DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, BARNALA, PUNJAB.

 

Complaint Case No : CC/13/2018

Date of Institution : 22.02.2018

Date of Decision : 05.08.2019

Medhansh Jindal minor son of Tinku Jindal through his father and natural guardian Tinku Jindal son of Sh. Kewal Krishan resident of H. No. D-11/901, K.C. Road, Street No. 5, Near Dr. Jyoti Kaushal, Barnala, Tehsil and District Barnala.                             …Complainant

Versus

1. Religare Health Insurance Registered Office: Religare Health Insurance, 5th Floor, Chawla House, Nehru Palace, New Delhi-110019 through its Authorized Signatory.

2. Religare Health Insurance, Corresponding Office: Vipul Tech Square, Tower C, 3rd Floor, Golf Course Road, Sector 43, Gurgaon-122009 (Haryana) through its Authorized Signatory.

…Opposite Parties

Complaint Under Section 12 of Consumer Protection Act, 1986.

Present: Sh. Rajiv Goyal counsel for complainant.

Sh. Dhiraj Kumar counsel for opposite parties.    

Quorum.-

1. Sh. Kuljit Singh : President

2. Sh. Tejinder Singh Bhangu : Member

3. Smt. Manisha : Member

(ORDER BY KULJIT SINGH, PRESIDENT):

1.    The complainant namely Medhansh Jindal minor son of Tinku Jindal through his father has filed the present complaint under Consumer Protection Act (In short the Act) against Religare Health Insurance, New Delhi and another. (hereinafter referred as opposite parties). 

2. The facts leading to the present complaint as stated by the complainant in his complaint are that the complainant has purchased a Religare Care Policy Cover Type Floater bearing No. 11376724 through on line from Barnala valid from 17.6.2017 to 16.6.2018 for his family having Client ID No. 56531952 of the complainant, 56311954 in the name of Medhansh Jindal and 56311954 in the name of Reema Garg issued by the opposite parties. The complainant got insured himself, his minor son and wife through the said policy. 

3. It is further alleged that son of the complainant was suffering from fever and cough and was admitted in Christian Medical College and Hospital, Ludhiana on 17.12.2017 and he was discharged from the said hospital on 20.12.2017 after treatment and Rs. 18,660/- was claimed by the said hospital from the opposite parties which was cleared by them. But the son of complainant again ill and was suffering from fever and cough and was again admitted in CMC College and Hospital, Ludhiana on 29.12.2017. He was treated there and was discharged from the said hospital on 6.1.2018 after treatment. In this regard Rs. 25,118/- was claimed by the said hospital for the treatment of minor but they have not cleared the same. The complainant also applied for the claim of Rs. 25,118/- alongwith all the required documents with the opposite parties which was paid by him to the said hospital during the treatment dated 29.12.2017 to 6.1.2018 but till date the opposite parties are linger on the matter without any reason. Even a legal notice was issued on 20.1.2018 but to no effect. This act of the opposite parties is deficiency in service and unfair trade practice on their part. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties be directed to pay the treatment charges of Medhansh Jindal to the tune of Rs. 25,118/- as per policy. 

2) To pay Rs. 2,00,000/- on account of mental tension, agony and physical harassment.           

3) To pay Rs. 10,000/- as litigation expenses.  

4) Any other relief which this Forum deems fit and proper. 

4. Upon notice of this complaint, the opposite parties filed written version taking preliminary objections interalia on the grounds  that this Forum has no territorial jurisdiction as the policy was purchased on line and complainant lodged the claim under the policy at Gurgaon and further the opposite party has no office in the jurisdiction of this Forum so this Forum has no jurisdiction to entertain and try the present complaint. Further, the complainant has suppressed the material facts regarding the pre-existing disease before purchasing the policy and in the present case the opposite party issued policy on 17.6.2017 to 16.6.2018. On investigation it was revealed that the complainant concealed the pre-existing disease of his son i.e. Respiratory Distress, Convulsion, PDA, PAH. The non disclosure was vital as the assured was under a duty to disclose the true and correct facts as regards medical history which was important to underwrite correct risk in issuance of the policy, but complainant has concealed the true facts from the opposite party so the complaint is liable to be dismissed. Further, intricate questions of law and facts are involved in the matter in hand so the complainant be advised to approach the civil court. The opposite parties further admitted that believing the information provided by proposer including the medical history in the on line proposal form to be true and correct policy No. 11376724 was issued for a sum of Rs. 3,00,000/- to the proposer Tinku Jindal for a period from 17.6.2017 to 16.6.2018. The opposite party has duly delivered all the relevant documents alongwith terms and conditions of the policy. Further, the claim under the policy firstly received from the hospital for cashless treatment of complainant for admission at CMC Medical College and Hospital from 17.12.2017 to 20.12.2017 and opposite party approved the cashless facility of the complainant vide letter dated 28.12.2017 for an amount of Rs. 17,478/-. The opposite party received another claim under the policy for cashless treatment for admission of complainant at CMC Ludhiana from 29.12.2017 to 6.1.2018 but after going through the documents the opposite party found that the proposer at the time of purchasing the policy concealed the true facts with regard to health of the complainant Medanshu Jindal with regard to pre-existing disease so the complainant is not entitled to any claim under the policy. So the opposite party repudiated the claim of the complainant as per terms and conditions of the policy on the grounds of non disclosure of material information. The opposite party further submitted that earlier claim was paid by them on wrong facts so the recovery for the same has been initiated and a letter dated 9.3.2018 was dispatched to the proposer for recovery of Rs. 17,478/-. The proposer also had the opportunity to disclose the complainant's pre-existing disease at the time of pre-verification call but no such disclosure was made by the proposer.   

5. On merits, it is admitted that the complainant after duly understood the terms and conditions of the policy had purchased a Health Insurance Policy of opposite party with sum assured of Rs. 3,00,000/- covering himself, spouse and son. It is also admitted that the opposite party paid the treatment amount to the network hospital for the hospitalization between 17.12.2017 to 20.12.2017 for the amount of Rs. 17,478/- but not opposite party dispatched a letter dated 9.3.2018 for the recovery of the said amount. But the cashless treatment from 29.12.2017 to 6.1.2018 was denied by the opposite party on the basis of concealment of true facts at the time of purchasing of policy. Rest of the averments of the complaint are denied by the opposite party and prayed for the dismissal of the present complaint with costs. 

6. In support of his case, the complainant tendered into evidence affidavit of his father Tinku Jindal as Ex.C-1, copy of discharge summary dated 6.1.2018 as Ex.C-2, copy of medical bill of CMC Ludhiana dated 29.12.2017 as Ex.C-3, copy of legal notice dated 20.1.2018 as Ex.C-4, copy of postal receipts as Ex.C-5, copy of acknowledgment as Ex.C-6, copies of policy ID Card as Ex.C-7, copy of policy Ex.C-8, copy of patient settlement receipt as Ex.C-9 and closed the evidence. 

7. To rebut the case of the complainant, the opposite parties  tendered into evidence affidavit of Ankit Shankar as  Ex.O.P-1, copy of  letter dated 16.6.2017 as Ex.O.P-2, copy of claim approval and settlement letter as Ex.O.P-3, copy of letter dated 9.3.2018 as Ex.O.P-4, copy of patient case note as Ex.OP-5, copy of out patient record as Ex.OP-6, copy of discharge card as Ex.OP-7, copy of letter dated 6.1.2018 as Ex.OP-8, copy of legal notice as Ex.OP-9, copy of notice dated 18.3.2018 as Ex.OP-10, copy of letter dated 6.6.2018 as Ex.OP-11 and closed the evidence.  

8. We have heard the learned counsel for the parties and have gone through the record. Written arguments filed by the parties have also been gone through.

9. It is an admitted fact between the parties that the father of the complainant purchased a Health Insurance Policy Ex.C-8 from the opposite parties for himself, his wife and minor son for the period from 17.6.2017 to 16.6.2018 for sum assured of Rs. 3,00,000/-. It is also admitted by the opposite parties that the ID card regarding issuance of policy was issued to the family of the father of the complainant Ex.C-7. It is also admitted by the opposite parties that first claim of the complainant for an amount of Rs. 17,478/- was paid by the opposite parties for his treatment form 17.12.2017 to 20.12.2017. It is also admitted by the opposite parties that the second claim of the complainant was also within the validity of the insurance policy i.e. for his treatment from 29.1.2017 to 6.1.2018. 

10. Now the main question before us whether the opposite parties repudiate the claim of the complainant on account of pre-existing disease or not ?

11. To prove that the opposite parties cannot repudiate the claim of the complainant on account of pre-existing disease the complainant firstly relied upon the affidavit of Tinku Jindal his father Ex.C-1 in which he duly deposed that the opposite parties have paid the first claim of Rs. 18,660/- for the treatment of his son from 17.12.2017 to 20.12.2017. He also added here that his son again ill and he admitted in the CMC Ludhiana for treatment from 29.12.2017 to 6.1.2018 but this time opposite parties have not paid the treatment amount of Rs. 25,118/- to the hospital or to the deponent and to prove this amount the complainant tendered in evidence copy of bill dated 6.1.2018 Ex.C-3 and receipt of payment Ex.C-9. On the basis of these documents the complainant claimed the amount of Rs. 25,118/- from the opposite parties.

12. To rebut the case of the complainant the opposite parties relied on affidavit of Ankit Shankar Ex.OP-1 in which he has reiterated the written version filed by the opposite parties. He also relied upon terms and conditions of policy Ex.OP-2 in which at Clause 7.1 it is mentioned that if any untrue or incorrect statement are made or there has been a misrepresentation or non disclosure of any material information, the company shall have no liability to make payment of any claims and premium paid shall be forfeited ab initio to the company. They also relied upon copy of letter dated 9.3.2018 Ex.OP-4 vide which they have started proceedings against the father of the complainant for recovery of the amount of Rs. 17,478/-. They also relied upon medical record of the complainant vide documents Ex.OP-5 to Ex.OP-7. Further, they also relied upon copy of letter dated 6.1.2018 Ex.OP-8 vide which they have denied the cashless treatment of the complainant on account of non disclosure of material facts and pre-existing ailments.

13. We have perused the documents filed by both the parties. Firstly, we deal with the main objection of the opposite parties that this Forum has no jurisdiction to try the present complaint. To rebut this objection the complainant placed on file account statement of his bank Account in Punjab National Bank and from the perusal of this document it is proved on the file that the payment of premium of this policy was made by the complainant on 16.6.2017 through on line from his bank at Barnala. In this way, it is proved on the file that there is partly cause of action arose at Barnala so under Section 11 (c) of the Consumer Protection Act this Forum has the jurisdiction to entertain and decide the present complaint. 

14. Secondly, the opposite party repudiated the claim of the complainant on account of pre-existing disease. It is admitted by the opposite parties in their written version and affidavit Ex.OP-1 that they have paid the first claim of the complainant of Rs. 17,478/- so we are of the view that if the opposite parties already paid the complainant first claim then they cannot deny for the second claim as it is clearly an afterthought of the opposite parties. The first claim was also given by the opposite parties after proper investigation of medical record of the complainant so at this stage they cannot repudiate the claim of the complainant on account of any pre-existing disease. Further, from the medical record tendered by the opposite parties Ex.OP-5 to Ex.OP-7 the opposite parties have failed to prove that previously the complainant was suffering from same problem which is suffering by him at the time of his treatment from 29.12.2017 to 6.1.2018. Merely that the complainant was born at 7 months 12 days gestation is no ground to repudiate the claim of the complainant.

15. The Hon'ble National Commission in case titled Future General India Insurance Company Limited Versus Inderjit Singh reported in III (2019) CPJ-22 (NC) held as under.-

“Consumer Protection Act, 1986-Sections 2(1)(g), 14(1) (d), 21(b)- Insurance (Mediclaim)-Medical reimbursement-Wilful concealment of pre-existing disease alleged-Claim repudiated- Deficiency in service- District Forum partly allowed complaint- State Commission dismissed appeal- Hence revision- Insurance policy was issued in the month of April 2016- Insured was subsequently diagnosed with chronic liver disease in November 2016- It cannot be said that insured concealed his disease while filling the proposal form- Insurance Company failed to prove that disease was pre-existing disease and was wilfully concealed- Repudiation not justified.”

This citation of the Hon'ble Commission is fully applicable to the facts of the present matter as in the present matter also the policy was purchased on 16.6.2017 but the complainant was admitted in the hospital for treatment from 29.12.2017 to 6.1.2018 for fever and cough for which any one can suffer any time so there is no wilful concealment of pre-existing on the part of the father of the complainant. So, repudiating the claim by the opposite parties on baseless ground is clear cut deficiency in service and unfair trade practice on their part. 

16. As a result of the above discussion, present complaint is  allowed and the opposite parties are directed to pay the amount of Rs. 25,118/- on account of insurance claim to the father of the  complainant Tinku Jindal who is also proposer of the insurance policy on behalf of the complainant who is minor, alongwith interest at the rate of 6% per annum from the date of repudiation of the claim by the opposite parties i.e. 6.1.2018 till actual realization and to pay Rs. 5,000/- as compensation to the father of the complainant Tinku Jindal for mental tension and harassment and Rs. 3,000/- on account of  litigation expenses. Compliance of order be made within the period of 30 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.

  ANNOUNCED IN THE OPEN FORUM:

5th Day of August 2019

 

 

            (Kuljit Singh)

           President

 

 

           (Tejinder Singh Bhangu)                Member

 

 

(Manisha)

Member