Chandigarh

DF-I

CC/608/2021

Smt. Nirmla Goyal - Complainant(s)

Versus

HDFC IRGO Health Insurance Co. Ltd. - Opp.Party(s)

Maninder Singh Bitta

07 Mar 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/608/2021
Date of Institution	:	07/09/2021
Date of Decision	:	07/03/2024

 

Smt. Nirmla Goyal wife of Late Shri Shiv Kumar, resident of Flat No.608, Tower No.2, SBP South City, VIP Road, Zirakpur, District SAS Nagar Mohali (Punjab).

… Complainant

V E R S U S

HDFC IRGO Health Insurance Co. Ltd. (e-Apollo Munich Health Insurance) SCO No.124-125, Sector 8, Madhya Marg, U.T., Chandigarh through its authorized signatory.

… Opposite Party

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

                                                                               

ARGUED BY	:	Sh. Ashok Kumar, Advocate for complainant
	:	Sh. Nitesh Singhi, Advocate for OP

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Smt.Nirmla Goyal, complainant against the aforesaid opposite party (hereinafter referred to as the OP).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that, in the year 2017, executive officer of Apollo Munich Health Insurance Co. (Now HDFC Ergo Health Insurance i.e. present OP) had approached the complainant for providing best health insurance policy and, being allured with the assurances, complainant had purchased a health insurance policy namely “Optima Restore Individual” valid w.e.f. 25.5.2017 to 24.5.2018 for the sum insured of ₹5,00,000/- and at that time she was hale and hearty and was not suffering from any ailment.  Before expiration of the said policy, OP again approached the complainant and advised her for the renewal and accordingly she got the same renewed w.e.f. 25.5.2018 to 24.5.2019, 25.5.2019 to 24.5.2020 and lastly w.e.f. 25.5.2020 to 24.5.2021 (Annexure C-1 colly.) (hereinafter referred to as “subject policy”).  At that time, the complainant had told the officials of the OP that she is undergoing treatment for Crest Syndrome at PGI, Chandigarh.  Unfortunately, in the month of March 2021, complainant suffered from COVID-19 and was admitted in Paras Hospitals, Panchkula (hereinafter referred to as “treating hospital”) on 21.3.2021 and was discharged on 27.3.2021.  The complainant spent an amount of ₹1,89,405.45 on her treatment and at the time of discharge, she was advised for further treatment and tests.  Copy of the treatment record and the bills are Annexure C-3. Even the doctors of the treating hospital had issued certificate (Annexure C-4) for processing her pre-authorization claim for treatment (cashless) certifying that the ailment with which the complainant was suffering i.e. Crest Syndrome is having no concern with the present disease of the complainant i.e. COVID-19, but, despite of the same, OP refused the facility of pre-authorization for treatment (cashless) vide email dated 27.3.2021 (Annexure C-5).  After discharge from the treating hospital, complainant lodged her claim for reimbursement with the OP and initially OP kept demanding documents one after the other from the complainant and even during that period, complainant was advised by the treating hospital to come for follow up and she had further spent an amount of ₹7,180/- vide bills (Annexure C-7) for the same and, in this manner, total amount of ₹1,96,589/- was spent by her.  However, the OP, put off the request of the complainant on one pretext or the other.  Having left with no option, complainant was compelled to serve a legal notice dated 6.7.2021 (Annexure C-8) upon the OP, but, despite of that OP did not settle the claim. In this manner, the aforesaid acts of the OP amounts to deficiency in service and unfair trade practice. OP was requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OP resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability, cause of action, concealment of facts and jurisdiction.  It is alleged that, in fact, complainant had concealed material facts qua her pre-existing disease as she was suffering from hypertension from 10 years and Crest Syndrome from last 10-12 years before obtaining the subject policy and the claim was repudiated vide letter dated 15.6.2021.  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.
3. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

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 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 complainant had initially purchased the health policy from the OP in the year 2017 and got the same renewed annually and finally got the subject policy renewed, which was valid w.e.f. 25.5.2020 to 24.5.2021, as is also evident from the certificate of insurance (Annexure C-1 Colly./Pg.20) and she was treated upon for COVID-19 at Paras Hospitals, Panchkula i.e. the treating hospital where she remained admitted from 21.3.2021 to 27.3.2021, as is also evident from discharge summary (Annexure OP-7) and the claim of the complainant was repudiated by the OP on the ground of non-disclosure and concealment of facts by the complainant about the pre-existing diseases from which she was suffering prior to obtaining the subject policy, as is also evident from the copy of repudiation letter (Annexure OP-10), the case is reduced to a narrow compass as it is to be determined if OP/insurer is unjustified in rejecting/repudiating the genuine claim of complainant on the said ground and she is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OP/insurer has rightly repudiated the claim of the complainant and the instant consumer complaint, 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 of the insured/complainant as well as the repudiation letter and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Perusal of subject policy/certificate (Annexure C-1 Colly./page 20) clearly indicates that the same was valid w.e.f. 25.5.2020 to 24.5.2021 and copy of policy schedule (Annexure OP-5) further indicates that in case the information provided by the insured is found to be incorrect, incomplete, suppressed or not disclosed, willfully or otherwise, insurer has right to cancel the subject policy and reject/ repudiate the claim.   
   4. Annexure OP-7 is discharge summary, having been relied upon and placed on record by OP itself, which clearly indicates that insured/complainant was diagnosed with “Bilateral Pneumonia (COIVD-19) & Steroid Induced Hyperglycemia”. Relevant portion of aforementioned discharge summary qua diagnosis, history of present illness, past medical history and course in hospital is reproduced below for ready reference:-

“DIAGNOSIS:

Bilateral Pneumonia (COVID-19)

Steroid Induced Hyperglycemia

HISTORY OF PRESENT ILLNESS:

Mrs. Nirmal Goyal, 61 years old lady, has been apparently well till 6 days back. Then he started having high grade fever. Now since past 3 days he is having complaints of cough associated with generalized weakness. She was taking treatment from outside hospital, but got no relief. Now brought here in emergency department of Paras Hospital further treatment. HRCT chest was done on 21.03.2021 was suggestive of Multi-focal, confluent, circumscribed areas of consolidation on the background of ground glass opacification in almost all the segments of both lungs with interspersed septal thickening and parenchymal & subpleural fibrotic bands. Patchy areas of atelectasis in the basal segments of bilateral lower lobes. The CT features are commonly reported and typical for temporal changes of COVID-19 pneumonia (CORADS 5 & CTSS: 17/25). She is admitted in hospital for further management and evaluation.

PAST MEDICAL HISTORY:

History of Hypertension since 10 years

History of Crest syndrome 10-12 years

COURSE IN THE HOSPITAL:

Mrs. Nirmal Goyal, 61years old lady, has been admitted in Paras Hospital Panchkula with above mentioned complaints. She has been shifted to COVID ICU for further management. COVID-19 RT PCR was done, which came out to be positive. She has been managed conservatively with Inj. Augmentin, Inj. Optineuron, Inj. Claribid, Inj. Clexane, Inj Solumedrol, inj. Remdesivir and other supportive medication. Her condition Improved. Serial CBC/RFT/LFT/D-Dimer/CRP monitoring has been done. She is afebrile, Spo2 is 93% at RA. Patient has been asymptomatic since 2-3 days. She is being discharged with following advise.”

 

5. Annexure OP-10 is copy of letter dated 15.6.2021, which clearly indicates that the claim of the complainant was repudiated for non-disclosure and concealment of facts and the relevant portion of the same is reproduced below for ready reference :-

“The medical history details of Known case of crest syndrome and hypertension since 10 yrs i.e. prior to policy inception and was not revealed in the proposal form while taking the policy. Hence the policy is cancelled and claim is repudiated due to Non disclosure and concealment of facts under section 6 r) of policy terms and conditions.

 

6. The contention of the complainant is that as it stands proved on record that the insured/complainant was treated for “Bilateral Pneumonia (COIVD-19) & Steroid Induced Hyperglycemia”, which has no nexus with alleged diseases of Crest Syndrome and hypertension, OP has wrongly repudiated the claim and the consumer complaint be allowed.
7. On the other hand, contention of OP is that since the insured/complainant had suppressed material facts and had not disclosed about her being suffering from Crest Syndrome and hypertension since 10 years i.e. prior to policy inception, her claim was rightly repudiated and the instant consumer complaint be dismissed.
8. However, there is no force in the contention of the OP as it stands proved from the record that the insured patient was treated for “Bilateral Pneumonia (COIVD-19) & Steroid Induced Hyperglycemia”. Even for argument’s sake, if it is believed that the insured/complainant was suffering from Crest Syndrome since 10-12 years and hypertension since 10 years prior to policy inception, as recorded by the medical officer in the discharge summary, same clearly has no nexus with the diseases/ailments for which the insured/complainant had taken treatment at the treating hospital i.e. “Bilateral Pneumonia (COVID-19) and Steroid Induced Hyperglycemia”.
9. Not only this, even the certificate (Annexure C-4) issued by the medical officer of the treating hospital clearly certifies that just because the insured/ complainant had past history of crest syndrome, which has no relation to current illness, claim cannot be denied. The relevant portion of the said certificate is reproduced below for ready reference :-

“Mrs. NIRMALA GOYAL 61 year old lady has past H/O CREST SYNDROME which has no relation to current illness. Current illness is due to COVID-19 pneumonia which is a infection disease which can occur to any person. This claim cannot be denied just because she has past H/O Crest Syndrome. Please do the needful.”

10. Otherwise also, 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.”

11. 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."

12. Further, the Hon’ble National Commission in 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.”

13. In view of the foregoing discussion and the ratio of law laid down above, it is clear that the OP/insurer has not been able to connect the previous diseases/ailments with the present diseases/ailments, for which the insured/complainant had taken treatment from the treating hospital.  Hence, it is unsafe to hold that the OP/insurer was justified in rejecting/repudiating the claim of the complainant and the present consumer complaint deserves to succeed. 
14. Now coming to the quantum of relief, the complainant has claimed ₹1,96,589/- towards the expenses spent on her hospitalisation/treatment as well as for post hospitalisation treatment and has also proved the bills Annexure C-3 Colly. and Annexure C-7 Colly.), therefore, it is safe to hold that OP/insurer is liable to pay the said amount to the complainant alongwith interest and compensation etc.

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

1. to pay ₹1,96,589/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 15.6.2021 onwards.
2. to pay ₹20,000/- 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 the OP 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. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. 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