Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 38
Instituted on : 20.01.2020
Decided on : 14.11.2022
Jaivir Singh age-58 yrs. S/o Sh. Karan Singh R/o H.No. 123-A, Kripal Nagar, Near Saini College, Rohtak.
………..Complainant.
Vs.
- Religare Health Insurance Company Limited Regd. Office 5th Floor, 19 Chawla House, Nehru Place, New Delhi-110019 through its Manager.
- Religare Health Insurance Company Limited Regional Office Unit No. 604,605,606,607, 6th Floor, Tower-C, Unitech Cyber Park, Sector-39, Gurugram-122001(Haryana) through its Manager
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR. VIJENDER SINGH, MEMBER.
Present: Sh. Raman Nehra, Advocate for the complainant.
Sh. Puneet Chahal, Advocate for opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case as per the complainant are that he availed the Health Insurance Policy for himself and his wife bearing No.14012492 by paying Rs.44,539/-. At the time of obtaining the said policy, the officials of opposite parties have told the complainant that all type of disease covered under the policy. On 07.12.2019, the complainant was got admitted in Khurana Hospital and undergone treatment and was discharged from hospital on 08.12.2019 and an amount of Rs.24,633/- was spent on treatment. The cashless facility was not available in the said hospital. So the complainant contacted with the officials of opposite parties on customer care number and the concerned officials asked the complainant to submit his claim form to get reimburse his medical bills. Complainant submitted all the treatment papers in original to opposite parties and applied for the insurance claim, but they denied the genuine claim of the complainant by alleging that "Benefit not covered in policy". The opposite parties denied the claim of the complainant on baseless and unreasonable grounds. As such there is deficiency in service on the part of opposite parties. Hence this complaint and it is prayed that opposite parties may kindly be directed to pay the claim amount of Rs.24,633/- alongwith interest @ 18% per annum to the complainant and also to pay an amount of Rs.2,00,000/- as compensation on account of harassment and Rs.11,000/- as litigation expenses to the complainant.
2. After registration of complaint, notices were issued to the opposite parties. Opposite parties in their reply submitted that complainant applied for reimbursement claim with the opposite parties for the hospitalization from 07.12.2019 to 08.12.2019 at M/s Khurana Eye Center where he was diagnosed with ‘Left Eye Branch Retinal Vein Occlusion and underwent the treatment of the same’. Upon careful examination of the claim documents made available to opposite party it was observed by them that insured was having Pre-existing history of Diabetes for last 6 years and took medication for the same which was not disclosed during the inception of the policy with the opposite party. Therefore, claim was denied vide Denial Letter dated 10 January, 2020 on the ground of Non-disclosure of Diabetes and Permanent Exclusion: Remicade, Avastin or similar injectable treatment. Therefore, the claim was denied on the ground of non-disclosure pre-existing history of diabetes at the time of inception of policy. All the other contents of the complaint were stated to be wrong and denied and opposite parties prayed for dismissal of complaint with costs..
3. Ld. Counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C16 and has closed his evidence on dated 02.09.2021. On the other hand, ld. counsel for the opposite parties has tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R7 and has closed their evidence on dated 01.07.2022.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present case the claim of the complainant has been repudiated by the opposite party vide its letter dated 10.01.2020 placed on record as Ex.C1 on the ground that “Benefit not covered in policy”. At the time of arguments, it has been submitted by the insurance company that the complainant took treatment from M/s Khurana Eye Centre where he was diagnosed with ‘Left eye branch retinal vein Occlusion and underwent the treatment for the same’. It is further submitted that the claim of the complainant was rightly repudiated because the complainant was suffering from diabetes and he has not disclosed this fact at the time of submission of the proposal form. It has been further submitted that the complainant has history of diabetes for last 6 years and he took medication for the same and this fact has not been disclosed during the inception of the policy with the insurance company. So he violated the terms and conditions of the policy.
6. We have minutely perused the policy placed on record by the respondent Ex.R1. In fact policy has been purchased by the complainant on 28.03.2017 and he port his policy with the respondent i.e. Religare Health Insurance Company. Initially it was from Star Health Insurance Company. It has been further submitted by the complainant that he also disclosed all the relevant facts with the Star Health Insurance Co. Ltd. and thereafter he port his policy with the respondent w.e.f. 29.03.2019 to 28.03.2020 and paid the premium of Rs.44539/- to the respondent. On the other hand respondent has not placed on record any document to prove that complainant has not disclosed this fact before the Star Health Insurance Co. Proposal form Ex.R3 is placed on record. As the policy was port by the complainant with the opposite party so the fresh proposal is not required in this case. Moreover in the proposal form (Ex.R3) some details have been allegedly submitted by the complainant with the respondent insurance company. Perusal of this document shows that previous policy detail have not been mentioned in this proposal form. It has been further submitted by the complainant that no fresh proposal form is required when a policy has been ported from one insurance company to another. It is also observed that now a days ‘diabetes’ is a life style disease and most of the people are suffering from it and they came to know about it at a later stage. Hence the repudiation of claim on this ground is illegal and there is deficiency in service on the part of opposite parties. As such opposite parties are liable to pay the claim amount to the complainant. Complainant in his complaint has demanded Rs.24633/- as claim amount but he has placed on record bills Ex.C9 to Ex.C12 amounting to Rs.21833/-. As such he is entitled for the said amount.
7. In view of the facts and circumstances of the case, we hereby allow the complaint and direct the opposite party to pay Rs.21833/-(Rupees twenty one thousand eight hundred and thirty three only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 20.01.2020 till its realization and shall also pay a sum of Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/- (Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
8. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
14.11.2022.
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Nagender Singh Kadian, President
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Tripti Pannu, Member.
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Vijender Singh, Member.
