State Consumer Disputes Redressal Commission
Religare Health Insurance Company Ltd. vs Sukhwinder Pal Singh on 4 November, 2020
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH.
First Appeal No.174 of 2020
Date of Institution: 16.03.2020
Date of Decision : 04.11.2020
Religare Health Insurance Company Ltd. (registered office), 5th
Floor, 19 Chawla House Nehru Place, New Delhi-110019, through its
Managing Director/Manager/Authorised Representative.
.....Appellant/Opposite Party
Versus
Sukhwinderpal Singh S/o Sumer Singh, R/o Village & Post Office
Noorpur Sethan Tehsil & District Ferozpur-152004.
.....Respondent/Complainant
First Appeal against order dated
09.01.2020 passed by District
Consumer Disputes Redressal Forum
(now 'Commission'), Ferozepur.
Quorum:-
Hon'ble Mr. Justice Paramjeet Singh Dhaliwal, President
1) Whether Reporters of the Newspapers may be allowed to see
the Judgment? Yes/No
2) To be referred to the Reporters or not? Yes/No
3) Whether judgment should be reported in the Digest? Yes/No
Argued By:-
For the appellant : Ms. Niharika Goel, Advocate
For the respondent : Sh. Sahil Khungar, Advocate
..................................................................................
JUSTICE PARAMJEET SINGH DHALIWAL, PRESIDENT
The instant appeal has been filed against the order dated 09.01.2020 passed by District Consumer Disputes Redressal Forum, Ferozepur (now in short the, "District Commission"), whereby the complaint of the complainant under section 12 of the Consumer First Appeal No.174 of 2020 2 Protection Act, 1986 (in short 'C.P. Act')has been allowed against opposite party (in short the 'OP') and following reliefs have been granted:-
"......Therefore, repudiation of the claim of the complainant in such an event is not justified at all. The opposite party admitted that the complainant lodged first claim for Rs.2,66,869/- and second claim for Rs.1,27,228/- for the treatment of his wife and total Rs.3,94,097/-, so the complainant is entitled to the said amount.
12. In view of what has been discussed above, the present complaint is allowed against opposite party with Rs.5000/- as consolidated compensation for mental agony, pain and harassment and the opposite party is directed to pay Rs.3,94,097/- as medi claim to the complainant alongwith interest @8% per annum from filing of present complaint till realization."
It would be apposite to mention that hereinafter the parties will be referred, as have been arrayed before the District Commission. Facts of the Complaint
2. Brief facts, as averred in the complaint, are that Sh. Kulwinder Singh, an agent of the OP approached the complainant at Village Noorpur Sethan and persuaded him to purchase a health insurance policy. On the persuasion of the said agent, the complainant purchased a health insurance policy for sum a assured of Rs.5,00,000/- and paid a premium of Rs.13,252/-. Thereafter, the OP issued a policy no.12788357, plan name Care, Cover Type First Appeal No.174 of 2020 3 Floater, which was valid from 31st July, 2018 to 30th July, 2019. The policy covered the complainant, his wife, son and daughter. It was averred that on 12.12.2018, wife of the complainant namely Smt. Balvir Kaur felt unwell. The complainant got her checked from Anil Baghi Hospital and MRI of brain and MRI contrast study was done. The detailed report was prepared by Dr. Parveen Popli, Radiologist. Thereafter, the complainant brought his wife Smt. Balvir Kaur to NHS (Nasa & Hub Superciality) Hospital, Jalandhar and she was admitted there on 13.12.2018. She was sent to Neurosurgery Department and was admitted in ICU. MRI was done and diagnose as "left parito- occipital convexity meningioma id32.0 and myelitis". In other words, she was detected having with brain tumor. Dr. Naveen Chitkara, M.Ch., Neuro Consultant, advised surgery. The surgery was conducted and Smt. Balvir Kaur was shifted to private ward on 14.12.2018 and was discharged on 16.12.2018. Information of the same was given to the OP and a claim, along with bill worth Rs.2,66,869/-, was submitted to the OP. Again on 23.02.2019, LS Spine MRI of Smt. Balvir Kaur was done and complainant paid a sum of Rs.3,500/- for that. Smt. Balvir Kaur was again admitted on 25.02.2019 for the same purpose and she was again treated. She remained admitted second time from 25.02.2019 till 01.03.2019. The said hospital issued the certificate that as per history Smt. Balvir Kaur had no history of hypertension before admission or at the time of discharge. During this period of treatment, the complainant spent First Appeal No.174 of 2020 4 Rs.1,27,228/-. OP was informed accordingly and claim was lodged, along with relevant documents and bill. However, the claim was wrongly repudiated on 27.05.2019 on the false ground of non- disclosure of hypertension at the time of policy inception, two years waiting period for internal tumors and non-disclosure and second claim was rejected on the ground that benefit not covered under the policy, as main claim has been repudiated. Hence, alleging deficiency in service, negligence and unfair trade practice, the complainant filed consumer complaint before the District Commission seeking following directions:-
(i) to pay Rs.3,94,097/- (being Rs.2,66,869/- for first claim and Rs.1,27,228/- for second claim) being the amount of medi claim bills already submitted to the OP and interest on this amount @ 18% per annum from the date of submitting of the bills till its payment;
(ii) to pay Rs.4,00,000/- as compensation for the harassment, inconvenience, frustration and mental agony suffered by the complainant in the hands of OP; and
(iii) to pay costs of proceedings i.e. Rs.22,000/- as counsel fee.
Defence of the Opposite Party
3. Upon notice, OP appeared and filed written reply raising preliminary objections that complaint is not maintainable in the present form, the complaint is alleged to be false, frivolous and vexatious; the claim of the complainant was processed; the First Appeal No.174 of 2020 5 complainant breached the terms and conditions of the policy and his claim was declined as 'No Claim'. It was further pleaded that there is two years waiting period for treatment of internal tumors, as such the claim was rightly denied and repudiated, vide claim denial letter dated 21.05.2019 on account of non-disclosure of having hypertension since 16 years. On merits, it was averred that complainant himself approached the advisor of the OP to purchase the health insurance policy of OP. He got entire information with regard to the policy in vernacular language and after satisfy with the same only then he paid the premium against the policy to OP and it issued the health insurance policy to complainant as per the provisions of Insurance Law, as applicable within India Territory. The OP received the reimbursement claim on 22.04.2019. As per discharge summary of NHS Hospital, the insured was diagnosed with left parito-occipital convexity meningioma. The insured got treatment for the period from 13.12.2018 till 16.12.2018. The OP sent a query letter dated 25.04.2019 to the complainant and asked him for past treatment records of the insured, but no documents were received. The OP also issued reminder letter dated 05.05.2019 and 15.05.2019 to him. The complainant again filed a reimbursement claim on 22.04.2019 for insured's hospitalization at NHS Hospital Jalandhar from 25.02.2019 till 01.03.2019 along with pre and post hospitalization expenses. The OP again sent query letter dated 24.04.2019 and asked for previous surgery medical record on dated First Appeal No.174 of 2020 6 13.12.2019 with discharge summary, 1st consultation peper, ICP and so on. But no documents were received from complainant. The OP sent reminder letter dated 04.05.2019 and 14.05.2019 to the complainant. The OP received the query reply from the complainant on 16.05.2019. On the basis of documents submitted along with cashless request, query reply and investigation, it came to light that the insured had history of hypertension since 16 years and the same was not disclosed by the complainant at the time of taking the policy. Denying any deficiency in service and unfair trade practice, the OP prayed for dismissal of the complaint.
Evidence of the parties and finding of the District Forum
4. In support of his case, the complainant tendered in evidence his affidavit Ex.C-1 along with documents i.e. policy documents Ex.C-2 (colly), photocopy of Health Insurance Card Ex.C-3, Receipt of Rs.3500/- along with MRI Brain Plain & Contrast report dated 12.12.2018 Ex.C-4 (colly), discharge summary for the period from 13.12.2018 to 16.12.2018 Ex.C-5, copy of rough calculation of amounts Ex.C-6, Copies of bills Ex.C-7 (colly), discharge summary for period from 25.02.2019 to 01.03.2019 Ex.C- 8, treatment record with prescriptions Ex.C-9 (colly), copy of bills C-10 (colly), copy of certificate dated 05.06.2019 Ex.C-11, Copy of deficiency letters dated 25.04.2019 and 24.04.2019 Ex.C-12 (colly), claim denial letter dated 21.05.2019 C-13 (colly), copy of notice dated 25.06.2015 for cancellation of policy-12788357 Ex.C-14. First Appeal No.174 of 2020 7
5. To rebut the aforesaid evidence, OP tendered in evidence affidavit of authorized signatory Shreya Chansoria Ex.OP- 11 along with documents i.e. welcome letter dated 30.07.2018 Ex.OP-1 (colly), proposal form Ex. OP-2 (colly), copy of deficiency letter dated 25.04.2019 Ex.OP-3, copy of reminders 1-2 dated 05.05.2019 and 15.05.2019 Ex.OP-4 (colly), copy of form Ex.OP-5 (colly), copy of deficiency letter dated 24.04.2019 and reminders Ex.OP-6 (colly), copy of claim denial letter dated 21.05.2019 Ex.OP- 7, copy of claim denial letter dated 27.05.2019 Ex.OP-8, copy of initial assessment Ex.OP-9 (colly) and other documents regarding cancellation Ex.OP-10 (colly).
6. The District Commission, after going through the record and hearing learned counsel on their behalf, allowed the complaint of the complainant, vide impugned order. Feeling aggrieved against the order, the present appeal has been filed by the appellant/OP. Contentions of the Parties
7. I have heard learned counsel for the parties and have also gone through the record of the case.
8. Learned counsel for the appellant vehemently argued that firstly the complainant did not disclose the true facts with regard to the health history of the patient i.e. Smt. Balvir Kaur, his wife, who was also insured along with the complainant and his children. The learned counsel further contended that the claim has been repudiated as neither proper information was given nor documents First Appeal No.174 of 2020 8 were supplied. It is a case of misinformation/concealment of facts before getting the insurance policy. For internal diseases the minimum period is two years. The learned counsel for the appellant prayed for acceptance of the appeal and setting aside the order of the District Commission.
9. On the other hand, learned counsel for respondent/complainant submitted that he had already submitted all the documents and he is still ready to submit any other documents for proper verification and medical record of treatment of Smt. Balvir Kaur. Thereafter, the claim should be examined by the appellant/OP and make payment in accordance with law. Learned counsel for respondent prayed for dismissal of the appeal.
Consideration of Contentions
10. I have given our thoughtful consideration to the contentions raised by the learned counsel for the parties and have also gone through the record of the case.
11. The admitted facts of the case are that complainant purchased the health insurance policy in question and got insured himself and his family members. Smt. Balvir Kaur insured got treatment from NHS Hospital, Jalandhar from 13.12.2018 to 16.12.2018, vide discharge summary Ex.C-5. The complainant incurred expenses of Rs.2,66,869/- on her treatment for this period. The complainant submitted the claim to OP. She again felt unwell on 23.02.2019, her LS Spine MRI was done and she again remained First Appeal No.174 of 2020 9 admitted in the above hospital from 25.02.2019 to 01.03.2019. This time the complainant incurred the expenses of Rs.1,27,228/- on the treatment of Smt. Balvir Kaur. The complainant submitted the claim to OP. The complainant pleaded that OP wrongly and illegally repudiated the two claims of the complainant, vide letter dated 27.05.2019 on the ground of non-disclosure of hypertension at the time of policy and inception two years waiting period for internal tumors.. On the other hand, OP pleaded that no documents were received from the complainant and OP sent a reminder dated 04.05.2019 and 14.05.2019 to the complainant. OP received the query reply from the complainant on 16.05.2019. On the basis of documents submitted along with the cashless request, query reply and investigation, it came to the light that the insured had a history of hypertension since 16 years and the same was not disclosed by the complainant at the time of taking the policy. Moreover, there is two years waiting period for treatment of internal tumors. Therefore, the claim of the insured was denied in accordance with policy terms and conditions.
12. The only grievance as put before this Commission by the appellant/OP is that relevant documents were not supplied by the complainant, so the order may be set aside and direction be issued to decide the claim within the stipulated period. The complainant/respondent is ready to supply the relevant documents to the appellant/OP.
First Appeal No.174 of 2020 10
13. I do not intend to go into other merits of the case, as it will prejudice the rights of the parties. However, since the OP has argued that the patient had history of hypertension for 16 years and there is two years period for internal diseases and the respondent/complainant even did not submit the relevant documents to the OP, as a result of which the claim has rightly been denied as per the investigation carried out by the surveyor and TPA. In these circumstances, I deem it appropriate that order can be set aside with a direction to the appellant/OP to decide the claim within two months from the receipt of fresh claim along with all the relevant documents of medical treatment of Smt. Balvir Kaur. The claim form and documents will be submitted by the complainant within 15 days from the date of receipt of copy of this order.
14. In these circumstances, the impugned order is set aside and the complaint of the complainant is dismissed with liberty to the complainant that he will submit the claim form, documents and other relevant records to the Insurance Company within 15 days from the date of receipt of copy of this order. Thereafter, Insurance Company will decide the claim within two months from the date of receipt of documents in accordance with law, as stated above. If the complainant still feel aggrieved against the decision of OP on the claim application, he will always have liberty to file fresh complaint. In view of this, the order of the District Commission is set aside and the present appeal is disposed of.
First Appeal No.174 of 2020 11
15. The appellant had deposited a sum of Rs.25,000/- at the time of filing of the appeal and further deposited the amount of Rs.1,90,096.50 on 03.08.2020 in compliance with interim order of this Commission. These amounts, along with interest which has accrued thereon, if any, shall be remitted by the Registry to the appellant/OP by way of crossed cheque/demand draft after the expiry of limitation period in accordance with law.
(JUSTICE PARAMJEET SINGH DHALIWAL) PRESIDENT November 04, 2020.
(MM)