State Consumer Disputes Redressal Commission
Religare Health Insurance Co. Ltd. vs Subash Chander Aggarwal on 26 April, 2017
2nd Additional Bench
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, DAKSHIN MARG, SECTOR 37-A, CHANDIGARH.
First Appeal No. 837 of 2016
Date of institution : 04.11.2016
Date of decision : 26.04.2017
Religare Health Insurance Company Ltd, Branch Office, 28, 1st Floor,
Taneja Tower, District Shopping Complex, Ranjit Avenue, Amritsar
through Ms. Ramnique Sachar, Manager Legal, Authorized
Signatory, Religare Health Insurance Co. Ltd., D3, District Centre,
Saket, New Delhi.
.......Appellant/Opposite Party.
Versus
Subhash Chander Aggarwal R/o H.No. 274/12, Gali OBC Bank Wali,
Tarn Taran.
.....Respondent/Complainant
First Appeal against the order dated
15.09.2016 of the District Consumer
Disputes Redressal Forum, Amritsar.
Quorum:-
Hon'ble Mr. Justice Paramjeet Singh Dhaliwal, President
Sh. Gurcharan Singh Saran, Judicial Member.
[ Present:-
For the appellant : Sh. Sachin Ohri, Advocate
For the respondent : Sh. Sukhandeep Singh, Advocate
GURCHARAN SINGH SARAN, JUDICIAL MEMBER:-
Order
This appeal has been preferred by appellant/opposite party (hereinafter referred as 'OPs') under Section 15 of the Consumer Protection Act, 1986 (hereinafter referred to as 'Act') against the order dated 15.09.2016 in C.C. No. 692 of 03.02.2016 passed by the learned District Consumer Disputes Redressal Forum, Amritsar (in short the 'District Forum') vide which the complaint filed by the First Appeal No. 837 of 2016. 2 respondent/complainant (hereinafter referred as 'complainant') was allowed with the directions to OPs to reimburse the medical amount of Rs. 2,04,457/- (57,517/- incurred at Parvati Devi Hospital and Rs. 1,82,940/- incurred at Medanta Hospital) on the treatment of the complainant alongwith Rs. 2000/- as cost of litigation. It was further directed to comply with the order within a period of 30 days, failing which it shall carry interest @ 9% per annum from the date of filing the complaint till the final recovery.
2. The complaint was filed by the complainant Sh. Subhash Chander Aggarwal, under sections 11 & 12 of the Act against OPs on the averments that the complainant got himself insured from Star Health and Allied insurance Co. Ltd in the year 2010 and took the mediclaim policy commenced from 23.11.2010. In the year 2013, the officials of OPs contacted the complainant and requested to shift the policy from Star Health and Allied Insurance Company to OPs and accordingly in the year 2013, the complainant shifted his Health Insurance Policy from Star Health Insurance to OPs. It was commenced from 23.11.2013 to 22.11.2014 and it was further renewed from 23.11.2014 to 22.11.2015 and from 23.11.2015 to 22.11.2016. On 16.07.2015, when the complainant felt sick, he remained admitted in Parvati Devi Hospital from 16.07.2015 to 23.07.2015 and spent Rs. 57,517/-. Then the complainant remained admitted Medanta Hospital from 25.07.2015 to 30.07.2015 and he incurred a sum of Rs. 1,82,940/- in Medanta Hospital. The complainant lodged the claim with OPs for a sum of Rs. 57,517/- and then the claim of Rs. 1,82,940/- and provided all the documents First Appeal No. 837 of 2016. 3 required for medical reimbursement. However, the complainant received the rejection letters 29.10.2015 and 02.11.2015 vide which the claim of the complainant was repudiated on account of non- disclosure of material fact that he was suffering from hypertension since 2011. The rejection is arbitrary, illegal and against the principle of law. Accordingly, the complaint was filed before the District Forum seeking directions against OPs to pay the claim of Rs. 2,40,457/- alongwith interest @ 24% per annum, to pay compensation to the tune of Rs. 50,000/- and litigation expenses.
3. The complaint was contested by OP who filed written reply taking preliminary objections that the complainant had concealed the material facts. Before taking the policy, he was suffering from hypertension since 2011. As per clause 6.1 of the policy terms and conditions, for non disclosure of any material particular and material information, the claim is not maintainable. On merits, the averments stated in the preliminary objections were reiterated. Issuance of the policy is a matter of record. It was also reiterated that the claim of the complainant was repudiated on the ground that the complainant failed to disclose before taking the policy that he was suffering from hypertension since 2011. Therefore, the claim was rightly repudiated as per clause 6.1 of the terms and conditions of the policy. The complaint is without merit and it be dismissed.
4. Parties lead evidence in support of their respective versions before the District Forum.
First Appeal No. 837 of 2016. 4
5. In support of his allegations, the complainant tendered in evidence his affidavit as Ex. C-1, Insurance Policy certificate issued by Religare Health Insurance for the year 2013-14, 2014-15, 2015-16 Ex. C-2 to Ex. C-4, Claim rejection letter dated 29.10.2015 Ex. C-5, Claim rejection letter dated 02.11.2015 Ex. C-6, discharge summary of complainant of Parvati Devi Hospital dated 23.07.2015 Ex. C-7, discharge bill dated 23.07.2015 issued by Parvati Devi Hospital Ex. C-8, Medical store bill of complainant dated 23.07.2015 Ex. C-9, receipt of complainant issued by Dhillon Scanning Centre dated 17.07.2015 Ex. C-10, reports of complainant and bill receipts Ex. C- 11, Ex. C-12, Ex. C-13, Discharge summary of complainant of Medanta Mediciti dated 30.07.2015 Ex. C-14, Hospital bills of Medanta Mediciti dated 30.07.2015 Ex. C-15 to Ex. C-21, Medicine bill of Medanta Mediciti Ex. C-22, additional affidavit of the complainant Ex. C-23 and closed the evidence. On the other hand OP tendered in evidence affidavit of Sh. Ramnique Sachar Ex. OP-1, copy of questionnaire Ex. OP-2, copy of computer snap shots Ex. OP-3 to Ex. OP-7, copies of policy Ex. OP-8 to Ex. OP-10, copy of terms and conditions Ex. OP-11, copy of letter dated 16.12.2015 Ex. OP-12, copy of letter dated 28.09.2015 Ex. OP-13, copy of letter dated 29.10.2015 Ex. OP-14, copy of claim form Ex. OP-15, copy of discharge summary Ex. OP-16, copy of letter dated 05.10.2015 Ex. OP-17, copy of claim rejection letter Ex. OP-18, copy of claim form Ex. OP-19, copy of discharge summary Ex. OP-20, copy of prescription dated 05.03.2015 Ex. OP-21, copy of certificate dated 05.03.2015 Ex. OP-22, prescription slip Ex. OP-23, copy of letter First Appeal No. 837 of 2016. 5 dated 26.10.2015 Ex. OP-24, Original letter dated 26.10.2015 Ex. OP-25, affidavit of Dr. Gurpreet Singh Ex. OP-26, copy of investigation report Ex. OP-27, copy of refund detail of cancellation of policy Ex. OP-28 and closed the evidence.
6. After going through the averments made in the complaint, written statement filed by OPs, evidence and documents brought on the record, the District Forum allowed the complaint, as referred above.
7. Aggrieved with the order, the appellant/OP has filed the present appeal.
8. We have heard counsel for the appellant/OP Sh. Sachin Ohri, Advocate and counsel for respondent Sh. Sukhandeep Singh and have carefully gone through the record of the case.
9. It was argued by the counsel for the OP that order passed by the District Forum is against the proceedings, evidence and documents on the record which were not properly appreciated by the District Forum. In the proposal form, a specific question was put up to the insured whether he was suffering from pre-existing disease i.e. hypertension and answer to that question has been given as 'No' and as per clause 6.1 of the policy terms and conditions, in case, the policy was taken on account of mis- representation or non disclosure of any material facts, that ground is sufficient to repudiate the claim.
10. In the proposal form, there is a column which is as under:-
"Have any of the above mentioned person (s) to be insured been diagnosed/hospitalized for any illness/ injury during the last 48 months"First Appeal No. 837 of 2016. 6
to which he has answered as 'No'. But there is no specific column whether the insured was suffering from hypertension as referred by the OP in the grounds of appeal. However, OP mainly relied upon the document Ex. OP-23 i.e. prescription slip in the name of Subhash Chander Aggarwal, whereas full particulars of the patient have not been given to check whether it relates to the complainant and that how the original document come in the possession. Counsel for OP stated that this document was submitted by the complainant alongwith claim. However, during the course of arguments, counsel for OP failed to refer the claim form in which this slip was submitted by the complainant to the OP. Then he stated that it was given by hand, even then it should be recorded in the record of OP. Therefore, counsel for OP is not sticking one stand. No affidavit of Health Care Centre has been filed that this prescription slip was given by them in favour of complainant. There is no investigation report in which the statement of doctor who prescribed this slip was recorded by the investigator of OP, therefore, counsel for OP has failed to connect with this document with that of the complainant.
11. Whether Hypertension is a disease which is required to refer in the proposal form. There is a judgment of Hon'ble National Commission reported as "Satish Chander Madan Vs. Bajaj Allianz General Insurance Co. Ltd", I (2016) CPJ 613 (NC), in which it was observed by the Hon'ble National Commission that Hypertension is a common disease and it can be controlled by medication and it is not necessary that person suffering from hypertension would always First Appeal No. 837 of 2016. 7 suffer a heart attack and repudiation on account of pre-existing disease was not justified. Otherwise discharge summary of Smt. Paarvati Devi Hospital Ex. C-7 in which there is no reference of Hypertension. Discharge summary of Medanta Hospital Ex. C-14, in which there is a reference of Diabetes Mellitus but no reference of Hypertension. Then there is another document i.e. Ex. OP-21 dated 05.03.2015 i.e. after taking the policy in which the B.P. of the complainant is 140/180 which is quite normal at the age of complainant. Therefore, the ground that the complainant was suffering from hypertension is not corroborated on the basis of the evidence on the record. As referred above, the OPs have not been able to prove on the record that the complainant before taking the policy was suffering from any pre-existing disease which was concealed by him at the time of taking the policy. It is also pertinent to mention here that the originally mediclaim policy was taken by the complainant from Star Health and Allied Insurance Co. Ltd. In the year 2010 and he shifted to OPs in the year 2013 on the representation of the representative of OPs. It was a continuous policy. Even if for the sake of arguments, it is taken that in the year 2011 he had some problem of Hypertension, it was after 2010 when the mediclaim policy was taken for the first time by the complainant from Star Health and Allied Insurance Co. Ltd. Therefore, in any circumstances, it is not a pre-existing disease. Therefore, the complaint was rightly allowed by the District Forum. The order passed by the District Forum is affirmed.
First Appeal No. 837 of 2016. 8
12. It is pertinent to mention here that no material information was concealed by the insured at the time of taking the policy. The claim was wrongly repudiate by OP on a frivolous ground for which they did not have any evidence. Despite passing of the order by the District Forum, instead of paying the claim to the complainant, they have filed this frivolous appeal, therefore, the appeal filed by appellant/OP is hereby dismissed with costs of Rs. 10,000/-.
13. Appellant had deposited an amount of Rs. 25,000/- with this Commission at the time of filing the appeal on 04.11.2016. It deposited another amount of Rs. 1,25,000/- in compliance with the order dated 21.12.2016 vide receipt No. 78701 dated 06.01.2017. Both these amounts alongwith interest accrued thereon, if any, be remitted by the registry to the concerned District Forum after the expiry of 90 days of sending the certified copy of the order to the parties. The complainant may approach the District Forum for the release of the above said amounts and the District Forum may pass the appropriate order in this regard.
14. Order be communicated to the parties as per rules.
(Justice Paramjeet Singh Dhaliwal) President (Gurcharan Singh Saran) Judicial Member April 26, 2017 RK First Appeal No. 837 of 2016. 9