DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II
Udyog Sadan, C-22 & 23, Qutub Institutional Area
(Behind Qutub Hotel), New Delhi-110016.
Case No.154/2016
Mr. Gope Kishnani SENIOR CITIZEN
Son of Late Sh. Hari Ram (69 years old)
Resident of O-22, First Floor,
Lajpat Nagar II.
New Delhi-110024 ….Complainant
Versus
Chairman and Managing Director
M/s Religare Health Insurance Company Ltd.
D 3, P3 B, District Centre
Saket
New Delhi-110017 ……Opposite Party
Date of Institution : 24.05.16 Date of Order : 07.02.17
Coram:
Sh. N.K. Goel, President
Ms. Naina Bakshi, Member
O R D E R
Complainant’s case, in short, is that in the month of Jan. 2016 he took a policy No. 10505590 from the OP for the plan Explore – Canada + for the period 14.01.2016 to 19.02. 2016 i.e. for 37 days and paid a premium of Rs. 10,014/- (premium + service tax) and disclosed all the material facts to the OP with all documents e.g. age proof, income proof etc. along with the proposal form. Complainant has stated that he was obtaining health insurance from the OP for the last more than six years; that while obtaining the health insurance, as usual, the OP got him and his wife Mrs. Asha Kishnani to undergo the medical tests and the OP personally went through the medical details. His wife Mrs Asha Kishnani got ill while travelling and was to be hospitalized during the period of insurance policy in Canada. She was hospitalized in Canada and had to spend a sum of Canadian dollars 16000.00 and accordingly the complainant submitted the claim which was duly acknowledged by the OP. It is submitted that the OP repudiated the claim on the ground of non-disclosure of pre-disease of the Claimant. Complainant is a heart patient and admittedly it was disclosed as he was a regular buyer of the insurance policy from the OP and, therefore, the allegation, as leveled by the OP in repudiating the claim of the complainant, is totally bad and figment of imagination of the OP. The complainant sent a legal notice on 23.02.2016 which was duly served upon the OP and reply dated 10.03.2016 was sent by the OP reiterating the same ground that the pre-disease of the Claimant had not been disclosed by the complainant. The OP vide another letter dated 15.04.2016 asked the Complainant some queries which were replied by him on 04.05.2016. He sent various communications to the OP but no reply was given by the OP. Hence, there is deficiency in service on the part of the OP. Hence, the complainant has prayed as under:-
- Direct the OP to pay the sum of claim incurred by the complainant to the tune of Canadian dollar 16000 i.e. Rs. 816000/- alongwith interest at the rate of 18% p.a.
- Direct the OP to pay a sum of Rs. 2,50,000/- towards the physical strain and mental agony suffered by the complainant and his family.
- Direct the OP to pay a sum of Rs. 50,000/- towards cost of the petition.
OP in the written statement has inter-alia stated that the complainant was interested in the travel insurance policy of the OP and wanted to avail the benefit of the same and thus on the basis of repeated requests sent by the complainant the OP issued the travel insurance policy, namely, Explore – Canada+ with the sum insured of US 5000 dollars only in the favour of complainant vide policy No. 10505590 which was valid from 14.01.2016 to 19.02.2016 for a total 37 days’ travel. The Complainant informed the OP that his wife was hospitalized in Canada and spent a sum of USD 16,000 i.e. around Rs. 8,16,000/- towards her medical treatment. However, the complainant had not attached any document pertaining to the hospitalization of his wife in Canada. It is submitted that the OP had registered the claim of the complainant vide claim no. 80066135 and appointed an investigator to investigate the whole matter thoroughly; that after going through the discharge summary dated 27.01.2016 issued by Dr. Mohammad Amir and Sheikh Yousuf of the Halton Health Service and other requisite documents pertaining to the claim of the Complainant the OP came to know that the Complainant had a history of hypertension(HTN), respiratory upper tract infection and hypothyroidism and the wife of the Complainant was also on anti- hypertensive and thyroid medication i.e. telmisartan and levo- thyroxin; that also the medical record dated 21.01.2016 mentions that the complainant’s wife was taking the medicines i.e. telmisartan,
hydrocholothiazide ( used to treat hypertension), and “ Past Medical history i.e. PMHX mentions Hypertension. It is stated that the same was not disclosed by the wife of the complainant or complainant himself at the time of issuance of the insurance policy and hence the complainant had deliberately concealed the facts about her medical history with a mala-fide intention. It is submitted that the policy was issued on the oral confirmation by the proposal and the same was so recorded in the policy certificate. It is submitted that the complainant had an opportunity to declare her pre-existing ailment to OP and a pre- issuance confirmation/datasheet form was sent to the complainant wherein the complainant had mentioned “No.” under the head of pre existing-disease. It is clearly mentioned in the said datasheet “should you feel that there are any discrepancies/variations, you are requested to write back us immediately at customerfirst@religarehealthinsurance.com or call us at 1800-20004488 for necessary changes and ratification.” However the complainant had never come back to them for any rectification in datasheet or in policy certificate. As per Clause 5.1 of the terms and conditions of the insurance policy “ If any untrue or incorrect statement are made or there has been a misrepresentation, mis-description or non-discloser of any material particulars or any material information having been withheld or if a claim is fraudulently made or any fraudulent means or devices are used by the policyholder or the insured person or anyone acting on his/their behalf, the company shall have no liability to make payment of any claims and premium paid shall be forfeited to the company”. It is submitted that had the correct health status of the insured person was disclosed then the OP would have issued the policy on different terms and conditions. Hence, the claim of complainant was rightly repudiated on 20-02-2016. It is denied that the complainant had incurred an amount of Canadian dollar 16,000 towards her expenditure as no document was annexed by the complainant. OP has prayed for dismissal of the complaint.
No rejoinder has been filed on behalf of the complainant.
Complainant has filed his own affidavit in evidence and written arguments while affidavit in evidence of Ms. Ramnique Sachar and written arguments have been filed on behalf of the OP.
We have heard the arguments on behalf of the parties and have also gone through the file very carefully.
The OP vide letter dated 20.02.16 repudiated the claim under clause No.5.1 “non-disclosure of pre-existing medical condition” (copy Ex. C-II). The Complainant vide letter dated 23.02.16 sent a legal notice to the OP (copy Ex. C-III colly). The OP vide letter dated 10.03.16 sent a reply to the legal notice to the Complainant (copy Ex. C-III colly). The OP has filed the copy of the discharge prescription of complainant’s wife issued by Halton Healthcare Services wherein the date of admission of the patient has been mentioned as 21.01.16 and discharge date 25.01.16 (copy Ex.OP-3). The relevant portions of document Ex. OP3 read as under:-
“Past medical history is significant for: 1. Hypertension
2. Recent upper respiratory tract infection for which she was treated with a 5 day course of azithromycin.
3. Hypothyroidism.
No known drug allergies.”
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“HISTORY OF PRESENT ILLNESS: The patient arrived from India on January 14, 2016.She is here principally to visit family. She was developing an upper respiratory tract infection when she came to Canada and given that her cough was progressing and there were subjective fevers at home, she went to see a walk-in clinic doctor and was given a 5 day course of azithromycin which she has completed. She, however, continued to feel unwell and had reduced oral intake and was having one to two loose bowel a day but no overt diarrhea, or no other GI losses, certainly no history of vomiting.
In the last two days and today, in particular, she has become progressively more somnolent, confused and difficult to rouse and that was the reason for the patient being brought to the hospital. The remainder of review of systems was fairly reassuring and specifically for etiologies of hyponatremia, there has been no polydipsia, no obvious cause as far as medications for hyponatremia with the exception of course of hydrochlorothiazide.”
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“IMPRESSION: This 67- year old female presents with SIADH secondary to medical illness in the form of an upper respiratory tract infection and her hydrochlorothiazde.”
The OP has filed a copy of the terms and conditions of the policy (copy Ex. OP5) wherein according to clause 5.1 “if any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particulars or the any material information having been withheld, or if a Claim is fraudulently made or any fraudulent means or devices are used by the Policyholder or the Insured Person or any one acting on his/their behalf, the Company shall have no liability to make payment of any Claims and the premium paid shall be forfeited to the Company on the cancellation of the Policy.”
Ex. OP4 is the copy of Datasheet- ‘Explore’ dated 11.01.16 issued by the OP Co. to the complainant wherein complainant has disclosed his pre-existing disease as “cardiac disorder” but written “none” in column “pre-existing disease” against the name of his wife. This document further shows that there had been no diagnosis/ hospitalization for any treatment or any illness/injury during the last 48 months. The claim in question was rejected by the OP because complainant’s wife had pre-existing disease known as hypertension and hypothyroidism and non-disclosure of the same by the complainant while taking policy in question amounted to mis-representation, mis-description or non-disclosure of material particulars. In our considered opinion, the OP was not justified in repudiating the claim of the complainant by taking recourse to clause 5.1 of the terms and conditions of the insurance policy in question. As reproduced hereinabove, the wife of the complainant had been presented with SIADH secondary to medical illness in the form of an upper respiratory tract infection and her hydrochlorothiazde. Whether or not the said disease has any co-relation with hypertension or hypothyroidism with the disease suffered by the complainant’s wife has not been clarified by OP since onus to prove this fact was on the OP and not on the complainant. No evidence has been filed on the record to show that complainant’s wife had received any diagnosis/hospitalization for receiving treatment of any disease during the last 48 months. Therefore, she had no pre-existing disease of such a nature which could entail the claim for medical treatment in Canada to be rejected by the OP. Therefore, we hold that repudiation of the claim of the Complainant by the OP amounted to serious deficiency in service.
Therefore, we allow the complaint and direct the OP to refund Canadian dollars 16000 equivalent to Rs.8,16,000/- to the complainant within a period of 30 days of receipt of copy of this order failing which the OP shall become liable to pay interest @ Rs. 6% per annum on the amount of Canadian dollars 16000 equivalent to Rs.8,16,000/- from the date of this order till its realization. We do not award any compensation for mental agony etc.
Let a copy of this order be sent to the parties as per regulation 21 of the Consumer Protection Regulations. Thereafter file be consigned to record room.
Announced on 07.02.2017
