Orissa

Cuttak

CC/65/2019

Manash Ranjan Rout - Complainant(s)

Versus

Authorized Signatory- claims,Star Health and Allied Insurance Co Ltd - Opp.Party(s)

R K Pattanaik

29 Nov 2022

ORDER

 

IN THE COURT OF THE DIST. CONSUMER DISPUTES REDRESSAL COMMISSION,CUTTACK.

C.C.No.65/2019

 

1.Manas Ranjan Rout,

S/O:Satyabadi Rout,

 

2.       Satyabadi Rout,

          S/O:LateParabasiRout,

 

          (Both are residing at Qr. No.E/12,Police Officers Colony,

           At:Chauliaganj,PO:College Square,Cuttack-3).            ... Complainants.

 

                                                Vrs.

1. Star Health & Allied Insurance Co. Ltd.,

Represented through its Authorized Signatory-Claims, No.15,

Sri Sri Balaji Complex,1^stFloor,WhitesLane,Royapettah,

Chennai-600014.

 

     2.       Star Health & Allied Insurance Co. Ltd.,

               Represented through its Branch Manager,

               Cuttack Branch Office,Plot No.1677(P)/1678(P),

               2^ndFloor,Gajanana  Complex,

               Dolamundai,PO:Buxibazar,Cuttack-1          ... Opp. Parties.

 

 

Present:               Sri DebasishNayak,President.

                                                Sri SibanandaMohanty,Member.

 

            Date of filing:     11.06.2019

Date of Order:   29.11.2022

 

For the complainants:          Mr.R.K.Pattnaik,Adv.& Associates.

For the O.Ps  :          Mr.L.Sarangi,Adv. & Associates.

 

Sri Debasish Nayak,President.                                               

The case of the complainants as made in the complaint petition in short is that complainant no.2 had obtained a “Senior Citizen Red Carpet” policy from the O.Ps vide policy no.P/700002/01/2018/073014 which was effective from 1.3.18 to 28.2.19.  The said policy was initially taken by the complainant no.2 for the year 2016 and was being renewed annually by paying the premium amount of Rs.25,223/-.  While the said policy was inforce, complainant no.2 was admitted to Prime Hospital at Cuttack on 1.1.19 as he was having high fever and burning sensation in his foot.  He was subsequently diagnosed of having hypertension,diabetic and CKD.  After hospitalisation complainant no.2 was discharged on 2.1.19 and since because he was having health insurance policy, he had made his insurance claim.  The O.Ps though had admitted claim of cashless and had agreed to pay Rs.10,000/- but subsequently had denied for the same.  The complainant no.2 had to bear a sum of Rs.26,000/- towards his hospitalisation expenses.  After being discharged from the hospital, complainant no.2 had initiated for the reimbursement of the said amount from the O.Ps but his claim was rejected.  Subsequently thecomplainant no.2 was admitted to Vivekananda Hospital at Bhubaneswar on 3.1.19 and he had to incur medical expenses of Rs.19,000/- from his own pocket there.  After being discharged therefrom on 4.1.19 he had also tried to reimburse the said amount from the O.Ps but his effort was futile.  The complainant no.2 was again hospitalised at Ashwini Hospital, Cuttack for the same diseases with effect from 4.1.19 to 17.1.19 and had to bear medical expenses to the tune of Rs.2,07,000/-.  After being discharged from the Ashwini Hospital at Cuttack complainant no.2 had raised his claim before the O.Ps.  The complainant no.2 was thereafter again hospitalised at Sadguru Hospital with effect from 1.3.19 to 26.3.19 for the same diseases.  There the complainant no.2 had to pay Rs.2,72,852/- for which he hadalso lodged claim for the said amount before the O.Ps.  But the claims of the complainant no.2 were repudiated by the O.Ps on the plea that he could not provide necessary documents and that he was suffering from pre-existing diseases.  According to the complainants, these pleas of the O.Ps were all false  as because complainant no.2 was never suffering from any ailment prior to taking the policy and that they had provided all the required documents for settling the claims.  The complainants, thus have filed this case claiming the total expenses as incurred towards the medical treatment of complainant no.2 at Prime Hospital of Cuttack,Vivekananda Hospital at Bhubaneswar, Ashwini Hospital at Cuttack and Sadguru Hospital to the tune of Rs.26,000/-,Rs.19,000,Rs.2,07,000/- & Rs.2,72,852/- respectively.  The complainants have further claimed compensation for their mental agony and harassment to the tune of Rs.1,00,000/- from the O.Psalongwith a cost of Rs.20,000/- towards their litigation expenses.

In order to establish their case, the complainants have filed copies of several documents including the insurance policy copy and hospitalisation expenses copy etc.

2.         The O.Ps have contested this case and have filed their written version jointly in the shape of objection.  According to them, complainant no.2 was admitted at Prime Hospital, Cuttack on 1.1.19 for treatment of bilateral Pneumonia, sepsis/diabetes,mellitus/hypertension/coronary artery diseases-Pulmonary Artery Hypertension/Acute kidney injury over chronic kidney disease.  The complainant no.2 had submitted a request for reauthorization for cashless treatment on 1.1.9 which was initially approved for a sum of Rs.10,000/- vide letter dt.2.1.19 but subsequently the O.Ps could notice from the documents that complainant no.2 had chronic kidney disease, chronicobstratic pulmonary disease, coronary artery disease with ejection fraction 41% duration of which cannot be ascertained in cash less processing.  It is for this the pre-authorization was withdrawn vide letter dt.2.1.19.  Since because the complainant no.2 was a known case of hypertension, diabetes, mellitus,coronary artery disease, chronic kidney disease, chronic obstratic pulmonary disease his claim for Rs.32,040/- on 11.1.19 could not be settled.  But subsequently the treating hospital had submitted a letter dt.2.1.19 stating therein that he had no past history of chronic kidney disease and hypertension but the claim of the complainants were rejected which was communicated through letter dt.5.3.19 relying upon the condition no.9 of the terms and conditions of the policy.

 Complainant no.2 being readmitted to Vivekananda Hospital at Bhubaneswar on 3.1.19 was being treated for type-2 diabetics, mellitus chronic kidney, pneumonia-morbid obesity, DCM, SEV-LV-dysfunction, hypertension.  For this treatment the complainant no.2 had made a claim of Rs.19,000/- on 15.1.19.  But the documents furnished thereto by the complainant no.2 were not sufficient for processing the claim for which the O.Ps had asked a letter from the treating doctor stating the exact duration of diabetes, mellitus, hypertension, DCM and cardiac ailments. They have also asked for any hospitalizations of similar episodes in the past, any history of proving hospitalizations for major illness in the past, all past ECG, ECHO and other relevant investigation report taken in the current admission and also all past OPD consultation papers relating to cardiac ailment and DCMs.   They had issued several reminders to complainant no.2 in this regard vide letter dt.24.1.19 and reminders dt.8.2.19 and 23.2.19.  It is for this, they have rejected the said claim of the complainant no.2.

The claim of the complainant no.2 as regards to his treatment at Ashwini Hospital,Cuttack was also repudiated due to want of the letter from the treating doctor stating the exact duration of diabetes, mellitus and hypertension, DCM and cardiac ailment, history of previous hospitalization for major illness in the past. All past OPD consultation papers relating to cardiac ailment and DCMs, reminders were also issued to the complainant no.2 in this regard.  The letter of the O.Ps in this context is dt.7.3.19 and reminders dt.22.3.19 and 6.4.19.  Thus due to want of the said documents the said claim was also repudiated through the letter of the O.Ps dt.21.4.19.

The complainant had further claimed for his treatment at Sadguru Hospital at Cuttack but that was also rejected by the O.Ps through their letter dt.24.4.19 due to want of the documents like letter from the treating doctor stating the exact duration of diabetes, mellitus and hypertension, DCM and cardiac ailments in the past, any history of similar episodes in the past, any history of previous hospitalizations for major illness in the past.  They had also issued reminders to the complainant no.2 in this aspect vide their reminders dt.9.5.19,24.5.19 and ultimately had repudiated the claim on 8.6.19.  Thus it is the claim of the O.Ps to reject the complaint petition as filed by the complainant.

3.         Keeping in mind the averments as made in the complaint petition and the contents of the written version, this Commission thinks it proper to settle the following issues in order to arrive at a proper conclusion.

i.          Whether the case of the complainant is maintainable?

ii.         Whether there was any deficiency in service on the part of the O.Ps and if they had practised unfair trade?

iii.        Whether the complainants are entitled to the reliefs as claimed ?

Issue No.ii.

Out of the three issues, Issue no.ii being the most pertinent issue is taken up first for consideration here in this case.

Admittedly, the complainant no.2. was having a health insurance policy from the O.Ps which was effective when he had undergone treatments as regards to his health issues first at Prime Hospital,Cuttack, then shifted to Vivekananda Hospital at Bhubaneswar, then shifted to Ashwini Hospital at Cuttack and ultimately at Sadguru Hospital.  He had borne the medical expenses at all these places for his hospitalization to the tune of Rs.5,24,852/-.  All his medical claims were repudiated by the O.Ps as because the complainant no.2 could not produce the desired documents as claimed by the O.Ps from the complainant no.2.  On perusal of the copies of documents as filed by the complainants here in this case, it is noticed that the hospitalization documents of the complainant no.2 were available with the complainants those which were submitted before the O.Ps for settling the medical claims of the complainant no.2. As it appears that the O.Ps had required several other documents those which were not in possession and control of the complainants but due to non-production of those, the claim of the complainant no.2 as regards to his medical treatments could not be settled.  In this context it would be worthwhile to quote the pertinent decision of our Hon’ble Apex Court settled in the case of Mr.Gurmel Singh Vrs. Branch Mananger,National Insurance Co. Ltd. wherein their lordships have held that “Insurance companies refusing claim on flimsy grounds and/or technical grounds- While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control”.   Thus, keeping in mind the aforesaid citation, the claim of the O.Ps as regards to documents those which are not within the possession and control of the complainants and by repudiating the claim in that score appears to be made unilaterally, arbitrarily which is illegal.  The O.Ps have also raised another context regarding suppression of material facts but they have not produced any document in order to apprise this Commission that infact the complainant no.2 had pre-existing diseases prior to entering into the insurance policy those which he had suppressed.  Rather, they admit that the treating hospital of the complainant no.2 through their letter dt.2.1.19 have mentioned that the complainant no.2 had no past history of any chronic kidney disease and hypertension.  Hence, such plea of the O.Ps also do not hold good.  Accordingly, by repudiating all the medical claims of the complainant no.2 clearly signifies deficiency in service on the part of O.Ps and also about their practice of unfair trade.  Accordingly, this issue is answered in favour of the complainants.

 

Issues no.i& iii.

From the above discussions, it is noticed that the case of the complainants as filed is definitely maintainable and the complainant is entitled to the reliefs as claimed by them.  Hence it is so ordered;

                                    ORDER

The case is decreed on contest against both the O.Ps who are found to be jointly and severally liable.  The O.Ps are thus directed to pay the complainants all the medical expenses as incurred by them to the tune of Rs.5,24,852/- alongwith interest thereon @ 12% per annum with effect from April,2019 till the total amount is quantified.  The O.Ps are further directed to pay compensation of Rs.1,00,000/- to the complainants towards their mental agony and harassment and to bear the litigation expenses of the complainants to the tune of Rs.20,000/-.  This order is to be carried out within a period of 30 days from the date of receipt of copy of this order.

Order pronounced in the open court on the 29^th day of   November,2022 under the seal and signature of this Commission.             

                                                                                                                                Sri Debasish Nayak

                                                                                                                                            President

                       

                                                                                                                                                                 Sri Sibananda Mohanty

                                                                                                                                                Member