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Prameet Kumar Sinha v. Religare Health Insurance
Factual and Procedural Background
The complainant purchased a Religare Health Insurance family floater policy (policy no. 10188153) for himself and his minor son, for the period 06.01.2015 to 05.01.2016 with sum insured of Rs. 10,00,000 and paid premium by cheque dated 05.01.2015. In March 2015 he discovered elevated blood sugar and was diagnosed with Diabetes Mellitus II on 27.03.2015 at Artemis Hospital, Gurgaon. Prior to renewal for the period January 2018–2019, the complainant sent a letter declaring he had been under treatment for Diabetes Mellitus II since 27.03.2015 and deposited a cheque for an enhanced premium to upgrade the sum insured from Rs. 10 lakhs to Rs. 15 lakhs.
The complainant alleges the insurer (OP) informed him that the upgrade was not approved but that Diabetes Mellitus II was included in policy records and excess premium was credited back. The OP issued a fresh policy (no. 11862984) which allegedly omitted Diabetes Mellitus II in the new policy document; the intermediary assured the complainant the condition was recorded but he did not receive any notification.
In July 2018 the complainant underwent CRT-D implantation at Narayana Superspeciality Hospital, Gurgaon (admitted 9.7.2018, discharged 12.7.2018). A pre-authorization request for cashless hospitalization was denied by the OP on 02.07.2018 citing "Non-disclosure of material facts/pre-existing ailment at the time of proposal (H/o DM & Dysplipidemia since prior to policy inception)". The complainant procured a certificate from his treating cardiologist stating the cardiomyopathy was not related to atherosclerosis/dyslipidemia and forwarded it to the OP, but the claim remained denied. The OP relied on a consultation paper dated 06.07.2014 (which the complainant says was a mistaken year and actually 06.07.2016) to justify repudiation. The complainant alleges all formalities were completed and seeks reimbursement of Rs. 9,94,000 with interest, Rs. 1,00,000 as compensation for mental agony and Rs. 20,000 as litigation expenses.
On notice, the OP filed a written statement denying liability, alleging non-disclosure/suppression of material facts (Diabetes, Dyslipidemia and prior CAG in 2007), reliance on policy Clause 7.1 to repudiate the claim, and contending there is no deficiency in service. The OP described two separate claims submitted by the complainant (a day-care CAG claim for Rs. 24,350 and a hospitalization claim for Rs. 10,25,852) and stated it had requested documentary evidence and initiated claim investigation. Both parties led evidence and the matter was heard by the tribunal (the provided excerpt ends after the tribunal states it has gone through the record and heard counsel).
Legal Issues Presented
- Whether the complainant failed to disclose material facts (prior history of Diabetes Mellitus and Dyslipidemia and past cardiac procedure) at the time of proposal/renewal, thereby justifying the insurer's repudiation under the policy terms (Clause 7.1).
- Whether the insurer's denial of pre-authorization and reimbursement for the CRT-D implantation amounted to deficiency in service on the part of the insurer.
- Whether the complainant is entitled to reimbursement of treatment expenses, interest, and compensation for mental agony and litigation costs.
Arguments of the Parties
Complainant's Arguments
- The complainant asserts he was diagnosed with Diabetes Mellitus II on 27.03.2015 and had requested inclusion of this condition in the renewal; he paid an enhanced premium intending an upgrade to Rs. 15 lakhs but the upgrade was not approved and excess was credited back.
- He contends he was told Diabetes Mellitus II was included in the policy records; although a new policy number was issued, the new policy document did not show mention of Diabetes Mellitus II, but an intermediary confirmed the condition was recorded in official records.
- The complainant underwent CRT-D implantation and the OP denied cashless authorization and later repudiated reimbursement citing non-disclosure of pre-existing conditions. He claims a misdated consultation note (06.07.2014 vs. correct 06.07.2016) was used to repudiate the claim; his treating doctors issued corrective certificates.
- He alleges the denial was arbitrary, contrary to natural justice, and despite repeated requests the OP failed to process his claim. Relief sought: reimbursement of Rs. 9,94,000 with interest, Rs. 1,00,000 as compensation, and Rs. 20,000 litigation expenses.
Opposite Party's Arguments
- The OP contends the complaint is not maintainable and that the complainant suppressed material facts (type II Diabetes, Dyslipidemia, and past CAG in 2007) when proposing for insurance; thus the complainant is guilty of suppressio veri and suggestio falsi.
- The OP states the complainant failed to produce supporting documents and hence did not establish deficiency on the insurer's part.
- The OP details policy issuance and renewals and identifies two claims submitted by the complainant (a day-care CAG claim and a hospitalization claim). For both claims, the OP sought additional records and initiated claim investigation.
- The OP points to consultation notes (including one dated 06.07.2014 and one dated 24.01.2018) and an initial assessment sheet indicating prior history. It argues the proposer is obliged to disclose material health facts under the doctrine of utmost good faith and that non-disclosure permits repudiation under Clause 7.1.
- The OP relied on precedents (Religare Health Insurance v. Jatinder Singh; Ravneet Singh Bagga v. KLM Royal Dutch Airlines) to contend that where there is a bona fide dispute and the insurer acts on available material, it does not amount to deficiency in service; the OP prayed for dismissal of the complaint.
Table of Precedents Cited
| Precedent | Rule or Principle Cited For | Application by the Court (as per provided excerpt) |
|---|---|---|
| Religare Health Insurance Vs. Jatinder Singh (State Commission Chandigarh, 17 May 2017) | Principle that nondisclosure of pre-existing ailment by the proposer violates policy terms; obligation to disclose all facts to insurer at time of taking policy. | Referenced by the Opposite Party in its written statement to support the proposition that non-disclosure of pre-existing conditions permits repudiation. The provided excerpt shows the OP relied on this decision; the tribunal's adjudicative application is not contained in the excerpt. |
| Ravneet Singh Bagga v. KLM Royal Dutch Airlines, (2000) 1 SCC 66 | Principle that plaintiff must prove deficiency in service and that a bona fide dispute where a service provider has acted after considering material does not amount to deficiency in service. | Quoted by the Opposite Party to argue that where a bona fide dispute exists and the insurer has acted on material, such conduct is not a deficiency in service. The provided excerpt records the OP's reliance; the court's use of the precedent in final reasoning is not present in the excerpt. |
Court's Reasoning and Analysis
The provided excerpt contains no detailed adjudicative reasoning by the tribunal. It records procedural steps: both parties led evidence, the tribunal reviewed the case record carefully, and heard the complainant and the counsel for the opposite party. The excerpt does not include the tribunal's step-by-step legal analysis or any findings on the factual disputes (e.g., on the date of the consultation note, the existence of prior ailments at proposal time, or the applicability of Clause 7.1).
Note: The excerpt contains the parties' contentions and the OP's reliance on Clause 7.1 and precedent, but it does not record how the tribunal resolved these contentions.
Holding and Implications
This information was not available in the provided opinion.
The complainant has filed the present complaint against the OP alleging deficiency in service on the allegations that he obtained a Religare Health Insurance Policy (family floater) vide policy number 10188153 for himself and minor son Praket Sinha for sum insured Rs. 10,00,000.00 from the OP for the period from 06.01.2015 to 05.01.2016 for which premium of INR 11,289.00 was paid to opposite party vide OBC cheque dated 05.01.2015. It has been alleged that in the later part of March, 2015, the complainant incidentally happened to check random blood sugar at home and found it was elevated and visited a reputed laboratory to reconfirm and on seeing the report visited Artemis Hospital, Gurgaon and consulted the Physician on 27.03.2015 and the doctor diagnosed him with Diabetes Mellitus Il and prescribed medicine to control his blood sugar. It has been alleged that for the renewal of complainant's policy for the period 06.01.2018 to January 2019, the OP sent a letter offering to upgrade the policy to higher sum insured from INR 10.00 Lakhs to INR 15.00 lakhs. It has been alleged that prior to renewal of his policy for the year January 2018 to 2019, he had written a letter to OP, in which he has self-declared that he has been under treatment at Artemis Hospital, Gurgaon for Diabetes Mellitus Il, since 27.03.2015 and requested to include Diabetes Mellitus ll in his renewal policy and had also deposited cheque number 000035 dated 30thNovember 2017 for INR 18,372.00 drawn on Kotak Mahindra Bank towards enhanced renewal premium of his policy number 10188153 with an up gradation of sum insured to INR 15.00 Lakhs. It has been alleged that the complainant received a phone call from OP that the request for upgrade the higher sum has not been approved but the inclusion of Diabetes Mellitus II has been approved and is included in the policy records and the excess amount paid was subsequently credited to his account by the OP. It has been alleged that a fresh policy containing new policy number 11862984 was issued by the OP, despite the fact that the complainant while issuing the cheque for renewal of existing policy, cited the old policy number on the reverse of the cheque. Further, there had no mention of Diabetes Mellitus Il in the new policy and on enquiring from intermediary Mr.Jain, he confirmed that it has been mentioned in the official record of the policy and had also assured the complainant to send the notification from the company, but the same was never received by him. It has been alleged that during the medical check-up, the complainant was confirmed of having LBBB and he was advised for implantation of CRT D. The complainant was admitted on 9th July, 2018 in Narayana Superspeciality Hospital, Gurgaon for CRT D implantation which was successful and he remained in ICU under observation after implantation of CRT D and was discharged on 12th July 2018. It has been alleged that a request for pre-authorization for estimated amount of INR 10,50,750.00 for cashless hospitalization has been sent to OP vide e-mail dated 25th June 2018 which was denied by the OP vide denial letter dated 02nd July 2018 stating following:- "Non-disclosure of material facts/pre-existing ailment at the time of proposal (H/o DM & Dysplipidemia since prior to policy inception)" but when the matter was intimated to Professor Dr. Vivek Chaturvedi, Senior Consultant Cardiology and Director Cardiac Electrophysiology, Narayana Superspeciality Hospital, Gurgaon who was of the strong view that the Complainant's cardiomyopathy was not related to atherosclerosis or dyslipidemia and, he had no significant symptoms of heart failure. As per history, he never had any episode of acute LVF and in this regard, a certificate has been issued which was forwarded to OP vide their e-mail dated 04th July 2018 but the OP denied the claim of the complainant mentioning that:- "Non-disclosure of material facts/pre-existing ailment at the time of proposal- As per consultation paper dated 6th July 2014 patient diagnosed case of Diabetes Mellitus, Dyslipidemia which is pre- policy. Hence, claim is not admissible, and rejected. In pursuance of this, it was clarified that the so mentioned prescription/consultation paper dated 06th July 2014 on the basis of which the claim has been denied, is factually dated 06th July 2016. The consultant doctor, Dr. Ved Prakash Yadav has inadvertently and erroneously mentioned the year as 2014 instead of 2016 and the correct date of consultation is 6th July 2016 and in this regard, he has issued a certificate dated 04.09.2019 which is on the file. The complainant has completed all the formalities as required but denial of claim by the OP for reimbursements of treatment expenses is fully unjustified arbitrary which is against the principle of natural justice. The complainant requested several times for his claim but the OP paid no heed towards his requests. On the aforesaid allegations, the complainant has prayed for reimbursement of Rs.9,94,000/- alongwith due interest besides Rs.1,00,000/- as compensation for causing him mental agony and physical harassment as well as litigation expenses of Rs.20,000/-.
2. Upon notice, OP appeared through its counsel and filed its written statement wherein it has been contended that the complaint was not maintainable and no cause of action has arisen in favor of the complainant and against the opposite party and the present complaint is liable to be dismissed. It has been contended that the complainant has the least concern for the sanctity and dignity of the judicial process and he in their endeavor to harass the humiliate the OP has not only concealed the material facts from this Honble Forum but has also misrepresented the material facts before this Honble Forum and being guilty of Suppressioveri and suggestion falsi have no right of maintaining the present complaint and is liable to be dismissed. Further contended that he failed to produce even a single document so as to substantiate the allegations made against the OP and has also failed to establish any deficiency on the part of the OP. It has been contended that the complainant is insured under the health insurance policy bearing no. 10188153 covering the complainant and his son with effect from 6.1.15 to 05.01.16 for sum insured of Rs.10,00,000/- subject to Policy Terms and Conditions and the said policy was further renewed on yearly basis with effect from 07.01.16 to 06.01.17. It has been contended that the said policy was further renewed from 07.01.2017 to 06.01.2018 and was further renewed from 07.01.18 to 06.01.19 and again from 07.01.19 to 06.01.2020. The Policy Certificate along with Policy Terms and Conditions are marked as Annexure OP-1. It has been contended that the complainant approached the OP-company with 2 claims and the details of which are as under:- Claim Details with regard to day care hospitalization (CL No: 90691321): That the complainant approached the OP Company with a Reimbursement Claim with regard to day care hospitalization of the complainant in Narayana Hospital, Gurgaon on 02.07.18 for the CAG (Coronary Angiography). The said claim was made for an amount of Rs. 24,350/-. That on receipt of the Reimbursement Claim, the OP Company sent a query letter dated 07.09.2018 Annexure OP-2 to the complainant requesting that to provide the following documents for assessment of the Claim: a. ALL HEALTH CHECKUP RECORDS OF JANUARY 2018 b. EXACT DURATION AND PAST HISTORY OF PRESENT AILMENT WITH 1ST CONSULTATION PAPER AND ALL PAST TREATMENT RECORDS OF DM, DYSLIPIDEMIA AND LV DYSFUNCTION c. PRE HOSPITALISATION OPD TREATMENT RECORD It has been contended that Claim Details with regard to day care hospitalization (CL No: 90691799): the complainant approached the OP Company with a reimbursement claim w.r.t to hospitalization of the complainant in Narayana Hospital, Gurgaon from 09.07.18 till 12.07.18 for the treatment of LV dysfunction, DM-I and CAG (Coronary angiography) and the said claim was made for an amount of Rs. 10,25,852/-. It has been contended that the OP-company also initiated claim investigation to check the veracity of the claim and on perusal of the claim the following facts came upfront:- a As per the Consultation Note dated 06.07.14 drawn by Dr. Ved Prakash Yadav, that is, prior to the issuance of policy, the complainant is mentioned to be a known case of Type-lI Diabetes and Dyslipidemia. Consultation note is annexed as Annexure OP-3. b. As per the Consultation Note dated 24.01.18 drawn by Dr. Ved Prakash Yadav, the complainant is mentioned to be a known case of Type-ll Diabetes and Dyslipidemia. Consultation note is annexed as Annexure OP-4. c. As per the Initial Assessment Sheet issued by Narayana Hospitals, Gurgaon, the Complainant had a history of CAG done in year 2007. Assessment sheet is annexed as Annexure OP-5. It has been contended that as per the contract of insurance, it is the duty of the proposer to disclose all the material facts to the insurer so that the insurer evaluates the material facts and decides whether to accept the proposal or not as the insurance contract is based on utmost good faith. In the case of health insurance contracts, disclosure of health details are the material facts. It has been contended that the insured had the opportunity to disclose about the history of past medical illness
i.e. Diabetes and Dyslipidemia back at the time of filling up the proposal form but no such disclosures were made for the reasons best known to the insured. It has been contended that the complainant is a known case of Diabetes and Dyslipidemia i.e. prior to inception of policy and the same was not disclosed at the inception of the policy period, the claim of the complainant was denied as per Clause 7.1 of the policy terms and conditions and the same was intimated to the complainant and Dyslipidemia, the Reimbursement Claims of the complainant was rejected in accordance to Clause 7.1 of the Policy Terms and Conditions and same was informed to the complainant vide letters dated 05.10.18 and 08.10.2018. It has been contended that at the time of taking the policy, the complainant was asked to submit the Proposal Form and discloses the true state of Health and the complainant had the opportunity to declare the history of Diabetes Dyslipidemia and CAG done in 2007 at the time of filling up the proposal form, but no such disclosures were made for the reasons best known to him. It has been contended that if the complainant would had disclosed the history of the Diabetes, Dyslipidemia and CAG at the inception of the policy, then the OP-company, subject to its underwriting guidelines would had issued the policy on different terms and conditions or not issued the policy at all. It was held in Religare Health Insurance Vs. Jatinder Singh passed by Honble State Commission Chandigarh dated 17th May 2017 that complainant was a known case of Hypertension and by not disclosing the pre-existing ailment of Hypertension, the complainant has violated the terms and conditions of the Insurance Policy. It was further held that it is obligation of the complainant to disclose each and every fact to the insurer at the time of taking the policy. It has been contended that the complainant cannot be allowed to ripe fruits of his own wrong doer. As such, the answering Opposite Party has rightly repudiated the claim of the complainant and there is no deficiency in service as has been laid down by the Honble Supreme Court in case titled Ravneet Singh Bagga vs. KLM Royal Dutch Airlines 2000 1 SCC 66 wherein it has been laid down that the test of deficiency in service lay upon the plaintiff for proving that there was some fault, imperfection, shortcoming or inadequacy in the manner of the Insurance Company and further such fault etc. must be willful. More importantly, the Hon'ble Supreme Court has held that where there is a bonafide dispute between the parties and where the service provider has after considering all the material with them and the relevant facts has acted in a particular manner, then such acts will not amount to deficiency in service. It has been further contended that the present complaint is wholly misconceived, groundless and unsustainable in law and same is liable to be dismissed. All the other allegations have been denied as false and baseless and dismissal of the complaint has been prayed for.
3. Both the parties have led their evidence in support of their respective version.
4. We have gone through the record of the case carefully and have heard the complainant as well as learned counsel for the opposite party.
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