The complainant Rattan Lal (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986, ( Now C.P. Act, 2019 here-in after referred to as 'Act') before this Forum (Now Commission) against Religare Health Insurance Co. Ltd & Other (here-in-after referred to as opposite parties).
Briefly stated, the case of the complainant is that opposite parties approached the complainant at his house at Bathinda for the sale of insurance and opposite party No.2 insured the complainant for medical insurance for sum insured of Rs.5,00,000/-. Opposite parties issued only certificate of insurance to the complainant alongwith pre-existing disease is mentioned in it vide policy No.10942721 w.e.f. 4.1.2017 to 3.1.2018 and charged Rs.20,675/-. Opposite parties also issued the I-card to the complainant. Opposite parties again approached the complainant at Bathinda at his house and suggested him regarding the next 2 years continuous insurance and also conducted his health check-up from Global Imaging & Path Labs at Bathinda.
It is alleged that the said insurance is cashless insurance with opposite parties. Opposite parties assured the complainant that in case of any emergency, the claim can be lodged anywhere in India with the nearest offices of opposite parties and insured can be admitted in any hospital in India and opposite parties would pay the entire claim upto sum assured i.e. Rs.5,00,000/- directly to the hospital for any kind of deceases.
It is further alleged that in the month of December 2018, all of a sudden, the complainant has severe knee pain and he was duly checked up as outdoor patient in Max Hospital, Bathinda on 3.12.2018, but nothing was improved and then he was checked up as outdoor patient in Fortis Hospital, Mohali and there Dr.Harsimran Singh suggested the complainant regarding knee replacement and thereafter the complainant admitted in Fortis Hospital, Mohali on 14.2.2019 and there left knee replacement was done on 15.2.2019 and he was discharge on 21.2.2019.
It is further alleged that in the discharge summary of Fortis Hospital, Mohali, it is clearly mentioned that the complainant has no past history of knee pain. He has complaint of pain and mild swelling in left knee since 6 months which is associated with difficulty in walking and climbing stairs that was evaluated on OPD basis and there he underwent X ray bilateral knee on 18.12.2018. He duly lodged the claim with opposite party No.1 and submitted all the original bills and medical files to opposite party No.l. Thereafter opposite party No.1 issued the letter dated 7.4.2019 in which it demanded the exact duration and past history of ailment with 1st consultation paper and all the past treatment records. Pre Hospitalisation OPD treatment record and complete indoor case papers with admission notes, history sheet, doctors notes nursing notes and vital chart, the complainant sent the reply on 18.4.2019. The claim amount of Rs.2,08,333/- is pending with opposite parties and complainant several times visited the office of opposite party No.2 at Bathinda regarding claim, but opposite parties did not listen.
It is further alleged that the opposite parties vide letters dated 25.4.2019 finally rejected the claim of the complainant and mentioned that the clause 'Claim is rejected as there is non-disclosure of Coronary Artery Disease and Myocardial infarction at the time of policy inception & Non-Disclosure of material facts/pre-existing ailments at time of proposal' whereas doctor of Fortis Hospital mentioned in the discharge summary that the complainant has no past history of knee pain. Whereas it is settled law by the Hon'ble Supreme court that exclusion clause must supply to the insured before issuing any insurance and Hon'ble Supreme Court also held that insurance is a contract like any other contract and it is not a statutory and should be constructed like any other contract. It is also stated that 1st Insurance issued on 4.1.2017 and surgery was done on 14/15.2.2019 beyond 24 months.
It is furthr alleged that the rejection of claim of Rs.2,08,333/- is illegal and claim of Rs.2,08,333/- is still pending with opposite parties. Opposite parties are malafidely and knowingly sitting on the claim of the complainant and by using this amount gaining the unlawful gains. Opposite parties are service oriented company and in case of any loss and damage, they are supposed to provide services and settle the claim.
It is also alleged that due to non-payment of Rs.2,08,333/-, the complainant has suffered from mental agony and pain.
On this backdrop of facts, the complainant has prayed for directions to opposite parties to pay Rs.2,08,333/- and compensation to the tune of Rs.1 lakh and interest @ 18% per annum from the date of discharge i.e. 21.2.2019 till payment and cost to the tune of Rs.50,000/-.
Upon notice, opposite parties appeared through counsel and opposite party No.1 contested the complaint by filing written version and raised the preliminary objections that the complaint is not maintainable and complainant has attempted to misguide and mislead this Forum. It is not maintainable in the present form as it involves disputed question of facts that cannot be determined in summary jurisdiction of Forum. It has been filed by the complainant with malafide intention and complainant has not come before this Forum with clean hands, being litigation for the sake of litigations is liable to dismissed with exemplary costs. That prima-facie, no cause has arisen in favour of the complainant to file this complaint as he till date has not file any reimbursement for claim. The intricate questions of law and facts are involved in the matter in issue and parties should have to lead evidence by examining the witnesses and other party should have to cross-examine the witnesses and matter involved in this case cannot be decided in the summary manner and complainant, if so advised, may approach the Civil Court. The complaint is false, frivolous and vexatious in nature, as such, the complainant is liable to pay penalty under 'Act' to opposite party. The complainant is estopped from filing the complaint by his own acts, conduct, omissions and acquiescence.
It is further pleaded that the complainant purchased the policy and for this, he submitted a proposal form bearing No.A-1100401306430 for issuing the policy under Plan Name CARE and after going through its contents, opposite party No.1 issued the policy. Opposite party No.1 issued a health insurance policy to the complainant bearing No.10942721 with effect from 4.1.2017 to 3.1.2018 covering the complainant for sum assured of Rs.5,00,000/- and policy was further renewed till 9.1.2020 covering the complainant subject to the policy terms and conditions. The copy of Schedule bearing relevant details of the Policy along with policy bond having terms and conditions were duly sent and delivered to the proposer. No assurance was given to the complainant beyond the terms and conditions of the policy. The policy kit containing all relevant documents was duly delivered to the complainant, thereby giving an opportunity to him to verify and examine the benefits, terms and conditions of the policy taken by him. The complainant never approached opposite party No.1 stating that any information given in the policy schedule was incorrect. The complainant through his treating hospital applied for a cashless request for the planned hospitalization at Fortis Hospital, Mohali from 29.12.2018 for the treatment of left total knee replacement. However, the cashless request was denied by the company on the ground of non-disclosure of material facts and same was intimated to the complainant's hospital vide claim denial letter dated 25.1.2019.
It is further pleaded that thereafter the complainant through his treating hospital applied for another cashless request bearing No. Al. No.80249174 for the planned hospitalization of the complainant at Fortis Hospital, Mohali from 14.2.2019 for the treatment of left total knee replacement. The cashless request was denied by opposite party No.1 on the ground of non-disclosure of material facts and same was intimated to the complainant's hospital vide claim denial letter dated 14.2.2019.
It is further pleaded that opposite party No.1 received the reimbursement claim vide claim No.CL No.90884989 with the company on 15.1.2019. Oppsoite party No.1 has given the details pertaining to the claim as the complainant was admitted for Left Unicondylar Knee Replacement (Knee Pain) from 14.2.2019 till 21.2.2019 at FORTIS Hospital, Mohali. On receipt of the reimbursement claim, the company triggered a claim investigation on the basis of the documents submitted alongwith the claim form and investigation and it came to light that the complainant is a known case of Coronary Artery Disease and Myocardial Infarction and same was not disclosed by the complainant at the time of taking of the policy. As such, the reimbursement claim of the complainant was rejected by opposite party No.1 vide letter dated 25.4.2019 under Clause 7.1 of the Policy Terms and Conditions for Non-Disclosure of Material Information.
It is furtehr pleaded that the contract of insurance is contract of Uberrima Fides and by not declaring correct and accurate information at the time of proposing for the referred policy, the complainant is guilty of breach of principle of utmost good faith. As per Clause 7.1 of the Policy Terms and Conditions, the complainant was under obligation to disclose all material facts at the time of taking of the policy. Opposite party No.1 has also referred Clause 7.1 of the Policy Terms and Conditions, detail of which is not necessary at this stage.
It is further pleaded that as per the In Patient History and Physical Record dated 14.2.2019 prepared by Fortis Hospital, Mohali, the complainant is specified to have a past history of Coronary Artery Disease and Myocardial Infarction since 1996 and was also on medication for the same. The Complainant had the opportunity to disclose his history of Coronary Artery Disease and Myocardial Infarction at the time of filling of the proposal form. No such disclosure was made by him. The declaration made by him under the head 'Details of the Person to be Insured including Proposer' regarding the questions asked in the proposal form i.e. Any cardiovascular/Heart Disease (including but not limited to Coronary Artery Disease/Rheumatic heart disease/Heart attack or Myocardial Infarction/Heart Failure/Bypass Grafting or CABG/Angioplasty or PTCA/Heart Valve disease/Pacemaker implantation'. The answer marked to this question is NO. Any other disease/health adversity/ condition/ treatment not mentioned above?:- The answer marked to this question is- NO
It is further pleaded that the complainant has also signed the proposal form dated 3.1.2017 The complaint is not at all maintainable. As such, there is no deficiency in services on part of company and this complaint is liable to be dismissed. The claims are paid by any insurance company out of the common pool of funds belonging to all policyholders of the company that makes it obligatory upon the insurance company to check the genuineness and admissibility of each claim before honoring it in the larger interest of all the policyholders. The insurance company cannot do injustice to genuine policyholders by allowing inadmissible claims.
On merits, opposite party No.1 have reiterated its stand as pleaded in the preliminary objections and detailed above. After controverting all other avements of the complainant, the opposite party No.1 has prayed for dismissal of complaint.
Opposite party No.2 did not file written version.
In support of his complaint, the complainant has tendered into evidence his affidavit dated 18.36.2019 (Ex. C-1) and documents (Ex.C-2 to Ex.C-14).
In order to rebut the evidence of complainant, opposite party No.1 has tendered into evidence affidavit of Tejinder Singh Dated 26.8.2019 (Ex.OP-1/1) and documents (Ex.OP-1/2 to Ex.OP-1/11).
We have heard learned counsel for the parties and gone through the record.
Counsel for complainant has argued that the complainant had obtained the health insurance policy for sum assured of Rs.5 lakhs valid from 4.1.2017 to 3.1.2018 and said policy was thereafter renewed and at the time of renewal, opposite parties got the complainant checked up from Global Imaging & Path Labs at Bathinda.
It is further argued that in the month of December 2018, the complainant had severe knee pain and had duly checked up as outdoor patient in Max Hospital Bathinda on 3.12.2018. Thereafter he was suggested knee replacement and he remained admitted at Fortis Hospital Mohali on 14.2.2019 where procedure of knee replacement was carried on by the hospital on 15.2.2019 and he was discharged on 21.2.2019. As per final bill and discharge summary, total amount of Rs.2,08,333/- was spent by the complainant.
It is further argued that the cashless claim of the complainant was declined by opposite parties and after denial of cashless, claim lodged thereafter was also rejected by opposite parties, which amounts to deficiency in services.
On the other hand, learned counsel for opposite parties has argued that issuance of policy of insurance and its renewal is admitted. However, cashless request of the complainant was denied by the insurance company on the ground of non-disclosure of material facts and claim of the complainant is not payable as per Clause 7.1 of the policy terms and conditions and he was under obligation to disclose the material facts at the time of taking the policy. Later on, opposite parties came to know about the patient history and physical record dated 14.2.2019 wherein it is specified that the complainant has concealed history of Coronary Artery Disease and Myocardial Infarction since 1996 and was on medication for the same. As such, claim is not payable on account of non-disclosure of major disease by the complainant. Counsel for opposite parties has also referred to patient history and record, (Ex.OP1/10), as per which, patient was suffering from pain and left knee palpable and had chest pain in the year 1996 and took treatment for one week and has prayed for dismissal of complaint.
To support these submissions, learned counsel for opposite parties has cited following cases law:-
i) Decision of Hon'ble National Commission in case SBI Life Vs. Baijnath Tanti, 2018(2) CPJ 95 NC;
ii) Decision of Hon'ble National Commission in case NIA Vs. Rakesh Kumar, 2014(3) CPJ 340 NC;
iii) Decision of Hon'ble National Commission in case Vipin Grover Vs. NIA, 2018(2) CPJ 374 NC;
iv) Decision of Hon'ble National Commission in case Life Insurance Coroporation Vs. Kunai Devi, 2008(4) CPJ 89 NC;
v) Decision of Hon'ble State Commission, Punjab, Chandigarh in case Religare Health Insurance Co. Vs. Swarn Kanta Jain, 2018(3) CPJ 1B (CN);
We have given careful consideration to these submissions and gone through the case law cited by learned counsel for opposite parties.
It is admitted fact that the complainant has purchased the health policy, which is Ex.OP1/2 and thereafter the said policy of insurance was renewed by opposite parties. It is further admitted fact that the complainant had to undergo knee replacement and spend amount of Rs.2,08,333/- as per Ex.C10 and Ex.C11. It is further admitted fact that the cashless and after cashless claim lodged by the complainant was repudiated by opposie party No.1 for concealment of pre-existing disease. To prove his case, the complainant has placed on record policy of insurance and investigation report. As per Ex.C5, the complainant had undergone for medical tests before renewal of policy. He has also placed on record treatment record and record of expenditures made, (Ex.C8 to Ex.C11).
On the other hand, opposite party No.1 has placed on record copy of policy terms and conditions, (Ex.OP1/3) and has mainly relied upon Ex.OP1/10, in Patient History and Patient Record by the complainant, as per which the complainant has suffered chest pain in the year 1996. However, this Commission is of the view that although, opposite party No.1 has placed on record documents, but it has not placed on record affidavit of any doctor who treated the complainant for such alleged heart disease to prove the alleged pre-existing disease.
This Commission is of the view that opposite parties had already got the complainant medical examined at the time of renewal of the policy. As such, question of concealment of pre-existing disease does not arise. Moreover discharge summary is not sufficient to conclude that the insured was in the knowledge that he was suffering from such disease. As per treatment record, the complainant had undergone knee replacement. However, alleged previous disease is alledgedly is of some heart problem and counsel for opposite parties has not been able to explain as to what is relationship between the knee problem and heart disease.
It is not the case of opposite party No.1 that the complainant has suffered knee problem on account of pre-existing disease. As such, this Commission is of the view that denial of the claim by opposite party No.1 to the complainant amounts to deficiency in services.
Accordingly, the present comlaint is partly allowed against opposite party No.1. Opposite party No.1 is directed to pay amount of Rs.2,08,333/- to the complainant alongwith interest @ 9% per annum from the date of filing of complaint till realization. No order as to costs.
The compliance of this order be made by opposite party No.1 within 45 days from the date of receipt of copy of this order.
The complaint could not be decided within the statutory period due to heavy pendency of cases.
Copy of order be sent to the parties concerned free of cost and file be consigned to the record room.
Announced:-
06-07-2023 (Lalit Mohan Dogra)
President
(Shivdev Singh)
Member
