Haryana

Ambala

CC/322/2021

Rajesh Kumar Gupta - Complainant(s)

Versus

Religare Health Inss Co Ltd - Opp.Party(s)

22 Sep 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, AMBALA.

Complaint case no.	:	322 of 2021
Date of Institution	:	18.10.2021
Date of decision	:	22.09.2023

 Rajesh Kumar Gupta, age 48 years S/o Sh. Kuldeep Kumar, R/o #204 BC Bazar, Ambala Cantt., Ambala

          ……. Complainant.

                                                Versus

1. Religare Health Insurance Company Limited, Branch Office, 6^th  Floor, Tower C, 3rd Floor, Cyber Park, Sector 39,Gurgaon,through its Branch Manager.
2. Religare Health Insurance Company Limited, 5th Floor, 19 Chawla House, Nehru Place, New Delhi.- 110019

                                                                                   ….…. Opposite Parties.

Before:       Smt. Neena Sandhu, President.

                     Smt. Ruby Sharma, Member,

         Shri Vinod Kumar Sharma, Member.           

 

Present:       Shri Ashish Sareen, Advocate, counsel for the complainant.

                    Shri Sandeep Kashyap, Advocate, counsel for the OPs.

Order:        Smt. Neena Sandhu, President.

                   Complainant has filed this complaint under Section 35 of the Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’) against the Opposite Parties (hereinafter referred to as ‘OPs’) praying for issuance of following directions to them:-

i)  To pay a sum of Rs.10,00,000/- as insured value.

ii) To restore the policy with its original regd. number and date.

iii) To pay a sum of Rs.1,00,000/-, as damages for harassing complainant and for not providing proper services.

iv) To pay a sum of Rs.25,000/- as litigation expenses  

v)  To pay the aforesaid amount alongwith interest @ 24% per annum from the date of submission of the papers till the date of realization.

                                      Or

Grant any other relief which this Hon'ble Commission may deems fit.

2.             Brief facts of the case are that the complainant had purchased a Health Insurance Policy bearing policy no.35350134152800000371 from New India Assurance Co. Ltd. on 28.01.2016 (Annexure-C-1) on making payment of premium of Rs.15,950/- The said Health insurance Policy was issued under the name- New India Floater Mediclaim, which was valid for the period from 07/02/2016 to 06/02/2017. The complainant, his wife Smt. Ruchi, his minor daughter Trakshi and his second minor daughter, Bhoomi were covered under the policy in question. Thereafter, the said policy was got renewed on 23/01/2017 by paying premium of Rs.16,353/- valid for the period from 07-02-2017 to 06-02-2018 under new policy number 35350134162800000352 (Annexure-C-2). The policy was again renewed on 06-02-2018 by paying premium of Rs.17,976/- which was valid for the period from 07-02-2018 to 06-02-2019 and the risk covered under this policy was total Rs 8,00,000/- (Annexure-C-3). Thereafter, in year 2019 the said policy was ported by the complainant from New India Assurance Co. Ltd to the OPs and a new contract was entered between the parties. The insurance policy number issued was 13726191, valid for the period from 08-02-2019 to 07-02-2020, for which the complainant paid premium of Rs.27,417/-. The said policy was again renewed on paying premium of Rs.43,434-/ to the OPs, which was valid for period from 08-02-2020 to 07-02-2021 and the risk factor was increased from Rs.8 lacs to Rs.10 lacs. In March, 2018, the daughter of the complainant was taken to PGI, Chandigarh where she was diagnosed with epilepsy symptoms. The complainant contacted OP No.1 seeking reimbursement of medical expenses of his daughter under the said policy, as a result of which he was asked to provide medical treatment record and bills etc. Resultantly, the complainant submitted the cash receipts/bills and medical report along with claim form  to OP No.2. The treatment of complainant's daughter is still ongoing and so far the complainant has spent Rs.5,00,000/- on it. However, OP No.1 vide letter dated 14-11-2019 (Annexures-C-6) informed the complainant that the claim of his daughter Bhoomi Gupta is not maintainable on the ground of non disclosure of disesase- seizures prior to inception of policy in question. Thereafter the OPs again deducted premium amount of Rs.43,434/- qua policy in question for the term 08.02.2020 to 07.02.2021. Thereafter, another letter dated 29.02.2020 (Annexure-C-7) was sent by the OPs informing the complainant that the policy in question stood cancelled and premium amount has been forfeited on the same ground. Thereafter, number of requests were made by the complainant to make payment of the claim amount but the OPs failed to do so. By not reimbursing the claim amount, the OPs have committed deficiency in service. Hence, the present complaint.
3.           Upon notice, the OPs appeared and filed written version and raised preliminary objections with regard to maintainability, jurisdiction, no locus standi, bad for mis-joinder and non-joinder of necessary parties, cause of action, estoppal, not come with clean hands and suppressed the true and material facts etc.  On merits, while admitting factual matrix of the case with regard to the fact that the complainant purchased the insurance policy in question from the OPs, in the manner stated by him, in his complaint, it has been stated that when the OPs issued the policy in question in favour of the complainant, it was not disclosed by him that his daughter was suffering from preexisting disease. The complainant filed a Reimbursement Claim No.91157941 with respect of insured's hospitalization at AIIMS Hospital, Delhi w.e.f. 05-10-2019 till 15-10-2019. As per the discharge summary, she was diagnosed with epilepsy (predominantly non motor, generalized, focal). As per the discharge summary itself, she was having complaints of seizures for the last 1.5 years. Age of onset was 12.5 years. The OPs rejected the claim of the complainant vide letter dated 14-11-2019 with the observation: CLAIM REPUDIATED UNDER NON-DISCLOSURE OF SEIZURE PRIOR TO POLICY INCEPTION, NON DISCLOSURE in view of  condition no.7.1 of the policy which says that 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 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 and the policy will be terminated under condition no.7.13. The Insurance Regulatory and Development Authority (IRDAI) (Protection of Policy Holder's Interest) Regulations, 2017 under Clause 19(4) enumerating the "General Principles" casts an absolute duty to disclose all material facts to the Insurer in order to assess the risk as per it's capacity. The complainant was given an opportunity to disclose the history of epilepsy/seizure by asking the questions - "8- Stroke/Paralysis/ Transcient Ischemic attack/ multiple sclerosis/ epilepsy// Mental Psychiatric illness/ Parkinsonism/alzeihmer's/ depression/dementia or any other disease of brain and nervous system?". Had he disclosed the same, the OPs would not have issued the policy in question. The notice for cancellation of the policy was sent vide letter dated 09-12-2020 and the policy was finally cancelled on 29-02-2020, Annexure 9. Rest of the averments of the complainant were denied by the OPs and prayed for dismissal of the present complaint with costs.
4.           Learned counsel for the complainant tendered affidavit of complainant as Annexure PW1/A alongwith documents as Annexure P-1 to P-7 and closed the evidence on behalf of the complainant. On the other hand, learned counsel for the OPs tendered affidavit of Ravi Boolchandani, Manager-Legal at Religare Health Insurance Company Limited (presently care Health Insurance Limited) having its registered office at Care Health Insurance Limited, 19, Chawala House, 5^th Floor Nehru Place, 110019 as Annexure R-X, alongwith documents as Annexures R-1 to R-10 and closed the evidence on behalf of OPs.
5.           We have heard the learned counsel for the parties and have also carefully gone through the case file.
6.           Learned counsel for the complainant submitted that since the complainant has taken medical cover for himself and his family members under the policy in question therefore he was entitled to get the reimbursement of the claim amount, , which was spent by him on the  treatment of his daughter, yet, genuine claim filed by him has been repudiated by the OPs, on vague grounds of concealment of pre-existing disease, which act amounts to deficiency in providing service. 
7.           On the contrary, the learned counsel for the OPs submitted that because the treatment of disease-epilepsy, for which the insured daughter of the complainant took treatment was  covered under the exclusion clause of the policy in question and also at the same time the said disease was not disclosed to the OPs, at the time of obtaining the policy in question, as such, the claim filed by the complainant was rightly repudiated by the OPs, strictly as per terms and conditions of the insurance policy.
8.           Since neither the issuance of the policy in question nor the fact that the daughter of the complainant took treatment for “Epilepsy” during currency of the said policy; nor submission of claim by the complainant nor repudiation of the same vide letter dated 14.11.2019, Annexure P-6/R-6, are not in dispute, therefore, the only moot question which falls for consideration is, as to whether, the claim filed by the complainant was rightly repudiated by the OPs or not. For coming to any conclusion, we need to refer relevant clause no.2.6 of the policy, Annexure R-7, pertaining to the exclusion clause, wherein it was clearly mentioned that the following diseases shall not be payable under this benefit:-

 

1. Asthma
2. Bronchitis
3. Chronic Nephritis and Chronic Nephritic Syndrome
4. Diarrhea and all types of Dysenteries including Gastro enteritis
5. Diabetes Mellitus and Diabetes Insipid’
6. Epilepsy
7. Hypertension
8. Influenza, cough or cold
9. All Psychiatric or Psychosomatic Disorders
10. Pyrexia of unknown origin for less than 10 days
11. Tonsillitis and Upper Respiratory Tract Infection including Laryngitis and Pharyngitis
12. Arthritis, Gout and Rheumatism.”

 

9.           From the afore-extracted relevant part of condition no.2.6, it is evident that the expenses incurred for the treatment of Epilepsy (Sr.no.6) was excluded and not payable under the policy in question.  However, in the present case also, it is clearly coming out from the Discharge Summary dated 15.10.2019, Annexure R-5 issued by the treating doctor of AIIMS, New Delhi, that the insured daughter of the complainant was diagnosed as “Epilepsy” and took treatment for the same, as she was brought to the hospital with chief complaints of seizures for the last 1½ years and the age onset of 12½ years. Thus, under these circumstances, the complainant was not entitled to get any amount incurred by him on the treatment of his daughter for epilepsy i.e. the disease which fell under the exclusion clause and as such, OPs cannot be said to be wrong in repudiating the claim of the complainant.  In case of Oriental Insurance Co. Ltd Vs Sony Cherian (II 1999 CPJ 13 SC), the Hon’ble Supreme Court of India has held that- ― “..The insurance policy between the insurer and the insured represents a contract between the parties. Since the insurer undertakes to compensate the loss suffered by the insured on account of risks covered by the insurance policy, the terms of the agreement have to be strictly construed to determine the extent of liability of the insurer. The insured cannot claim anything more than what is covered by the insurance policy. That being so, the insured has also to act strictly in accordance with the statutory limitations or terms of the policy expressly set out therein…”.
10.           In view of peculiar facts and circumstances of this case, it is held that because the complainant has failed to prove his case, therefore, no relief can be given to him. Resultantly, this complaint stands dismissed with no order as to cost.  Certified copy of the order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the Record Room.

Announced:- 22.09.2023.

 

(Vinod Kumar Sharma)	(Ruby Sharma)	(Neena Sandhu)
Member	Member	President