Order by:
Smt.Priti Malhotra, President
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 covering himself and his family from Opposite Parties on 15.12.2020, vide policy no.P/211222/01/2023/009523 and the said policy got renewed without break and now the policy is valid upto 14.12.2023. Unfortunately, on 28.06.2023, the complainant got admitted in Global Heart Hospital, Ludhiana and after treatment got discharged from the hospital on 04.07.2023. At the time of treatment and after discharge from the hospital, the complainant requested the Opposite Parties to pay the medical expenses including pre and post, to the complainant, but the Opposite Parties did not pay the expenses of treatment and thus, the complainant has to pay whole of the amount from his own pocket. After the treatment, the complainant submitted all the medical record with Opposite Parties as per their demand, but despite that the Opposite Parties have not paid any amount in lieu of medical expenses to complainant. Alleged that the complainant made a payment of Rs.66,982/- to the said hospital with regard to his treatment. Alleged further that the Opposite Parties vide letter dated 21.08.2023, repudiated the claim of the complainant on false and baseless reason. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to pay a sum of Rs.66,982/- alongwith interest @ 24% p.a. till its realization.
b) To pay an amount of Rs.30,000/- as compensation on account of mental tension and harassment and for deficiency in service.
c) To pay an amount of 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 the present Pre Mature complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Parties as per the insurance policy terms and conditions. Averred that the present complaint pertains to insurance claim under “Family Health Optima Insurance Plan bearing no.P/211222/01/2023/009523 valid from 15.12.2022 to 14.12.2023 covering the complainant self and his spouse Jaswinder Kaur for a sum of Rs.5,00,000/- for the first time. However it is submitted that the aforesaid insurance policy was issued to the insured by the answering Opposite Parties subject to the terms and conditions of the insurance policy. 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 insured admitted to Global Heart and Super Speciality on 28.06.2023 and requested for cashless for the treatment of ‘Haemothorax’. To evaluate the admissibility of the claim, it was asked to submit the cause for haemothorax vide letter dated 29.06.2023. Further it was found that patient had history of RTA hence vide query letter dated 29.06.2023, it was asked to provide exact date and time with circumstance of injury, first consultation report and follow-up treatment record alongwith all relevant investigation report. Again a query letter was sent on dated 29.06.2023 to provide letter from the treating doctor with seal and sign clarifying when HCV was first diagnosed-provide its all previous consultation and treatment records. Opposite Parties scrutinized the request for approval for cashless treatment of above insured patient for the diagnosed disease of ‘Haemothorax’. As per submitted record patient is positive finding for HCV and cirrhosis. It is observed from the hospital records that the insured patient has the above disease which is a longstanding ailment. Opposite Party was not able to ascertain the duration of the disease based on the documents/details submitted by the hospital. It requires further evaluation. Hence it was suggested that the insured may submit the documents to Opposite Party seeking reimbursement of the expenses incurred relating to the treatment of above disease. Subsequently, the complainant filed claim documents for reimbursement for the treatment of Heamothroax, at Global Heart and Super Speciality Ludhiana on dated 28.06.2023 to 04.07.2023. On scrutiny of claim documents, the following documents were necessary to process the claim, hence Opposite Parties advised the insured vide two letters dated 28.07.2023 and 12.08.2023 to furnish the following documents:-
To submit original discharge summary alongwith hospital seal and sign to process the claim.
To submit all treatment details taken after injury.
To submit letter from treating doctor when HCV was first diagnosed.
To submit first and all past OPD consultation papers, endoscopy, USG abdomen, LFT and viral market test report.
Further insured has submitted the query reply, on scrutiny of claim documents, it has been observed that the insured has not submitted the treating doctor stating the duration of HCV called for by them which amounts to non submission of required documents. In the absence of the above documents/details Opposite Parties were not able to further process the alleged claim. Averred that as per Condition No.18 of the above policy, the insured person has to submit all the required documents and details called for by the Opposite Parties. Hence, the claim was repudiated vide letter dated 21.08.2023. Averred further that the claim was denied due to incomplete query after revert regarding duration and past treatment records of HCV+ve & CLD.
i. Patient admitted as a case of Right Haemothorax, after he had an RTA 1 months back.
ii. As per Bansal Ortho & General Hospital document dated 25.05.2023, the patient is known to be HCV + ve.
iii. As per prescription dated 19.12.2022, the patient was diagnosed with HCV + ve with CLD.
iv. As per reports available, the patient has Chronic Liver Disease with Portal Hypertension with Esophageal varices, which is a long-standing chronic disease.
The requisite documents are mandatorily required to ascertain the admissibility of the claim. However the complainant instead of submitting the documents preferred to file the present complaint and thereby the answering Opposite Parties got no opportunity to decide claim of the complainant with complete medical record. The instant complaint is neither maintainable in law nor on facts; no deficient services have been rendered by the answering Opposite Parties as alleged by the complainant; the complaint being pre-mature and false; the complainant has not come with clean hands. The complainant has also suppressed the material facts from this Commission as well as from the answering Opposite Parties. 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 his case, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C7.
4. On the other hand, Opposite Parties have placed on record affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. as Ex.OP1,2/A alongwith copies of documents Ex.OP1,2/1 to Ex.OP1,2/12.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. It is well proved on record that the complainant is the holder of Insurance policy namely “Family Health Optima Insurance Plan” having no.P/211222/01/2023/009523 for the period 15.12.2022 to 14.12.2023. It is also proved that during the policy period, the complainant got admitted in Global Heart & Super Speciality Hospital, Ludhiana with complaints of Fever Since 3-4 days and pains in right side Upper Back since 3 days and remained admit in the hospital for the period 28.06.2023 to on 04.07.2023, where he was diagnosed as Right Sided Haemothorax, Fracture of 1st to 8th rib, Comminuted Displaced Fracture of Right Clavicle Mid Part and Right Scapula, D1 Mild Compression Fracture, Fail LV Systolic function with LVEF of 52%. From the perusal of the record it transpires that before taking the treatment, the complainant requested the Opposite Parties for cashless authorization and on receiving the cashless authorization, the Opposite Parties issued a letter dated 29.06.2023 to the complainant requiring some documents/details and later on denied the pre authorization request for cashless treatment, vide letter dated 30.06.2023. It is also proved on record that when the complainant lodged the claim with Opposite Parties for reimbursement of the expenses, the claim of the complainant was repudiated by the Opposite Parties vide letter dated 21.08.2023.
7. The perusal of the record reveals that on receiving the request for pre authorization for cashless treatment, the Opposite Parties issued a letter dated 29.06.2023 to the complainant requiring following details.
“Letter from the treating doctor with seal and sign clarifying when HCV was first diagnosed-provide its all previous consultation and treatment records.”
Thereafter the Opposite Parties vide letter dated 30.06.2023 denied the preauthorization request of the complainant. The contents of said letter are reproduced as under:-
“As per submitted record patient is positive finding for HCV and cirrhosis. It is observed from the hospital records that the insured patient has the above disease which is a longstanding ailment. We are not able to ascertain the duration of the disease based on the documents/details submitted by you. It requires further evaluation.”
We therefore deny the approval for cashless treatment of above diagnosed disease.”
Further vide letter dated 21.08.2023, the Opposite Parties repudiated the claim of the complainant on the following grounds:-
“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of Heamothorax.
It is observed that the insured has not submitted the treating doctor stating the duration of HCV called for by us which amounts to non submission of required documents. In the absence of the above documents/details, we are not able to process your claim.
As per Condition No.18 of the above 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.”
8. We have given the due consideration to the admitted and proved facts on record and also considered the rival contentions of the ld. Counsels for both the parties and have gone through the record meticulously. The main contention raised by ld. counsel for the Opposite Party with regard to repudiation of the claim is that the insured patient/complainant has past history of HCV and she did not furnish the letter from the treating doctor with seal and sign clarifying when HCV was first diagnosed and failed to provide its all previous consultation and treatment records and in the absence of said documents/details, they were not able to process the claim and accordingly, repudiated the claim of the complainant. We do not agree with the aforesaid contention of the ld. counsel for the Opposite Parties, as first of all, the onus to prove that the complainant/insured was suffering from a pre-existing disease as per settled law is on the Opposite Party. For this observations we are well guided by judgments of Hon’ble National Consumer Disputes Redressal Commission in case titled Reliance Life Insurance Co. Ltd & Anr. v. Tarun Kumar Sudhir Halder in Revision Petition No. 2097 of 2019 has also held so:-
"The Insurance Company has not filed any evidence to show that the DLA was taking treatment for the disease prior to filling up of the proposal form. Even if there was disease inside the body, but the life insured did not know about the disease and was not taking any treatment for the same, the insurance claim cannot be denied on mere presumption that the life assured might be suffering from pre-existing disease. Thus, on merits, I am convinced on the (FA-383/2016) PAGE 8 OF 10 basis of the entries in the Medical Attendant Certificate that the disease was complained for the first time by the DLA on 22.06.2011, which is much after the date of the proposal form. The onus to prove the pre-existing disease lies on the Insurance Company and no supporting documents have been filed by the Insurance Company in support of their assertion.
However, in the present case, the Opposite Parties have not produced any documentary evidence/expert medical opinion in support of its case. Further the repudiation of the claim of the complainant is also not sustainable as from the perusal of the record, it transpires that the complainant came to know about her disease when he approached Global & Super Speciality Hospital, Ludhiana, where she was thoroughly been investigated and had undergone several medical tests and from the report of which, she came to know that she is suffering from ‘Haemothorax’. Moreover, if the complainant failed to procure certificate of the treating doctor stating the duration of HCV as alleged by Opposite Parties, the Opposite Parties would have enquired from the concerned doctor of the concerned hospital about the same at their own, but they failed to do so. Further no medical literature is being made part of the record revealing that the ailment suffered by the complainant was longstanding disease as alleged by the Opposite Parties in their cashless rejection letter dated 30.06.2023.
9. From the discussion above, we are of the concerted view that Opposite Parties illegally and wrongly repudiated the genuine claim of the complainant.
10. Vide instant complaint, the complainant claimed the amount of Rs.66,982/-. However, perusal of the record reveals that the complainant has placed on record copies of bills (Ex.C4) amounting to Rs.61,277/- only. Hence we allow the said amount.
11. From the above discussion, we allow the instant complaint in part and direct the Opposite Parties to pay an amount of Rs.61,277/- (Rupees Sixty One Thousand Two Hundred Seventy Seven only) to the complainant. Opposite Parties are also directed to pay compository costs of Rs.7,000/-(Rupees Seven Thousand only) as compensation and litigation expenses to the complainant. 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 further burdened with additional cost of Rs.10,000/-(Rupees Ten 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
