Haryana

Kaithal

216/21

Ram Pal - Complainant(s)

Versus

Cholamandalam MS General Insurance Company - Opp.Party(s)

Sh.Abhishek Gupta

23 Jan 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KAITHAL

 

                                                               Complaint Case No. 216 of 2021.

                                                               Date of institution:   03.09.2021.

                                                               Date of decision:      23.01.2024.

 

Ram Pal s/o Shri Suraj Bhan, r/o Shop No.82, Anaj Mandi Pundri, Tehsil Pundri and District Kaithal.

                                                                                      …Complainant.

                                                       Versus

 

Cholamandalam MS General Insurance Company Limited, SCO 2463-2464, IInd Floor, Sector-22C, Chandigarh.

...Opposite Party.

 

          Complaint under Section 35 of the Consumer Protection Act

 

 

CORAM:   SMT. NEELAM KASHYAP, PRESIDENT.

                   SMT. SUMAN RANA, MEMBER.

                   SHRI SUNIL MOHAN TRIKHA, MEMBER.

                  

Present:       Shri Abhishek Gupta, Advocate for the complainant.   

                   Shri M.R. Miglani, Advocate for the Opposite Party.

                  

ORDER  -  NEELAM KASHYAP, PRESIDENT:

        Complainant has filed this complaint under Section 35 of Consumer Protection Act, 2019 (hereinafter referred to as ‘the Act’), against the OPs.

2.                In the complaint, complainant alleged that he had purchased a Group Health Insurance Policy (Family Floater/Arogya750) for himself and his wife w.e.f. 24.12.2020 to 23.12.2021 by paying premium amount of Rs.17895/- with sum insured of Rs.7,50,000/- from OP vide Policy Certificate No.2876/00107473/000002/000/00. On 24.05.2021, he suffered chest pain and profuse sweating and got admitted on 24.05.2021 at Cygnus Super Speciality Hospital, Kaithal, where Dr. Bhawani Shanker after checkup, done some investigation/tests and gave some medication to him and then, he was taken to Max Super Speciality Hospital, Mohali, where also his several investigation/tests were conducted and thereafter Operation (Bypass surgery) was advised/planed by the doctors. Max Super Speciality Hospital, Mohali had requested for cashless authorization from OP, who issued a cashless authorization letter to the hospital, through arbitrarily only an amount of Rs.75,000/- was initially approved by OP. Thereafter, Max Super Speciality Hospital, Mohali had requested for authorization of Rs.4,37,599/- from OP, which was denied vide denial letter dated 02.06.2021 by mentioning reasons: “Cashless cannot be extended in this case as probability of present ailment (Type II Diabetes Mellitus) to be a pre existing disease cannot be ruled out. Hence, cashless facility is being denied. Kindly note – initial approval stand null & void”. He remained admitted in the hospital from 24.05.2021 to 02.06.2021 and operation (Coronary Artery/By Pass) of him has been done on 28.05.2021. He also visited Dr. Rajan Mehra for his post operation follow up on 09.6.2021, 23.06.2021 and 27.06.2021. He had now spent an amount of Rs.4,62,043/- on his treatment/operation, testing/investigations, conveyance, medications and post hospitalization expenses etc. The denial of his claim by the OP, amounts to gross deficiency in service, on its part , due to which, he suffered huge physical harassment, mental agony as well as financial loss, constraining him, to file the present complaint, against the OP, before this Commission.

3.             Upon notice of complaint, OP appeared before this Commission and filed its written statement, the complainant had approached the OP for cashless claim only which was denied by OP and requested him to approach the OP for reimbursement of claim along with all requisite documents within 30 days from the date of discharge as mentioned in denial letter. It is further submitted that which documents were submitted by complainant are fabricated and manipulated one. Claim is inadmissible under general condition No.9 of the insurance policy. So, the insurance company has repudiated the claim of complainant on the legal and valid ground. Hence, there is no deficiency in service on the part of OP and prayed for dismissal the present complaint against it with costs.

4.                To prove the case, complainant tendered into evidence affidavit Ex.CW1/A alongwith documents Annexure-C1 to Annexure-C16.

5.                On the other hand, OP tendered into evidence affidavit Ex.RW1/A along with documents Annexure R-1 to Annexure R-3.

6.                We have heard the learned counsel for the parties and perused the record carefully.

7.                Learned counsel for the complainant has argued that the complainant had purchased a Group Health Insurance Policy (Family Floater/Arogya750) for himself and his wife w.e.f. 24.12.2020 to 23.12.2021 from OP with sum insured of Rs.7,50,000/-. He further argued that on 24.05.2021, the complainant suffered chest pain and profuse sweating and got admitted on 24.05.2021 at Cygnus Super Speciality Hospital, Kaithal and then, taken to Max Super Speciality Hospital, Mohali, where his several investigation/tests, Operation (Bypass surgery) was advised/planed by the doctors. He further argued that Max Super Speciality Hospital, Mohali had requested for cashless authorization from OP, who issued a cashless authorization letter to the hospital, through arbitrarily only an amount of Rs.75,000/- was initially approved by OP. He further argued that thereafter, Max Super Speciality Hospital, Mohali had requested for authorization of Rs.4,37,599/- from OP, which was illegally denied vide denial letter dated 02.06.2021. The complainant remained admitted in the hospital from 24.05.2021 to 02.06.2021 and operation (Coronary Artery/By Pass) of him has been done on 28.05.2021 and had spent an amount of Rs.4,62,043/-, on his treatment/operation, testing/investigations, conveyance, medications and post hospitalization expenses etc. The denial of his claim, by the OP, amounts to gross deficiency in service, on its part.

8.                On the other hand, learned counsel for OP has argued that the complainant had approached the OP for cashless claim, which was denied by OP and requested him to approach the OP for reimbursement of claim along with all requisite documents, within 30 days, from the date of discharge, as mentioned in denial letter. He further argued that which documents were submitted by complainant are fabricated and manipulated one and claim is inadmissible under General Condition No.9 of the insurance policy. So, the insurance company has repudiated the claim of complainant on the legal and valid ground. He further argued that there is no deficiency in service on the part of OP and prayed for dismissal the present complaint.

9.                 Undisputedly, the complainant had purchased a Family Floater/AROGYA750 policy from the OP for himself and his wife Radha Devi w.e.f. 24.12.2020 to 23.12.2021, by paying a premium amount of Rs.17,895/-, with sum insured of Rs.7,50,000/-, vide Policy Certificate No.2876/00107473/000002/000/00 Annexure  C-1.

10.              The grievance of the complainant is that he remained admitted in Max Super Speciality Hospital, Mohali from 24.05.2021 to 02.06.2021 vide Discharge Summary Annexure C-4 and other medical documents Annexure C-5 & C6 and spent an amount of Rs.4,62,043/-, but OPs illegally denied authorization request of said amount vide denial letter dated 02.06.2021 Annexure C-2, with the reason: “CASHLESS CANNOT BE EXTENDED IN THIS CASE AS PROBABILITY OF PRESETN AILMENT (Type II Diabetes Mellitus) TO BE A PRE EXISTING DISEASE CANNOT BE RULED OUT. HENCE CASHLESS FACILITY IS BEING DENIKED. Kindly note – Initial approval stands null & void”.

11.              From the perusal of above Denial Letter Annexure C-2, we found that the OP had denied the cashless facility, to the complainant, on the ground that complainant was suffering from Type-II Diabetes Mellitus i.e. pre-existing disease. However, it is pertinent to mention here that the OP cannot use the “diabetes mellitus” as pre-existing disease, for denial of the cashless authorization request. In this regard, we can rely on the case law titled “Life Insurance Corporation of India Vs. Sudha Jain 2007(2) CLT 423”, wherein the Hon'ble Delhi State Consumer Disputes Redressal Commission, New Delhi has drawn conclusions in para 9 of the order and the relevant clause 9(iii) is reproduced as under:-

"9(iii) Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease."

 

12.              Moreover, it is pertinent to mention here that the OP has not produced any medical record/documentary proof, on the case file vide which it can be proved that the complainant was suffering from Type-II Diabetes Mellitus or taking the treatment for the same. Further, affidavit of the treating doctor, who had diagnosed the alleged disease, to the complainant, has not been produced on the record by the OPs.

13.              From the record, it is born out that the age of complainant was more than 68 years, at the time of taking the policy in question, therefore, as per IRDAI guidelines, it was incumbent upon the OP, prior to accepting the premium and issuing the policy, got medically examined the complainant. As it has been held by the Hon’ble State Commission, U.T., Chandigarh, in the case of Manish Goyal Vs. Max Bupa Health Insurance Co. Ltd. and others, 2018 (2) CLT, 205 that “If the opposite parties themselves, failed to adhere the instructions issued by Insurance Regulatory & Development Authority of India (IRDAI), by putting the insured to through 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”.

14.              Furthermore, from perusal of Cashless Denial Letter dated 06.06.2021, written by the OP to the hospital Annexure R-3, we found that the OP had mentioned that “the claim is inadmissible under general condition D-9 as the insured person advanced claim knowing the same to be false or fraudulent in amount or otherwise”, but it is pertinent to mention here that the OP had failed to produce even a single document on the case file, vide which, it can be gathered that what type of fraud or manipulation, has been done by the complainant, violating general condition D-9 of the insurance policy.

15.              Learned counsel for the OP has further contended that the OP has demanded complete treatment details from the complainant vide letters dated 02.06.2021 and 06.06.2021 Annexure  R-2 and R-3, but the complainant failed to provide the same, as such, the present complaint is pre-mature and liable to be dismissed on this ground. In this regard, learned counsel for the complainant has contended that the complainant never received any alleged letter dated 02.06.2021 and 06.06.2021 from the OP. From perusal of letters Annexure R-2 and R-3 we found that these letters were written by the OP to Max Super Speciality Hospital, Mohali not to complainant. Moreover, OP has further produced any document on the case file, vide which, it can be proved that OP had written/sent those letters directly to the complainant. From the above pleadings, this contention of OP that complaint is pre-mature as complainant failed to supply the requisite treatment record with the OP, has no force, hence rejected.

16.              Keeping in view the case laws laid down by the superior Fora, in the case referred to above and the facts & circumstances of the present case, it has clearly been established on the record, the OP insurance company, without application of mind, in routine manner, declined the valid claim of the complainant, which amounted to an act of gross deficiency in service on the part of OP, causing mental agony, physical harassment and financial loss, to the complainant. Thus, the denial of the claim, done by the OP, is held to be unjustified. Hence, the OP is liable to reimburse the amount, which the complainant had incurred on his treatment.

17.              Now the question which arises for consideration is what should be the quantum of indemnification? In his complaint, complainant stated that he had spent total Rs.4,62,043/- on his treatment/operation, testing/investigations, conveyance, medications and post hospitalization expenses etc. and produced bills of Rs.12300+129.99+9000.97+430024+205.78+649.11+2104+840+2890 (Annexure C-8 to Annexure C-16 respectively), total for Rs.4,58,144/-. Since the sum insured in the policy in question was Rs.7,50,000/-, as such, OP is liable to reimburse the total amount of Rs.4,58,144/-, to the complainant along with compensation amount and litigation expenses.

18.              In view of our above discussion, we accept the present complaint and direct the OP, to make the payment of Rs.4,58,144/-, to the complainant, along with compensation amount of Rs.5,000/- + litigation expenses of Rs.5,000/-, within a period of 45 days, from the date of preparation of certified copy of this order, failing which, the award amount shall carry interest @6% per annum, from the date of this order, till its realization.

19.              In default of compliance of this order, proceedings shall be initiated under Section 72 of Consumer Protection Act, 2019, as non-compliance of Court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both. A copy of this order be sent to the parties free of cost. File be consigned to the records, after due compliance.     

Announced in open Commission:

Dt.:23.01.2024.

                                                                                      (Neelam Kashyap)

                                                                                      President.

 

(Sunil Mohan Trikha).             (Suman Rana).              

Member.                                  Member.

 

 

 

 

 

 

Typed by: Sham Kalra, Stenographer.