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 23.02.2018 and the said policy got renewed regularly. Earlier, the complainant availed the policy vide no.P/211222/01/2023/012490, which is valid upto midnight of 22.02.2024. Unfortunately on dated 25.03.2023, the complainant admitted in RG Stone Hospital, Ludhiana and after treatment got discharged from the hospital on 26.03.2023. 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 expenditure on treatment 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 discharge from the hospital, the complainants 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 have made the payment of Rs.1,06,138/- to the said hospital from their own pocket. The complainants 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 09.08.2023, the Opposite Parties repudiated the claim of the complainant. Due to such 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.1,06,138/- 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 DM and its complication disclosed by Pawan Kumar for himself. Averred that the complainant availed the ‘Family Health Optima Insurance Plan’ Policy No.P/211222/01/2023/012490 renewed for the period 23.02.2022 to 22.02.2024 and in this policy complainant, his wife Poonam Rani and dependent children Tanisha Rani and Krishana Gaba 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 was registered vide claim no.CIR/2023/211222/169102. After this the insured has submitted the claim documents in present case regarding the medical reimbursement expenses towards treatment taken by him at RG Stone and Super Speciality Hospital, Ludhiana on 25.03.2023 to 26.03.2023 for the treatment of ‘Renal Calculi’. As per submitted documents from 2018 patient is k/c/o HCV Positive with CLD, ITS, but the complainant has not submitted first consultation slips, investigation and treatment record not submitted. Hence cashless was denied vide letter dated 27.03.2023. Thereafter insured applied for medical reimbursement for same treatment and it is observed from the claim documents that the above said documents are necessary to process the claim, hence they advised the insured vide letters dated 24.04.2023, 09.05.2023, 24.05.2023 and 08.06.2023 to furnish the following documents:-
i. Complete set of indoor case papers with the temperature, SPO2, vitals monitoring chart.
ii. As per the submitted documents insurer is a known case of Liver paranechymal disease, pyelonephritis, since 2018.
iii. First consultation, with all its initial investigation and all serial follow up records.
iv. USG, HCV, LFT reports taken before 4/2018, all follow up USG, LFT HCV report.
v. Current and past viral load report.
vi. Past admission and follow up records.
However, the insured submitted query documents on 08.08.2023. In order to process the claim, the Opposite Parties requested the insured to furnish all the OP consultation reports, treatment records and investigation reports taken in 2018. Opposite Parties noticed that insured have not furnished the required documents and details. In the absence of the above documents/details, Opposite Parties are not able to further process the 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 Opposite Parties. Hence the claim was repudiated vide letter dated 09.08.2023. Averred further that the insured has not provided them the treatment/investigation records prior to 06.04.2018. Even after reminders, insured has not furnished the above sought documents. Therefore, the answering Opposite Parties was forced to reject the claim for non-submission of documents in the absence of which the claim could not be processed. 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.OP15 and affidavit of Sh.Sumit Kumar Sharma, Senior Manager, Star Health & Allied Insurance Co. Ltd. as Ex.OP16.
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 renewed health insurance policy namely ‘Family Health Optima Insurance Plan’ bearing no.P/211222/01/2023/012490 for the period 23.02.2023 to 22.02.2024 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 ‘C/O Obstructed voiding + and Dysuria +’ and got admitted in RG Stone and Super Speciality Hospital, Ludhiana on 25.03.2023, where he was diagnosed as ‘B/L renal stone & Left ureter stone and Urethral stricture’ and after the treatment, got discharged from the hospital on 26.03.2023. It is also proved on record that during the hospitalization, the complainant applied for cashless treatment, which was accepted by the Opposite Parties vide letter dated 23.03.2023 and vide said letter they approved the amount of Rs.30,000/-. However after that vide letter dated 27.03.2023, the Opposite Parties denied the cashless request of the complainant and withdrawn the approval given earlier. Thereafter vide letter dated 08.06.2023, the Opposite Parties rejected the claim of the complainant for want of previous medical records of the complainant and vide letter dated 09.08.2023 repudiated the claim of the complainant for want of medical records of the complainant regarding the treatment taken by him in the year, 2018.
7. The perusal of the record reveals that the main contention raised by ld. counsel for the Opposite Parties with regard to repudiation of the claim is that the insured patient/complainant has past history of ‘Liver Paranechymal Disease, Pyelonephritis, since 2018 and he did not furnish all past treatment details related to it. But the repudiation of claim of the complainant for want of previous medical records is not genuine, 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, in case, if the complainant has failed to submit aforesaid documents, the Opposite Parties can get the said documents from the hospital concerned at their own, but the Opposite Parties have not placed on record any documents showing that they ever approached the hospital concerned for getting the aforesaid documents. In the instant case, there no any medical record on file showing that the complainant was k/c/o Liver parenchyma disease since 2018.
8. Further such exercise was to be done by the Opposite Parties at the time of inception of the policy, which the Opposite Parties failed to do. It means that at the time of issuing the policy, they did not bother about the past ailment and when the insured raised or lodged the claim, they started enquiring about the health status of the insured from the scratch, which clearly shows that they are only interested to collect premiums only. It is usual with the insurance company to show all types of green pasters to the customer at the time of selling insurance policies, and when it comes to payment of the insurance claim, they invent all sorts of excuses to deny the claim. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., III (2008) CPJ 63 (SC) is wherein it was held that
“Insurance Company being in a dominant position, often fully attracted, acts in an unreasonable manner and after having accepted the value of particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible. It is generally seen that the insurance companies are only interested in earning the premiums and find ways and means to decline claims.”
9. Here it is pertinent to mention that the policy in question has been purchased by the complainant since 2018 and after availing the policy since six years, the question of pre existing disease raised by the Opposite Parties is quite surprising. Moreover after 3-4 years of continuation of the policy, pre existing disease itself covered under the policy plan as per IRDA Guidelines issued vide letter no.IRDAI/HLT/REG/CIR/046/02/2020 dated 10.02.2020, which is reproduced as under:-
Pre-existing disease means any condition, ailment, injury or disease; that is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement.
So, if we go by the guidelines as referred above, the question of pre existing disease raised by the Opposite Parties is not maintainable as the complainant is availing the policy from the Opposite Parties since, 2018.
10. Further the repudiation of the claim by Opposite Parties on the ground that complainant is suffering from liver disease since, 2018 is also not genuine, as the complainant has claimed the amount with regard to the treatment of Renal Calculi i.e. Kidney Stone and not regarding the treatment of Liver Disease, so the demand of Opposite Parties regarding the documents related to Liver Disease is unjustified.
11. Vide instant complaint, the complainant has claimed the amount of Rs.1,06,138/-, however, the complainant has placed on record copies of bills (Ex.C4) amounting to Rs.96,390/-. Hence, we allow the said amount.
12. In view of the above discussion, the instant complaint is allowed in part and Opposite Parties are directed to pay a sum of Rs.96,390/-(Rupees Ninety Six Thousand Three Hundred Ninety only) to the complainant. Opposite Parties are also directed to pay compository costs of Rs.10,000/-(Rupees Ten 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
