Haryana

Fatehabad

CC/18/2019

Naresh Bala - Complainant(s)

Versus

Religare Health Insurance - Opp.Party(s)

Pankaj Bansal

01 Sep 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION FATEHABAD.

                                         Sh.Rajbir Singh, President.                                                      Dr.K.S.Nirania and Smt.Harisha Mehta, Members

 

                                                           C.C.No.18 of 2019.                                                                                    Date of Instt.: 04.01.2019.                                                                         Date of Decision:01.09.2023.

Smt.Naresh Bala wife of Jaibir resident of H.No.158, village Bangaon Tehsil & District Fatehabad.

                                                                             ..Complainant

                                                Versus

1.Religare Health Insurance Company Limited Service Branch, Vipul Tech Square Tower-C, Third Floor, Sector 43-,Golf Course Road, Gurugram - 122009 through its Manager.

2.Religare Health Insurance Company Limited, 5^th Floor, 19 Chawla House, Nehru Place, New Delhi-110019 through its Manager.

                                                                             ..Opposite Parties.

Complaint U/S 35 of the Consumer Protection Act, 2019            

Present:                 Sh.Pankaj Bansal, Advocate for complainant.                                              Sh.Vishnu Delu, Advocate for Ops.                                                                     

ORDER

SH.RAJBIR SINGH, PRESIDENT

1.                          This complaint has been filed under Section 12 of the Consumer Protection Act, 1986 against the Ops with the averments that the complainant had obtained a health insurance policy bearing No.11908329 under plan assure 4, cover type individual having validity from 05.01.2018 to 04.01.2019 for a sum assured of Rs.10,00,000/-; that at the time obtaining the said policy medical was also done and the complainant was declared hale and hearty; that the said policy was also covering 20 critical illness as well as personal accident; that the complainant had paid Rs.24,222/- as premium for the said policy; that on dated 21.06.2018, the complainant felt ill and during medical examination it was found that her right kidney has damaged; that due to this the complainant remained under treatment as an indoor patient at Sarvodya Multispecialty and Cancer Hospital; that after operation right kidney of the complainant was removed and the complainant had spent Rs.2,00,000/- on her treatment; that the complainant gave intimation to the Ops besides submitting all the relevant documents as per the instructions and directions of Ops with a request to make the payment of sum assured of Rs.10 lacs alongwith expenses incurred by her on the treatment; that the complainant visited the Ops many a times but they firstly lingered on the matter on one pretext or the other and finally refused to honour the claim of the complainant. The act and conduct of the Ops clearly amounts to deficiency in service on their part.  In evidence, the complainant has tendered her affidavit Annexure CW1/A and documents Annexure C1 to Annexure C13.

  2.                        Averments of the complaint have been strongly opposed in the joint written statement filed on behalf of Ops wherein it has been submitted that the policy was issued to the complainant subject to policy terms and conditions which was issued on believing the information provided by the complainant in her proposal form; that the complainant was fully aware about the terms and conditions of the policy and further agreed under the agreement therein that if any untrue statement is found in the proposal form, the policy contract shall be liable to be declared null and void; that the replying Ops had received an claim intimation vide reimbursement No.CL-90646809-00 with claim amount of Rs.10 lac with respect to the hospitalization of the complainant at Survodya Hospital, Hisar from 25.06.2018 till 29.06.2018 with compliant of pain right loin region since 10 days; that the complainant was diagnosed with right non functioning gross hydro-nephritic kidney and underwent laparoscopy right nephrectomy on 25.09.2018; that the complainant was discharged on 29.06.2018 and in the discharge report no sight of kidney failure was noted, therefore, the complainant does not fall under any critical illness benefit criteria, therefore, her claim was rejected as per Clause 2.1 Benefit I (a) (c) (ii) of the Policy terms and conditions and the same was informed to the complainant vide letter dated 23.07.2018. The requisite clause 2.1 of policy terms and conditions is hereby reproduced as under:

“As per Clause 2.1 Benefit I: Critical Illness, Medical Events & surgical procedure (a) If during the policy period, an insured person:

(i)is diagnosed to be suffering from a critical illness or a critical illness manifests in that insured person or

(ii)undergoes any covered surgical procedure or

(iii)suffers from any of the covered medical events,

The Company will pay the sum insured as specified in the policy certificate against this benefit.

(C) For the purpose of this benefit, Critical Illness means the following illness and diseases to the extent described below only:

(ii) End Stage Renal Failure

(I)End Stage renal disease presenting an chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis (haemodialysis or peritoneal dialysis) is instituted or renal transplant is carried out. Diagnosis has to be confirmed by a consult physician.

Preliminary objections as cause of action, maintainability, compliant being false and frivolous, estoppal and jurisdiction etc. have also been taken. Other contentions have been controverted and in the end, a submission was made for dismissal of the complaint. In evidence, the Ops have tendered affidavit of Kashif Nazki, Manager, Legal as Ex.OPW1/A with documents Annexure OP1 to Annexure OP7.

4.                          We have heard oral final arguments from both sides. We have also perused the case file minutely.

5.                          The complainant has come with the plea that she felt ill during the currency of the policy (Annexure C5) period but the Ops did not indemnify the loss despite the fact that she remained under treatment and underwent surgery for critical disease.

6.                          As per discharge summary (Annexure C10) Right Nephrectomy was done on the person of the complainant on 25.06.2018 but perusal of this document does not reflect that there was sign of kidney failure and the complainant was at the end stage of renal failure. Learned counsel for the Ops has rightly argued that though the complainant was hospitalized during the policy period but the disease as mentioned in the hospital record/treatment chart and discharge summary does not make the complainant entitle for benefit on account of critical illness as per Clause 2.1 Benefit I (a) (c) (ii) of the Policy terms and conditions. The requisite clause 2.1 of policy terms and conditions is hereby reproduced as under:

“As per Clause 2.1 Benefit I: Critical Illness, Medical Events & surgical procedure (a) If during the policy period, an insured person:

(i)is diagnosed to be suffering from a critical illness or a critical illness manifests in that insured person or

(ii)undergoes any covered surgical procedure or

(iii)suffers from any of the covered medical events,

The Company will pay the sum insured as specified in the policy certificate against this benefit.

(C) For the purpose of this benefit, Critical Illness means the following illness and diseases to the extent described below only:

(ii) End Stage Renal Failure

(I)End Stage renal disease presenting an chronic irreversible failure of both kidneys to function, as a result of which either regular renal dialysis (haemodialysis or peritoneal dialysis) is instituted or renal transplant is carried out. Diagnosis has to be confirmed by a consult physician.

In the discharge summary (Annexure C10) the history of present illness was mentioned as Patient presented with c/o pain right loin region since 10 days. Earlier treatment taken from PP. Now, patient brought here for further management.  In this very document the course in hospital is mentioned as Patient presented here with above mentioned complaints. Patient planned for surgery. On 25.06.2018 Lap Right Nephrectomy was done. Patient Managed on iv fluids, antibiotics, analgesics, antacids & other supportive treatment. Patient responded well to treatment. Gradually patient started improving. Now, patient is stable & being discharged in stable condition.  The version mentioned in the discharge summary is quite contrary to the pleas taken by the complainant in her compliant.  In this very document, it is  nowhere mentioned that the kidneys of the patient have failed and are at end stage of failure. It is not the case of the complainant that the terms and conditions were never supplied and intimated to her before obtaining the policy in question.   Undisputedly, the insurance is a contract and its terms and conditions are equally applicable to both the parties and no one can be allowed to add or alter in it. On this point reliance can be taken from case law titled as  V.K.Kariyana Store V. Oriental Insurance Company Limited III (2014) CPJ 182 (NC) wherein Hon’ble National Commission has held that Nature of Contract-Since upon issuance of insurance policy, insurer undertakes to indemnify loss suffered by insured on account of risks covered by policy, its terms have to be strictly construed to determine the extent of liability of insurer. Endeavour of Court should always be to interpret words in which contract is expressed by parties.

 

 7.                         In view of the above mentioned reasons/discussions, we do not find any merits in this complaint, as the complainant has not been able to prove any deficiency in service and unfair trade practice on the part of Ops, therefore, the present complaint is hereby dismissed.  In the given facts and circumstances of this case, parties are left to bear their own costs. Copy of this order be supplied to the parties concerned, free of cost, as per rules, and thereafter, the case file be consigned to record room, as per rules, after necessary compliance. This order be also uploaded forthwith on website of this Commission, as per rules, for perusal of parties herein.

          

Announced in open Commission.                                                            Dated: 01.09.2023

 

                                                                                                        

          (K.S.Nirania)                 (Harisha Mehta)                 (Rajbir Singh)                        Member                                 Member                              President