Chandigarh

DF-I

CC/212/2023

RAJ KUMAR KHOSLA - Complainant(s)

Versus

CARE HEALTH INSURANCE - Opp.Party(s)

GAURAV KANT GOEL

02 May 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/212/2023
Date of Institution	:	21/04/2023
Date of Decision	:	02/05/2024

 

Raj Kumar Khosla aged 76 years S/o Late Sh. Ram Prakesh R/o House No.638/1, Sector-41 A, Chandigarh-160030.

… Complainant

V E R S U S

1. Care Health Insurance through its Managing Director/ Authorized Person having its registered office at SCO No.56-57-58, 2^nd Floor, Sector-9-D, Chandigarh- 160009.

        2nd Address: Corporate Office at Unit No.604-607, 6^th Floor, Tower-C, Unitech Cyber Park, Sector-39, Gurugram, Haryana-122001.

2.     Care Health Insurance (Formerly known as Religare Health Insurance Co. Ltd.) through its Managing Director/ Authorized Person having its registered office at 5^th Floor, 19 Chawla House, Nehru Place, New Delhi-110019.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

 

                                                                                       

ARGUED BY	:	Sh. Gaurav Kant Goel alongwith Ms. Sonali Aggarwal, Advocates for complainant
	:	Sh. Raj K. Narang, Advocate for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Raj Kumar Khosla, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that as the complainant and his wife, Smt. Kanta Khosla had planned to meet their son and his family in London, therefore, on 1.9.2022, they took an insurance policy namely “Platinum WW-EX-US/Canada” (hereinafter referred to as “subject policy”) from the OPs on payment of requisite premium with sum assured of US $ 1,00,000/- each and the same was valid w.e.f. 7.9.2022 to 31.1.2023.  As per the scheduled programme, complainant and his wife went to London on 7.9.2022.  On the midnight of 19.1.2023, complainant felt uneasiness and when he went to the rest room, he noticed passing of black stool.  On the very next day i.e. 20.1.2023, son of the complainant took him to Northwick Park Hospital, London (hereinafter referred to as “Treating Hospital”) in emergency and at that time it was found by the said hospital that the complainant was suffering from the disease of ‘Duodenal Ulcers’ which needed to be operated on urgent basis.  The complainant was hospitalised on 20.1.2023 in the Treating Hospital and various tests were conducted and it was declared by the doctors that he was suffering from bleeding in upper digestive system due to ulcers for which he was required to be operated.  Upon knowing the aforesaid fact, son of the complainant immediately informed the OPs regarding the operation/treatment through email dated 23.1.2023 (Annexure C-2) with the request for cashless insurance and the OPs vide email (Annexure C-3) replied that the pre-authorization can only be availed within 24 hours of admission in the hospital.  In pursuance to the email dated 23.1.2023, son of the complainant had sent all the documents required by the OPs vide email dated 26.1.2023 (Annexure C-4).  OPs had raised certain query vide email dated 1.2.2023 (Annexure C-7) which were addressed by the son of complainant vide email dated 2.2.2023 (Annexure C-8). However, vide letter/email dated 10.2.2023 (Annexure C-9 & C-10), OPs rejected the claim of the complainant on the ground of non disclosure of pre-existing disease.  The complainant was discharged on 25.1.2023 vide discharge summary (Annexure C-11) and due to rejection of claim, complainant was compelled to pay an amount of 6828 pounds i.e. ₹7,01,386.71 towards the expenses spent on his hospitalization and surgery.  Copies of invoice and payment receipt are Annexure C-12 & C-13.  It is further alleged that, in fact, complainant was treated for ‘duodenal GIST’ in the year 2012 and even otherwise the said treatment taken by him long back does not make the same as pre-existing disease as per terms and conditions of the subject policy.  In this manner, the aforesaid act of the OPs in illegally and arbitrarily rejecting the genuine claim of the complainant amounts to deficiency in service and unfair trade practice.  OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action and concealment of facts.  However, it is admitted that the subject policy was purchased by the complainant and cashless request was made by the complainant with the OPs, which was denied on the ground of concealment of material facts qua pre-existing disease from which the complainant was suffering and had taken treatment in the year 2012 at PGI, Chandigarh and in the year 2018 at Medanta Hospital, Gurgaon.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had obtained the subject policy (Annexure C-1) from the OPs, which was valid w.e.f 7.9.2022 to 31.1.2023 with sum assured of US $ 1,00,000/- each for the complainant and his wife and the complainant had even disclosed about the pre-existing diseases at the time of purchasing the subject policy i.e. ‘BP, cholesterol, thyroid, prostate gland medicine undergone bile duct stone removal in June 2019’ and the complainant had earlier taken treatment for ‘duodenal GIST’ in the year 2012 from PGI, Chandigarh, as is also evident from copy of discharge summary (Ex.OP-5) and for ‘GIST – duodenal tumour’ on 4.5.2018, as is also evident from the copy of discharge summary (Ex.OP-4) of Medanta Hospital, Gurgaon, having been relied upon by the OPs, and he had been treated for ‘bleeding in upper digestive system due to ulcers’ at the Treating Hospital in London where he remained hospitalized from 20.1.2023 to 25.1.2023, as is also evident from the discharge summary (Annexure C-11) and the claim of the complainant had been rejected by the OPs vide letter/email dated 10.2.2023 (Annexure C-9 & C-10) on the ground of non-disclosure of pre existing disease, the case is reduced to a narrow compass as it is to be determined if the OPs/insurers are unjustified in rejecting/denying the claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs/insurers have rightly denied/rejected the claim of the complainant and the consumer complaint of the complainants being false and frivolous is liable to be dismissed, as is the defence of OPs. 
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the subject policy as well as its terms and conditions, medical record and claim rejection/denial letter and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Perusal of the subject policy (Annexure C-1) clearly indicates that the same was obtained by the complainant on 1.9.2022 and the same was valid w.e.f. 7.9.2022 to 31.1.2023 with sum assured of US $ 1,00,000/- each covering the complainant and his wife.  Further, terms & conditions of the subject policy (Annexure C-14) defines the pre-existing disease as under :-

“1.62 Pre-existing Disease means any condition, ailment or Injury or related condition(s) for which the Insured Person had signs or symptoms, and/or were diagnosed, and/or received Medical Advice/treatment within 48 months to prior to the first policy issued by the Company.”

4. Perusal of discharge and follow up card (Ex.OP-5) of the PGI, Chandigarh clearly indicates that the complainant was diagnosed with ‘Duodenal GIST’  and surgery was performed on 13.1.2012. Ex.OP-4 is the discharge summary of Medanta Hospital, Gurgaon, which clearly indicates that the complainant was admitted in the said hospital on 2.5.2018 and was treated for ‘duodenal GIST’ and the relevant portion of the same is reproduced below for ready reference:-

 “Diagnosis & Co-morbidities :

Duodenal GIST - post Whipple's with hepatico jejunostomy (2012)

Intermittent cholangitis with intrahepatic stones and choledocholithiasis

Post HJ dilation with CBD clearance done (4 drains in situ)

Post intrahepatic stone extraction (By IR team)

Iron deficiency anemia”

5. Annexure C-11 is copy of discharge summary of the Treating Hospital at London, which clearly indicates that the complainant was admitted in the said hospital on 20.1.2023 and discharged on 25.1.2023 and he was diagnosed with ‘Duodenal ulcer’.
6. Annexure C-9 & C-10 are copies of letter/email dated 10.2.2023 through which claim of complainant for cashless settlement was rejected/denied by the OPs on account of non-disclosure of pre existing disease. The relevant portion of the said letter is reproduced below for ready reference :-

“We are in receipt of your request for cashless settlement related to hospitalization of Mr Raj Kumar Khosla, as per the following detail:

Policy Number: 45798245

Claim reference number: IN1300019770

We have reviewed your request, and hereby inform you that the cashless settlement for hospitalization cannot be approved as per the Policy Terms & Conditions. For ease of your perusal, we have reproduced the reason below:

CLAUSE: 7.1 NON DISCLOSURE OF PRE EXISTING DISEASE

GIST Duodenal tumour Whipples Resection IDA IHD.”

 

7. The learned counsel for the complainant contended with vehemence that as it stands proved on record that the insured patient had suffered from ‘Duodenal GIST’ in the year 2012 and 2018, for which he had taken treatment from the PGI, Chandigarh and Medanta Hospital, Gurgaon respectively whereas the subject policy was purchased by him on 1.9.2022 i.e. much after the prescribed period of 48 months as per terms and conditions of the subject policy,  OPs have wrongly denied/rejected the genuine claim of the complainant.
8. On the other hand, learned counsel for the OPs contended with vehemence that as it stands proved on record that the complainant had concealed material facts while obtaining the subject policy, the claim was rightly rejected/denied for non-disclosure of pre-existing disease.
9. However, there is no force in the contention of the learned counsel for the OPs as it stands proved on record that the subject policy was purchased by the complainant on 1.9.2022 i.e. after more than 51 months of the last treatment, which was taken by him on 4.5.2018 in the year 2018, i.e. beyond the prescribed period of 48 months.  Hence, it is safe to hold that the denial of the claim of the complainant by the OPs on the ground of non-disclosure of material facts qua pre-existing disease is against the terms conditions of the subject policy and is illegal and arbitrary.
10. In support of his case, learned counsel for the complainant has relied upon the order dated 22.11.2007 passed by the Hon’ble Delhi State Commission in Oriental Insurance Co. Ltd. & Ors. Vs. Hans Raj Khurana, Appeal No.162 of 2004 in which it was held as under :-

        “Consumer Protection Act, 1986 Sections 2 and 14 Medical Insurance Claim - Medical claim was rejected by appellant/company on ground of ‘non-disclosure' of pre-existing disease - Surgery of gall bladder stones - At time of taking policy in question, there was no pre- existing disease since earlier operation was done seven years back - Failure to produce papers of previous illness - Held - If, same problem developed after seven years it cannot assume a character of pre-existing disease or non-disclosure of pre-existing disease - Facts and circumstances considered - Insurance company directed to pay Rs.45,007/- towards medical expenses and Rs.15,000/- towards mental agony and harassment - Appeal partly allowed.”

 

11. The learned counsel has further relied on the order dated 22.3.2018 passed by our own Hon’ble State Commission in Manish Goyal Vs. Max Bupa Health Insurance Company Limited in which it was held as under :-

B. Consumer Protection Act, 1986 Section 2(1)(g) Insurance claim - Rejected on ground that insured not disclosed the pre-existing disease and doctor recorded the past history of illness - Age of insured was more than 45 years at the time policy issued - No medical examination got conducted by Insurance Company - Held, if the opposite parties themselves, failed to adhere the instructions issued by Insurance Regulatory and Development Authority of India (IRDAI), by putting the insured to thorough medical examination, being her age more than 45 years, and were interested in collecting premium from the complainant, as such, now at this stage, they cannot evade their liability - Complaint partly allowed.”

12. In view of the foregoing discussion and the ratio of law laid down above, it is unsafe to hold that OPs/insurers were justified in denying/rejecting the claim of the complainants qua the subject policy and the present consumer complaint deserves to succeed. 
13. Now coming to the quantum of amount, since the complainant has proved the invoice/bill dated 30.1.2023 amounting to £6828 = ₹7,01,386.71 (rounded off to ₹7,01,387/-) towards the expenses spent on his hospitalisation/treatment and the subject policy further indicates 200 USD was deductible in case of in-patient and out-patient care, and the equivalent of the same in Indian currency comes to 200 x 73 (average rate of 2023) = ₹14,600/-, it is safe to hold that the OPs/insurers are liable to pay total amount of ₹7,01,387 – ₹14,600 = ₹6,86,787/- to complainant alongwith interest and compensation etc.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹6,86,787/- to complainant alongwith interest @ 9% per annum from the date of denial/rejection of the claim i.e. 10.2.2023 onwards.
2. to pay ₹30,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainants as costs of litigation.

5. This order be complied with by the OPs within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

02/05/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member
	Sd/- [Suresh Kumar Sardana] Member