District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.301/2021.
Date of Institution: 01.07.2021.
Date of Order: 20.09.2022.
Atul Gautam son of Shri Jagannath Gautam, resident of House No. 758, Sector-21A, Faridabad.
…….Complainant……..
Versus
Religare Health Insurance, Dwarka Complex, SCO-102-103, Office No. 219, IInd floor, Sector-16, Faridabad – 121007 through its Divisional Manager.
…Opposite party……
Complaint under section-12 of Consumer Protection Act, 1986
Now amended Section 34 of Consumer protection Act 2019.
BEFORE: Amit Arora……………..President
Mukesh Sharma…………Member.
Indira Bhadana…………Member.
PRESENT: Sh. V.D.Kaushik, counsel for the complainant.
Sh. P.L.Garg, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant and his family members namely Mrs. Jyoti Gautam, Kabir Gautam & Yovraj were insured with opposite party vide mediclaim insurance policy No. 10481350 client I.D.No. 52924077, commencing from 07.12.2016 to 20.12.2019. On dated 04.11.2018 the wife of the complainant admitted with Asian Institute of Medical Sciences, Sector-21A, Faridabad due to complaints of unknown poisoning (Tab. Lorazepem). On examination patient was unconscious, labored breathing, into bated in emergency and shifted ot ICU. All routine investigation were sent and patient was started with IV fluids IV antibiotics and other conservative management. Patient become conscious, vital stable. Patient was gradually warn off and extubated on 04.11.2018. Patient was symptomatically better and shifted to IMCU. Psychiatrist consultation was done and advise followed. After getting treatment the wife of the complainant discharge don 06.11.2018. The said hospital raised a bill of Rs.65,760/-. The complainant duly submitted his claim papers for the above stated expenses incurred by the complainant on treatment of his wife with opposite party. On 10.09.2019 the wife of the complainant again admitted in Asian Institute of Medical Sciences, Sector-21A, Faridabad with complaint of higestion of some unknown pills at home at about 9.30p.m. on 10.09.2019 followed by altered sensorium and drowsiness. At admission patient was drowsy responding to deep stimuli but not following command, pupils – BERL, patient was otherwise hemodynamiccally stable. Patient was evaluated and investigated. After getting treatment the wife of the complainant discharged on 12.09.2019. The said hospital raised a total bill of Rs.38,706/-. The complainant duly submitted his claim papers for the above stated expenses incurred by the complainant on treatment of his wife with opposite party. On 23.11.2019 the wife of the complainant admitted with Fortis Hospital Limited, Neelam Bata Road, Faridabad. After getting treatment the wife of the complainant discharged on 12.09.2019. The said hospital raised a total bill of Rs.38,706/-. The complainant duly submitted his claim papers for the above stated expenses incurred by the complainant on treatment of his wife with opposite party. On 23.11.2019, the wife of the complainant admitted with Fortis Hospital Limited, Neelam Bata Road, Faridabad. After getting treatment the wife of the complainant discharged on 24.11.2019. The hospital raised a total bill of Rs.23,616/-. The complainant duly submitted his claim papers for the above stated expenses incurred by the complainant on treatment of his wife with opposite party. The complainant requested opposite party so many times to reimburse the total amount of Rs.1,28,082/- which had been spent by the complainant on the treatment of his wife but opposite party had not given any heed towards to the request of the complainant. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) pay the amount of Rs.1,28,082/- which was incurred by the complainant on the treatment of his wife.
b) pay Rs. 50,000/- as compensation for causing mental agony and harassment .
c) pay Rs. 11,000 /-as litigation expenses.
2. Opposite party put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that the complainant had taken Health Insurance policy initially bearing NO. 10481350 covering the complainant namely Atul Gautam, his spouse Jyoti Gautam and his two sons namely Kabir Gautam and Yuvraj Gautam initially w.e.f. 17.12.2015 to 16.12.2016, 17.12.2016 to 16.12.2017, 19.12.2017 to 18.12.2018 and lastly 21.12.2018 to 20.12.2019 for a sum insured of Rs.5,00,000/- subject to policy terms & conditions.
First Cashless Request (claim No. 80318405-00)
a) The complainant filed for cashless facility request claim for the hospitalization of his wife namely Jyoti Gautam. As per the pre-authorization, she was hospitalized at Asian Hospital, Faridabad w.e.f. 4.11.2018 to 6.11.2018. She was having a history of unknown poisoning at home at about 3;00a.m. She had complaints of breathlessness, weakness, unconscious. The opposite party company raised deficiency letter dated 4.11.2018 to seek the below documents:
Kindly provide:
i. Copy MLC/FIR Copy
ii. Detail narration of injury with exact date and time.
But the complainant kept mum with no response. The opposite party company rejected the claim of the complainant vide denial letter dated 5.11.2018 with the following observations:
i. Non disclosure of material facts/pre-existing ailments at the time of proposal (patient having H/o depression since prior to policy inception).
ii. Non disclosure of material facts/pre-existing ailments at the time proposal.
b) IInd Cashless Request (Claim NO. 80318405.00)
The complainant filed second cashless re-imbursement claim w.r.t. his wife namey Jyoti Gautam hospitalization. As per the request of pre –authorization form, she was hospitalized at Asian Hospitals, Faridabad w.e.f. 10.09.2019 to 12.09.2019, she was diagnosed with unknown poisoning. The opposite party company rejected the claim of the complainant vide denial letter dated 11.09.2019 with the following observations:
i. Previous claim rejected claim NO. (80221505) for non disclosure of material facts/pre-existing ailments at the time of proposal (patient having H/o depression since prior to policy inception).
ii. Non disclosure.
C. IIIRD CASHLESS REQUEST (CLAIM no. 80346985-00)
The complainant filed second cashless re-imbursement claim w.e.t. his wife namely Jyoti Gautam hospitalization. As per the procured discharge summary, she was hospitalized at Fortis Hospitals, Faridabad w.e.f. 23.11.2019 till 24.11.2019. She was diagnosed with Pyrexia U/E, Acute Viral hepatitis? Hematemesis and anemia. The claim was initially approved for an amount or Rs.20,000/-. However, with subject to some conditions a stated in the approval letter.
Further concealment: It was also observed by the answering opposite party during investigation form the hospital records that patient was in ICU suicidal attempt tby patient 4 times last time admitted in Sarvodaya Hospital but the said factum, of treatment of Sarvodaya hospital and factum of disease was concealed by the complainant.
Rejection of cashless request: As soon as the company got to know that the earlier claims were rejected on history of depression. The opposite party company rejected the claim of the complainant vide denial letter dated 24.11.2019 with the following observations:
Non disclosure of material facts/pre0existing ailments at the time of proposal (patient having H/o depression since prior to policy inception), note initial authorization also stands null and void.
Non Disclosure of material facts/pre-existing ailments at the time of proposal.
The company triggered its claim investigation and it found that the insured had attempted for suicide 4 times in past. Hence, owing to the suicidal tendencies of the insured, the complainant rightly observed that the insured was a known case of depression which was a declined risk as per policy terms and conditions. The investigations had procured an audio visual recording which proves the same. The complainant had an opportunity to declare his wife’s history of pre-existing ailments/ depression at the time of filing of proposal form, but the complainant intentionally did not disclose the same to the opposite Party company “Which itself is a concealment on the part of complainant and to put the principle of at most good faith regarding policy was not at all followed by the complainant”.
The declaration made by the insured to the following questions asked in the proposal form was as under:
Is any of the member proposed to be insured suffering from any illness or disease? If yes provide details:
Others
Has anyone been diagnosed/hospitalized or under any treatment of any illness/injury during the last 48 months?
The complainant answered No to the above questions.
The complainant also signed the below declarations
A. I have read and understood the scheme details/brochure/prospectus/sales literature/terms and conditions of the group policy and confirm to abide by the same.
D. I understand that the policy shall became void at the company’s option in the event of any untrue or incorrect statements, misrepresentation, non-description or non-disclosure of any material fact, in the proposal form/personal statement, declaration and connected documents or any material information having been withheld by me or anyone acting of my behalf.
I, the undersigned hereby declare on my behalf and on behalf of each of the persons proposed to be insured that the above statements, answers and/or particulars given by me are true, accurate and complete in all respects and that there is all information which is relevant to this proposal that has been disclosed and not withheld from the company. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.
3. The parties led evidence in support of their respective versions.
4. We have heard learned counsel for the parties and have gone through the record on the file.
5. In this case the complaint was filed by the complainant against opposite parties– Religare Health Insurance Company ltd. with the prayer to: a) pay the amount of Rs.1,28,082/- which was incurred by the complainant on the treatment of his wife. b) pay Rs. 50,000/- as compensation for causing mental agony and harassment . c) pay Rs. 11,000 /-as litigation expenses.
To establish his case the complainant has led in his evidence, Ex.CW1/A – Atul Gautam, ExC1 – Denial letter, Ex.C-2 – Discharge summary,, Ex.C3 & 4 – Discharge summary, Ex.C5 & C6– Final Bills, Ex.C-7 – Inpatient summary bill, Ex.C-8 – postal receipt, Ex.C-9 – legal notice, Ex.C-9 – Identity card.
On the other hand counsel for the opposite party strongly agitated and
opposed. As per the evidence of the opposite party , Ex.RW1/A – affidavit of Shri Ravi Boolchandani, Religare Health Insurance Co. Ltd., Ex.R-1 - policy with terms and conditions, Ex.R-2 – Request for Cashless Hospitalization for Medical Insurance Policy, Ex.R-3 – Deficiency letter dated 04.11.2018, Ex.R-4 – Denial letter dated 05.11.2018, Ex.R-5 – Pre-authorization Form, Ex.R-6 – Denial letter dated 11.09.2019, Ex.R-7 – ICU note of the hospital, Ex.R-8 – denial letter dated 24.11.2019, Ex.R-9 –CD, Ex.R-10 – Proposal Form, Ex.R-11 –letter dated 14.10.2019 regarding notice for cancellation of policy, Ex.R-12 – letter dated 29.02.2020, Ex.R-13 –affidavit of Girraj Singh, Investigator, Care Health Insurance, Ex.R-14- Affidavit of Girraj Singh.
6. In this case, the complaint was filed by the complainant with the prayer to pay the amount of Rs.1,28,082/- which was incurred by the complainant on the treatment of his wife.
During the course of arguments, Shri V.D.Kaushik, counsel for the complainant has made a statement that I only press for the claim of D.O.
A dt.23.11.2019 to 24.11.2019 in Forties Hospital for an amount of Rs.23,616/-. On the other hand counsel for the opposite party argued at length and agitated on the ground of depression. The claim of the complainant was repudiated on the ground of depression/suicidal attempt and also to support their evidence opposite party has led in their evidence letter dated 11.09.2019 vide Ex.R6 in which it has been mentioned that i) Previous claim rejected claim NO. (80221505) for non disclosure of material facts/pre-existing ailments at the time of proposal (patient having H/o depression since prior to policy inception).ii. Non disclosure.. As per Ex.R-7 – during the investigation form the hospital records that patient is in ICU suicidal attempt by patient 4 times last time admitted in Sarvodaya hospital but the said factum of treatment of Sarvodaya hospital and factum of disease was concealed by the complainant.. It is evident from audio visual recording into a CD format vide Ex.C9 in which it has stated that The company triggered its claim investigation and it found that the insured had attempted for suicide 4 times in past. Hence, owing to the suicidal tendencies of the insured, the complainant rightly observed that the insured was a known case of depression which was a declined risk as per policy terms and conditions. The investigations had procured an audio visual recording which proves the same. The complainant had an opportunity to declare his wife’s history of pre-existing ailments/ depression at the time of filing of proposal form, but the complainant intentionally did not disclose the same to the opposite Party company “Which itself is a concealment on the part of complainant and to put the principle of at most good faith regarding policy was not at all followed by the complainant”.
7. After going through the evidence vide Ex.R-6, R-7 & R-9 led by the opposite party, the Commission is of the opinion that the claim of the complainant was repudiated on the perfect ground. Hence, no deficiency in service on the part of the opposite party has been proved. Resultantly, the complaint is dismissed. Copy of this order be sent to the parties concerned free of costs. File be consigned to the record room.
Announced on: 20.09.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
(Indira Bhadana)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
