Order by:
Aparana Kundi, Member
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant availed a health insurance policy for himself and his family from Opposite Parties on 16.09.2022, bearing no.P/211222/01/2023/006113 and the said policy is valid upto 15.09.2023. Unfortunately on dated 04.04.2023, the complainant got admitted in Neuro Citi, Ludhiana and after that he was referred to Hero DMC Hospital for treatment on 05.04.2023 and after treatment got discharged from the DMC & Hospital on 11.04.2023. At the time of treatment and after discharging from the hospital, the complainant requested the Opposite Parties to pay all the medical expenses including Pre and Post to the complainant, but the Opposite Parties lingered on the matter on one pretext or the other and did not pay the expenses of treatment. After taking treatment from the hospitals, the complainant also submitted all the medical record to Opposite Parties as per their demand, but inspite of that the Opposite Parties had not paid any amount in lieu of medical expenses to the complainant. Alleged that the complainant has made the payment of Rs.1,63,244/- to the said hospitals with regard to his treatment from this own pocket. The complainant requested many time to make the payment of claim, but the Opposite Parties refused to make the payment to the complainant. However, vide letter dated 17.08.2023, the Opposite Parties repudiated the claim of the complainant on the basis of false and baseless reason. Due to such an act and conduct of the Opposite Parties, the complainant has suffered mental tension and harassment. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to pay an amount of Rs.1,63,244/- alongwith interest @ 24% p.a. till its realization.
b) To pay a sum of Rs.30,000/- as compensation on account of mental tension, and harassment.
c) To pay Rs.22,000/- as litigation expenses.
d) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination, which is not possible in the summary procedure under C.P. Act; the complainant has concealed material facts and documents from this Commission as well as from the Opposite Parties, therefore, the complainant is not entitled to any relief. The complainant has concealed the fact that he has violated the terms and conditions of policy in question and no PED was declared and the policy inception was 16.09.2022. The real facts are that the complainant availed the ‘Family Health Optima Insurance Plan’ bearing No.P/211222/01/2023/006113 for the period 16.09.2022 to 15.09.20023 and in this policy complainant, his wife Rita Rani and two dependent children namely Yogesh Bansal and Chandan Bansal were insured for an amount of Rs.5 lakh. The terms and conditions of the policy were explained to the complainant at the time of proposing the policy and same were served to the complainant alongwith policy schedule. The complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Averred further that the claim in dispute is reported in the first year of the policy and complainant filed two claims CIR/2024/211222/0025693 and CIR/2024/211222/0380287 with Opposite Parties. Submitted that with regard to first claim, the insured has requested for cashless only and submitted claim documents for the treatment of HTN at Dayanand Medical College and Hospital, Ludhiana on dated 05.04.2023 to 11.04.2023. On the basis of the claim documents, the cashless was denied with the reason that Opposite Parties are not able to ascertain the duration of the disease based on the documents/details submitted and it requires further evaluation and later on insured applied for the reimbursement of medical expenses. On scrutiny of claim documents, the following documents were necessary to process the claim:-
Treating doctor’s letter stating exact duration and cause of DVT, PTE and clarify duration of Hypertension, Epilepsy, kindly submit past treatment records.
As per submitted documents patient is known case of Liver disease submit all treatment records towards the same, past and recent USG, LFT, clarify cause for liver disease.
Past admission and treatment records.
Vide letter dated 16.05.2023, 31.05.2023, 15.06.2023 and 30.06.2023 insured was advised to furnish the aforesaid documents. Further insured submitted the query reply. In order to process the claim, Opposite Parties requested the insured to furnish the past medical reports, but the insured has not furnished the required documents and details. In the absence of above documents/details, Opposite Parties are not liable to process the claim. Hence, the claim was repudiated vide letter dated 17.08.2023.
With regard to second claim, it has been submitted that the insured has requested for reimbursement and submitted documents for the treatment of HTN at Dayanand Medical College and Hospital, Ludhiana on dated 04.04.2023 to 05.04.2023 (wrongly mentioned in written reply as 04.04.2023 to 04.04.2023). In order to process the claim following documents were necessary to process the claim:-
Treating doctor’s letter stating exact duration and cause of DVT, PTE and clarify duration of Hypertension, Epilepsy, kindly submit past treatment records.
As per submitted documents patient is known case of Liver disease submit all treatment records towards the same, past and recent USG, LFT.
Clarification letter from treating doctor stating the exact cause for liver disease.
Past admission and treatment records.
Vide letter dated 26.06.2023, 11.07.2023 and 26.07.2023 insured was advised to furnish the aforesaid documents. Even after reminders, the insured has not sent the aforesaid documents. Hence, the claim was repudiated vide letter dated 10.08.2023. Averred that before repudiating the claim of insured, sufficient reminders/opportunities were given to the complainant to submit the required documents. Even after reminders, insured has not furnished the above sought documents. Therefore the Opposite Parties were forced to reject the claim for non-submission of documents. Averred further that the complainant has no locus standi or cause of action to file the present complaint against the Opposite Parties; the complaint is not maintainable in the present form; the complainant has violated the terms and conditions of the policy. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. In order to prove the case, complainant has placed on record his affidavit as Ex.C1 alongwith copies of documents Ex.C2 to Ex.C7.
4. On the other hand, Opposite Parties have placed on record copies of documents Ex.OP1 to Ex.OP16 and affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd. as Ex.OP17.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. It is admitted and proved on record that the complainant availed health insurance policy namely ‘Family Health Optima Insurance Plan’ bearing no.P/211222/01/2023/006113 for the period 16.09.2022 to 15.09.2023 for self, his wife and two dependent children for a sum insured of Rs.5,00,000/-. It is also proved on record that during the policy coverage, complainant suffered ‘Acute Pulmonary Thrombo-embolism with Pulmonary Artery Hypertension compensated Respiratory Alkalosis Seizures Elevated Venous Ammonia’ and got admitted in Neurocity Hospital, Ludhiana on 04.04.2023 and after treatment got discharged from the hospital on 05.04.2023. Thereafter, complainant again suffered ‘Hypertension, Acute DVT Right Popliteal Vein and Acute Pulmonary Thromboembolism and got admitted in Hero DMC Heart Institute on 05.04.2023 and after treatment the complainant discharged from the hospital on 11.04.2023. It is also not disputed that during hospitalization period, the complainant requested the Opposite Parties for cashless treatment, but the request of the complainant was denied by the Opposite Parties, vide letter dated 06.04.2023. The lodging of claim by the complainant is also not denied.
7. It is pertinent to mention here that wrong facts regarding the admission of the complainant in Neurocitiy Hospital is mentioned in the written reply of Opposite Parties. In written reply, Opposite Parties mentioned that the complainant admitted in Dayanand Medical College and Hospital for the period 04.04.2023 to 04.04.2023, however perusal of the record reveals that complainant was not admitted for the said period in DMC Medical College and Hospital. Further it has been mentioned by Opposite Parties that they issued letters/reminders dated 26.06.2023, 11.07.2023 and 26.07.2023 and thereafter vide letter dated 10.08.2023, they repudiated the claim of the complainant, but on record, there is no any such letter as well as repudiation letter dated 10.08.2023.
8. Now, we come to the second claim lodged by the complainant regarding the hospitalization expenses incurred by him at DMC Hero Heart Institute, Ludhiana for the period 05.04.2023 to 11.04.2023. It is on record that on lodging of the claim by the complainant, the Opposite Parties issued letters dated 16.05.2023, 31.05.2023, 15.06.2023 and 30.06.2023 requiring the following documents:-
Treating doctor’s letter stating exact duration and cause of DVT, PTE and clarify duration of Hypertension, Epilepsy, kindly submit past treatment records.
As per submitted documents patient is known case of Liver disease submit all treatment records towards the same, past and recent USG, LFT, clarify cause for liver disease.
Past admission and treatment records.
But the complainant failed to supply aforesaid documents to the Opposite Parties. Thereafter, Opposite Parties repudiated the claim of the complainant, vide letter dated 17.08.2023. The contents of which are reproduced as under:-
“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of HTN. Acute DVT Popliteal Vein, Acute Pulmonary Thromboembolism.
In order to process the claim, we requested you to furnish the past medical reports. We note that you have not furnished the required documents and details. In the absence of the above documents/details, we are not able to further process your claim.
As per Condition No.18 of the policy, the insured person has to submit all the required documents and details called for by us.
We therefore regret to inform you that for the reasons stated above we are unable to settle your claim under the above policy and we hereby repudiate your claim.
9. We are of the considered view that the repudiation of the claim of the complainant for want of past medical history/documents is not genuine, as in the Discharge Summary (Ex.C3) under heading History of illness, it is mentioned that “51 years male, presented with chief complaints of chest pain and shortness of breach since 4-5 days and syncope one day prior to admission. Furthermore the Certificate duly issued by doctor concerned of Hero DMC Heart Institute (attached with Ex.C3), it is mentioned as under:-
“Patient was presented with chief complaints of chest pain and shortness of breath since 4-5 days and syncope one day prior to admission. DVT and Pulmonary Thromboembolism diagnosed on presentation to the emergency department. Hypertension from last two months, prior to hospital admission.
From the aforesaid documents, it is clear that the complainant is suffering from the ailment in question few days from the admission in the hospital and the complainant came to know about his disease after admitting in the hospital. Hence, the demand of the Opposite Parties regarding the past medical history/documents is unjustified. Moreover, if the complainant was suffering from any disease prior to issuance of the policy, in question, the same must not have been escaped from the notice of the empanelled doctors of the Insurance Company. However, no such investigation record has been produced by the opposite parties.
10. Further as per policy document (Ex.C2), the complainant has mentioned his date of birth as 20.12.1971 and date of inception of first policy is mentioned as 16.09.2022, meaning thereby that at the time availing the first policy, the age of the complainant was more than 45 years, so it was the bounden duty of the Opposite Party-Insurance Company to get the life assured medically examined before issuing the policy in his/her name who was above the 45 years of age. As per the I.R.D.A.I Rules and Instructions with regard to thorough medical examination if the insured is more than 45 years which is reproduced as under:-
“As per instructions issued by the Insurance Regulatory and Development Authority of India (IRDAI), it was bounded duty of the insurer to put insured to thorough medical examination in case Mediclaim insured was more than 45 years and if insurance company failed to do so then insurance company has no right to decline the insurance claim on account of non disclosure of the facts of pre existing disease when the policy was taken. The above observations is supported by law cited in SBI General Insurance Company Limited Vs. Balwinder Singh Jolly” 2016(4) CLT 372 of the Hon’ble State Commission, Chandigarh.”
However, the Opposite Party-Insurance Company has not placed on record any evidence that before issuing the policy they ever got medically examined the insured. From the discussion above, we are of the concerted view that Opposite Party illegally and wrongly repudiated the genuine claim of the complainant.
11. It is again pertinent to mention here that the complainant has placed on record only one claim form as Ex.C5, whereas, the Opposite Parties have placed on record two claim forms as Ex.OP6 and Ex.OP9. While claim form produced on record as Ex.C5 and Ex.OP6 are of same hospitalization period and it showed the amount of Rs.1,63,244/-, but the other claim form placed on record by Opposite Parties as Ex.OP9 is not in the complainant’s record and moreover in this claim form there is no mentioning of dates of treatment, hospital name etc. and it only shows the claimed amount of Rs.48,409/-, but the said amount is not proved on record. Moreover, the bills produced on record pertaining to 1st hospitalization was amounting to Rs.26,160/- and bills pertaining to the hospitalization is there in records, but complainant did not demand it separately. It is again pertinent to mention here that the claim forms Ex.OP6 and Ex.OP9 are having same claim number. There is no document placed on record which shows that whether the complainant ever lodged the 1st claim or not. Hence, we allow the amount of Rs.1,62,774/- as per the final bill of Hero DMC Heart Institute, Ludhiana placed on record by the complainant (attached with Ex.C4).
12. In sequel to the above discussion, the instant complaint is allowed in part and Opposite Parties are directed to pay an amount of Rs.1,62,774/-(Rupees One Lakh Sixty Two Thousand Seven Hundred Seventy Four only) to the complainant. Opposite Parties are further directed to pay Rs.3500/-(Rupees Three Thousand and Five Hundred only) to be paid to the complainant on account of litigation expenses. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Parties within 30 days from the date of receipt of copy of this order, failing which, the Opposite Parties are burdened with additional costs of Rs.5,000/-(Rupees Five Thousand only) to be paid to the complainant for non compliance of the order. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced on Open Commission
