Final Order / Judgement | DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION PATIALA. Consumer Complaint No. 156 of 3.5.2017 Decided on: 9.3.2021 Ashok Kumar son of parshotam Dass c/o resident of Des Raj Dhani Ram Chunagra Road, Behind Old Bus Stand, Patran, District Patiala. …………...Complainant Versus Religare Health Insurance Company Limited, Registered Office 3-D, P3B, District Centre Saket New Delhi, through its Managing Director. …………Opposite Party Complaint under Section 12 of the Consumer Protection Act, 1986. QUORUM Sh. Jasjit Singh Bhinder, President Sh.Y.S.Matta, Member ARGUED BY Sh.Asheen Khan, counsel for complainant. Sh.Amit Gupta, counsel for OP. ORDER JASJIT SINGH BHINDER,PRESIDENT - This is the complaint filed by Ashok Kumar (hereinafter referred to as the complainant) against Religare Health Insurance Co. Ltd.(hereinafter referred to as the OP/s) under the Consumer Protection Act.
Facts of the complaint - Briefly the case of the complainant is that he got insured himself and his family members i.e. wife Geeta Goyal, daughter Kashish Singla and son Kunal Singla under the Health Insurance Cashless policy bearing No.10367750 for the period from 21.8.2015 to 20.8.2016 and paid premium of Rs.10,744/-.He got the said policy further renewed for another one year and deposited Rs.16,519/-in the account of the company.
- It is averred that his son master Kunal suffered from pediatric problem and he was got treated from Bhatia Nuro Centre, Patiala on 22.8.2016.Thereafter he got treated from Dr.Janak Raj Sachdeva at Patiala and further he was got treated from Dayanand Medical College and Hospital, Ludhiana where he admitted vide admission No.43185 CR No.171782 from 30.8.2016 to 5.9.2016 and the complainant had to pay Rs.60,000/- to the hospital for the treatment of his son. After the discharge of his from the hospital, he approached the OP for the reimbursement of the amount spent by him on the treatment of his child but nothing has been paid by the OP. The complainant also got sent legal notice dated 29.9.2016 upon the OP who replied the same but refused to pay the amount .There is thus deficiency in service on the part of the OP which caused mental agony and harassment to the complainant. Hence this complaint with the prayer to accept the same by giving direction to the OP to pay the amount of Rs.60,000/-so spent by the complainant on the treatment of his son and also to pay Rs.1lac as compensation.
Reply/Written statement - Upon notice OP appeared through counsel and contested the complaint by filing written reply having raised preliminary objections that the present complaint is premature as the complainant has never filed reimbursement claim with the OP. Further it is submitted that the complainant had purchased health insurance policy bearing No.10367750 from the OP for the period from 21.8.2015 to 20.8.2016 for a sum insured of Rs.3,00,000/- and the said policy was further renewed from 21.8.2016 to 20.8.2017 under which his spouse, son Kunal Singla and daughter were covered in accordance with the terms and conditions of the policy.It is further submitted that during the currency of the said policy, complainant approached the OP for cashless facility/pre authorization request on 30.8.2016 for the hospitalization of the patient at Dayanand Medical College & Hospital, Ludhiana with provisional diagnosis as “Conversion Disorder”. However, the said cashless facility request was denied under clause 4.3(a)(xii) for permanent exclusion relating to treatment of mental illness, stress or psychiatric disorder and the said information was duly communicated to the complainant and concerned hospital authorities vide letter dated 2.9.2016 and also in order to substantiate its stand took an expert medical opinion from an independent doctor in this regard.
- On merits, issuance of the policy in question to the complainant and renewal of the same is admitted. Further the receipt of the legal notice and reply to the same is also admitted. It is further submitted that the claim of the complainant falls outside the purview of the policy as such the complainant is not entitled for anything as alleged. There is also no deficiency in service on the part of the OP. After denying all other averments, the OP prayed for the dismissal of the complaint.
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- In support of the complaint, the ld. counsel for the complainant has tendered in evidence Ex.CA affidavit of th complainant alongwith documents Exs.C1 to C23 and closed the evidence.
- On the other hand, the ld. counsel for the OP has tendered in evidence Ex.OPA affidavit of Sh.Prashant Singh, Manager Legal alongwith documents Exs.OP1 to OP7 and closed the evidence of OP.
- We have heard the ld. counsel for the parties and have also gone through the record of the case, carefully.
- The ld. counsel for the complainant has argued that the complainant is holding Health Insurance Cashless policy through online at Patran for himself, his wife Geeta Goyal, his daughter Kashish Singla and son Kunal Singla for the period from 21.8.2015 to 20.8.2016 and the complainant had paid premium of Rs.10,744/-The said policy was further renewed for one year and the amount of Rs.16519/- was deposited. The ld. counsel for the complainant has argued that Kunal Singla, minor son of the complainant suffered from pediatric problem and he was got treated from Bhatia Nuro Centre, Patialaon 22.8.2016,thereafter he was got treated from Dr.Janak Raj Sachdeva at Patiala and then he was got treated from Dayanand Medical College and Hospital Ludhiana and was admitted there from 30.8.2016 to 5.9.2016.The ld. counsel further argued that at the time of admission of son of the complainant the complainant approached concerned section of the hospital for getting medical treatment of his on the basis of the policy in question but the hospital authorities did not give any response and the amount of Rs.60,000/- was spent by the complainant but the claim was repudiated by the OP after legal notice was sent. The ld. counsel has relied upon the citation of the Hon’ble Madras High Court passed in the case of Dr.Shanti Rengarajan Vs. Oriental Insurance Co. Ltd. and another W.P.No.43202 of 2016 decided on 9.3.2018, wherein it has been held , “ that (i) Right to avail health insurance is an integral part of the Right to Healthcare and the Right to Health, as recognized in Art.21 of the Constitution” and it has been further held that “(iv) The Exclusionary clause of ‘genetic disorders’. In the insurance policy, is too broad, ambiguous and discriminatory- hence violative of Art.14 of the Constitution of India”.
- On the other hand, the ld. counsel for the OP has argued that the complainant has never applied for the reimbursement of the claim.The ld. counsel further argued that the complainant has purchased the health insurance policy but the disease falls under exclusion clause, as such no amount can be given and he relied upon the citations Life Insurance Corporation of India Vs. Manish Gupta MANU/SC/0599/2019, Surinder Kaur Vs. National Insurance Company Ltd.MANU/CF/0208/2016 and National Insurance Co.Ltd. Vs. Abdul Razak MANU/CF/1077/2015.
- To prove the case Sh.Ashok Kumar has tendered his affidavit, Ex.CA and he has deposed as per his complaint, Ex.C1 is health insurance policy, Ex.C2 is account statement of Axis bank,Ex.C3 is medical certificate of DMC and Hospital, Ludhiana, which shows “conversion disorder” and the child was admitted for five days in the hospital,Exs.C4 to C18 are receipts of hospital,Ex.C21 is legal notice sent to the OP by the ld. counsel for the complainant,Ex.C23 is reply to legal notice. It is stated that the company reviewed all the documents and his claim was rejected on the basis of the documents. It is further stated that son of the compllainant was suffering from conversion disorder which falls under Permanent exclusion.
- So the claim was rejected on the ground that the son of the complainant was suffering from conversion disorder which falls under permanent exclusion .But it has been clearly held by the Hon’ble Madras High Court in the case Dr.Shanti Rengarajan Vs. Oriental Insurance Co. Ltd. and another(supra), that right to avail health insurance is an integral part of the right to healthcare and the right to health, as recognized in article 21 of the constitution. Discrimination in health insurance against individual based on their genetic disposition or genetic heritage, in the absence of appropriate genetic testing and laying down of intelligible differentia, is unconstitutional. It has been further clearly held by the Hon’ble Madras High Court that the exclusionary clause of genetic disorder in the insurance policy is too broad, ambiguous and discriminatory. Hence violative of Section 14 of the Constitution of India.
- So, it is clear that right to avail health insurance is an integral part of the right to healthcare as is recognized under Section 21 of the Constitution of India. Any order against the provision of Constitution of India is illegal and cannot be accepted to Exclusionary clause. In the present case a small child was only suffering from genetic problem from conversion disorder. This type of minor ailment sometimes happens in a child, so the insurance company has played with the rights of the small children and they have violated Section 14 of Constitution of India.
- On the other hand Sh.Prashant Singh,Manager Legal has tendered his affidavit, Ex.OPA and he has deposed as per the written statement, Ex.OP1is the insurance policy, Ex.OP2 is refusal for cashless medical insurance of conversion disorder.Ex.OP4 is receipt of Dayanand Medical College and Hospital Ludhiana of Kunal Singla of functional disorder,Ex.OP5 are the rules of the insurance company and mental illness, stress or psychological disorder in the Permanent Exclusion. There is no medical evidence on the file to show that the child was suffering from acute medical illness. Also there is no evidence on the file to prove that these terms and conditions were given to the complainant. So it is clear that the claim was wrongly declined by the OP .The complaint stands allowed and the OP is directed to refund the amount of Rs.60,000/- , so spent by the complainant on the treatment of his child and the complainant shall sent all the bills to show that he had actually spent Rs.60,000/- and the complainant is held entitled to interest on the amount so spent by him @6% per annum from the date of discharge of his from the hospital till its realization, with no order as to costs. Compliance of the order be made by the OPs within a period of 45 days from the date of the receipt of the certified copy of this order.
ANNOUNCED DATED:9.3.2021 Y.S.Matta Jasjit Singh Bhinder Member President | |