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. 836 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 First Appeal No. 836 of 2016. 2 order dated 15.09.2016 in C.C. No. 67 of 16.02.2016 passed by the learned District Consumer Disputes Redressal Forum, Amritsar (in short the 'District Forum') vide which the complaint filed by the respondent/complainant (hereinafter referred as 'complainant') was allowed with the directions to OPs to reimburse the medical amount of Rs. 86,689/- incurred 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 medical 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 feel ill, 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 First Appeal No. 836 of 2016. 3 complainant lodged the claim with OPs for a sum of Rs. 57,517/-. Then the complainant again filed a separate claim of Rs. 1,82,940/- for reimbursement of expenditure incurred at Medanta Hospital and provided all the medical record and bills. However, the OPs repudiated the claim for which the complaint is already pending before the District Forum. The complainant was then diagnosed as the patient of Cancer which is also duly covered under policy. Doctor recommended Chemotherapy. The complainant started getting Chemotherapy and due intimation was given to OPs on 27.11.2015 and claim number 15111089393 was given and during the treatment of Cancer on 18.12.2015, the complainant informed the OPs and claim No. 15121131742 was given for registration of the claim. Then the complainant received the letter dated 16.12.2015 from the OPs and explanation was sought regarding the pre-existing ailment stating that the complainant was suffering from Hypertension since 2011. The reply to the said letter was given on 08.01.2016 in which it was submitted that the complainant never suffered from Hypertension. Even medical record shows no Hypertension. However, the complainant received letter dated 20.01.2016 showing cancellation of the policy and refund. OPs had no right to cancel the policy, once they accepted it on false and frivolous ground. Alleging deficiency in service on the part of OPs, the complaint was filed before the District Forum seeking directions against OPs to reimburse the amount of Rs. 86,689/- incurred on the treatment till the filing of the complaint, to pay compensation to the tune of Rs. 50,000/- and litigation expenses.
First Appeal No. 836 of 2016. 4
3. The complaint was contested by OPs who filed written reply taking preliminary objections that the complainant had concealed the material facts and before taking the policy, he was suffering from hypertension since 2011 and that as per clause 6.1 of the policy terms and conditions, for non disclosure of any material particular and material information, the claim was not maintainable. On merits, it was admitted that the complainant was getting the policy from OPs and lastly the policy was got renewed from 23.11.2015 to 22.11.2016 and same has been cancelled according to clause 6.1 and 6.13 of the policy terms and conditions and cancellation letter was sent to the complainant 15 days prior to the cancellation and in the absence of any sufficient reply, the policy was cancelled. The matter was investigated by the investigator of OPs and he found that the complainant was suffering from pre-existing disease of Hypertension since 2011 and this fact was concealed by the complainant at the time of taking the policy. Therefore, the policy was rightly cancelled by OPs. No deficiency in service on the part of Ops. The claim was not payable and was rightly repudiated by OPs. The complaint is without merit and it be dismissed.
4. Parties lead evidence in support of their respective versions before the District Forum.
5. In support of his allegations, the complainant tendered in evidence his affidavit as Ex. C-1, copy of query letter dated 16.12.2015 Ex. C-2, copy of postal receipt of reply of query letter Ex. C-3, copy of reply letter of query Ex. C-4, copy of policy cancellation refund letter Ex. C-5, copies of medicine bills Ex. C-6 to Ex. C-14, First Appeal No. 836 of 2016. 5 copy of blood test bill dated 24.11.2015 Ex. C-15 & Ex. C-16, copies of medicine bills Ex. C-17 to Ex. C-19, copy of Sukh Sagar Hospital bill of Chemotherapy dated 27.11.2015, 19.12.2015, 08.01.2016 Ex. C-20 to Ex. C-22, copies of medicine bills Ex. C-23 to Ex. C-25, copy of Sukh Sagar Hospital bill of Chemotherapy dated 29.01.2016 Ex. C-26, copy of receipt of Dhillon Scanning Centre dated 29.01.2016 for Rs. 5000/- Ex. C-27, copy of Sukh Sagar Hospital Bill of Chemotherapy dated 06.11.2015 Ex. C-28, copy of premium receiving letter for the year 23.11.2013 to 22.11.2014 Ex. C-229, copy of list of covered disease under the policy Ex. C-30, additional affidavit of the complainant Ex. C-31, copy of bill dated 19.02.2016 bearing invoice No. 3511 Ex. C-32, copy of bill dated 19.02.2016 issued by Sukh Sagar Hospital bearing No. BS-7291 Ex. C-34, copy of bill dated 05.04.2016 bearing invoice No. 3502 Ex. C-35, copy of bill dated 05.04.2014 bearing invoice No. 3703 Ex. C-36, copy of bill dated 05.04.2016 bearing invoice No. 3704 Ex. C-37, copy of bill of Sukh Sagar Hospital bearing No. BS-8066 Ex. C-38, copy of bill dated 26.04.2016 bearing invoice NO. 3781 Ex. C-39, copy of bill dated 26.04.2016 bearing invoice No. 3782 Ex. C-40, copy of bill dated 26.04.2016 bearing invoice No. 3783 Ex. C-41, copy of bill issued by Sukh Sagar Hospital dated 26.04.2016 bearing invoice No. BS-8066 Ex. C-42, copies of the complainant for the year 2013-14, 2014-15 and 2015-16 Ex. C-43 to Ex. C-45 and closed the evidence on behalf of the complainant. On the other hand OP tendered in evidence affidavit of Sh. Sahil Chadha Ex. OP-1, copy of questionnaires Ex. OP-2, copy of computer snap shots Ex. OP3 to First Appeal No. 836 of 2016. 6 Ex. OP7, copies of policy Ex. OP8 to OP10, copy of terms and conditions Ex. OP11, copy of letter dated 16.12.2015 Ex. OP12, copy of letter dated. 28.09.2015 Ex. OP13, copy of letter dated 29.10.2015 Ex. OP-14, copy of claim form Ex. OP15, copy of discharge summary Ex. OP16, copy of letter dt. 05.10.2015 Ex. OP17, copy of claim rejection letter Ex. OP18, copy of claim form Ex. OP19, copy of discharge summary Ex. OP20, copy of prescription dated 05.03.2015 Ex. OP21, copy of certificate dated 05.03.2015 Ex. OP22, copy of prescription slip Ex. OP23, copy of letter dt. 26.10.2015 Ex. OP24, copy of letter dated 26.10.2015 Ex. C-25, affidavit of Dr. Gurpreet Singh Ex. OP26, copy of investigation report Ex. OP27, copy of detail of refund of cancellation of policy Ex. OP28 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 pleadings, 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 First Appeal No. 836 of 2016. 7 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. 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"
to which he has referred 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 have not been given whether it relates to the complainant. The original document has been tendered in the complaint No. 692 of 2015 and it has not been explained how the original documents had come in the custody of the OPs. 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 document was submitted by the complainant to the OP. Then he stated that it was given by hand, 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 complaint. There is no investigation report in which the statement of doctor who prescribed this slip was recorded by the investigator of OP, First Appeal No. 836 of 2016. 8 therefore, counsel for OP has failed to connect this document with that of the complainant.
10. Whether Hypertension is a disease which is required to be referred 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 suffer a heart attack and repudiation on account of pre-existing disease was not justified. Otherwise in the 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 referred 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.
11. We have perused the terms and conditions of the policy. Clause 6.1 and 6.13 of the policy terms and conditions are read as under:-
6.1 Disclosure to Information Norm:-
If any untrue or incorrect statements are made or there has been a misrepresentation, mis-description or non-disclosure of any material particulars or any material information having First Appeal No. 836 of 2016. 9 been withheld or if a claim is fraudulently made or any fraudulent means or devices are used by the Policyholder or the Insured Person or any one acting on his/their behalf, the Company shall have no liability to make payment of any claims and the premium paid shall be forfeited to the Company.
6.13 Cancellation/Termination a. The company may at any time, cancel this Policy on grounds as specified in Clause 6.1 by giving 15 days' notice in writing by Registered Post Acknowledgment Due/recorded delivery to the Policyholder at his last known address.
b. The Policyholder may also give 15 days' notice in writing to the Company for the cancellation of this Policy, in which, case the Company shall from the date of receipt of the notice, cancel the policy and refund the premium for the unexpired period of this policy at the short period scales as mentioned below, provided no Claim has been made under the policy.
c. Refund % to be applied on premium received.
Cancellation date up 1 Year 2 Year 3 Year
to (x months) from
Policy Period Start
Date
Upto 1 month 75.0% 87.0% 91.0%
Upto 3 months 50.0% 74.0% 82.0%
Upto 6 month 25.0% 61.5% 73.5%
Upto 12 months 0.0% 48.5% 64.5%
Upto 15 months N.A. 24.5% 47.0%
Upto 18 months N.A. 12.0% 38.5%
Upto 24 months N.A. 0.0% 30.0%
Upto 30 months N.A. N.A. 8.0%
Beyond 30 months N.A. N.A. 0.0%
d. In case of demise of the Policyholder,
i) Where the Policy covers only the Policyholder, this Policy
shall stand null and void from the date and time of demise of the Policyholder.
First Appeal No. 836 of 2016. 10
ii) Where the Policy covers other insured Members, this Policy shall continue till the end of Policy Period. If the other insured Persons wish to continue with the same Policy, the Company will renew the Policy subject to the appointment of a Policyholder provided that:-
I. Written notice in this regard is given to the Company before the Policy Period End Date; and II. A person over Age 18 who satisfies the Company's criteria to become a Policyholder.
12. According to clause 6.1, in case, the complainant concealed the true facts, then the company reserved the right to repudiate the claim and forfeited the premium, whereas clause 6.13 deals with the free look period that after came to know the material concealment, policy can be cancelled within 15 days. 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 continuous policy. Even if for the sake of arguments 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 and then shifted to OPs. Therefore, in any circumstance, it is not a pre-existing disease.
13. It is pertinent to mention here that no material information was concealed by the insured at the time of taking the policy. The First Appeal No. 836 of 2016. 11 claim was wrongly repudiated 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/-.
14. 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. 50,000/- in compliance with the order dated 21.12.2016 vide receipt No. 78500 dated 06.01.2017. Both these amounts alongwith interest accrued thereon, if any, be remitted by the registry to respondent/complainant by way of a crossed cheque/demand draft after the expiry of 90 days of sending the certified copy of the order to the parties, subject to stay, if any, by the higher Fora/Court. Remaining amount, if any, be paid within 30 days from the date of receipt of copy of the order.
15. 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. 836 of 2016. 12