DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .
Complaint No. 373
Instituted on: 13.09.2018
Decided on: 15.02.2021
1. Amrit Lal Singla son of Shri Sham Lal C/o Sham Lal Amrit Lal Singla, Shop No.52, New Grain Market, Sangrur.
- Reeta Rani wife of Sh. Amrit Lal Singla, C/o Sham Lal Amrit Lal Singla, Shop No.52, New Grain Market, Sangrur.
…. Complainant.
Versus
1. Religare Health Insurance Limited, 5th Floor, 19, Chawla House, Nehru Place, New Delhi-110019 through its Managing Director.
2. Union Bank of India through its Branch Manager, Patiala Gate Market, Branch Sangrur.
….Opposite parties.
For the complainant: :Shri Yogesh Gupta, Adv.
For the OP No.1 :Shri Jatinder Verma, Adv.
For the OP No.2. :Shri Amit Bhalla, Adv.
Quorum: Shri Jasjit Singh Bhinder, President
Shri V.K.Gulati, Member
ORDER:
Shri Jasjit Singh Bhinder, President
1. Complainant has filed this complaint pleading that the complainant has taken medical policy bearing No.11935755 from the OP number 1 through OP number 2. The bank has remitted the premium as per their internal arrangement on 20.12.2017. The complainants and Vishal Singla were insured for Rs.5,00,000/- with the OPs. Further case of the complainant is that complainant number 2 had visited Fortis Hospital Mohali on 18.8.2018 for routine check up and test only, as such the complainant submitted claim of Rs.72,789/- to the OPs regarding the payment made by the complainant to the hospital. Complainants had taken cashless hospitalization for medical insurance from the OP. The said hospital charged Rs.72,789/- from the complainant and the OP was bound to pay the amount to the hospital, but the payment was not made. The complainant has alleged that non payment of amount to the hospital is deficiency in service on the part of the OP. The OP sent letter dated 19.8.2018 and repudiated the claim on flimsy ground. The complainant has further averred that hypertension is not a disease. Thus, alleging deficiency in service on the part of the OPs, the complainant has prayed that the Opposite parties be directed to pay to the complainant the amount of Rs.72,789/- along with interest and further to pay Rs.20,000/- as compensation on account of mental agony, tension and harassment and an amount of Rs.22,000/- on account of litigation expenses.
2. In reply filed by the OP number 1, preliminary objections are taken up on the grounds that the complaint is not maintainable, that the complainant has filed this complaint with malafide intention and has not come to the Court with clean hands, that the complaint is false, frivolous and vexatious in nature. On merits it is admitted that the complainant had taken the health insurance policy with assured sum of Rs.5,00,000/- covering himself and spouse. The policy terms and conditions were also supplied to the complainant. It is further averred that the complainant was also supplied policy certificate, premium acknowledgement, key policy information, policy terms and conditions and claim process. It is stated further that the alleged claim under the above said policy was received from the hospital for hospitalization of the complainant’s spouse at Fortis Hospital Mohali for the treatment of sinusitis and spondylitis from 18.8.2018 to 19.8.2018. The complainant herein applied for a cashless facility request via its concerned hospital authorities with the OP and on the basis of documents received, it was observed that the patient is specified to be having a history of hypertension. The OP company post receipt of the cashless claim facility request triggered a claim investigation in order to authenticate the claim of the patient. During the course of investigation the son in law of the patient submitted his written declaration to the investigating officer specifically stating that the patient is suffering from hypertension since September 2016. It is further mentioned that the said condition was not disclosed by the complainant at the time of inception of the policy, as such the cashless facility request of the patient was denied under clause 7.1 of the policy terms and conditions for non disclosure of material information. It is stated that the complainant is not entitled to receive any claim.
3. In reply filed by OP number 2, preliminary objections are taken up on the grounds that the complainant has dragged the OP into uncalled litigation, that the complainant has got no locus standi to file the present complaint and that the complainant has no cause of action, that the complaint is false and frivolous. On merits, it is admitted that the policy in question was issued to the complainant. The other allegations leveled in the complaint have been denied.
4. The learned counsel for the parties produced their respective evidence.
5. The learned counsel for the complainant has argued that the complainant obtained medical policy from OP number 1 through OP number 2 for Rs.5,00,000/- by paying the requisite premium. It is further argued that the complainant number 2 Reeta Rani took treatment from Fortis Hospital, Mohali and spent an amount of Rs.72789/- and payment was made to the hospital authorities by the complainant. The learned counsel for the complainant has further argued that the OP was bound to repay the amount of the insurance claim as she was insured with the OP, but the Op has not paid the same. The learned counsel for the complainant has further argued that Reeta Rani has not taken treatment from Dr. R.S.Rai in Sangrur. The learned counsel further argued that there is no evidence on the file that the patient was suffering from hypertension and the claim has been wrongly rejected.
6. The learned counsel for the complainant has cited United India Insurance Co. Ltd versus Alka Maheshwari 2017(1) CLT 83 (NC) wherein it has been stated – Insurance claim- Death of Insured by falling in bathroom- Award of compensation- Sustainability of- No evidence on record to establish that deceased was suffering from hypertension and that same was known to him, before taking policy. Opinion given by panel doctor of Insurance Company and Government doctor that fall was on account of hypertension, seems to be quite remoter possibility. Evident that patient died shortly after suffering fall in bathroom and succumbed to his injuries even before reaching hospital, leading to implication that he did suffer from in internal injury after fall in bathroom. Therefore, no illegality, irregularity or jurisdictional error in orders passed courts below. Hence, revision petition dismissed. The learned counsel has further cited Abedin S. Baldiwala versus United India Insurance Co. Ltd. Mediclaim policy. Bye-pass surgery. Repudiation of claim to incur expenses-suppression of medical problem while taking policy – Deficiency in service-Complaint allowed. Order reversed in appeal. Revision petition- Held, no evidence that any treatment for diabetes and hypertension was taken before the proposal form was signed and that insured was aware about these two ailments at the time of filing of policy. Medical evidence shows that bye-pass surgery in the present case may not be directly related to ailments of diabetes and hypertension- Policy amount was enhanced after blood test and sugar test and after full satisfaction of the insurer- Mediclaim cannot be denied under policy only on a technical ground, which is not proved beyond doubt – Insurance company directed to pay Rs.3,00,000/- along with interest @ 6% p.a. The learned counsel for the complainant further relied upon Rajesh Singla versus Max Bupa Health Insurance Co. Ltd. and another 2018(3) CPJ 172 (Punjab State Commission) wherein it has been held that “Consumer Protection Act 1986 Section 17 Health Companion Health Insurance policy- Reimbursement denied on ground of suppression of pre-existing disease- Alleged deficiency in service- Thus, the complaint –Held, mere reference in the record mentioned by the Doctor that he was suffering from hypertension for the last 5 years is not sufficient to say so. Moreover, hypertension is not a disease, which is required to be referred in the proposal form. Ops have not been able to collect any evidence that before taking policy, complainant/insured was suffering from hypertension or his liver disease was complication arising on account of misuse of substance therefore, claim cannot be repudiated on basis of any complication of hypertension. OPs are directed to pay Rs.22,22,352 to complainant along with interest @ 9% per annum. Hence, complaint disposed of.” The complainant has also cited ICICI Lombard General Insurance Company Ltd. versus Jasbir Singh 2014(1) CLT 220, wherein it has been stated that Insurance Claim – Repudiation on the ground that insured suppressed pre-existing disease hypertension at the time of proposal form. Insured medically examined by the empanelled medical officer of the insurance company before issuing insurance policy. Record withheld by insurance company. Held appellant is liable to an adverse inference for withholding the said record. Hypertension is a life style disease and easily controllable with conservative medicines. Appeal of the insurance company dismissed. As such, the learned counsel for the complainant has prayed for acceptance of the complaint.
7. On the other hand, the learned counsel for the OPs has argued that the complainant was suffering from hypertension and this fact was not disclosed at the time of taking the insurance policy. The learned counsel for the OPs has further argued that a person who suppresses the disease at the time of insurance the same is not entitled to get any claim.
8. To prove the case, the complainant has produced Ex.C-1 is welcome letter of Religare, Ex.C-2 is copy of card, Ex.C-3 is copy of proposal form, Ex.C-4 is the bill of Fortis Hospital for Rs.42,789/-, Ex.C-5 is the receipt, Ex.C-6 is prescription slip, Ex.C-7 is record of hospital, Ex.C-8 is the affidavit of Shri Amrit Lal Singla who has deposed as per the complaint. Ex.C-9 is the affidavit of Smt. Reeta Rani and has deposed as per the complaint.
9. On the other hand, the OP number 1 has produced Ex.OP1/1 copy of policy, Ex.OP1/2 affidavit of Shri Prashant Singh, who has deposed as per the written version of OP number 1, Ex.OP1/3 is copy of policy terms and conditions, Ex.OP1/4 is copy of statement of Shri Himanshu Garg, son in law of patient and has stated that his mother in law is suffering from minor hypertension. Ex.OP1/5 is the request for cashless hospitalization for medical insurance policy, Ex.OP1/6 is the copy of judgment. As such, the learned counsel for the OP has stated that the claim has rightly been rejected.
10. Admittedly, both the bills submitted by Reeta Rani are on the file and the total amount of bills is Rs.72,789/-, but the claim was not paid by the OP number 1 on the ground that the patient was suffering from hypertension. Various citations were cited by the learned counsel for the complainant that hypertension is not a disease and the insurance claim cannot be rejected on this ground alone. More over, the Op number 1 has failed to prove on record that Reeta Rani was suffering from hypertension since long. Although there is a document which is signed by son in law of Reeta Rani stating that she was suffering from minor hypertension, but the claim cannot be rejected on this ground.
11. As the complainant was insured with the OP number 1 and Reeta Rani took treatment from Fortis Hospital, Mohali, the OP number 1 is duty bound to pay the insurance claim amount to the complainant.
12. After taking the legal position and circumstances of the case, we allow the complaint and direct OP number 1 to pay to the complainant the amount of Rs.72,789/- along with interest @ 6% per annum from 19.8.2018 i.e. the date of repudiation of the claim till realization in full. We further direct OP number 1 to pay to the complainant an amount of Rs.5,000/- on account of compensation for mental tension, agony and harassment and an amount of Rs.5000/- on account of litigation expenses. This order be complied with by the opposite parties within 60 days from the date of receipt of certified copy of this order. A certified copy of this order be issued to the parties free of cost as per rules. File be consigned to records.
Pronounced.
February 15, 2021.
(Vinod Kumar Gulati) (Jasjit Singh Bhinder)
Member President
