Chandigarh

DF-I

CC/282/2022

Mr. Ayodhya Prasad Bansal - Complainant(s)

Versus

HDFC ERGO General Insurance Co. Ltd. - Opp.Party(s)

S.K. Sinha

07 Mar 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/282/2022
Date of Institution	:	21/02/2022
Date of Decision	:	07/03/2024

 

Mr. Ayodhya Prasad Bansal, Age 74 years R/o H.No.702 B1, Trishla City, Zirakpur, S.A.S. Nagar, Punjab-140603.

… Complainant

V E R S U S

1.     HDFC ERGO General Insurance Company Ltd., 1st Floor, HDFC House, 165-166 Backbay Reclamation, H.T. Parekh Marg, Churchgate, Mumbai 400 020.

2.     The Manager, M/s Equitas Small Finance Bank Ltd., SCO No.2421-22, Sector 22 С, Chandigarh - 160 022.

3.     ALCHEMIST HOSPITAL, Sector-21, Panchkula, Haryana-134 112.

… Opposite Parties

 

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

                                                                               

ARGUED BY	:	Sh. S.K. Sinha, Advocate for complainant
	:	Sh. Sachin Ohri, Advocate for OP-1 (through VC)
	:	Sh. Bhawan Deep Jindal, Advocate for OP-2 (OP-2 ex-parte)
	:	Ms. Ritika Garg, Advocate for OP-3

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Ayodhya Prasad Bansal, 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 the complainant had purchased a Group Assurance Health Plan/policy vide certificate (Annexure C-2) (hereinafter referred to as “subject policy”) in the name of his wife, Smt.Anita Bansal, from OP-1/insurer through its intermediary/OP-2, by paying premium of ₹13,824.28 and the same was valid w.e.f. 16.2.2021 to 15.2.2022. At the time of purchase, it was explained to the complainant that the subject policy is a cashless facility and in case of any medical emergency, insured can approach the empanelled hospital and on production of the card issued by the company/OP-1, insured can avail cashless facility.  On 22.9.2021, wife of the complainant i.e. the insured (hereinafter referred to as “DLA”) fell ill and she was taken to the Alchemist Hospital, Panchkula (hereinafter referred to as “Treating Hospital”) for treatment. The complainant immediately submitted the cashless insurance card to the said hospital who forwarded the details to OP-1 for approval of cashless facility and thereafter the treatment was started.  However, surprisingly on the third day of admission, complainant was informed by the hospital authorities that OP-1 has denied the cashless facility vide letter dated 25.9.2021 (Annexure C-3).  In the meantime, the condition of the wife of the complainant became critical and started deteriorating. The complainant again requested the hospital authorities to pursue the claim with the company. Even after getting all the documents of the ongoing treatment, OP-1 did not sanction the cashless facility to the complainant. A query was raised by OP-1 if the ailment of the patient was due to pre-existing disease and on this complainant requested the treating doctor to issue certificate to that effect and accordingly the medical certificate (Annexure C-4) was issued by the hospital with complete medical record (Annexure C-5).   However, due to deterioration of the health of the wife of the complainant, she died on 8.10.2021 as per death certificate (Annexure C-6). The Treating Hospital (OP-3) had raised a bill of ₹9,19,713.25 (Annexure C-7 colly.), but, after giving discount of ₹58,764.60, it had finally charged an amount of ₹8,60,749/- from the complainant. Thereafter the complainant lodged claim with OP-1/insurer by submitting all the documents by sending email (Annexure C-8), but, instead of settling the claim, OP-1 started asking him to submit more documents for processing the claim and even after submission of documents by the complainant, OPs did nothing, as a result of which he was compelled to send a legal notice (Annexure C-9) to OPs. In this manner, the aforesaid act of the OPs 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. OP-1 and OP-3 resisted the consumer complaint and filed their separate written versions.
3. In its written version, OP-1, inter alia, took preliminary objections of maintainability, cause of action, concealment of material facts, jurisdiction and non-joinder and mis-joinder of necessary parties.  On merits, admitted that the subject policy was issued by the answering OP in the name of wife of the complainant (i.e. the DLA), which was valid w.e.f. 16.2.2021 to 15.2.2022.  It is, however, alleged that the DLA was admitted in the treating hospital on 22.9.2021 for the ailment of Lower Respiratory Tract Infection, Sepsis Septic Shock, Acute Kidney Injury and recurrent hypoglycemia/ Hyponatremia, Sarcoidosis, obesity and obstructive sleep apnea.  It is further alleged that the claim of the complainant was analyzed by the in-house experts of the answering OP and on post scrutinization of the claim, it was noted that the DLA had past medical history of DM and HTN.  Hence, as per available information and on finding of possibility of the ailment being pre-existing disease, cashless request of the complainant was declined vide letter dated 25.9.2021 (Annexure R-2).  It is further alleged that on 7.11.2021, claim was lodged by the complainant with the answering OP and the claim form and death summary are Annexure R-3 Colly.  It is further alleged that certain queries were raised by the answering OP vide letters dated 11.11.2021 (Annexure R-4), 26.11.2021 (Annexure R-5) and reminder letters (Annexure R-6 Colly.) through which the complainant was asked to submit certain documents and as the complainant could not submit those documents with the answering OP, the claim was rightly closed and the same is liable to be repudiated on the ground of on disclosure of past history.  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.
4. OP-2 did not turn up before this Commission, despite proper service, hence it was proceeded against ex-parte vide order dated 1.2.2023.
5. In its written version, OP-3/treating hospital admitted that the wife of the complainant had taken treatment from it and despite of best efforts, she could not survive and she died on 8.10.2021.  It is further admitted that the discount of ₹58,764.60 was given to the complainant on the bill. It is further alleged that the complainant has no cause of action against the answering OP.  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.
6. Despite grant of sufficient opportunity, rejoinder was not filed by the complainant to rebut the stand of the OP.

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 contesting 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 wife of complainant namely Smt.Anita Bansal i.e. DLA, being member and holder of Group Assurance Health Plan i.e. subject policy, issued in the name of Equitas Small Finance Bank Ltd./OP-2, was covered under the subject policy/plan (Annexure C-2) w.e.f. 16.2.2021 to 25.2.2022 with sum insured of ₹15,00,000/- on payment of gross premium of ₹13,624.28 and due to her illness, she was admitted at Treating Hospital on 22.9.2021 where she  remained under treatment and finally she died on 8.10.2021, as is also evident from the discharge summary (Annexure C-6) and the cashless claim was firstly denied by OP-1/insurer vide letter 25.9.2021 (Annexure C-3) on the ground that possibility of pre-existing disease to the DLA could not be ruled out and finally the claim of complainant was closed vide claim closure letter dated 11.1.2022 (Annexure R-7),  the case is reduced to a narrow compass as it is to be determined if OP-1/insurer is unjustified in rejecting/repudiating the claim of the complainant on the ground that DLA was suffering from DM (Diabetes Mellitus) and HTN (Hypertension) i.e. pre-existing diseases prior to obtaining the subject policy, which fact was concealed by complainant/ DLA, and the same is fundamental breach of the terms and conditions of the subject policy and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant or if OP-1/insurer has rightly rejected/ repudiated the claim of the complainant and the consumer complaint of the complainant, being false and frivolous, is liable to be dismissed, as is the defence of the OP.
   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 terms and conditions of the subject policy, medical record, repudiation letter and the investigation report and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Perusal of subject policy/plan (Annexure C-2) clearly indicates that as per the terms and conditions reflected under Section 2(iii), the claim with respect to direct complications to the insured in case of treatment of pre-existing disease for 36 months after the date of inception of the first policy was excluded. The relevant portion of the subject policy is reproduced below for ready reference :-

“iii.  Pre-Existing Diseases

a)     Expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 36 months of continuous coverage after the date of inception of the first policy with insurer.

b)     In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.

c)     If the insured person is continuously covered without any break as defined under the portability/migration norms of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of prior coverage.

d)     Coverage under the policy after the expiry of 36 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by insurer.”

4. Annexure C-3 is letter dated 25.9.2021 whereby the insurer/OP-1 rejected the request for cashless facility made by the complainant on the ground that as per information available, possibility of ailment being pre-existing disease cannot be ruled out. 
5. Annexure C-4 is certificate dated 30.9.2021 issued by the doctor of the Treating Hospital certifying diagnosis of the DLA probably did not relate to any previous ailment/condition. The relevant portion of certificate is reproduced below for ready reference :-

        “This is to certify that patient Mrs. Anita Bansal is admitted in Alchemist Hospital MICU with the diagnosis of Pneumonia/Septic Shock/HODI & appears to be a fresh incident & which most probably unlikely related to any previous condition except/or Age.”

6. Annexure C-6 is death summary of DLA issued by treating hospital which indicates about the diagnosis, brief history of present illness and the cause of death of the DLA. The relevant portion of the death summary is reproduced below for ready reference :-

“Diagnosis:

Lower Respiratory Tract Infection

Sepsis, Septic Shock

Acute Kidney Injury

Recurrent Hypoglycemia / Hyponatremia

K/C/O

Sarcoidosis

Obesity/Obstructive Sleep Apnea

Chief Complaint (Reason/s for Admission):

Decreased urine output+

Generalized weakness+

Brief History of Present Illness:

66yrs female is known case of Obesty/Obstructive Sleep Apnea and Sarcoidosis on HCQS & Methotrexate. Now patient presented to us with above mentioned complaints and admitted for further evaluation and management.

                CAUSE OF DEATH

Part I

Immediate Cause:

(Disease or condition directly leading to death*)

(a): Septic Shock

Antecedent Cause:

(Morbid conditions, if any, giving rise to the above cause stating the underlying condition last)

(b): Lower Respiratory Tract Infection/Multiple Organ Dysfunction

(c): Acute kidney injury

Part-II

(Other significant conditions contributing to death, but not related to the disease or condition causing it)

:Sarcoidosis.”

 

7. Thus, one thing is clear from the aforesaid death summary that the DLA was diagnosed with Lower Respiratory Tract Infection, Sepsis, Septic Shock, Acute Kidney Injury and Recurrent Hypoglycemia/ Hyponatremia and the immediate cause of her death was septic shock, lower respiratory tract infection/ multiple organ dysfunction and acute kidney injury and contributing cause of death was Sarcoidosis.
8. The investigation report (Annexure R-8), having been relied upon by OP-1, indicates that it was unearthed during investigation that the doctor had verified the fact that the patient was known case of DM and HTN, but, no duration was specified by the said doctor.
9. Annexure R-7 is claim closure letter dated 11.1.2022 which indicates that the claim of the complainant was closed on the ground that the complainant could not provide the complete set of indoor case papers requested from him. 
10. Learned counsel for the complainant contended with vehemence that as it stands proved on record that the DLA was not suffering with DM and HTN prior to obtaining the subject policy and the same even had no nexus with the cause of her death and the complainant had supplied all the relevant documents as asked by OP-1/insurer, it has wrongly rejected/ repudiated the claim of the complainant and the instant consumer complaint deserves to be allowed.
11. On the other hand, learned counsel for OP-1/ insurer contended with vehemence that as it stands proved on record that the DLA has concealed the factum of being suffering from DM and HTN prior to obtaining the subject policy and further the complainant has not submitted the documents relating to the medical treatment of the DLA, the claim was rightly closed/repudiated and the consumer complaint deserves to be dismissed.
12. However, there is no force in the contention of the learned counsel for OP-1/insurer as it stands proved on record that whatever documents were asked by OP-1, to be submitted by the complainant, and were required for settlement of the claim, had already been submitted by the complainant with OP-1 and also that OP-1 itself has investigated the facts qua the disease from which the DLA was suffering by deputing an independent investigator who has submitted his report (Annexure R-8). Even perusal of the said investigation report nowhere indicates that the medical officer has opined that the DLA was suffering from the diseases of DM and HTN prior to obtaining the subject policy, rather it has been mentioned in the report that no duration was specified by the doctor qua the said diseases. 
13. Not only this, when the medical officer of the treating hospital vide certificate (Annexure C-4) observed that the DLA diagnosed with pneumonia/septic shock/HODI and appears to be a fresh incident which most probably unlikely related to any previous condition except/or age and thereby ruled out the possibility of any pre-existing disease due to which the DLA has died, it stands proved on record that OP-1 has wrongly closed/rejected the genuine claim of the complainant by forming its own opinion that the DLA was suffering from pre-existing diseases of DM and HTN prior to obtaining the subject policy.
14. Moreover, even if for arguments sake it is presumed that DLA was suffering from DM and HTN before inception of the subject policy, law on this point is well settled.  It has been held by the Hon’ble State Commission, Delhi, in the case titled S.S. Jaspal Vs. National Insurance Co. Ltd. & Ors., IV (2022) CPJ 26 (Del.) that common lifestyle disease like diabetes and hypertension, cannot be treated as pre existing diseases and cannot be a ground of repudiation of claim by Insurance companies. The relevant portion of the order is reproduced as under :-

 “Consumer Protection Act, 1986 - Sections 2(1)(g), 14(1)(d), 15 - Insurance (Mediclaim) -Angioplasty and Stenting - Suppression of pre-existing disease alleged - Repudiation of claim Deficiency in service - District Forum dismissed Complaint - Hence Appeal - Complainant experienced pain in chest and remained admitted in Hospital from 24.6.2004 to 30.6.2004, where he had undergone Angioplasty and Stenting, by incurring Rs.3,20,126 on treatment - Previous medical history is based upon information provided by family of patient - Respondents failed to show any evidence regarding pre-existing disease suffered by insured at time of getting policy - Common lifestyle disease like diabetes and hypertension, cannot be treated as pre existing diseases and cannot be a ground of repudiation of claim by Insurance companies - Respondents failed to show any evidence that any medical tests or examination was done, before issuing said policy in question - Respondents are directed to pay a sum of Rs.3,20,126 (Cost of Medical Expenses) to Appellant along with interest @ 6% p.a.”

15. Similarly, the Hon’ble National Commission in the case titled Sunil Kumar Sharma v. Tata AIG Life Insurance Company and Ors., Revision Petition No.3557 of 2013 decided on 1.3.2021, while dealing with the issue of pre-existing disease, has held as under:-

“14.   Moreover the claim had been repudiated only on the ground that the insured was suffering from diabetes for a long time. So far as life style diseases like diabetes and high blood pressure are concerned, Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., W.P.(C) No.656 of 2007, decided on 17.09.2007 held as under:

"Insurance – Mediclaim -Reimbursement-Present Petition filed for appropriate directions to respondent to reimburse
expenses incurred by him for his medical treatment, in accordance with policy of insurance - Held, there is no dispute that diabetes was a condition at time of submission of proposal, so was hyper tension - Petitioner was advised to undergo ECG, which he did - Insurer accepted proposal and issued cover note. It is universally known that hypertension and diabetes can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications depending upon varied factors. That implies that there is probability of such ailments, equally they can arise in non-diabetics or those without hypertension. It would be apparent that giving a textual effect to Clause 4.1 of policy would in most such cases render mediclaim cover meaningless. Policy would be reduced to a contract with no content, in event of happening of contingency. Therefore Clause 4.1 of policy cannot be allowed to override insurer's primary liability. Main purpose rule would have to be pressed into service. Insurer renewed policy after petitioner underwent CABG procedure. Therefore refusal by insurer to process and reimburse petitioner's claim is arbitrary and unreasonable. As a state agency, it has to set standards of model behaviour; its attitude here has displayed a contrary tendency. Therefore direction issued to respondent to process petitioner's claim, and ensure that he is reimbursed for procedure undergone by him according to claim lodged with it, within six weeks and petition allowed."

16. Further, the Hon’ble National Commission in the case titled as Neelam Chopra Vs. Life Insurance Corporation of India & Ors., IV (2018) CPJ 321 (NC) while dealing with the question of suppression/ non-disclosure of material facts has held as under :-

     12. In the present case, clearly the cause of death is cardio respiratory arrest and this disease was not existing when the proposal form was filled. Clearly, there is no suppression of material information in respect of this disease, which is the main cause of death. The other disease of LL Hansen, which was prevailing for five weeks on the date of admission on 1.8.2003 was also not existing when the proposal was filed by the DLA. The fact of DLA having been treated in the year 2002 for LL Hansen is not supported from any direct evidence though PGI Chandigarh in its certificate has mentioned that disease was treated in 2002. Moreover, this disease does not have any correlation with the cause of death in the present case. Hon’ble Supreme Court in Sulbha Prakash Motegaonkar and Ors. v. Life Insurance Corporation of India, Civil Appeal No.8245 of 2015, decided on 5.10.2015 (SC) has held the following:

        “We have heard learned Counsel for the parties.

                It is not the case of the Insurance Company that the ailment that the deceased was suffering from was a life threatening disease which could or did cause the death of the insured. In fact, the clear case is that the deceased died due to ischaemic heart disease and also because of myocardial infarction. The concealment of lumbar spondylitis with PID with sciatica persuaded the respondent not to grant the insurance claim.

                We are of the opinion that National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim by the respondent. The death of the insured due to ischaemic heart disease and myocardial infarction had nothing to do with this lumbar spondylitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified.”

17. In view of the foregoing discussion and the ratio of law laid down above, it is clear that OP-1/insurer has not been able to connect the previous diseases/ailments with the cause of death of the DLA. Hence, it is unsafe to hold that OP-1/insurer was justified in closing/rejecting/repudiating the claim of the complainant qua the subject policy and the present consumer complaint deserves to succeed. 
18. Now coming to the quantum of amount to be awarded in the instant case, though the complainant has claimed an amount of ₹9,19,713.25, but, as the complainant himself has averred in para 14 of the consumer complaint that on account of the discount given by the treating hospital to the tune of ₹58,764.60 he has finally paid an amount of ₹8,60,749/-, as is also evident from the bills (Annexure C-7 colly.), OP-1/insurer is liable to pay the said amount of ₹8,60,749/- to the complainant alongwith interest and compensation etc. for the harassment caused to the complainant.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP-1/insurer is directed as under :-

1. to pay ₹8,60,749/- to the complainant alongwith interest @ 9% per annum from the date of closure of the claim i.e. 11.1.2022 onwards.
2. to pay ₹30,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by OP-1 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. Since no deficiency in service or unfair trade practice has been alleged or proved against OPs 2 & 3, the consumer complaint qua them stands dismissed with no order as to costs.
7. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
8. Certified copies of this order be sent to the parties free of charge. The file be consigned.

07/03/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member
	Sd/- [Suresh Kumar Sardana] Member