Order dictated by:
Sh.S.S.Panesar,President.
- Gurpinder Singh complainant has filed the present complaint under section 11 & 12 of the Consumer Protection Act on the allegations that complainant got issued health policy from the opposite party bearing No. P/211111/01/2015/005339 under the name and title of Family Health Optima Insurance policy for himself, his wife Harpreet Kaur and minor son Samarbir Singh which was valid from 25.3.2015 to 24.3.2016 after paying premium to the tune of Rs. 8466/- to the opposite party. On 11.1.2016, suddenly the blood pressure of the wife of the complainant fell down with complaint of vomiting and she approached K.D.Hospital where Dr. Dushyant Thaman after thorough examination prescribed the medicines to the wife of the complainant. But suddenly on 31.1.2016, the blood pressure of the wife of the complainant again fell down . The complainant approached Dr.H.P.Singh at Fortis Hospital, Amritsar where after examining the wife of the complainant , Dr. H.P.Singh advised her admission in the hospital. As per advise of the treating doctor, the wife of the complainant remained admitted in Fortis Hospital from 31.1.2016 to 2.2.2016 where the complainant incurred an expenditure of Rs. 31,302/- on the treatment of his wife. It is pertinent to mention over here that at the time of admission , Fortis Hospital made request to the opposite party for pre-authorization for cashless treatment, which has been rejected by the opposite party vide letter dated 2.2.2016 on the ground that “The treatment relating to anxiety is not payable as policy”. The opposite party wrongly rejected the claim of the complainant knowing well that it is coverable under the policy. The complainant has sought for the following reliefs vide instant complaint:-
- Opposite party may be directed to make payment of Rs. 31,302/- alongwith interest @ 18% p.a till realization of the amount.
- Compensation to the tune of Rs. 50000/- may also be awarded to the complainant .
- Litigation expenses to the tune of Rs. 10000/- may be awarded to the complainant.
Hence, this complaint.
2. Upon notice, opposite party appeared and contested the complaint by filing written version taking certain preliminary objections therein inter alia that the complaint is not maintainable either in law or on facts and is liable to be dismissed in limine ; that the complainant has availed the Family Health Optima Insurance policy No. P/211111/01/2015/005339 for himself, his wife Harpreet Kaur and minor son Samarbir Singh which was valid from 25.3.2015 to 24.3.2016 for the sum insured of Rs. 50000/- ; that the insured was admitted in Fortis Hospital, Amritsar on 31.1.2016 for the treatment of Anxiety and submitted pre authorization request for providing cashless treatment, the same was denied on the ground that the treatment is related to anxiety which is not payable as per terms and conditions of the policy and the same was communicated to the treating hospital vide letter dated 2.2.2016; that complainant had submitted claims records seeking reimbursement of medical expenses. On scrutiny , it was observed that the insured/patient was admitted on 31.1.2016 and discharged on 2.2.2016 and diagnosed as Anxiety, which is a psychiatric ailment ; that as per exclusion No.6 of the policy, the company is not liable to make any payment in respect of expenses incurred for treatment of psychiatric and behavioral disorder. Hence, the claim was repudiated and the same was communicated to the complainant vide letter dated 7.4.2016 ; that complainant has violated the terms and conditions of the policy, therefore he is not liable for any compensation. On merits facts narrated in the complaint have been specifically denied and a prayer for dismissal of complaint was made.
3. In his bid to prove the case Sh.S.S.Channa,Adv.counsel for the complainant tendered into evidence duly sworn affidavit of the complainant Ex.CW1/A alongwith documents Ex.C-1 to Ex.C-7 and closed the evidence on behalf of the complainant.
4. To rebut the aforesaid evidence Sh.R.P.Singh,Adv.counsel for the opposite party tendered into evidence affidavit of Sh.Rajnish Kohli Ex.OP1 alongwith documents Ex.OP2 to Ex.OP10 and closed the evidence on behalf of the opposite party.
5. We have heard the ld.counsel for the parties and have carefully gone through the record as well as written synopsis of arguments submitted on behalf of the complainant.
6. On the basis of the evidence on record, it becomes evident that Harpreet Kaur, one of the insured was admitted in Fortis Hospital, Amritsar on 31.1.2016 for treatment of Anxiety who submitted pre-authorization request for providing cashless treatment . Request for cashless treatment was declined on the ground that treatment relating to “anxiety” was not payable as per terms and conditions of the Insurance policy . Repudiation was communicated to the treating hospital and the insured vide letter dated 2.2.2016, copy whereof is Ex.OP5 on record. However, it is not denied that the complainant availed Family Health Optima Insurance Revised Policy No. P/211111/01/2015/005339 for the period from 25.3.2015 to 24.3.2016 covering Gurpinder Singh, self, Harpreet Kaur, spouse, Samarbir Singh dependant child of the sum insured of Rs. 50000/-. The complainant had submitted Insurance claim seeking reimbursement of medical expenses to the tune of Rs.31,302/-. On scrutiny of the claim record, it was found that as per discharge summary, the insured patient was admitted on 31.1.2016 and discharged on 2.2.2016 and diagnosed as Anxiety, which is a psychiatric ailment . As per exclusion clause 6 of the Insurance policy in dispute, the company was not liable to make any payment in respect of expenses incurred at hospital for treatment of psychiatric and behavioral disorder. Hence, the claim was repudiated and the same was communicated to the complainant vide letter dated 7.4.2016, copy whereof accounts for Ex.OP5. Moreover, the insured has not intimated to the opposite party regarding the ailment suffered by her at the time of filling of proposal form for issuing of Insurance policy which amounts to concealment of material facts. Reliance in this connection has been placed on Satwant Kaur Sandhu Vs. New India Assurance Company Limited 2009(8) SCC 316wherein it has been laod down that any act which would influence the mind of a prudent insurer in deciding whether to accept or not to accept the risk is a “material fact”. If the proposer has knowledge of such fact, he is obliged to disclose it particularly while answering questions in the proposal form. Needless to emphasize that any inaccurate answer will entitle the insurer to repudiate his liability because there is clear presumption that any information sought for in the proposal form is material for the purpose of entering into a contract of insurance.
7. Ld.counsel for the opposite party has vehemently contended that from aforesaid discussion, it becomes amply clear that the insurance claim of the complainant has rightly been repudiated and it is contended that complaint may be dismissed accordingly with cost.
8. But,however, from the appreciation of the facts and circumstances of the case, it becomes evident that the wife of the complainant suffered from low blood pressure and she also started vomiting on 31.1.2016 and she was admitted in Fortis Escort Hospital from where she was discharged on 2.2.2016. The complainant incurred an expenditure of Rs. 31,302/- for the treatment of his wife which is not a disputed fact. However, request of the complainant for cashless treatment was denied by the opposite party vide their rejection letter dated 2.2.2016 on flimsy ground that treatment relating to ‘Anxiety’ is not payable as per policy terms. Opposite party wrongly repudiated the claim of the complainant knowing fully well that it was coverable under the policy. Discharge card of Fortis Escort Hospital Ex.OP2 shows that treating doctor has specifically mentioned “course in the hospital” that lab investigations were done which showed low level of calcium (7.9) and creatinine (0.7) which clearly shows that patient was suffering from “Hypocalcaemia” meaning thereby that she was having low calcium. Therefore, plea of the opposite party for rejecting the claim that wife of the complainant was suffering from “Anxiety”, is totally false and has been coined simply to escape from the liability. Apart from that , the wife of the complainant was never treated by a psychiatrist at Fortis Hospital. From this fact, it becomes quite clear that wife of the complainant was not suffering from Anxiety rather she was suffering from Hypocalcaemia. Simply because some Neuro surgeon was consulted during treatment does not mean & imply that the complainant was a psychiatric patient.
9. Moreover, the opposite party has not denied that intimation regarding the ailment of the insured was given in time. Opposite party has not denied the legality and validity of the medical record which the complainant had submitted for reimbursement of the insurance claim. It is usually seen that insurance companies show green pastures to the insured persons at the time of selling the insurance policy and when it comes to payment of the insurance claim, they invent all sort of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is fully attracted, wherein it was held that, Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. In similar set of facts the Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seams that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy.
The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
10. From the above discussion, it transpires that complainant has been able to prove his case and the complainant is entitled for reimbursement of medical expenses incurred on the treatment of his wife to the tune of Rs. 31,302/- The amount is ordered to be paid with interest @ 9% p.a. from the date of filing of the complaint until full and final recovery. Cost of litigation are assessed at Rs. 2000/-. Compliance of this order be made within a period of 30 days from the date of receipt of copy of order ; failing which, complainant shall be at liberty to get the order executed through the indulgence of this Forum. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Forum
Dated : 5.10.2016
/R/
