CONSUMER DISPUTES REDRESSAL COMMISSION – X

GOVERNMENT OF N.C.T. OF DELHI

Udyog Sadan, C – 22 & 23, Institutional Area

(Behind Qutub Hotel)

New Delhi – 110016

Case No.42/2019

Mr. Ranjit Madan

S/o Sh. K.D. Madan

R/o B-62, Vasant Vihar

New Delhi-110057.                                                       …..COMPLAINANT

Vs.

Religare Health Insurance Company Ltd.

Having its Registered office at:

5^th Floor, 19 Chawla House

Nehru Place, New Delhi-110019.

Having its correspondence address:

Vipul Tech Square, Tower-C

3^rd Floor, Gold Course Road

Sector-43, Gurugram-122009.                                        …..RESPONDENT

                                                                              Date of Institution-   11.04.2014

    Date of Order-30.08.2024

                                                O R D E R

RITU GARODIA-MEMBER

1.  The complaint pertains to deficiency in service on the part of OP in repudiating the claim of complainant.

2. Facts as stated in the complaint are that the complainant was insured with OP from 30.03.2014 onwards for sum insured of Rs.10,00,000/-.  Before the inception of the policy, the complainant underwent various test including blood cholesterol test in the year 2013. 

3. On 24.07.2018, the complainant felt a mild discomfort in his chest.  He went to Forties Escorts Heart Institute.  An assessment/notes was prepared by junior doctors.  The complainant was advised coronary Angiography by Dr. Ashok Seth, the treating cardiologist. The complainant applied for pre-authorization which was denied by OP vide 26.7.2018 on grounds of non-disclosure of material facts. The complainant alleges that an interpretation was drawn by OP that since the word ‘non’ was mentioned before ‘HTN’ and ‘DM’ and not before ‘Dyslipidemia’, it would mean that the complainant was suffering from the same in the year 1994.

4. Dr. Ashok Seth, a reputed doctor at Fortis Escorts, issued a justification letter dated 02.07.2018 stating that the complainant was neither a patient of nor did he have a history of Hypertension, DM or Dyslipidemia.

5. The complainant post-surgery applied for reimbursement of the claim vide claim form dated 25.08.2018 for the amount of Rs.3,59,850/-.  The said claim was denied by the OP vide claim denial letter dated 13.09.2019 stating ‘Insured Underwent Angiography Prior to Policy Inception and same was not disclosed.”   The complainant underwent a CT Angiography, the result of which as per the notes of the junior doctors was negative.

6. The complainant was also entitled to be reimbursed for post hospitalization expenses for upto two months.  He, therefore, submitted a few bills with OP amounting to Rs.8573/-. The said claim was denied by OP vide letter dated 14.01.2019.

7. Complainant prays for refund of Rs.3,59,850/-alongwith interest @24%, Rs.8,573/- towards post hospitalization expenses, Rs.10,00,000/- towards metal agony and harassment and Rs.1,00,000/- towards litigation costs.

8. OP in its reply submits that the complainant purchased Health Insurance Policy bearing No.10092219 from OP for sum insured of Rs.10,00,000/- w.e.f. 30.03.014 till 19.03.2015 subject to the policy terms and conditions. The said policy was ported from New India Assurance Company wherein the policy inception period was 30.03.2010.

9. The complainant was hospitalized at Fortis Escorts Hearts Institute, New Delhi from 26.07.2018 to 28.07.2018 on complaints of chest discomfort.  He was diagnosed with Coronary Artery Disease and underwent Coronary Angiography.  The complainant approached  OP on 24.07.2018 with the cashless facility request.  On the scrutiny of the documents, OP came up  with the following facts :

1. The pre-hospitalization medical record dated 24.07.2018 issued by the concerned hospital authorities, i.e. Fortis Escorts Hospital stated that the complainant is non-hypertensive/non Diabetes Mellitus/ Dyslipidemia in 1994.
2. Prescription letter issued by Dr. Vikas Kumar Jha dated 13.07.2018(sic) states that the complainant is suffering from Hypertension and was on regular medication of Tab Angispam.  
3. As per investigation report issued by Mahajan imaging dated 20.07.2018, the complainant also underwent CT-Coronary Angiography.

10. It is alleged that no disclosure regarding the above mentioned observations was made by the complainant at the time of policy. OP further states that no disclosure was made at the time of pre-policy medical examination. OP denied the cashless facility request vide letter dated 24.07.2018 and 26.08.2018 on the basis of clause 7.1 of the policy terms and condition i.e. non-disclosure of material information.

11. The treating doctor of the complainant i.e. Dr. Ashok Seth (Medical Superintendent, Fortis Escorts Hospital) issued a justification letter dated 25.08.2018 which stated that the complainant is not having any history of Hypertension, Diabetes Mellitus and Dyslipidemia.  OP raised query to doctor (QTD) vide letter dated 30.08.2018 pertaining to the past medical history of Dyslipidemia.  OP issued QTD to Dr. Vikash Kumar Jha to seek for previous medical record of Hypertension.  OP also raised query to doctor (QTD) to Dr. Vivek Sama, seeking explanation for referring the complainant for CT Angiography.    Queries raised by the OP for consideration of the treating doctors have not been reverted till date.

12. The complainant approached OP with the reimbursement claim.  As per the pre-hospitalization medical record dated 24.07.2018, the complainant also underwent Coronary Angiography in 2011.  But no such disclosure was made by the complainant at the time of the filing of the proposal form.  OP rejected the claim filed the complainant vide letter dated 14.09.2018 on the basis of clause 7.1 of the policy terms and conditions.

13. OP submits that the declarations made by the complainant at the time of filing proposal form are as follows:

• Is any of the member proposed to be insured suffering from any illness/disease

-Heart Disease

• Has anyone been diagnosed/hospitalized or under any treatment for any illness/injury during the last 48 months.

OP submits that the answer was marked ‘NO’ by the complainant to the above asked question.  The complainant also underwent pre-policy medical examination but no disclosure regarding coronary angiography was made by the complainant.

14.  OP sent a notice of cancellation of policy vide letter dated 26.11.2018 which was replied by the complainant vide letter dated 08.12.2018.  OP cancelled the policy of the complainant vide letter dated 02.01.2019 in accordance of clause 7.13 of the policy terms and condition.

15. The complainant in its rejoinder has re-iterated the averment made in the complaint. The complainant clarified that the policy of complainant has never been terminated.  This Commission vide order dated 22.04.2019 has directed the party to maintain status-quo on the policy.

16. Complainant has filed evidence by way of an affidavit and has exhibited the following documents:

1. Copy of the policy is exhibited as Exhibit CW1/1.
2. Copy of the latest policy is exhibited as Exhibit CW1/2.
3. Copy of test reports is exhibited as Exhibit CW1/3.
4. Copy of patient record is exhibited as Exhibit CW1/4.
5. Copy of denial letter is exhibited as Exhibit CW1/5.
6. Copy of justification letter is exhibited as Exhibit CW1/6.
7. Copy of claim form is exhibited as Exhibit CW1/7.
8. Copy of claim denial letter is exhibited as Exhibit CW1/8 & 9.

17. OP has filed evidence by way of an affidavit and has exhibited the following documents:

1. Copy of policy certificate is exhibited as Exhibit Ex.R-1.
2. Copy of cashless claim policy is exhibited as Exhibit Ex.R-2.
3. Copy of pre-hospitalization medical record is exhibited as Exhibit Ex.R-3.
4. Copy of prescription letter is exhibited as Exhibit Ex.R-4.
5. Copy of investigation report is exhibited as Exhibit Ex.R-5.
6. Copy of denial letter is exhibited as Exhibit Ex.R-6.
7. Copy of terms and condition is exhibited as Exhibit Ex.R-7.
8. Copy of justification letter is exhibited as Exhibit Ex.R-8.
9. Copy of QTD is exhibited as Exhibit Ex.R-9.
10. Copy of QTD to Dr. Vikas is exhibited as Exhibit Ex.R-10.
11. Copy of QTD to Dr. Vivek Sama is exhibited as Exhibit Ex.R-11.
12. Copy of claim form and claim rejection letter is exhibited as Exhibit Ex.R-12.
13. Copy of proposal form and pre-policy medical examination is exhibited as Exhibit Ex.R-13.
14. Copy of policy cancellation letters is exhibited as Exhibit Ex.R-14.
15. Copy of Grievance letter is exhibited as Exhibit Ex.R-15.

18. The Commission has considered the material and documents on record.  Perusal of the record shows that the complainant was insured from 30.03.2014 onwards with OP.  Admittedly, the said policy was ported from New India Assurance commencing from year 2010.    The complainant was hospitalised from 26.07.2018 to 28.07.2018 in Fortis Escorts Heart Institute.  Relevant potion of the discharge summery is as follows :

FINAL DIAGNOSES:

1. CORONARY ARTERY DISEASE

2. STRESS THALLIUM NEGATIVE-2011

3. CT ANGIO (20.07.2018) LAD PROX 90%, DI 50%, LCX (PROX-MID) 80%, OM2-50-60%, PROX RCA 50-60%

4. CAG: LAD 80-90%, LCX 90%, RCA 70% (26.07.2018)

3. PICA WITH STENT TO LCX, LAD & DI (26/01/2018)

HISTORY OF PRESENT ILLNESS

The patient is normotensive, non-diabetic, non-smoker and has no family history of cardiovascular disease. Patient presented with complaints of chest discomfort since 30 days. He had underwent CT angio on 20.07.2018. Patient is now admitted to FEHI for further evaluation and management

PROCEDURE DONE:

CORONARY ANGIOGRAPHY LAD 80-90%, LCX 90%, RCA 50-70% (26/07/2018)

PTCA USING XIENCE XPEDITION SV (2.25 X XMM) STENT TO D1, XIENCE XPEDITION (3.5 X 12MM) STENT TO LAD, RESOLUTE ONYX (2.75 X 30MM) STENT TO LAD & XIENCE XPEDITION (3.5 X 28MM) STENT TO LCX (26/07/2018)

19.  OP  in its letter 28.07.2018 rejected the cashless claim of the complainant stating the following reasons - 

We have reviewed your request, and hereby inform you that the cashless hospitalization carrot be approved as per the terms & conditions of the policy stated below-

• Non-Disclosure Of Material Facts Pre-Existing Ailments At Time Of Proposal (Patient Is K/C/O Dyslipidaemia Prior To The Policy Inception), Reaction Remain Same
• Non-Disclosure Of Material Facts Pre-Existing Ailments At Time Of Proposal

20. OP vide letter dated 13.09.2018 rejected the  claim  for re-imbursement stating the following reasons –

• Insured underwent angiography prior to policy inception and same was not disclosed.  Hence claim is repudiated under non-disclosure.
• Non-disclosure.

21. OP vide letter dated 14.09.2018 rejected the  claim  for re-imbursement stating the following reasons- 

• As main claim is repudiated
• Non-disclosure of material facts/pre-existing ailments at time of proposal

22. OP has rejected the claim of the complainant on different grounds in different letters.  OP while rejecting the cashless claim of the complainant has stated that the insured was suffering from Dyslipidaemia prior to the policy inception.  OP has relied on handwritten, unsigned patient notes dated 24.07.2018 wherein it is noted ‘non HTM/non DM/ Dyslipidaemia’. The year 1994 was mentioned in the line below.  A  clarification letter from the treating doctor,  Dr. Ashok Seth, dated 25.07.2018 is as follows- 

This is to certify that Mr. Ranjit Madan VIDE FEHI Reg. No. 1652231, 63 years old male is getting admitted on the 26/07/18 for his heart treatment (Coronary Angiography +/-PCI)

This is in reference against the query raised for cashless treatment where you have misinterpreted our notes. We would like to inform you that the patient is not having any history of Hypertension, DM and Dyslipidemia.

It was in 1994, when the first routine checkup was done and all blood works including the lipid profile were normal.

23. Thus it is evident that the patient notes meant that the complainant/patient was not having any history of hypertension, diabetes or Dyslipidaemia.

24. The OP subsequently repudiated the claim for reimbursement on the grounds of non-disclosure of facts, such as the complainant's angiography prior to the policy inception. The OP also mentioned that the complainant had answered 'No' to the question of whether the insured was suffering from any illness. However, OP has not submitted any proposal form. OP presumed that the complainant was suffering from heart disease based on the fact that the complainant had undergone angiography before the policy's inception. OP has neither stated nor provided any angiography report indicating that the results were abnormal or showed any heart disease.

25. As per the Judgment of National Commission in Star Health & Allied Insurance Co. Ltd. and Ors. Vs. Atul Kumar and Ors. 2023 (4) CPR 60 has observed:

21. It is a fundamental principle in the insurance contracts that the party claiming the exemption clause needs to establish the same. However, Appellants failed to substantiate that the insured child had such medical condition by birth and that, while being aware, Respondent No. 1 failed to notify the same to the Appellant the stage of making the proposal. On the other hand, Respondent No. 1 repeatedly asserted the absence of knowledge of such medical condition, if any, and that the first discovery of the same was made much after the insurance contract was entered into and, therefore, he is entitled for reimbursement of medical expenses under the scope of the policy.

22.    It is in common amongst children of tender age to have convulsions during high fever conditions and recover after high temperature recedes. Therefore, mere isolated event of such incident cannot constitute knowledge of an entirely independent medical condition that may be revealed at a subsequent stage. The stated facts and records reveal that, while the Complainant No. 1 clarified the circumstances under which he discovered the medical condition of his child, the Appellant/OPs failed to establish that Master Anshuman Rai was suffering from this disease by birth and there was concealment of fact at the time of taking the insurance policy. Therefore, the claim is liable to be allowed.

26. The insurance company has provided no justification for requiring disclosure of normal medical test results. A policyholder is not obligated to disclose all normal medical test results at the time of policy application. Moreover, OP has also not requested this information from the complainant in the proposal form. It is unreasonable to penalize a complainant for undergoing precautionary tests, investigations, or procedures that yield normal results.

27. OP in its written statement has also relied on prescription issued by Dr. Vikas Kumar Jha.  The prescription dated 13.07.20 indicates that the complainant was taking various medications including capsule angispam. The said prescription also note HTN.  This prescription is in the year 2020 much after the inception of the policy in the year 2014. OP has alleged that the prescription is dated 13.07.2018 but the copy of the prescription filed with its reply only provides the date 13.07.20.

28. Perusal of record also reveals that the complainant underwent a health check-up prior to the inception of the policy.  The same was admitted in the reply filed by OP.

29. Admittedly, the complainant was insured with OP from 13.03.2014. The said policy was ported from New India Assurance which commented on 30.03.2010.  It is also admitted by both the parties that complainant underwent medical check-up prior to inception of the policy.  There was no illness as per the medical examination prior to the inception of the policy.  There was no specific question in the proposal regarding any investigation/test undertaken by the complainant in which the result were normal. Hon’ble National Commission in Smt. Daya Rani Vs Life Insurance Corporation of India IV(2009) CPJ174(NC) has held complainant is not liable to give voluntarily information which is not sought for by the insurer.

30. OP vide letter dated 26.11.2018 sent a notice for cancellation of policy. The complainant replied vide letter dated 08.12.2018.  OP vide letter dated 02.01.2019 cancelled the policy as void ab-initio on ground of non-disclosure of material facts. The complainant had filed an application for stay.  This Commission vide its order dated 22.04.2019 directed the parties to maintain status quo.  In the light of discussion above, there was no non-disclosure of material facts and OP was deficient in cancelling the policy.

31. OP has annexed bill dated 08.09.2018 for Rs.2,638/-, bill dated 10.09.2018 for Rs.750/-, bill dated 10.09.2018 for Rs.5,785/- towards doctors consultation and medicine. OP has annexed claim form dated 25.08.2018 which shows that the claim amount is as follows-

Hospital Main Bill 2 Nos.3,38,515/-

Pre-hospitalization Bills 5 Nos.14,053/-

Post-hospitalization Bills 4 Nos.7,282/-

32. Hence we hold OP guilty of deficiency in service in not paying the claim of the complainant on frivolous ground.  We direct OP to pay 

1. Rs.3,59,850/- (Rs.3,38,515+14,053+7,282) with 9% interest from date of claim till realisation.
2. Rs.9,173/- (Rs.2,638+750+5,785) with 9% interest from date of claim till realisation.
3. The policy to be renewed with continuity benefit.
4.  Rs.10,000/- as compensation for mental harassment, physical inconvenience inclusive of litigation expenses.

33. Order to be uploaded and complied with   within 30 days and file be consigned to record room.