Punjab

Ludhiana

CC/20/96

Rajan Kumar Garg - Complainant(s)

Versus

Apollo Munich Health Insurance - Opp.Party(s)

L.C.Bector

29 Jul 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:96 dated 08.07.2020.                                                 Date of decision: 29.07.2024.

Rajan Kumar Garg @ Rajan Garg, age 47 years son of Mohan Lal, r/o. House No.231/19, Near Bhisham Parkash Park, Aggarwal Niwas, Peerkhana Road, Khanna, Tehsil Khanna, District Ludhiana.                                                                                                                                           ..…Complainant

                                                Versus

1. HDFC ERGO Health Insurance Limited, formally known as M/s. Apollo Munich Health Insurance Co. Ltd., iLABS Centre, 2^nd and 3^rd Floor, Plot No.404-405, Udyog Vihar, Phase-III, Gurgaon-122016, through its Branch Manager.
2. HDFC ERGO Health Insurance Limited, formally known as M/s. Apollo Munich Health Insurance Co. Ltd., 2^nd Floor, SCO 146, Feroze Gandhi Market, Ludhiana-141001, Punjab through its Branch Manager.                                                                                           …..Opposite parties 

Complaint Under Section 12 of the Consumer Protection Act.

 

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. L.C. Bector, Advocate.

For OPs                          :         Sh. Ajay Chawla, Advocate.

 

ORDER

PER MONIKA BHAGAT, MEMBER

1.                Briefly stated, the facts of the complaint are that the complainant is a holder of health insurance policy No.110600/11121/6000087683-04 w.e.f. 19.03.2018 to 18.03.2019 of the OP which was in continuance since 4 years. At the time of purchasing the policy, the complainant was medically fit and policy was issued after completing all the necessary formalities. The OPs assured that at the time of any health problem, the policy will give health cover to the complainant and other family members. The complainant stated that on 10.08.2018, he was admitted to DMC & Hospital, Ludhiana and was discharged on 13.08.2018 where he spent Rs.43,905/- on his treatment and also spent Rs.5054/- on his pre and post hospitalization expenses. But the OPs refused to pass the cashless claim on the ground of concealment regarding diabetes. The complainant further stated that the treating doctor mistook the factum of diabetes whereas he was diagnosed as diabetes in the year 2015, after purchase of the policy and the treating doctor clarified the mistake vide his letter dated 10.08.2018 and same was sent to the OPs. The complainant contacted the OPs for disbursement of the medi-claim vide claim form dated 11.12.2018. The OPs asked the complainant to file an affidavit mentioning exact duration of detection of diabetes from the treatment doctor of DMC, Ludhiana and the same was mentioned in the clarification given by the DMC & Hospital, Ludhiana. However, the OPs have repudiated his genuine claim on 13.12.2018. The complainant further stated that he purchased a policy from PNB MetLife in the year 2011 after getting his clinical tests where no diabetes was detected to the complainant. The complainant claimed to have suffered loss of mental agony, harassment etc. due to repudiation of his claim for which he is entitled to compensation from the OPs. In the end, the complainant has prayed for issuing direction to the OPs to pay the amount of treatment of Rs.48,959/- i.e. Rs.43,905/- and Rs.5054/- along with interest and compensation of Rs.1,00,000/-.

2.                Upon notice, the OPs appeared and filed written statement by taking preliminary objections assailed the complaint on the ground of maintainability; lack of cause of action; concealment of material facts; concocted story for misleading the Commission has been generated in the complaint etc. The OPs stated that claims are paid by any insurance company out of the common pool of funds belonging to all policy holders and as such, insurer has to check admissibility of the claim before honouring it.

                   Under the column Brief Facts of the Case, the OPs stated that the complainant Rajan Kumar Garg submitted proposal form for purchase of Easy Health Individual Standard Plan for himself and his wife, on the basis of which policy No.110600/11121/6000087683 having validity from 12.03.2013 to 11.03.2014 was issued. The policy kit containing all the relevant documents were duly sent to the complainant giving free look period of 15 days from the receipt of the policy documents to review the terms and contract of the policy. The complainant raised no objection within the free look period and as such, he is strictly bound by the terms and conditions of the policy. A cashless claim request form treatment at Dayanand Medical College and Hospital for the complainant for treatment of UTI-Sepsis on 10.08.2018 with estimated amount of Rs.54,300/- was received. On post reviewing the documents, it was found that the complainant was having history of Diabetes syndrome since 10 years, which he has not disclosed at the time of the policy and as such, an evaluation query was raised, which is reproduced as under:-

                   “Exact duration of Diabetes, first consultation paper, Provide All              previous treatment records pertaining to Diabetes since 10 years.”

The OPs further stated that a reply to that effect was received wherein it was mentioned in the certificate of treating doctor that the complainant was suffering from DM since 3 years. Along with the said reply, the complainant also sent ICP where it was mentioned that DM was since 10 years.  The said fact was not disclosed at the time of availing the insurance policy. As such, the cashless claim was rejected vide letter dated 11.08.2020. The OPs further stated that they received reimbursement claim on 11.09.2018 request for treatment at Dayanand Medical College and Hospital for Rajan Kumar Garg who got admitted on 10.08.2018 to 13.08.2018 for Diagnosis made UTI- with mild prostatomegaly with DM2 with a claimed amount Rs.43,905/-. Since the case was already rejected in cashless due to Non-Disclosure of Diabetes, hence here also the case got rejected on wordings of non disclosure dated 23.09.2019.          

                   The OPs further stated that after the rejection of the claim the complainant approached them for grievance for reconsideration wherein the case was sent for investigation and after investigation discrepancy was noted about duration of Diabetes as the complainant stated that he was diagnosed Diabetes in 2015 and he also submitted prescription of year 2015 wherein it was mentioned K/C/O dm, hence left with no other alternative, an affidavit was asked from Treating doctor. When no such affidavit was received, then Reminders were sent on dated 22.11.2018 and 30.11.2018 but no reply was received, as such, the case was rejected on non-submission of documents vide letter dated 13.12.2018.

                   The OPs further stated that after the above said rejection, the complainant submitted a reply along with Hospital certificate in which hospital authority denied to provide affidavit and stated that whatever mentioned in ICP was based on history given by patient/attendant, so in absence of affidavit and above statement of hospital, the team was not in state for conclusion hence case got again rejected vide letter dated 22.12.2018 under non submission of affidavit. The OPs further stated that they have rightly rejected the claim as per the terms and conditions of the policy and the same was communicated to the complainant.

                   On merits, the OPs reiterated the facts stated in preliminary objections and brief facts of the case and denied the deficiency of service on their part. In the end, a prayer for dismissal of the complaint has been made.

3.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 is the copy of policy renewal letter dated 18.03.2018 along with policy schedule, Ex. C2 is the copy of detail bill dated 13.08.2018, Ex. C3 is the copy of In-Patient Final bill dated 13.08.2018, Ex. C4 to Ex. C23 are the bills/receipts of medicine etc., Ex. C23-A is the copy of test report of Kamal Computerized Laboratory, Khanna, Ex. C24 is the copy of rejection letter dated 13.12.2018Ex. C25 is the copy of Aadhar Card of the complainant and closed the evidence.

4.                On the other hand, counsel for the OPs tendered affidavit Ex. OPA of Sh. Manoj Kumar Prajapati, Manager-Corporate Legal of the OPs along with documents Ex. OP1 is the copy of proposal form dated 12.03.2013 and policy terms and conditions, Ex. OP2 is the copy of Pre-authorization form, Ex. OP3 and Ex. OP4 is the copy of Additional Information Request Form dated 11.08.2018 along with treatment record, Ex. OP5 is the copy of denial of cashless service dated 11.08.2018, Ex. OP6 is the copy of claim form, Ex. OP7 is the copy of rejection letter dated 23.09.2018, Ex. OP8 is the copy of First Reminder Letter dated 22.11.2018, Ex. OP9 is the copy of Final Reminder Letter dated 30.11.2018, Ex. OP10 is the copy of Rejection Letter dated 13.12.2018, Ex. OP11 is the copy of letter submitted by the complainant along with hospital documents, Ex. OP12 is the copy of rejection letter dated 22.12.2018 and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit produced on record by both the parties.       

6.                On the basis of proposal form dated 12.03.2013 Ex.OP1, the OPs issued Optima Restore Insurance coverage policy bearing No. 110600/11121/6000087683 having a sum insured of Rs.5,00,000/- for complainant and his wife Mrs. Indu Bala. The insurance policy was having validity from 12.03.2013 to 11.03.2014. The complainant got renewed the policy from time to time and vide policy Ex. C1 No.110600/11121/6000087683-04 having validity from 19.03.2018 to 18.03.2019.  On 11.08.2018, the complainant got admitted in Dayanand Medical College and Hospital, Ludhiana and was discharged on 13.08.2018 where he got treatment for UTI (E. Coli), Mild Prostatomegaly  and he incurred a sum of Rs.43,905/- vide bills Ex. C2 and Ex. C3. Besides this, the complainant claimed to have incurred a sum of Rs.5054/- on his pre and post hospitalization. The hospital authorities raised a cashless approval with the OPs vide pre-authorization form dated 10.08.2018 Ex. OP2 but the OPs vide letter dated 11.08.2018 Ex. OP5 repudiated the pre-authorization, the operative part of which is reproduced as under:-

                   “Reasons:

As per the available documents, we have observed that there is a non-disclosure of __ Diabetes__ (ailment) which may have an impact on policy and hence cashless approval would not be possible at this juncture.”

Thereafter, the complainant submitted a claim of Rs.43,905/- vide claim form Ex. OP6 but the OPs also rejected vide letter dated 23.09.2018 Ex. OP7. The operative part of Ex. OP7 is reproduced as under:-

“We have carefully reviewed your claim based on the document(s) submitted. We regret to inform you that your claim is not payable under the policy.

Reasons:

1. As per the available documents, we have observed that there is a non-disclosure of Diabetes, which may have an impact on policy and hence the claim is being rejected.”

On the request of the complainant for reconsideration of his claim, the OPs investigated the matter and asked the complainant to submit affidavit of treating doctor regarding exact duration of Diabetes Mellitus. The OPs sent reminders dated 22.11.2018 Ex. OP8 and 30.11.2018 Ex. OP9 calling upon the complainant to submit the particulars of details/documents required for settlement of the claim, which the complainant vide letter dated 17.12.2018 Ex. OP11 submitted the documents with the OPs. However, the OPs again rejected the claim of the complainant vide rejection letter dated 22.12.2018 Ex. OP12. The operative part of Ex. OP12 reads as under:-

1.“As per the query letters sent to you, we have observed that requirement raised by us has not been complied. Hence due to Non compliance of the requested documents we regret to inform you that your claim is repudiated under section VI i i of the policy. Please submit below documents at earliest to enable us to reopen the claim & decide on admissibility

2.Need Affidavit worth Rs 100/- from treating doctor for exact duration of diabetes mellitus

3.As per the available documents, we have observed that there is a non- disclosure of Diabetes, which may have an impact on policy and hence the claim is being rejected.”

 

7.                The main basis of repudiation of the claim by the OPs is that due to non-compliance of the requested documents as well as non submission of affidavit of treating doctor for exact duration of diabetes mellitus. The OPs did not produce any evidence in the form of medical record with regard to the diagnosis and treatment of said pre-existing disease except discharge summary dated 13.08.2018 attached with claim form Ex. OP6. As per this discharge summary the complainant was admitted with at DMC Hospital with complaint of fever for 25 days, burning micturation for 25 days and urgency and frequency of urine for 25 days where he was diagnosed of DM2 (HbA1C-9.5g%), UTI (E. Coli) and Mild Prostatomegaly and was discharged on 13.08.2018 in a stable condition. The complainant vide letter dated 17.12.2018 Ex. OP11 submitted the documents with the OPs except the demanded affidavit from treating doctor of DMC Hospital. However, the complainant submitted certificate dated 30.11.2018 of Dr. Neeraj Saini, PG Resident, Department of Medicine, DMC & Hospital, Ludhiana, which is reproduced as under:-

“This is to certify that Patient Sh. Rajan Garg S/o. Sh. Mohan Lal, 42 years old male, resident of Ward Number 231 , Aggarwal Niwas, Near Bhishan Parkash Park, Peer Khana Road, Khanna, Ludhiana (Punjab) was admitted to this hospital on 10^th October 2018; vide admission No.2018050565, MRD No.2018-557919 as a case of Type II DM (HBA1C-9.5g%) with UTI (E. Coli), Mid Prostastomegaly. I have gone through the contents of affidavit. There is no test to exactly determine the history of duration type II DM. Duration of Diabetes mentioned in clarification previously in based on history given by attendants & Patient. Hence the demanded affidavit cannot be given.”

8.                Perusal of discharge summary dated 13.08.2018 and certificate Ex. OP11 shows that the complainant was diagnosed of DM2 (HbA1C-9.5g%), UTI (E. Coli) and Mild Prostatomegaly and was discharged on 13.08.2018 in a stable condition. As per medical science, the UTI (E. Coli) is a type of UTI which usually caused by Escherichia coli (E. coli). E. coli is a type of bacteria commonly found in the gastrointestinal (GI) tract. But sometimes other bacteria are the cause. Further UTIs typically occur when bacteria enter the urinary tract through the urethra and begin to spread in the bladder. The urinary system is designed to keep out bacteria. But the defenses sometimes fail. When that happens, bacteria may take hold and grow into a full-blown infection in the urinary tract.

                   Further as per medical science, Mild Prostatomegaly is the condition of an enlarged prostate that means the gland has grown bigger. Prostate enlargement happens to almost all men as they get older. An enlarged prostate is often called benign prostatic hyperplasia (BPH). It is not cancer, and it does not raise your risk for prostate cancer.

                   However, no report of any treating doctor/expert has been placed on record either by the investigator or thereafter during the course of proceedings in the present complaint, so to arrive at a definite conclusion with regard to pre-ailment of the DM-II. Even assuming that at the time of his admission, the complainant was a known case of DM, still the claim cannot be repudiated treating this to be preexisting disease. Further, there is no nexus between the diagnosed disease and the alleged pre-existing disease. It is well settled that on account of non-disclosure of such general diseases, the genuine claim cannot be rejected. In this regard, reference can be made to Religare Health Insurance Company Ltd. Vs Subhash Chander Aggarwal in 2017(3) CLT 140 whereby it has been held by Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh that hypertension is a common disease and can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack.

9.                In this regard, reference can be made to Tarlok Chand Khanna Vs United India Insurance Co. Ltd. 2012(1) C.P.J. 84 whereby it has been held by Hon’ble National Consumer Disputes Redressal Commission, New Delhi  that the onus to prove that the insured was suffering from pre-existing disease was on the insurer and if the insurer has not produced the expert opinion, the reasons for repudiation of the claim were held to be unjustified. A reference can be further made to Lakhwinder Singh and another Vs United India Insurance Company etc.  decided in Appeal No.29 of 2009 whereby it has been held by Hon’ble State Consumer Disputes Redressal Commission, U.T, Chandigarh that the maladies like diabetes, hypertension being normal wear and tear of the life cannot be treated as pre-existing diseases.

10.              Further in a case titled as Manmohan Nanda Vs United India Assurance Co. Ltd. and others 2022(I) CPJ 20 (SC) wherein the Hon’ble Supreme Court of India has observed as under:-

“(6)   The appellant’s argument that there is no hard and fast rule that every person with DM-II will necessarily have a cardiac disease merely because it is a risk factor holds water. A person who does not suffer from DM-II can also suffer from a cardiac ailment. He had disclosed his DM-II status for which he was under treatment. The ECG report and other tests also indicated normal parameters. Further, statins were a preventive prescription to prevent development of cardiac issues as DM-II is a risk factor, not because he had a cardiac ailment or hyperlipidaemia. Further, the examining physician was informed of the same before the policy was taken. Accordingly, there was no suppression of any material fact by the appellant to the insurer.

(7)     It was for the insurer to gauge related complications based on the information provided. The insurance company did not think that the medical and health condition of the appellant was such which did not warrant issuance of a medical policy. The insurance company therefore did not decline the proposal of the assured as a prudent insurer.”

Therefore, in our considered view, the repudiation of the claim on the basis of non-disclosure of pre-existing diseases such as diabetes could not have been made a ground to reject the claim of the complainant.  The insurance companies are required to be more liberal in their approach without being too technical. In this case, the complainant has raised a claim of Rs.48,959/- (Rs.43,905/- and Rs.5054/- as pre and post hospitalization). In the given set of above said facts and circumstances, it would be just and appropriate if the OPs are directed to settle and pay the claim of the complainant within 30 days from the date of receipt of copy of order along with composite costs of Rs.10,000/-.

11.              As a result of above discussion, the complaint is partly allowed with direction to the OPs to settle and pay the claim of the complainant with respect to his hospitalization at Dayanand Medical College & Hospital, Ludhiana from 10.08.2018 to 13.08.2018 in terms of policy terms and conditions along with interest @8% per annum on the settled amount from the date of filing of complaint till its actual payment within 30 days from the date of receipt of copy of order. The OPs shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the complainant within 30 days from the date of receipt of copy of order.  Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

12.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)                                (Sanjeev Batra)

Member                                                President         

 

Announced in Open Commission.

Dated:29.07.2024.

Gobind Ram