BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 732 of 2022
Date of Institution : 28.12.2022
Date of Decision : 06.11.2024
Nikhil aged about 25 years son of Shri Manish Chugh, resident of H. No. 488, Gali No.8, Aggarsain Colony, Sirsa.
……Complainant.
Versus.
1. Aditya Birla Health Insurance Co. Ltd. through its Managing Director, Office Address: SCO-24, 1st Floor, HUDA Shopping Complex, Sector 14, Gurugram, Haryana.
2. Aditya Birla Health Insurance Co. Ltd. through its Manager Office Address: Property No. SRS/ B16/1095, Ground Floor, Dabwali Road, Adjoining BPCL Petrol Pump, Sirsa, Haryana.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA………MEMBER
Present: Sh. Ashish Singla, Advocate for the complainant.
Sh. Dheeraj Bansal, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that brother of complainant namely Shri Akhil Chugh had purchased a health insurance policy from the ops which was a Group Activ Health Insurance Policy in collaboration with Axis Bank Ltd. and ops issued Master Policy No. 71-20-00035-00-00 and certificate of insurance bearing no. GHI-TS-21-2000845 with unique ID No. 1631276507 and the policy was valid from 10.09.2021 to 09.09.2022. The complainant was a nominee on behalf of his brother i.e. insured Akhil Chugh. It is further averred that ops charged a sum of Rs.9867/- as insurance premium through Axis Bank. That at the time of inception of policy, the insured/ policy holder had informed the ops regarding his pre existing disease i.e. Diabetes (DM). It is further averred that unfortunately the insured had fallen ill and was taken to Fortis Hospital, Mohali for treatment of his kidney failure due to diabetes. He visited there on 01.11.2021 and again on 22.11.2021 for his treatment but due to his deteriorating health condition, he was advised for urgent kidney transplant and as per medical matching report his mother namely Smt. Neelam Kumari had become Donor for the same. It is further averred that the insured had informed the hospital authorities about his insurance with the ops and had submitted all the papers for cashless treatment. The hospital authorities had applied for cashless treatment to the insurance company and it had required case history and other relevant records for this purpose. That complainant and insured were very much sure about the cashless treatment as all the norms and conditions for the same are fulfilling by the insured but surprisingly on 24.11.2021 the ops had rejected the claim for cashless treatment of the insured by raising the objection about pre existing disease. The insured as well as complainant were surprised because at the time of inception of policy nothing was concealed by them and it was duly informed that insured is a patient of DM. It is further averred that forced with the circumstances, as complainant was not ready with the requisite source to meet out the hospital expenditure he could not get the insured operated and admitted in the hospital immediately because the hospital authorities never entertained the patient without advance deposit except in case of cashless treatment. Ultimately after arrangement of money, the insured was admitted to Fortis Hospital, Mohali on 28.11.2021 and was operated upon for kidney transplant and he was discharged on 05.12.2021. That mother of insured who was the donor was also admitted in the hospital on 28.11.2021 and was discharged on 2.12.2021. It is further averred that complainant being the care taker alongwith his family members were forced to pay an approximate sum of Rs.3,50,000/- for the treatment of insured and had spent an approximate sum of Rs.2,00,000/- on the medical treatment of donor and complainant arranged the said amount from his sources to deposit with the hospital for treatment. That later on the insured had received an email dated 07.12.2021 from the ops’ side vide which they have apologized for their act and informed that the policy is active and that the insured had provided correct details regarding pre existing disease at the time of issuance of policy. The complainant as well as the insured felt relaxed about the same and had asked for indemnification of the hospital expenses, which is still pending. It is further averred that unfortunately some complications arisen with the insured and for this purpose he again got himself admitted at Fortis Hospital Mohali on 20.12.2021. That this time again relying upon the ops’ email dated 07.12.2021 hospital authorities applied to them for cashless treatment sanction but to the utter surprise of complainant, insured and hospital authorities, the ops again denied for sanctioning the cashless treatment for the reasons best known to them.
3. It is further averred that this time it was a matter of life and death for the insured because he was not ready to meet out the treatment expenditures and was assured about cashless treatment from their side and for this reason he was unable to get the best possible treatment and to extreme bad luck, the insured had expired on 03.01.2022 at Fortis Hospital, Mohali. That his death is the result of the non co-operative and gross negligent behavior of the ops in providing cashless treatment to the insured. It is further averred that at this time the complainant had spent another sum of Rs.6,50,000/- for treatment of his brother i.e. insured but all in vain as the insured could not survive. The treatment provided to the insured was limited due to the limited resources of complainant and because the ops have denied the cashless treatment. It is further averred that in this manner, the ops are completely negligent in providing services to the insured and are responsible for the untimely death of the insured. The conduct on their part is unbearable at any cost because their wrongful denial to cashless treatment has caused death of a young man aged 31 years and his widow as well as the only girl child of about two years have become orphan what to talk for the parents who have lost their son. The complainant got issued a legal notice to the ops on 06.07.2022 but to no effect and the act and conduct of ops clearly amounts to deficiency in service and unfair trade practice due to which complainant has suffered unnecessary harassment. Hence, this complaint seeking reimbursement of the amount of Rs.10,00,000/- spent on the treatment of insured alongwith interest, seeking reimbursement of the amount of Rs.2,00,000/- spent on the treatment of donor alongwith interest and also seeking a sum of Rs.35,00,000/- as compensation for harassment etc. and also seeking litigation expenses.
4. On notice, ops appeared and filed written version submitting therein that Mr. Akhil Chugh, the insured who is said to be the brother of complainant had purchased a health insurance policy from the insurance company for the term of 10.09.2021 to 09.09.2022. Before obtaining the policy, the ops sought for details of the insured such as the name, the pre existing diseases, treatments, if any taken by the insured and such other details relevant for evaluation for risks covered under insurance policy. Based on such information collected, the ops issued a customized insurance policy to the complainant. The insured had informed the ops that he was suffering from Diabetes Mellitus. As per terms and conditions of the policy, the expenses related to treatment of a pre existing disease or its direct complications of the pre existing disease/ medical conditions are not covered under the policy for a period of two years from the commencement of the policy. This period is known as waiting period. It is further submitted that in the insurance context, waiting period is a pre decided time span post which a selected list of ailments starts getting covered under the health insurance policy. This concept of waiting period can be found in any health insurance policy. Once such waiting period expires, even if the insured suffers from any of the said exclusions, the policy will be applicable subject to the other conditions of the policy. It is further submitted that pre existing diseases exempted during the waiting period has been clearly expressed in the policy terms and conditions. That in November, 2021 Fortis Hospital intimated the ops that the insured was admitted in their hospital and that insured had applied for cashless claim in respect of the medical expenses incurred by him. The complainant had not filed all the relevant documents required for analyzing the policy alongwith the claim form and as such ops sought for the required case history and all the relevant documents to understand about the illness complained of. Upon scrutiny of the documents, it was found that insured was admitted for Kidney failure which was caused due to Diabetes. This fact is admitted by complainant himself in the complaint and as per medical literature the Diabetes has direct implication on kidneys and is the root cause of kidney failure. It is further submitted that as per clause 41 of the policy, the insured is not covered for treatment of pre existing diseases or its direct implications for a period specified in the policy schedule. In the policy schedule, it is clearly stated that the waiting period is two years from the date of commencement of policy. It is further submitted that claim was with respect to treatment between 24.11.2021 to 01.12.2021 and as claim was filed during the waiting period, the cashless claim was repudiated by ops by a correspondence dated 24.11.2021. The reason for rejection of claim was clearly stated in the rejection letter and the relevant clauses of the policy pertaining to waiting period for pre existing disease was also mentioned therein. It is further submitted that after receipt of the rejection letter sent by the ops, the complainant had approached the ops with a request to reconsider the claim by alleging that waiting period for Diabetes was only for 30 days and not for two years. The ops clarified it to them stating that 30 days mentioned in the policy schedule is only for those specific diseases which includes Diabetes. It is not with respect to complications and medical conditions arising out of such diseases. It is well established principle of insurance law that when the terms and conditions of the policy are clear and unambiguous, the clauses have to be given effect to and the parties are subject to the terms of the policy in its literal sense. It is further submitted that thereafter on 28.11.2021, once again a cashless claim was filed with the ops stating that the insured was going to be admitted for the second time for the purpose of kidney transplantation. As the surgery was to be done during the waiting period, the ops rejected the cashless claim. However, instead of mentioning that the claim was rejected in view of subsisting waiting period, the ops inadvertently mentioned the reason for rejection as non disclosure of pre existing diseases. It is further submitted that insured approached the ops and sought for a review of the decision of the ops. After perusing the records, the ops sent an email dated 07.12.2021 clarifying that the pre existing disease was disclosed earlier by the complainant and the waiting period was rightly stated in the policy. In December, 2021 Fortis Hospital, Mohali once again intimated the ops that the insured was admitted to their hospital on 20.12.2021. The claim was repudiated on 22.12.2021, as the insured was under the waiting period of his pre existing disease. The claims of the complainant had been rejected by ops under the clause 41 of the insurance policy i.e. in view of subsisting waiting period. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
5. The complainant in evidence has tendered his affidavit Ex. C1 and documents Ex.C2 to Ex.C22.
6. On the other hand, ops have tendered affidavit of Sh. Swastik Chandra, Senior Manager Legal as Ex. RW1/A, documents Ex.R1 to Ex.R3 and written version Ex.R4.
7. We have heard learned counsel for the parties and have gone through the case file. Written arguments/ version on behalf of complainant as well as ops also filed which have also been perused which are almost repetition of their pleadings.
8. From the certificate of insurance placed on record by complainant as well as ops as Ex.R1, it is evident that Akhil Chugh insured purchased the health insurance policy in question from the ops for the period 10.09.2021 to 09.09.2022 for the sum insured amount of Rs.10,00,000/- and complainant Nikhil is nominee in the said policy. No doubt, at the time of issuance of the policy in question to the insured Akhil, it was disclosed to the ops that insured is suffering from Diabetes Mellitus as is evident from certificate of insurance itself but the claim of complainant is regarding reimbursement of the amounts spent by complainant on the treatment of insured Nikhil for treatment of kidney failure due to diabetes started in Fortis Hospital Mohali allegedly from 01.11.2021 i.e. within two months from the date of purchase of policy and for kidney transplant and for medical treatment of the donor Smt. Neelam as their cashless request as well as claim have been rejected by the ops. According to the ops, as per clause 41 of the policy the insured is not covered for treatment of pre existing diseases or its direct implications for a period specified in the policy schedule and the waiting period is two years from the date of commencement of policy and as such according to clause 41 of the policy the ops have repudiated the claim of complainant on the ground that insured is not covered for treatment of pre existing disease or its direct implications for waiting period of two years and as such ops have repudiated the claim of complainant as per terms and conditions of the policy as it is mentioned in the certificate of insurance that waiting period for pre existing disease is two years. During the course of arguments, learned counsel for ops has also contended that there is even cutting on the date in the prescription slip of Fortis Hospital as date 25.08.2021 has been made as 25.10.2021 by cutting meaning thereby that insured was already having problem of kidney disease right before the issuance of the policy in question and this fact has also been concealed by them from the ops at the time of taking the policy in question from ops and only the pre existing disease of Diabetes Mellitus was disclosed by them to the ops. We also found substance in the plea of learned counsel for ops in this regard because there is cutting on the date of prescription slip as date 25.08.2021 has been made as 25.10.2021 through cutting and it is observed from the record that insured Nikhil now deceased was already having disease of kidney before purchasing of policy in question and this fact was also concealed by insured party from the ops and as such ops have rightly repudiated the claim of complainant on the ground of waiting period of two years for pre existing disease as per terms and conditions of the policy and the claim of complainant also deserves rejection on the ground of non disclosure of material fact because it cannot be said that condition of insured only deteriorated after purchase of policy. Rather it is proved on record that health of insured was already deteriorated and as such insured party purchased the policy in question from ops. The contention of learned counsel for complainant that pre existing disease waiting period of Asthma, Blood Pressure, Cholesterol and Diabetes is 30 days as per terms and conditions of the policy has no substance because the insured was treated for kidney disease and not for only Diabetes and even kidney transplant was done during short period after purchase of policy in question and ultimately insured died on 03.01.2022 at Fortis Hospital, Mohali. The insured was having diabetes since 2007 and therefore, it cannot be said that he was having pre existing disease of diabetes only and not any other serious disease/ complications for which waiting period is two years.
9. In view of our above discussion, we do not find any merit in the present complaint and same is hereby dismissed but with no order as to costs. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member Member President,
Dated: 06.11.2024. District Consumer Disputes
Redressal Commission, Sirsa.
