State Consumer Disputes Redressal Commission
Krishan Lal vs Religare Health Insurance Company on 7 November, 2024
STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
PUNJAB, CHANDIGARH
First Appeal No.202 of 2022
Date of institution : 17.03.2022
Date of Reserve : 18.10.2024
Date of Decision : 07.11.2024
Krishan Lal son of Shri Shanker Dass, resident of House No.128,
Aman Nagar, P.O. Area, Jalandhar City, Punjab-144 001.
.......Appellant/Complainant
Versus
Religare Health Insurance Company Limited through its Managing
Director/Incharge, Corporate Office: Vipul Tech Square, Tower C, 3rd
Floor, Sector 43, Golf Course Road, Gurgaon-122009.
.......Respondent/Opposite Party
First Appeal under Section 41 of the
Consumer Protection Act, 2019
against the Order dated 20.12.2021
passed by the District Consumer
Disputes Redressal Commission,
Jalandhar in CC No.39 of 2018.
Quorum:-
Hon'ble Mrs. Justice Daya Chaudhary, President
Ms. Simarjot Kaur, Member
Mr. Vishav Kant Garg, Member
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 Present :-
For the appellant : Sh.P.K.Kukreja, Advocate
For the respondent : Ms.Niharika Goel, Adv. for
Sh.P.M.Goyal, Advocate
SIMARJOT KAUR, MEMBER
This Appeal has been filed by the Appellant/Complainant under Section 41 of the Consumer Protection Act, 2019 (in short 'The Act') being aggrieved by the impugned Order dated 20.12.2021 passed by the District Consumer Disputes Redressal F.A.No.202 of 2022 2 Commission, Jalandhar (in short 'the District Commission') whereby the Complaint of the Complainant had been dismissed.
2. It would be apposite to mention that hereinafter the parties will be referred, as had been arrayed before the District Commission.
3. Briefly, the facts of the case as made out by the Complainant before the District Commission are that The Complainant had obtained Health/Illness Risk Cover Insurance Policy from the OP. He was got medically examined by the doctor of Kapil Hospital, Jalandhar in the month of January, 2017. After the medical examination, he was insured by the OP w.e.f. 29.01.2017. He was further medically examined before obtaining another Insurance Policy by the Doctors of Kapil Hospital, Jalandhar. A copy of the previous report of medical examination record was retained by the OP and he was not supplied the same. The record of second medical examination was in the possession of the Complainant and the same has been annexed with the Complaint. He had paid the renewal premium for the said Insurance @ Rs.38,152/- to the OP. The renewed insurance policy was valid w.e.f. 02.02.2017 to 01.02.2018 (valid for 12 months period). Said policy was again got renewed. The OP had assured to cover the benefit of life, medical, health, accident etc. of the complainant during the subsistence of insurance period by paying lump-sum insurance benefit. The OP had issued Renewal Policy Certificate bearing No.10524756 in the name of the Complainant. The OP had not supplied the terms and conditions/particulars/schedule of critical illness of any of the Insurance Policy. The Insurance Certificate indicated that the said policy was issued to the Complainant by F.A.No.202 of 2022 3 covering the health illness insurance but no terms and conditions were supplied/given by the OP. In the month of June, 2017, the Complainant had suffered with chest pain and slurred speech. He immediately rushed to Tagore Hospital and Heart Care Centre, Jalandhar on 30.06.2017. He was admitted in the said hospital vide admission No.72845 in emergency. A number of tests were conducted upon him i.e. blood sugar, lipid profile etc. under the medical advice for diagnosing his disease/ailment. After examination of the doctors in the said hospital the attending Dr. Ashwani Suri, got conducted more investigations i.e. ECHO report, CAD (N) Size with DISTAL IVS and Apex Akinetic, Moderate LV Systolic Dysfunction, LVEF, CONCERTRIC LVH, DIASTOLIC DSYFUNCTION (N), NUKD MR/TR, MRI Brain etc. A 2D Colour Doppler test was also conducted. After that the team of the doctors had carried out various tests upon him, it was concluded that he was suffering from the diseases i.e. Moderate LV Systolic Dysfunction, CAD, Normal size LV with distal IVS and apex akinetic, Global LVEF is 40%, Concentric LV Hypertrophy, Grade 1 diastolic dysfunction, Milt Mitral Regurgitation, Mild Tricuspid Regurgitation, No AS/AR, No intracardial Clot/Vegetation/Pericardial Effusion. As per medical advice of Dr. Rajesh Verma, M. D. of the said hospital and Heart Care Centre Pvt. Limited, Jalandhar the Department of Radiology and Imaging Investigation report was prepared. Attending doctor had opined problems i.e. Changes of mild diffuse cerebal atrophy, No gross brain parenchymal lesion. Dr.G.S.Bholla and Dr.Ritika Joshi gave radiological report. ECG was also conducted at the said hospital. The Complainant was discharged from the hospital on 04.07.2017. Discharge summary dated 04.07.2017 was issued by F.A.No.202 of 2022 4 the Dr.Nipun Mahajan, Senior Cardiologist and Interventionist and Dr.Rajnikant Shastry, Consultant Noninvasive Cardiology of Tagore Hospital & Hear Care Center (P) Ltd.
4. It was also mentioned in the Complaint that critical illness of the Complainant was covered under the Insurance contract issued by the OP. Accordingly, he had lodged claim relating to his medical problem with the OP. However, the OP had repudiated the claim vide letter dated 18.11.2017 on the ground that he had not disclosed material fact of old myocardial infarction, anterior wall and hypertension. As per the OP, he had suffered from Old Myocardial Infarction and the said diseases were not covered under the policy issued to him. The fact of critical illness, health of the Complainant etc. were ignored by the OP. The OP had wrongly referred to the terms and conditions of the policy in the repudiation letter whereas no terms and conditions were supplied to him. The OP had wrongly interpreted the alleged contention to escape from their liability arising out of the Insurance Policy. It was reiterated in the Complaint that the Complainant had no medical history of Anterior Wall Myocardial Infarction and hypertension. In fact the said ailment/disease came to his knowledge during the period of Insurance Policy. The OP had wrongly repudiated his genuine Insurance Claim, due to the said act he had suffered financial loss and mental agony. Hence, the Complaint filed by the Complainant by seeking directions to be issued to the OP to pay Rs.10,00,000/- with consequential payments with interest @ 18% p.a. from 01.03.2017 onwards till actual date of realization and to pay Rs.5,00,000/- as compensation. Further, to pay Rs.44,000/- as litigation expenses.
F.A.No.202 of 20225
5. Upon issuance of notice, OP had appeared and filed its written reply by raising certain preliminary objections that the Complainant had concealed the material facts. Therefore, he was not entitled to any claim sought in the Complaint. As per the documents provided by the Complainant he had undergone treatment for CAD, old anterior wall myocardial infarction, LV Dysfunction. On the perusal of said documents and investigation of the claim it was found that it had a history of Anterior Wall Myocardial Infarction and hypertension prior to the inception of the current policy. It was further alleged that he had violated the terms and conditions of the policy. The claim was rejected under Clause 6.1 of the policy terms and conditions for non-disclosure of material facts/pre-existing ailment. He had not approached the District Commission with clean hands as he had suppressed the material facts from the Commission which were necessary for the adjudication of the Complaint. The Complaint was filed without any cause of action against the OP, therefore it was liable to be dismissed. On merits, it was admitted that the Complainant had purchased the Health Insurance Policy. The other allegations as made in the complaint were categorically denied. The Complaint was liable to be dismissed as it was devoid of merits.
6. By considering the averments made in the Complaint as well as in the reply thereof, the Complaint filed by the Complainant was dismissed vide order dated 20.12.2021 passed by the District Commission. The relevant part of said order is reproduced as under:-
F.A.No.202 of 20226
"11. In view of the above detailed discussion, the complaint of is dismissed with no order of costs. Parties will bear their own costs. This complaint could not be decided within stipulated time frame due to rush of work."
7. The Appellant/Complainant has filed the present Appeal being aggrieved by the order dated 20.12.2021 passed by the District Commission by raising a number of arguments.
8. Mr.P.K.Kukreja, Advocate, learned Counsel for the Appellant has submitted that the District Commission had wrongly passed the Impugned Order. It has been argued that the observation made by the District Commission in the said order that the claimed amount of Rs.10 lac had no nexus with the treatment because the Appellant/Complainant had refused to avail treatment suggested by the doctor was without any basis. The expenses incurred on the treatment had been borne by the Complainant from his pocket. He has relied upon two judgments of Hon'ble National Commission i.e. 1) LIC of India Vs. Mohinder Kaur, RP No.1903 of 1999, decided on 18.02.2003, 2) Gurram Varalakshmi Vs. LIC of India, RP No.637 of 2003, decided on 14.02.2005, in support of his arguments.
9. Ms.Niharika Goel, Advocate, learned proxy Counsel for the Respondent/OP has argued on the similar lines as per the written reply filed before the District Commission. Learned Counsel has submitted that there was ample proof that the Complainant was suffering from pre-existing disease of old Anterior Wall Myocardial Infarction since 2.5 years which was prior to the inception of the policy. Same can be verified from the documents i.e. statement given by F.A.No.202 of 2022 7 Dr.Sejsni dated 31.07.2017, Discharge Summary, Medical History, Physical Examination Form dated 30.06.2017 and OPD slip dated 24.07.2017 of the Tagore Hospital & Heart Care Centre, Jalandhar. The Appellant/Complainant had concealed material facts regarding his pre-existing medical condition just to get unlawful monetary gains. The Respondent/OP had rejected the claim vide letter dated 18.11.2017, under Clause 6.1 of the Policy Terms and Conditions for non- disclosure of material information.
10. Learned Counsel has further submitted that the Appellant/Complainant himself had admitted that he was issued policy (Ex.C-3, C-4), which included policy Certificate a specific note has been mentioned "Note: Attached with this policy certificate are the policy terms and conditions. Add on benefits (if opted) and Annexures. Please ensure that these documents have been received, read and understood if any of these documents have not been received please email at customerfirst@religarehealthinsurance .com or contact the company at 1800-200-4488. This policy certificate in original must be surrendered to the company in case cancellation of policy. Summary of matters that are state in the Policy Terms and Conditions to Comply Regulations 7 of protection of Policyholders interest 2002 and copy of the Key Policy Information are also enclosed herewith."
11. Further, learned Counsel has submitted that the copy of Terms and Conditions was attached with the said policy Certificate. In case the Appellant/Complainant had not received the same he could F.A.No.202 of 2022 8 have immediately approached the Insurance Company as per the aforesaid disclaimer note. Further, the learned Counsel has submitted that the Appellant/Complainant had not proved his major contention that the policy in question was only for critical illness purpose and not a general health insurance policy.
12. Besides to lodge an Insurance Claim it is necessary for the Complainant/insured to provide bills or any other related document wherein the details of the expenses made by him during the diagnosis as well as treatment are reflected. Learned Counsel has also submitted that the Appellant/Complainant has also admitted the fact that he had not undergone any interventional medical treatment or surgery during the period of his hospitalization. He had only been diagnosed with certain medical conditions and after that he had filed for Medical Insurance Claim. The same had been repudiated by Respondent/OP.
13. Learned Counsel has further submitted that the Appellant/Complainant himself had mentioned in the Complaint that the disease suffering by him was covered under critical illness if he had not received terms and conditions of the policy how could he referred to critical illness which is mentioned itself in terms and conditions of the policy. The relevant Clause No.2.1 (e) (iii) of policy wherein Myocardial Infarction (disease suffered by the Complainant) has been defined as under:
"(e) for the purpose of this benefit covered medical events means occurrence of any of the following events for as more specifically described below only for the first time during the lifetime of the insured person."F.A.No.202 of 2022 9
Furthermore, it was submitted that as per the said clause the illness reported by the Appellant/Complainant had to be only for the first time during his lifetime. Whereas in the present case it has been clearly mentioned that the Appellant/Complainant was suffering from AWMI for the past 2.5 years. He had been taking regular treatment for the same. In addition to it he was suffering from hypersensitive as well for the last 1.5 years and was under a regular treatment (Ex.OP-3) as stated by the treating doctor. The said statement has never been denied by the Appellant/Complainant in the Appeal. Learned Counsel has also submitted that the District Commission had rightly passed the order that the Complainant had failed to provide any documents with regard to the amount spent and had rightly dismissed the Complaint.
14. We have heard the oral arguments raised by learned Counsel for the parties. We have also perused the order dated 20.12.2021 as well as all the relevant documents available on the file.
15. Facts relating to the filing of the Complaint by the Complainant before the District Commission, reply thereof, the oral arguments raised by learned counsel for the parties and passing of impugned order dated 20.12.2021 by the District Commission, thereafter filing of present appeal before this Commission by the Appellant/Complainant are not in dispute.
16. The issue for adjudication before us is as to whether the District Commission has rightly passed the impugned order while dismissing the Complaint of the Complainant?
F.A.No.202 of 202210
17. List of documents tendered by the parties before the District Commission.
I. Ex.CA affidavit of the Complainant II. Ex.C-1 Medical Certificate III. Ex.C-2 Premium Acknowledgment Rs.38,152.00 IV. Ex.C-3 Policy Certificate V. Ex.C-4 Renewal Letter VI. Ex.C-5 Discharge Summary VII. Ex.C-6 advice on discharge diet/activity/precautions VIII. Ex.C-7, C-8 2D Colour Doppler Report IX. Ex.C-9, C-10 CT Scan Report X. Ex.C-11 ECG Report XI. Ex.C-12 Repudiation Letter XII. Ex.C-13 Medical Treatment Record (colly) XIII. Ex.C-14 History and Physical Examination Form (colly) XIV. Ex.OP-1 Policy Certificate/Premium Acknowledgment Receipt/ Renewal of Policy/terms and conditions (colly) XV. Ex.OP-2 Claim Form XVI. Ex.OP-3 details of diseases suffered by the Complainant XVII. Ex.OP-4 Discharge Summary XVIII. Ex.OP-5 History of present illness XIX. Ex.OP-6 Medical prescription XX. Ex.OP-7 Repudiation letter dated 18.11.2017 XXI. Ex.OP-8 Proposal Form XXII. Ex.OP-9 Medical Examination Form/Confirmation of Medical Examination (colly) XXIII. Ex.OP-10 judgments (colly)
18. A thorough perusal of aforesaid documents clearly shows that Appellant/Complainant was insured for sum of Rs.10 lac with Respondent/OP (Ex.OP-1) for Health Insurance. He was admitted in the hospital on 30.06.2017 and was discharged on 04.07.2017 (Ex.OP-
2). During his admission in Tagore Hospital and Heart Care Centre Pvt. F.A.No.202 of 2022 11 Ltd. Jalandhar, he was diagnosed with CAD i.e. a condition of heart and thrombotic stroke i.e. medical condition caused by a thrombus (blood clot) that develops in the arteries supplying blood to the brain.
19. It has clearly been mentioned in Ex.OP-3, Ex.OP-4 that he was suffering from Anterior Wall Myocardial Infarction (AWMI) for the last 2.5 years and had taken treatment for the same. It has clearly been established from the discharge summary (Ex.OP-4) that he had undergone certain medical tests at Tagore Hospital, Jalandhar and had been discharged thereafter. The Appellant/Complainant had not undergone any invasive treatment i.e. surgery/medical procedure during the period he remained admitted in the hospital. He had lodged his Claim No.90366886-00 with the Respondent/OP. His claim was repudiated due to non-disclosure of material facts regarding old Myocardial Infarction-Anterior Wall and Hypertension. The Appellant/Complainant had not disclosed these medical problems in his proposal Form (Ex.OP-8). Therefore, the repudiation of the claim by the Respondent/OP was justified.
20. We have also perused condition No.2.1 (e) (iii) with regard to the benefits offered to the insured where in under the caption of Benefit I: Critical illness, Medical Events and Surgical Procedures has been defined as :
2.1 Benefit I : Critical Illness, Medical Events and Surgical Procedures
(e) For the purpose of this Benefit Covered Medical Events means occurrence of any of the following Medical Events as F.A.No.202 of 2022 12 more specifically described below only, for the first time during the lifetime of the Insured Person:
XXXXXX (III) MYOCARDIAL INFARCTION The first occurrence of myocardial infarction which means death of a portion of heart muscle as a result of inadequate blood supply to the relevant area. The diagnosis for this will be evidenced by all of the following criteria: A) History of typical clinical symptoms consistent with the diagnosis of Acute Myocardial Infarction (for e.g. Typical Chest pain) B) New characteristic electrocardiogram changes C) Elevation of infarction specific enzymes, Troponins or other specific biochemical markers.
Meaning thereby that the Appellant/Complainant was eligible for Insurance Claim if the said medical condition had manifested for the first time. However, as per discussion in the preceding paras it has been clearly established he was suffering from the disease/ailment for the last 2.5 years. The said fact has been substantiated by Ex.OP- 3/Ex.C-5/Ex.C-14 (page 2) wherein it has clearly been mentioned that the medical condition of the Complainant was a case of Old Anterior Wall Myocardial Infarction.
21. With regard to the issue of supply of Terms and Conditions of the Insurance Policy by the Respondent/OP, we have perused Ex.C- 2, C-3 and C-4. Ex.C-2 is the acknowledgment receipt wherein it is clearly mentioned "In case of any discrepancy, the policy holder is requested to contact the company immediately." Furthermore, document Ex.C-4 is the Renewal letter for policy number 1052476, wherein it has clearly been mentioned that Policy Certificate, Premium F.A.No.202 of 2022 13 Acknowledgment have been annexed with it. It has also been mentioned in the said document that "Renewal of this policy does not change or alter policy terms and conditions of "care"." In the Policy Certificate there is a note which reads as under :-
"Note: Attached with this policy certificate are the policy terms and conditions. Add on benefits (if opted) and Annexures. Please ensure that these documents have been received, read and understood if any of these documents have not been received please email at customerfirst@religarehealthinsurance .com or contact the company at 1800-200-4488. This policy certificate in original must be surrendered to the company in case cancellation of policy. Summary of matters that are state in the Policy Terms and Conditions to Comply Regulations 7 of protection of Policyholders interest 2002 and copy of the Key Policy Information are also enclosed herewith."
All these aforesaid references/documents clearly prove that Terms and Conditions of the Policy were supplied to the Appellant/Complainant. In case he did not receive the same he was to contact/email to the Respondent/OP at customerfirst@religarehealthinsurance .com or contact the company at 1800-200-4488. Moreover, the said policy had been renewed. It is not worth believing that the Appellant/Complainant had neither received the terms and conditions at the time of inception of policy nor during the renewal of the same. In case he was not supplied with the terms and conditions of the policy, he could have demanded for the same as per the aforesaid discussion. Therefore, it is concluded that the contention of learned Counsel for the Appellant/Complainant regarding non-supply of terms and conditions is not correct and the same is hereby rejected. F.A.No.202 of 2022 14
22. It has also been further observed by us that the Complainant has not annexed any bills related to medical expenses incurred by him during the course of his hospitalization. In absence of any such details the Respondent/OP could not have processed his medical claim to the tune of Rs.10 lac lodged by him. Therefore, the contention of the Appellant/complainant that his claim was wrongly repudiated by the Respondent/OP is not justified as he himself had failed to annex any bills/details of medical expenses alongwith his Complaint before the District Commission as well as before this Commission in the present Appeal.
23. In the aforesaid context, we have also perused the impugned order passed by the District Commission which has explicitly dealt with all the averments/issues raised by the Complainant in his Complaint. The relevant part of the order is reads as under:-
9. It is not disputed that the complainant was issued health insurance by the OP and the insured/risk amount was Rs.10,00,000/-. The complainant has alleged that the terms and conditions were never supplied to the complainant, therefore he was not aware about the terms and conditions of the policy. The OP has also not produced on the record any documents to show that the complainant was ever supplied with the terms and conditions of the policy. The complainant has proved on record the document showing that he was admitted in the hospital on 30.06.2017 and was discharged on 04.07.2017. It has also been proved that during this period the insurance of the complainant was existing. The complainant has not produced any document to show how much amount he had spent for admission, for his treatment or for any procedure ever done by the doctors, bills of any medicine prescribed by the doctor. Nothing has been proved on record by the complainant nor have these documents been F.A.No.202 of 2022 15 produced by the complainant on the record. He has simply stated that he be granted Rs.10,00,000/-, the insured amount. Even in the claim form submitted to the OP, he has not mentioned the amount spent by him on his treatment. The claim form is Ex.OP-
2. He has sought the amount of Rs.10,00,000/- in lump-sum, but on what basis this amount has been sought, nothing has been proved by the complainant.
10. The contention of the OP is that the complainant has concealed the pre-existing disease, therefore he is not entitled to any relief. As per the discharge summary Ex.C-5/Ex.OP-4, he was diagnosed for CAD, AWMI, LV Dysfunction, Rt.
Hemiparesis, Left MCA Infarct, Subacute Infarct. No procedure was done as per this report. Medicine was prescribed to the complainant, but whether he had taken the medicine or not and if so from where, nothing has come on record. As per the document Ex.OP-5, the slip of the doctor at the time of admission the patient was diagnosed with CAD, AWMI, LV Dysfunction, Rt. Hemiparesis, Left MCA Infarct, Subacute Infarct. The questionnaire of the OP i.e. Ex.OP-8 and Ex.OP-9 show that the complainant has given the information about his health as good and in the questionnaire, he has mentioned that he is not suffering from any pre-existing disease nor he has been diagnosed, hospitalized or any treatment for any illness during the 48 months. Ex.OP-3 is the opinion of the doctor of Tagore Hospital, Jalandhar sought by the OP regarding the patient, the complainant. As per this document, the complainant has been suffering from AWMI since 2.5 years and is on regular treatment. He has also been diagnosed for hypertension since 1.5 years and was on regular treatment, meaning thereby that prior to his admission in the hospital, he was suffering from this disease at the time of purchasing of the policy, but he has not disclosed the OP regarding his disease. So from all angles, the complainant has not produced the detail of the amount spent for his treatment and concealed the pre-existing disease and as per terms and conditions of the insurance policy, if any insured misrepresent to F.A.No.202 of 2022 16 the insurance company then company is not liable to make any payment or compensation. So in these circumstances, the complainant is not entitled for the relief.
24. In view of our above details discussion, facts and reasons we do not find any infirmity as well as illegality in the well-reasoned order passed by the District Commission. Accordingly, the present Appeal filed by the Appellant is hereby dismissed. The order dated 20.12.2021 passed by the District Commission is upheld.
25. Since the main case has been disposed off, so all the pending miscellaneous applications, if any, are accordingly, disposed off.
26. The Appeal could not be decided within the statutory period due to heavy pendency of court cases.
(JUSTICE DAYA CHAUDHARY) PRESIDENT (SIMARJOT KAUR) MEMBER (VISHAV KANT GARG) MEMBER November 07, 2024 (Rupinder 2)