the premium for the said period was paid to the tune of Rs.14,256/- and then on 08.09.2016 to 07.09.2019 and the premium for the said period was paid to the tune of Rs.38,825/- and all the three times the insured persons were also medically checked by the doctors of insurance company through which the father of the complainant Shri Shishpal was covered under the policy named as Hospitalization and Domiciliary Hospitalization Benefit Policy. The OP no.3 has been appointed by the OPs no.1 and 2 for providing the facility of cashless policy to the policy holders. As per the terms and conditions of the policy, the policy holder entitled to cashless treatment from the penal hospital. At the time of doing the policy, the agent of the company as well as other officials of the OPs assured that in case of hospitalization of insured persons namely Shish Pal, the company will pay the claim covered under the policy to the hospital. The father of the complainant suffered a problem in his eye and on 29.10.2016 was taken to Bhatnagar Eye Care Centre, Karnal. He admitted on 30.11.2016 and his eye was operated and he remained admitted from 30.11.2016 to 01.12.2016. The complainant submitted the claim covered under the policy before the OPs but OPs refused the claim of the complainant without any reason. Complainant spent about Rs.32,500/- on the treatment of his father in Bhatnagar Eye Care, Centre, Karnal and he submitted the bills for Rs.32,500/- with the OPs. The father of the complainant again suffered problem in Heart and on 8.3.2017 and was taken to Arpana Hospital, Madhuban, Karnal. He admitted on 28.03.2017 and discharge on 1.4.2017. The complainant again submitted the claim covered under the policy before the OPs but OPs refused to pay the claim of the complainant. Complainant again spent about Rs.30,000/- on the treatment of his father in Arpana Hosptial, Madhuban and submitted bills for Rs.30,000/- with the OPs. The complainant visited the office of OPs so many times and requested to make the payment of his claim but officials of the OPs postponed the matter on one pretext or the other and did not pay any claim. 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, who appeared and filed written version raising preliminary objections with regard to jurisdiction; maintainability; cause of action and concealment of true and material facts. On merits, it is pleaded that a policy bearing no.10133633 for a period from 10 August, 2014 to 09 August, 2015 and subsequently renewed from 08 September, 2015 to 07 September, 2016 and 08 September, 2016 to 07 September, 2019 was issued to the complainant covering the father of the complainant for a sum insured of Rs.5,00,000/- subject to the policy terms and conditions. It is further pleaded that the complainant has filed a Reimbursement Claim with the OPs for Hospitalization of the insured Shishpal at Bhatnagar Eye Centre, Karnal on 30.11.2016 for cataract surgery. It is further pleaded that no cashless facility has been availed by the complainant. The OP as observed that the patient was suffering from diabetes since 8 years hence the company rejected re-imbursement claim on 13.02.2017 under 6.1 for Non-disclosure of material fact/pre-existing aliment of filing proposal that is diabetes since 8 years. It is further pleaded that complainant has again filed a Reimbursement claim with the OP for hospitalization of the insured Shispal at Arpana Hospital, Karnal from 28.03.2017 to 1.4.2017 for treatment of acute inferior wall MI. The OP again rejected the 2^nd re-imbursement claim vide claim rejection letter dated 03.05.2017 on the grounds mentioned therein under clause 6.1 of the policy terms and conditions, for non-disclosure of material fact/pre-existing ailments at the time of proposal i.e. diabetes before policy inception. Hence there is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied by the OP and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence his affidavit Ex.P1 and documents Ex.P2 to Ex.P16 and closed the evidence on 6.8.2018.

4.             On the other hand, OPs tendered into evidence affidavit Ex.RW1/A and documents Ex.R1 to Ex.R16 and closed the evidence on 19.12.2018.

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 complainant has filed above complaint against OPs alleging deficiency in providing service in repudiating the claim of his father to reimburse the amount spent by him upon the medical treatment of his father. It was stated by him that he obtained a policy from the OPs in the year 2015 and subsequently renewed to 7 September 2019, covering the father of the complainant for a sum insured of Rs.5,00,000/-On 30.11.2016 the father of the complainant suffered a problem in his eye, was operated and the hospital raised a bill for an amount of Rs.32,500/- which he paid from his own resources. Father of the complainant again suffered problem in heart on 8.3.2017 and was taken to Arpana Hosptial, Madhuban, Karnal. Said hospital raised a bill for an amount of Rs.30,000/-, which he paid from his own resources, because both time, request for cashless treatment as stipulated in the insurance policy, was declined by the OPs on the ground that before issuance of above insurance policy, the father of the complainant was suffering from diabetes since 8 years, and he had not disclosed that fact of pre-existing disease in the proposal form to get insurance policy issued.

8.             On the other hand, the case of the OPs is that for non-disclosure of the fact of pre-existing disease in the proposal form, before inception of the policy, virtually amount to fraud committed by complainant in getting the policy issued. The father of the complainant was suffering from diabetes for the last 8 years before he had taken treatment. 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 OPs 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 prescription note dated 30 November, 2016 (Ex.R6), discharge summary (Ex.R7) and history sheet dated 28 March, 2017 (Ex.R8) prepared by the hospital staff, when after treatment father of the complainant was discharged from the Hospital, 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 complainant took the health insurance policy from OPs in the year 2015. The policy was valid upto 7^th September, 2019. The father of the complainant also covered in the policy and sum insured was of Rs.5 lakhs. Ex.R1 is the copy of that policy. Ex.R6 and Ex.R8 are the discharge summary of the father of the complainant which proves that he was diagnosed of Eye & Heart Problem. As per the past history, there is mention of diabetes (8 years). Ex.R3 is the denial of claim access to the father of the complainant by the OPs and operative part of the same reads as under:-

        “Non-disclosure of material facts pre-existing Diabetes-8 years.”

Thus, it is proved that the claim of the father of the complainant was denied on account of diabetes and its related complication and it is mentioned that there was diabetes since 8 years which is pre-existing in nature. Thus, we are the view that the burden was on the OPs 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.R6 to Ex.R8 (prescription slip and history of treatment) issued by the concerned hospital, where he was admitted and remained under treatment. OPs have failed to produce on record any document to show that the father of the complainant was suffering from diabetes from the last 8 years. The OPs have 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 OPs who supply this information to the hospital. It is also the duty of the OPs to conduct a thorough enquiry about the previous treatment of 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.R6 to Ex.R8), it cannot be said that the patient was suffering diabetes at the time of taking the policy and he was intentionally concealed the said material fact.

11.            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.

12.            So, in the present case the OPs have failed to produce cogent evidence to prove that prior to the date of taking the policy, the complainant’s father was suffering from 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 OPs but the same are not applicable to the facts of the present case because in the present case the OPs have 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.R6 to Ex.R8, there is no other evidence on record that the father of complainant was getting the treatment of 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 for the last 8 years.

13.            OPs have failed to prove that the complainant has suppressed material facts while obtaining the policy. As such OPs were not justified in repudiating the claim of the complainant. The complainant has placed on record Ex.P2 to P14 which are copy of bills making the payment to the Arpana Hospital, Madhuban and complainant also paid Rs.32,500/- to Bhatnagar Eye Care Centre, Karnal. As such OPs are liable to reimburse the amount of Rs.62,500/- to the complainant. The complainant is also entitled to compensation because of denial of his rightful claim by the OPs.

14.            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.

15.            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. 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.  

16.            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 IRDAI, 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 OPs to pay Rs.62,500/-(32,500+30,000) to the complainant with interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OPs 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:18.03.2019

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

               

        (Vineet Kaushik)         

            Member