State Consumer Disputes Redressal Commission
Religare Health Insurance vs Ranjeet Singh on 12 January, 2024
APPEAL NO.260 OF 2021 12.01.2024
RELIGARE HEALTH INS. CO. LTD. & ANR. VS. RANJEET SINGH VERMA
STATE CONSUMER DISPUTES REDRESSAL COMMISSION
HARYANA, PANCHKULA
Date of Institution: 19.10.2021
Date of final hearing: 08.01.2024
Date of Pronouncement: 12.01.2024
APPEAL NO.260 OF 2021
IN THE MATTER OF
1. Religare Health Insurance Co. Ltd. Main HUDA Market, Sector 16,
Faridabad (Haryana) 121002 through its Director/Principal
Officer.
2. Religare Health Insurance Co. Ltd. Corporate Office Vipul Tech
Square Tower-C, 3rd Floor, Sector 43, Golf Course Road, Gurugram-
122009 through its Director/Manager/Principal Officer.
....Appellants/Opposite Parties
Versus
Ranjeet Singh Verma son of Shri Ram Prakash Verma, resident of House
No.10, Block 20, Spring Field Colony, Sector 31, Faridabad.
....Respondent/Complainant
CORAM: HON'BLE MR. JUSTICE T.P.S. MANN, PRESIDENT
MS. MANJULA, MEMBER
Present: Shri Jatin Sehrawat, proxy counsel for Shri P.M. Goyal,
counsel for the appellants.
Shri Ashish Jhamb, counsel for the respondent.
PER: T.P.S. MANN, J.
ORDER
1. The present appeal has been preferred by the opposite parties i.e. Religare Health Insurance Company Limited (insurance company) for challenging the order dated 01.09.2021 passed by the District Consumer Disputes Redressal Commission, Faridabad, whereby Page 1 of 6 APPEAL NO.260 OF 2021 12.01.2024 RELIGARE HEALTH INS. CO. LTD. & ANR. VS. RANJEET SINGH VERMA complaint preferred by complainant Ranjeet Singh Verma was allowed and insurance company directed to process his claim within 30 days from the date of receipt of copy of the order and pay the due amount to the complainant along with interest @ 6% per annum from the date of filing of complaint till its realization. It was also directed to pay compensation of Rs.1,100/- on account of mental tension, agony and harassment besides Rs.1,100/- as litigation expenses to the complainant.
2. The facts of the complaint are that the complainant purchased a comprehensive health insurance policy (Annexure A2) valid from 27.07.2018 to 26.07.2019 from the insurance company. The complainant being a policyholder, his wife and three children were insured under the policy. The sum insured was Rs.5,00,000/-. Premium payment mode under the policy was single. On 19.03.2019, the complainant felt chest pain and was admitted in Asian Hospital & Research Centre, Badkhal Flyover, Faridabad. Coronary angiography procedure of the complainant was done on 19.03.2019. The complainant remained under treatment from 19.03.2019 to 21.03.2019. Intimation in this regard was given to the insurance company. The complainant sent a request for cashless hospitalization to the insurance company but it denied the claim of the complainant vide letter dated 21.03.2019 on the ground of non- disclosure of material facts/pre-existing ailment at the time of proposal. Hence, the complaint.
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APPEAL NO.260 OF 2021 12.01.2024 RELIGARE HEALTH INS. CO. LTD. & ANR. VS. RANJEET SINGH VERMA
3. Upon notice, the insurance company appeared and filed its written version alleging therein that the complainant did not disclose about the pre-existing case history of seizure at the time of obtaining the policy. In accordance with Clause 7.1 of the terms and conditions of the policy, the complainant was bound to disclose his correct health history to the insurance company at the time of inception of policy but the complainant did not do so and violated the terms and conditions of the policy. Prayer for dismissal of the complaint was made.
4. The parties to the lis led their respective evidence to support their pleas.
5. After hearing counsel for the parties and on going through the record, the District Consumer Commission passed the order as mentioned above.
6. Aggrieved of the impugned order, the insurance company filed the instant appeal.
7. The State Commission has heard counsel for the parties and perused the record, which stands requisitioned.
8. Indisputably, the complainant had obtained the policy in question from the insurance company. It is also not in dispute that during the subsistence of the policy, the complainant remained under treatment in the hospital from 19.03.2019 to 21.03.2019. The claim filed by the complainant was repudiated on the ground of non-disclosure of material facts/pre-existing ailment at the time of proposal. The insurance company is stressing upon the questionnaire filled by the Page 3 of 6 APPEAL NO.260 OF 2021 12.01.2024 RELIGARE HEALTH INS. CO. LTD. & ANR. VS. RANJEET SINGH VERMA complainant's father in claim form that the complainant had history of seizure 27 years ago but the insurance company failed to produce any such medical record. However, in discharge summary, the treating doctor mentioned that there was no past history of HT, DM, CAD, COPD or any chronic illness of the complainant. Merely proceeding on questionnaire filled by the complainant's father is no ground to presume that the complainant was having any pre-existing disease. Further, the insurance company did not produce any evidence with regard that seizure is a critical or life threatened disease. Further, the insurance company did not enquire that the complainant was having any pre-existing disease prior to obtaining the policy.
9. In the instant case, the questionnaire filled by the complainant's father in claim form (Annexure A-6) placed on record by the insurance company cannot be termed as authenticated document to prove its version. Onus was upon the insurance company to prove that the complainant had suffered from pre-existing disease. Reliance can also be placed on the observation made by Hon'ble National Commission in Tarlok Chand Khanna vs. United India Insurance Company Ltd. I(2012) CPJ 84 (NC), wherein it has been held that:-
"The onus to prove that the Petitioner was suffering from a pre-existing disease as per settled law is on the respondent. We note that the respondent has not produced any credible documentary evidence/expert medical opinion in support of its case............"Page 4 of 6
APPEAL NO.260 OF 2021 12.01.2024 RELIGARE HEALTH INS. CO. LTD. & ANR. VS. RANJEET SINGH VERMA
10. Counsel for the appellants has placed reliance on judgment passed by the Hon'ble Supreme Court in Reliance Life Insurance Co. Ltd. & Anr. Versus Rekhaben Nareshbhai Rathod, Civil Appeal No.4261 of 2019, decided on 24.04.2019. However, the said judgment is not applicable to the facts and circumstances of the present case because in Rekhaben's (supra) case the insured did not disclose about the previous policy whereas in the present case there was no suppression of any type.
11. As a sequel to the aforesaid discussion, it has not been established by the insurance company that the complainant had any pre-existing disease which would justify repudiation of the claim. The order under challenge does not require any interference. Thus, the appeal fails and is hereby dismissed.
12. Application(s) pending, if any, stand disposed of in terms of the aforesaid order.
13. The statutory amount of Rs.85,410/- deposited by the appellants at the time of filing the appeal be released in favour of the complainant against proper receipt and identification but in accordance with law. The State Commission vide order dated 23.02.2022 directed the appellants to deposit half of the awarded amount with the District Consumer Commission and in the event of depositing the same, the amount was to be kept in the shape of FDR by the District Consumer Commission with a nationalized bank. The District Consumer Page 5 of 6 APPEAL NO.260 OF 2021 12.01.2024 RELIGARE HEALTH INS. CO. LTD. & ANR. VS. RANJEET SINGH VERMA Commission is now directed to release the amount of FDR, if any, in favour of the complainant against proper receipt.
14. A copy of this order be provided to all the parties free of cost as mandated by the law. The order be uploaded forthwith on the website of the Commission for the perusal of the parties.
15. File be consigned to record room along with a copy of this order.
(T.P.S. MANN) PRESIDENT (MANJULA) MEMBER Pronounced On: 12.01.2024 DR Page 6 of 6