Punjab

Nawanshahr

CC/20/2019

Hardyal Singh - Complainant(s)

Versus

Religare Health Insurance - Opp.Party(s)

V.K. Chopra

09 Aug 2019

ORDER

DISTRICT CONSUMER DISPUTES   REDRESSAL FORUM, SHAHEED BHAGAT SINGH NAGAR

 

Consumer Complaint No.   20 of 18.03.2019

              Date of Decision           :  09.08.2019

 

Hardyal Singh S/o Tara Singh, r/o Ghakewal Road, Rahon, Tehsil Nawanshahr, District SBS Nagar.

….. Complainant

Versus

 

1.       Religare Health Insurance Company Ltd, 2^nd Floor, SCO-44, Puda Complex, Opposite Administration Complex, Jalandhar, District Jalandhar.

2.       Religare Health Insurance Company Ltd., Vipul Tech Square, Tower C, 3^rd Floor, Golf Course Road, Sec-43, Gurgaon – 122009 (Haryana).

3.       Punjab Gramin Bank, Machiwara Chowk, Rahon 144517

 

…Opposite parties

 

(Complaint U/s 12 of the Consumer Protection Act, 1986)

 

QUORUM:

SH.KULJIT SINGH, PRESIDENT

SH.KANWALJEET SINGH, MEMBER.

COUNSEL FOR THE PARTIES:

 

For complainant              :         Sh.V.K Chopra, Advocate

For OPs no.1&2             :         Sh.Anil Kataria, Advocate

For OP no.3                   :         Sh.A.K. Sareen, Advocate                                              

Per KULJIT SINGH, PRESIDENT

 

1.                 The present complaint has been filed under Section 12 of the Consumer Protection Act, 1986 against OPs on the averments that complainant is having account bearing no.85960100026069 in Punjab Gramin Bank, Machiwara Chowk Rahon. During his visit, OP no.3/Bank introduced an employee of Religare Insurance to him on the pretext that medical insurance policy is necessary in today’s life and he would get cashless policy benefit up to Rs.1 lac in any of the empanelled hospital. On the consisting saying of the Bank that it would also cover his family and money would automatically deducted from his account. The bank in connivance with Religare Insurance person got the signature of the complainant on health proposal form and premium of the same i.e. Rs.2412/- was deducted  from the said account on dated 05.07.2018.  Unfortunately, on 10.12.2018 he got severe pain in his chest and was rushed to IVY Hospital at  Nawanshar , where he was admitted on 10.12.2018 and discharged on 11.12.2018. He suffered from blockage in arteries and he was treated for it. He spent Rs.2,01,915/-on his treatment in the IVY Hospital.  During his admission in the Hospital, Insurance Companies/OPs no.1 and 2 was intimated but on 11.12.2018 at the time of discharge repudiated his claim of Rs.1 lac on the pretext of waiting period of three years for pre-existing disease and its complications. OPs in connivance with each other has cheated with complainant and given false reasons for repudiation of the claim. The complainant has never suppressed/concealed any fact regarding his pre-existing diseases. Moreover,  no brochure was ever given to him. Due to unlawful act of OPs, he suffered financial loss, therefore he has filed the present complaint and prayed that OPs be directed to pay Rs.1 lac along with interest @ 18% per annum on monthly compounded basis from the date of payment by complainant to hospital i.e. 11.12.2018 till its realization, besides Rs.50,000/- on account of mental harassment, Rs.20,000/- on account of damages and Rs.30,000/- as cost of litigation.

2.                 Upon notice, OPs no.1 and 2 appeared and filed its separate written reply and contested the complaint of the complainant by raising preliminary objections that OPs Company duly incorporated under the Companies Act 1956 and indulged into the business of providing Health Insurance Services. The complaint is not maintainable as it involves disputed questions of facts, which cannot be determined in summary jurisdiction of Consumer Forum. The complainant has not come to the Forum with clean hands. The complaint is false, frivolous and vexatious in nature. On merits, it was averred that OPs issued Master policy bearing no. 10963194 to OP no.3 providing insurance coverage to its eligible customers and issued certificate of insurance bearing no.12687913 wherein he was provided with insurance coverage w.e.f. 06 July 2018 till 05 July 2019 for a sum insured of Rs.1,00,000/-, subject to policy terms and conditions. The policy detail is reproduced as under :-

POLICY DETAILS
A	Group Policy Number	10963194
B	Certificate of Insurance No.	12687913
C	Sum Insured (Rs.     )	1,00,000/-
D	Policy Period	Above said policy was w.e.f. 06 July 2018 till 5 July 2019 subject to the policy terms and conditions.
E	Members Insured	The said policy is Group Care (Scheme for Punjab Grameen Bank (PGB) where the Complainant (Hardayal Singh) & his family members were covered under the said policy subject to the policy terms and conditions.

 

On providing details by complainant, OPs accepted the premium and added him as a beneficiary member under master policy for sum assured of Rs.1,00,000/- from 06.07.2018 to 05.07.2019. All the terms and conditions including the Exclusions mentioned in the policy were made clear to him. Terms and conditions were duly sent to him. On 10.12.2018 alleged claim under the policy was received from IVY Hospital where complainant was admitted because of chest pain. He was diagnosed with Acute AWMI with Cardiogenic Shock.  He was applied for Cashless Facility Request vide Pre-Authorization Request Form for the above stated hospitalization bearing Cashless No.80231545. OPs on reception of claim no.80231545 sent a query letter dated 10.12.2018 to Hospital to provide following documents :-

1. Complete indoor case papers with Admission Notes, History Sheet, Doctor’s Notes, Nursing Notes and Vital Chart.
2. Exact Duration and past history of present ailment with Ist Consultation paper and all fast treatment records.
3. Investigation report supporting diagnosis.
4. Pre-hospitalization OPD treatment record.

While investigation, doctor of complainant, vide questionnaire dated 11.12.2018 mentioned that complainant had history of Hypertension, Diabetes II (DM II) from past 1.5 years. Moreover, as per the ICU Admission Record dated 10.12.2018 it is mentioned that the patient/complainant is a known case of Hypertension and Type II DM. On investigation and reply sent by Hospital to above mentioned query letter dated 10.12.2018, Ops rejected the cashless claim no.80231545, vide non-registration of claim letter dated 11.12.2018 with following observations:-

“We hereby inform you that we are not registering your claim since the present ailment (Other acute ischaemic heart diseases) for which admission has been done.

For ease of your perusal we have listed the reason for denial :-

“3 years waiting period for treatment of pre-existing disease and its complications (patient is known diabetic prior to policy inception)

3 year waiting period.”

The rejection of cashless claim is in accordance to the Key Exclusions mentioned in the policy certificate dated 10.07.2018, is reproduced below:-

Key Exclusions:-

“The company shall not be liable to make payment for any claim directly or indirectly caused by, based on, arising out of or howsoever attributable to any of the following except covered by way of an extension:-

Any claim for Medical Expenses incurred for diagnosis or treatment of any pre-existing disease shall not be admissible until the completion of first 36 months of continuous insurance coverage from the first cover start date under the first policy with us.”

In the Key Exclusions of Policy Certificate  that no claim shall be admissible for treatment of any pre-existing disease until completion of first 36 months  of continuous insurance coverage from the first cover start date. The complainant paid Rs.2,01,915/- for operating and medical costs at Ivy Hospital Nawanshar. However, OPs/Company cannot ascertain the liability, if any, because the complainant has not submitted all the requisite documents and expenditure incurred by him during his hospitalization.  The complainant has not filed for reimbursement of claim with OPs/Company. Rest of the averments of the complainant were denied by OPs no.1 and 2 and they prayed for dismissal of the complaint.

3.                 OP no.3 appeared and filed its separate written reply and contested the complaint of the complainant by raising preliminary objections that complaint is not legally maintainable. The present complaint filed only to harass OP no.3. On merits, it was averred that OP no.3 never introduced any employee of Religare Insurance with complainant. If any insurance was obtained by complainant with his sweet will and after admitting all the formalities and conditions from OPs no.1 and 2, then OP no.3 has no concerned with the insurance policy. OP no.3 has only concern with Bank account, which is lying in his bank. Moreover, OP no.3 is not duty bound to clear the bill of the complainant if any and there is no relation of customer and consumer between the complainant and OP no.3.

4.                 The complainant has tendered in evidence his affidavit Ex.CW-1/A along with copies of documents Ex.C-1 to Ex.C-5 and closed the evidence. As against it; OPs no.1 and 2 tendered in evidence affidavit of  Tejinder Singh Manager Legal as Ex.OP-1/A along with copies of documents Ex.OP-1/1 to Ex.OP-1/10. OP no.3 tendered in evidence affidavit of Rajiv Kumar Verma as Ex.OP-3/A  and closed the evidence.

5.                 We have heard learned counsel for the parties and have also examined the record of the case very minutely.

6.                The complainant has deposed his deposition by way of affidavit Ex.CW-1/A on the record. He deposed that on the assurance of OPs no.1 and 2, he purchased Medical Insurance Policy and on consisting saying of the Bank/OP no.3 that above mentioned policy cover risk of his family and money would automatically deducted from his account. The Bank in connivance with Insurance Companies/OPs no.1 and 2 got signature of complainant on health proposal form and premium of the same i.e. Rs.2412/- was deducted from his account. Unfortunately, on 10.12.2018 he got severe pain in his chest and was rushed to IVY Hospital at Nawanshahr, where he was admitted on 10.12.2018 and discharged on 11.12.2018.  He suffered from blockage in the arteries and was treated for it.  On 11.12.2018, at the time of his discharge, OPs repudiated his claim on the ground that “waiting period of 3 years for pre-existing disease and its complications. The complainant averred that he has never suppressed/concealed any fact regarding his pre-existing diseases as complainant never suffered from any disease. Ex.C-1 is photocopy of statement of account of Punjab Gramin Bank. Ex.C-2 is copy of premium acknowledgement. Ex.C-3 is copy of certificate of insurance. In this certificate Cover Start date mentioned as 06.07.2018 and cover end date as 05.07.2019. Ex.C-4 is bill dated 11.12.2018 of Rs.208565/- issued by Ivy Hospital Nawanshahr. Ex.C-5 is copy of non-registration of claim dated 11.12.2018.

7.                 To counter this evidence of the complainant, OPs no.1 and 2 relied upon affidavit of Tejinder Singh Manger-Legal of Religare Health Insurance Co.Ltd as Ex.OP-1/A  on the record. This witness stated that OP no.3 /Punjab Grameen Bank providing insurance coverage to its eligible customers. The complainant herein being an eligible customer of PGB was issued certificate of insurance bearing no.12687913, wherein he was provided with insurance coverage w.e.f. 06.07.2018 to 05.07.2019 for a sum insured of Rs.1 lac, subject to policy terms and conditions. On 10.12.2018 alleged claim under the policy was received from IVY Hospital where complainant was admitted because of chest pain and he was diagnosed with Acute AWMI with Cardiogenic Shock. The complainant applied for cashless facility vide pre-authorization request form for the above stated hospitalization bearing cashless claim no.80231545. OPs rejected the cashless claim no.80231545, vide non-registration of claim letter dated 11.12.2018. The said rejection of cashless claim is in accordance to Key Exclusions mentioned in policy certificate. Ex.OP-1 is copy of certificate of insurance no.12587913. Ex.OP-2 is Request for cashless hospitalization for medical insurance policy.  Ex.OP-3 is copy of letter regarding additional information required for pre-authorization of “Hardyal Singh”.  Ex.OP-4 is copy of Insurance Company /TPA Claim Verification Form. Ex.OP-5 is copy of ICU Admission Record of Hardyal Singh/complainant. Ex.OP-6 is certificate dated 10.12.2018 issued by Medical Superintendent IVY Hospital. Ex.OP-7 is copy of letter regarding non-registration of claim dated 11.12.2018. Ex.OP-8 to Ex.OP-10 are photocopies of judgments produced on record in support the case of OPs.

8.                 OP no.3 relied upon affidavit of Rajiv Kumar Verma Manager of Punjab Gramin Bank. This witness stated that if any insurance policy  obtained by complainant with his sweet will and after admitting all the formalities and conditions from OPs no.1 and 2 then OP no.3 has no concerned with that insurance policy. He further stated that OP no.3 is not duty bound to clear the bill of the complainant if any and there is no relation of customer and consumer between the complainant and OP no.3. He denied any deficiency in service on the part of OP no.3 in this case.

9.                It is an established fact that on the assurance of OPs no.1 and 2, he purchased insurance policy from them and he paid premium of Rs.2412/-. Unfortunately, on 10.12.2018, he got severe pain in his chest and admitted in IVY Hospital Nawanshahr on 10.12.2018 and discharged on 11.12.2018. For this purpose, he spent Rs.2,01,915/- on his treatment. After that, he submitted his claim with OPs. But Ops repudiated his claim on the ground of “waiting period of 3 years for pre-existing disease”. OPs rejected cashless claim of the complainant in accordance to Key Exclusions that any claim for medical expenses incurred for diagnosis or treatment of any pre-existing disease shall not be admissible until completion of first 36 months of continuous insurance coverage from the first cover start date under the first policy with us.  No claim shall be admissible for treatment of any pre-existing disease until completion of first 36 months of continuous insurance coverage from the first cover start due.

10.               The counsel for OPs relied upon various judgments in support of their case, which are reproduced as under :-

1. New India Assurance Company Ltd. versus Rekha Malhotra by Hon’ble National Commission, New Delhi reported in 2016(4) CPR 455.
2. Export Credit Guarantee Corp. of India Ltd.  versus M/s Garg Sons International by Hon’ble Supreme Court of India.
3. Ravneet Singh Bagga versus KLM Royal Dutch Airlines by Hon’ble Supreme Court reported in 2000(1) SCC Page 66.

The above noted judgments related to pre-existing ailments. But the present case in hand is on different footings. In this case, OPs have not produced any document or cogent evidence to prove this fact the complainant is suffering from pre-existing disease or not.

11.               The first question, which arises for consideration in this case is as to whether the insured was suffering from any pre-existing disease or not. The onus was upon the insurer to prove the misrepresentation alleged to have been made by the insured, meaning thereby that it was the insurer to prove that he was suffering from any pre-existing disease at the time the proposal was submitted. There was no affidavit filed by doctor to prove that insured was suffering from pre existing disease. The treatment report of IVY Hospital Nawanshahr does not indicate since when the insured was suffering from pre-existing disease.

12.               The above view of ours stands fortified by Hon’ble National Commission New Delhi in PNB Metlife India Insurance Company Limited and another versus Sunita Goyal and others reported in Revision Petition no. 1729 of 2016 decided on 26.08.2016. This citation proves that the onus was upon the insurer to prove the misrepresentation alleged to have been made by the  insured, meaning thereby that it was for the insurer to prove that he was suffering from pre-existing disease at the time when proposal was submitted. 

13.               The insurance is a contract between the parties based on good faith. Both parties are bound by the terms and conditions of the insurance policy. Opposite parties/Insurance Companies can not wriggle out from their liability. In the present case, OPs themselves produced certificate of Insurance Ex.OP-1 placed on the record. In this document the Details of insured are given as under:-

Name	Client ID	Date of BIRTH	Relationship	Insured with the company (since)	Pre-existing disease
Hardyal Singh	61229876	04 Feb.1972	Member	06 Jul.2018	None

 

In the above cited document produced by OPs themselves Ex.OP-1, nowhere mentioned that complainant/insured was suffering from pre-existing disease. In column Pre-existing disease = None is mentioned. From this document, it is crystal clear that complainant/insured was not suffering from any pre-existing disease.

In this document/Certificate of Insurance Ex.OP-1 the Plan name is mentioned as Group Care Scheme for PGB, Cover start from 06.07.2018 and cover end date is mentioned as 05.07.2019. The complainant/insured admitted in the IVY Hospital Nawanshahr on 10.12.2018 and discharged on 11.12.2018. The insured admitted in the hospital during currency period of the policy. Therefore, he is entitled to receive the insurance claim from OPs.

14.               From document Ex.C-1 it is clear that insured paid the premium of Rs.2412/- on 05.07.2018 to OPs for continuing his insurance policy. Ex.C-2 is acknowledgment thereof placed on the record. Ex.C-3 is certificate of insurance issued by OPs to complainant. In this document in column Pre-existing disease = None is mentioned. From this very document, it is further clear that insured was not suffering from any pre-existing ailment. Therefore, the authenticity of the aforesaid addition could not be established by the insurer/OPs. In these circumstances, when neither any affidavit or report of doctor produced by OPs to prove that insured was suffering from pre-existing disease nor any cogent or documentary evidence placed on record to show above referred addition in this case that insured was suffering from pre existing disease at the time of proposal was submitted by him. There is nothing on the record to prove that insured was suffering from alleged pre existing diseases. 

15.               In the light of our above discussion, we allow the complaint of the complainant and OPs are directed to settle and pay the claim of Rs.1,00,000/- to the complainant, which he has been deposited with OPs along with interest @ 9% per annum from the date of deposit till its realization. within one month from receipt of copy of this order. The complainant is further entitled to Rs.5000/- as compensation for mental harassment and costs of litigation.

16.               The compliance of the order be made within a period of one month from receipt of certified of this order.

17.               File be indexed and consigned to record room.

18.               Let copies of the order be sent to the parties, as permissible, under the rules.

 

Dated:09.08.2019

                             (Kanwaljeet Singh)                 (Kuljit Singh)

                                 Member                                  President