State Consumer Disputes Redressal Commission
Reliance Health Insurance Company Ltd. vs Ram Sarup on 22 November, 2021
Daily Order STATE CONSUMER DISPUTES REDRESSAL COMMISSION, UNION TERRITORY, CHANDIGARH Appeal No. 201 of 2019 Date of Institution 11.09.2019 Date of Decision 22.11.2021 Religare Health Insurance Company Ltd., Registered Office 5th Floor, 19 Chawla House, Nehru Place, New Delhi 110019, through its Chairman/Managing Director/Director. Religare Health Insurance Company Ltd., Vipul Tech Square, Tower-C, 3rd Floor, Sector 43, Golf Course Road, Gurgaon 122009, through its Branch Manager/Office Incharge. Religare Health Insurance Company Ltd., SCO 56-58, 2nd Floor, Sector-9, Chandigarh 160017, through its Branch Manager/Office Incharge. .....Appellants/Opposite Parties Versus Ram Sarup aged about 61 years S/o Sh. Manohar Lal, R/o 3390, Sector 47-D, Chandigarh .....Respondent/Complainant BEFORE: JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT. MRS. PADMA PANDEY, MEMBER
MR. RAJESH K. ARYA, MEMBER Argued by: Sh. Paras Money Goyal, Advocate for the appellants.
Sh. Mohit Singla, Advocate for the respondent.
PER PADMA PANDEY, MEMBER This appeal is directed against an order dated 25.06.2019, rendered by District Consumer Disputes Redressal Forum-II, UT, Chandigarh, now District Consumer Disputes Redressal Commission-II (hereinafter to be called as the District Commission only), vide which, it allowed the Consumer Complaint bearing No.693 of 2018, filed by the complainant, with the following directions: -
"17]. In view of the above findings, the complaint is allowed with directions to the Opposite Parties to reimburse an amount of Rs.2,91,354/- to the complainant with interest @12% p.a. from the date of repudiation i.e. 22.10.2018 till payment, along with litigation cost of Rs.10,000/-.
The Opposite Parties/Religare Health Insurance Company is also imposed with compensatory cost of Rs.2.00 lacs on account of their misdemeanor, which shall be deposited with Department of Cardiology, Advanced Cardiac Centre, PGIMER (Post Graduate Institute of Medical Education & Research), Chandigarh, Through its Head of Department, for use on treatment of needy patients.
18] This order shall be complied with by the Opposite Parties in toto within the period of 30 days."
In brief, the facts of the case are that the complainant took Health Insurance Policy from Opposite Parties on 14.05.2015 and got it renewed from time to time till the period 27.06.2018 to 26.06.2019 vide Annexures C-1 and C-2. It was stated that the complainant was operated for knee surgery on 22.10.2018 at Max Super Specialty Hospital, Mohali while remained admitted there from 21.10.2018 to 27.10.2018. It was further stated that the pre-authorization request of cashless Hospitalization of the complainant was denied by the Opposite Parties on 22.10.2018 on flimsy ground of non-disclosure of material facts/pre-existing disease, whereas he was covered under cashless health insurance policy issued by them. It was further stated that on 27.10.2018 when the complainant was discharged, he had to make the payment of Rs.2,91,354/- (Annexure C-10) to the Hospital towards his medical treatment bill. It was further stated that the complainant requested many times to the Opposite Parties to pay his claim, but they did not pay any heed. It was further stated that the aforesaid act of the Opposite Party, amounted to deficiency in service and unfair trade practice. When the grievance of the complainant, was not redressed, left with no alternative, a complaint was filed.
The Opposite Parties filed its written version of the case and admitted the factual matrix of the case, stated that after going through the documents supplied by the complainant, it transpired that he suppressed material facts from the company at the time of taking the policy, as the complainant at the time of pre-anesthesia check-up, disclosed that he is suffering from hypertension for past five years and is on regular medication and further suffering from diabetes T-II DM for the past 8 to 10 years and is under regular checkup (Annexure OP-3). It was further stated that the complainant never disclosed about his suffering from hypertension and diabetes as pre-existing ailment at the time of proposing for the policy or thereafter. It was further stated that the complainant has suppressed the material information about his pre-existing disease from the Opposite Parties, and therefore, the claim of the complainant was rightly repudiated. It was further stated that there was no deficiency, in rendering service, and remaining averments, were denied, being wrong, on the part of the Opposite Parties.
The Parties led evidence, in support of their case.
After hearing the Counsel for the Parties, and, on going through the evidence, and record of the case, the District Commission, allowed the complaint, as stated above.
Feeling aggrieved, the instant appeal, has been filed by the appellant/Opposite Parties.
We have heard the Counsels for the parties, and have gone through the evidence, and record of the case, carefully.
After giving our thoughtful consideration, to the rival contentions, advanced by the Parties and the evidence, on record, we are of the considered opinion, that the appeal is liable to be dismissed, for the reasons to be recorded hereinafter.
On observing the record, we find that the learned District Commission-II had partly allowed the complaint as discussed in the preceding paragraph. After thorough examination of the case and taking reliance of various judgments of the Hon'ble National Consumer Disputes Redressal Commission, Punjab State Consumer Disputes Redressal Commission and also that of the apex court in the case of Biman Krishna Bose Vs. United India Insurance Company, Civil Appeal No.3438 of 1995, this Commission is of the view that the order passed by the District Commission does not suffer from any illegality and deserves to be upheld and accordingly, the appeal is dismissed.
This order also disposes of MA/580/2019 for staying operation of the impugned order passed by the District Commission-II, Chandigarh in Complaint Case No.693 of 2018. Since the appeal stands dismissed, this miscellaneous applications become infructuous.
For the reasons recorded above, the appeal, being devoid of merit, must fail, and the same is dismissed, with no order as to costs. The order of the District Commission is upheld.
Certified copies of this order, be sent to the parties, free of charge.
The file be consigned to Record Room, after completion.
Pronounced.
22.11.2021 Sd/-
[JUSTICE RAJ SHEKHAR ATTRI] PRESIDENT Sd/-
[PADMA PANDEY] MEMBER Sd/-
[RAJESH K. ARYA] MEMBER Gp