Chandigarh

DF-I

CC/710/2021

Mahesh Gautam - Complainant(s)

Versus

The Religare Health Insurance Co. Ltd. - Opp.Party(s)

Nitin Verma

22 Sep 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

 

                    

Consumer Complaint No.	:	CC/710/2021
Date of Institution	:	18/10/2021
Date of Decision	:	22/9/2023

 

Mahesh Guatam son of Sh. Rameshwar Dass Gautam resident of Ward No.6, Nalagarh, Distt. Solan, Himachal Pradesh 174101.

 

… Complainant

V E R S U S

1. The Religare Health Insurance Company Limited through its authorized representative SCO No.56-57,58, second floor, Sector 9-D, Chandigarh.
2. The Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited) through its authorized representative SCO No.56-57,58, second floor, Sector 9-D, Chandigarh.

.  … Opposite Parties

 

CORAM :	PAWANJIT SINGH	PRESIDENT
	SURJEET KAUR	MEMBER

                       

ARGUED BY		Sh. Anmol chandan, Advocate for complainant.
		Sh. Amarpreet Singh, Advocate proxy for Sh. Ramdeep Partap Singh, Advocate for OPs.

Per SURJEET KAUR, Member

     Briefly stated the complainant purchased a health policy for himself and his wife valid from 19.10.2019 to 18.10.2020 with coverage of Rs.7.00 lacs by paying Rs.23,001/- as premium.  On 25.11.2019 the complainant fell unconscious and initially taken to GArgi Medical Centre at Nalagarh and thereafter  admitted  in Alchemist Hospital sector 21 Panchkula on 26.11.2019 where he was diagnosed  the seizure disorders. The  family members of the complainant requested the OPs for cashless facility as assured by them at the time of issuance of policy, however, the OPs without investigating the matter denied for the cashless facility vide their denial letter dated 26.11.2019.  It  is averred that at the time of filling the admission form the friend inadvertently told the complainant is having history of seizure disorders by birth though upon arrival of family the same was corrected. It is alleged  that despite several  requests made the OPs did not provide the cashless facility to the complainant as a result of that the complainant had to pay the entire hospital expenses from his own pocket. Alleging the aforesaid act of Opposite Parties deficiency in service and unfair trade practice on their part, this complaint has been filed

2. The Opposite Parties  in their reply while admitting the factual matrix of the case stated that  after examination of medical documents received alongwith pre-authorization cashless form, the respondent company observed that the insured i.e. the complainant was having history of seizure since birth.  Thus, the OP insurance company rejected the cashless request of the insured vide letter dated 26.11.2019 for non disclosure of material/pre-existing ailments at the time of proposal. All other allegations made in the complaint has been  denied being wrong.
3. Rejoinder was filed and averments made in the consumer complaint were reiterated
4. Contesting parties led evidence by way of affidavits and documents.
5. We have heard the learned counsel for the contesting parties and gone through the record of the case.
6. The main point for consideration in the present case is that whether repudiation of  claim of the complainant by the OPs on the ground of non-disclosure of pre-existing disease is valid or not. The answer to the same is in negative.
7. The sole grouse of the complainant revolves around the admission of the complainant in the Alchemist hospital when he was unconscious and the patient history was given by the friend of the complainant who without knowing the fact have disclosed the hospital that the complainant was suffering from seizure since birth as is evident from Annexure R-4.  On this very document the OPs are assuming the disease in question is since birth and as such the complainant did not disclose the pre-existing disease and repudiated the claim of the complainant. The sister of the complainant vide Annexure C-11 intimated the OPs that the complainant is not suffering from seizure since birth and requested them to correct the record as the said fact was quoted by mistake by the friend of the complainant.  Further more Annexure C-10 is certificate issued  by the treating doctor of the hospital verifying the fact that the complainant is not suffering from seizure by birth.
8. Thus, if we peruse the  Annexures R-4, C-10  and C-11 in collaboration, it comes forth that in fact the complainant was not suffering from seizure since his birth but the OPs in an arbitrary manner despite the certification of the treating doctor that the complainant was not suffering from seizure since his birth, repudiated his genuine claim. Even otherwise the OPs failed to place on record any medical history of the insured that he was suffering from seizure prior to commencement of the policy in question. Hence, there is merit in the complaint and the same deserves to be allowed.      
9. In view of the above discussion, the present consumer complaint succeeds and the same is accordingly allowed. OPs are directed as under:-

 

1. to pay Rs.63,450/- to the complainant with interest @9% P.A.from the date of rejection of claim till onwards.

 

2. to pay Rs.10,000/- to the complainant as compensation for causing mental agony and harassment to him;

 

 

3. to pay Rs.10,000/- to the complainant as costs of litigation.

 

10.      This order be complied with by the OPs within thirty days from the date of receipt of its certified copy, failing which, they shall make the payment of the amounts mentioned at Sr.No.(i) & (ii) above, with interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
11. Pending miscellaneous application(s), if any, also stands disposed off.
12.      Certified copies of this order be sent to the parties free of charge. The file be consigned.

			sd/- [Pawanjit Singh]
			President
			Sd/-
			[Surjeet Kaur] Member