Chandigarh

StateCommission

A/260/2017

Religare Health Insurance Company Ltd - Complainant(s)

Versus

Sarita Garg - Opp.Party(s)

Sachin Ohri, Adv.

15 Nov 2017

ORDER

   STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

UNION TERRITORY, CHANDIGARH

 

Appeal No.	260 of 2017
Date of Institution	30.10.2017
Date of Decision	15.11.2017

 

Religare Health Insurance Company Ltd., D-3S P3B, District Centre, Saket, New Delhi through Ramnique Sachar, Corporate Legal Manager, Authorised Signatory, 3^rd Floor, Vipul Tech Square, Tower C, Sector 43, Golf Course Road, Gurgaon, Haryana.

                                        …..Appellant/Opposite Party

                                Versus

Sarita Garg w/o Sh. Vinod Garg, Resident of House No.1633/1, Sector 30-B, Chandigarh.

                                   …..Respondent/Complainant.

BEFORE:    SH. DEV RAJ, PRESIDING MEMBER

                MRS. PADMA PANDEY, MEMBER

 

Argued by:

 

Sh. Sachin Ohri, Advocate for the appellant/ Opposite Party.

 

PER PADMA PANDEY, MEMBER

              This appeal is directed against the order dated 01.09.2017, rendered by District Consumer Disputes Redressal Forum-II, UT, Chandigarh (in short ‘the Forum’ only), vide which, it allowed Consumer Complaint bearing No.865 of 2016, with the following directions :-

 “10]      In view of the above findings, we are of the opinion that the complaint deserves to be allowed. Accordingly, the complaint is allowed against Opposite Party with following directions:-

1. To reimburse Rs.1,57,500/- being the cost of the treatment incurred by the complainant;

2. To pay an amount of Rs.15,000/- as compensation for the harassment suffered by the complainant on account of deficiency in service on the part of Opposite Party.
3. To pay litigation cost of Rs.7000/-.

         This order shall be complied with by Opposite Party within a period of 30 days from the date of receipt of copy of this order, failing which it shall also be liable to pay interest @9% per annum on amount mentioned in sub-para (a) & (b) above from the date of filing this complaint till realization, apart from paying litigation cost.” 

2.           The facts, in brief, are that the complainant got Health Insurance Policy bearing No.10327303 – Plan – Care (for IndusInd Bank) from Opposite Party effective from 05.07.2015 to 04.07.2017 (Annexure C-2). It was stated that the complainant met with an accident on 10.06.2016 at 1:30 PM near Village Tutam in Uttarakhand and no FIR or MLC No. was registered. The complainant suffered injuries on right shoulder and forehead, therefore, she was taken to Civil Hospital, Village Tutam in Uttarakhand and then to Max Hospital, Phase-6, Mohali, where, x-ray was conducted on 11.06.2016. It was further stated that the complainant was admitted in hospital on 12.06.2016 and was discharged on 15.06.2016. Copy of Discharge Summary is at Annexure C-3.  It was further stated the complainant suffered a major fracture in her shoulder and was advised for surgery of the shoulder, as such, she was operated on 13.06.2017 at Max Hospital, Mohali. Copy of medical bills is Annexure C-4 (Colly.).  It was further stated that cost of the treatment at Max Hospital was Rs.1,57,500/- paid by the complainant.  It was further stated that the claim lodged with the Opposite Party for reimbursement of the medical expenses incurred by the complainant was rejected vide letter dated 19.07.2016 on the ground that she had concealed the material fact that she was suffering from hypothyroidism since December, 2015 and is under medication for the same (Annexure C-6). It was further stated that repudiation of the claim is illegal. Therefore, the Opposite Party was deficient, in rendering service, as also indulged into unfair trade practice.  When the grievance of the complainant was not redressed, left with no alternative, a complaint under the Consumer Protection Act, 1986 (hereinafter to be called as the “Act” only), was filed.

3.           In its written statement, the Opposite Party, admitted the factual matrix of the case. It was admitted that the complainant lodged the claim with the Opposite Party and  as per the terms and conditions of the policy, after thoroughly analysing the same, it was found that the complainant concealed the fact that she was suffering from Hypertension since 3-4 years before the inception of the Policy and from the Discharge Summary it is clear that the complainant is suffering from Hypertension and was on  medication  Tab   “Telma 40 mg”. The said fact was concealed by the complainant in the proposal form at the time of taking Policy and, therefore, the claim of the complainant was rightly repudiated. It was further stated that the replying Opposite Party was neither deficient, in rendering service nor indulged into unfair trade practice.

4.           The complainant filed rejoinder to the written statement of the Opposite Party, wherein he reiterated all the averments, contained in the complaint, and refuted those, contained in the written versions of the Opposite Party. 

5.           The parties led evidence, in support of their case.

6.           After hearing Counsel for the complainant and, on going through the evidence, and record of the case, the Forum, allowed the complaint, as stated above. 

7.           Feeling aggrieved, the instant appeal, has been filed by the appellant/Opposite Party.

8.           We have heard the Counsel for the appellant/Opposite Party, and have gone through the evidence and record of the case, carefully. 

9.           After going through the evidence and record of the case, we are of the considered opinion, that the appeal is liable to be dismissed, at the preliminary stage, for the reasons to be recorded, hereinafter.

10.          Counsel for the appellant/Opposite Party has submitted that District Forum while passing the impugned order has failed to appreciate the Discharge Summary & Anaesthesia notes of the doctor. He further submitted that no pre-medical examination was conducted and the policy was issued on the basis of declaration given in the proposal form by the complainant. The report submitted by the complainant was in fact the complainant’s own health check-up report, which was conducted post the policy issuance. He further submitted that the report is dated 01.10.2015, whereas, the proposal form was filled on 03.07.2015 and the policy was issued from 05.07.2015. He further submitted that the complainant kept the Insurance Company in dark regarding the pre-existing disease and did not mention the said fact in the proposal form and, as such, the claim was rightly repudiated. He prayed for allowing the appeal and setting aside the impugned order. 

11.          It is the admitted fact that the complainant took Health Insurance Policy bearing No.10327303 from the appellant/Opposite Party for the period from 05.07.2015 to 04.07.2017, as is evident from Premium Acknowledgment (at page No.15 of Forum file). It was also the admitted fact that the complainant met with an accident and surgery of her shoulder was conducted at Max Hospital, Mohali, after payment of Rs.1,57,500/-. It was also the admitted fact that  the claim was lodged with the Opposite Party for reimbursement but the same was repudiated by the Opposite Party vide Claim Rejection Letter dated 19.07.2016, which reads thus :-

“We have reviewed the claim (Claim No.:90229416 in the name of “Sarita Garg”), filed by you pertaining to Health Insurance Policy (#10327303), and hereby inform you that the claim is not payable as per policy terms & conditions. For ease of your perusal we have listed the reason for denial below :

. NON DISCLOSUER OF MATERIAL FACTS/PRE-EXISTING AILMENTS AT TIME OF PROPOSAL.

.  HYPERTENSION SINCE 3 TO 4 YEARS.”

12.          After going through the record of the District Forum, we are not agreeable with the contention of the Counsel for the appellant/Opposite Party because the complainant specifically denied in her rejoinder that she was suffering from hypertension since 3 to 4 years and admitted that the complainant was 1^st diagnosed for hypothyroidism in December, 2015. The complainant further stated in her rejoinder that the fact regarding problem of hypertension from 3 to 4 years is without any documentary evidence and has been raised in order to reject the claim of the complainant. The complainant also stated in her rejoinder that the Opposite Party got her medically examined from its empanelled doctor/lab i.e. from Satyam Clinical Laboratory, Sector 45, Chandigarh and Dr.Priya Mahajan issued a Medical Certificate dated 01.10.2015 regarding the complainant being completely medically fit (Annexure C-8). It is pertinent to note that the claim filed by the complainant, when she met with an accident, due to which, surgery was conducted and not on account of treatment of any disease vis-a-vis hypertension. The plea of the appellant that the complainant did not disclose the fact qua suffering from hypertension while filling up the proposal form, is not well based as the Policy, in question, was issued by the appellant Insurance Company after following proper procedure and norms as per the standards governing in the said Policy. Moreover, as per established norms of Insurance, Policy is only issued after thoroughly examining the life assured by doctor at the penal of the Insurance Company. However, for the sake of arguments, if it is accepted that the complainant was suffering from hypertension, which fact she allegedly did not disclose in the proposal form, still there is no nexus between suffering from hypertension or hypothyroidism and fracture of the complainant due to an accident. If the said shoulder surgery was conducted due to hypertension or hypothyroidism only then the plea of the appellant/Opposite Party is acceptable. However, in the present case, surgery was conducted due to accident and not hypertension or hypothyroidism. So, we are of the view that the District Forum rightly observed in paras Nos.8 & 9 of the impugned order, which reads thus :-

“8]       The perusal of the whole record on file reveals that the OP in order to repudiate the claim relied solely upon the recording made in the Discharge Summary of the complainant (Annexure C-3) qua her suffering from Hypertension since 2/3 years. There is no independent evidence on record establishing that the complainant in actual is suffering from disease of hypertension since 2-3 years.  Further, there is no clarification of the fact that by whom the recording in the Discharge Summary has been made and the author of that recording has not been examined. Hence, the conclusion arrived at by the OPs on the basis of Discharge Summary alone is not sufficient to believe that the complainant is suffering from pre-existing disease of hypertension.  Thus, the ground taken for rejection of the claim of the complainant, in the absence of any concrete evidence, is not sustainable.

 

9]       In addition, it is pertinent to mention that the complainant has duly placed on record the report of pre-medical examination got conducted at the instance of the OP Company wherein she was declared as ‘medically fit’ person.  When once the person is declared as medically fit while issuing the policy, then no question of any pre-existing disease arise.  Therefore, the rejection of the claim done by the OP on account of non-disclosure of pre-existing disease, is highly objectionable and hence, held to be not justified.  Thus, the deficiency in service on the part of the Opposite Party is writ large.”

 Hence, the order passed by the Forum, being based on the correct appreciation of evidence and law, on the point, does not suffer from any illegality or perversity.

13.          For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same stands dismissed, at the preliminary stage, with no order as to costs. The order of the Forum is upheld.

14.          Since the appeal filed by the appellant/Opposite Party is dismissed, therefore, the application for condonation of delay of 27 days in filing the appeal is rendered infructuous.

15.          Certified Copies of this order be sent to the parties, free of charge.

16.          The file be consigned to Record Room, after completion.

Pronounced.

15.11.2017                                                  Sd/-

 (DEV RAJ)

PRESIDING MEMBER

 

Sd/-

(PADMA PANDEY)

       MEMBER

 

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