DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, U.T. CHANDIGARH

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Shri Aneesh Mitra Bhanot, resident of H.No. 3727, Sector 46-C, Chandigarh.

                   --- Complainant

V E R S U S

1]      ICICI Lombard General Insurance Company Limited, 1^st Floor, SCO No. 24-25, Sector 8-C, Madhya Marg, Chandigarh.

2]      FORTIS HEART INSTITUTE MULTI SPECIALITY HOSPITAL, Sector 62, Phase VIII, Mohali, Punjab.

---- Opposite Parties

BEFORE:      SH. LAKSHMAN SHARMA                    PRESIDENT

MADHU MUTNEJA                               MEMBER

                   SH.JASWINDER SINGH SIDHU             MEMBER

Argued By:             Ms. Harpriya Khaneka, Counsel for Complainant.

None for Opposite Party No.1.

Sh. Munish Kapila, Counsel for Opposite Party No.2

PER JASWINDER SINGH SIDHU, MEMBER

1.                Briefly stated, the Complainant took an insurance policy namely “Family Floater Insurance Policy” from Opposite Party No.1, for the purpose of medical insurance, for himself and his family, for an amount of Rs.4 lacs. He has been regularly taking the above mentioned insurance policy for the last three years from 2009-2010, 2010-2011 and currently holds a policy valid from 2011 till 2012 (Annexure C-1 [colly]). During the currency of the policy, the Complainant was admitted to Opposite Party No.2 Hospital from 01.02.2011 to 10.02.2011, with the symptoms of dairrhoea, fever, vomiting etc. and was diagnosed for “Enteric Fever with Salmonella Hepatitis” more commonly known as Typhoid Fever. The Complainant was at the given time known to have a history of Hypertension and Diabetes Type-II for which he was on regular treatment. After being treated at Opposite Party No.2, the Complainant was discharged on 10.02.2011 (Discharge Summary at Annexure C-2) and a bill of Rs.2,29,268/- was raised (Annexure C-3). The Complainant claims that upon being admitted to Opposite Party No.2 Hospital for treatment for Enteric Fever with Salmonella Hepatitis, he filed his claim, duly filled in all respects, and the approximate claim arrived at was Rs.1.70 lacs (Annexure C-4). However, on 05.02.2011, Opposite Party No.1 in reply to the claim filed sent a ‘Denial of Cashless Access’ letter to Opposite Party No.2 Hospital, on the ground of non-declaration of pre-existing illness (Annexure C-5). After fully recovering and recuperating from the illness, the Complainant has obtained a letter dated 04.05.2011 (Annexure C-6) from the Doctor In-charge of Opposite Party No.2 Hospital to the effect that Salmonella infection did not have any relation with the Diabetic status of the patient. The Complainant claims that Enteric Fever with Salmonella Hepatitis is an infection which can be contracted by any person at any time upon ingestion of infected food/ water, and as such did not pre-exit at the time of taking the insurance policy and denial of the claimed amount by the Opposite Party No.1 amounts to deficiency in service. Hence, this complaint.

2.                Notice of the complaint was sent to Opposite Parties seeking its version of the case.  

3.                Opposite Party No.1 in its reply admitted the issuance of the policy in question. It is pleaded that the Complainant though suffering from certain disease even prior for a period of nearly 20 years did not opt to declare the same inspite of several renewals. The Complainant himself admits that he was suffering from HTN and Diabetes which fact was not informed at the time of the taking and renewal of the policies. The grounds of repudiation are non declaration of pre-existing illness. Even as per the medical records he was suffering from the pre-existing disease which were not informed earlier at the time of taking of the policy, however, the same is not payable under the policy as the policy is null and void based on fraud. Hence, the claim has been rightly repudiated. Denying all other allegations and pleading that the Complainant is not entitled to any amount from the answering Opposite Party, a prayer has been made for dismissal of the complaint. 

4.                Opposite Party No.2 in its reply admitted that the Complainant was admitted to Fortis Hospital, Mohali on 1.2.2011 with complaints of diarrhea, fever, vomiting since one week with decreased urine output since 2 days. Complainant was discharged from the Hospital on 10.2.2011 after undergoing treatment at Fortis Hospital, Mohali. At the time of his initial admission the treating doctor of the hospital filled in the necessary particulars of the patient including the approximate treatment expenses and forwarded a pre-authorization admission request for cashless treatment to the ICICI Lombard General Insurance Co. Limited. However, the same was denied by the Opposite Party No.1. On being brought the same to the notice of the Complainant, he paid the entire expenses to the tune of Rs.2,29,268/-.  Pleading that the dispute, if any, is between the Complainant and the Opposite Party No.1, wherein the answering Opposite Party has no role to play, a prayer has been made for the dismissal of the complaint qua the answering Opposite Party. 

5.                Parties were permitted to place their respective evidence on record in support of their contentions.

6.                On 25.04.2013, when the case was fixed for arguments, none appeared on behalf of opposite party No.1. Therefore, we proceeded to dispose of this complaint, on merits, under Rule 4 (8) of the Chandigarh Consumer Protection Rules, 1987, read with Section 13(2) of the Act (as amended upto date), even in the absence of opposite party No.1.

7.                We have heard the learned counsel for the Complainant and learned counsel for the Opposite Party No.2 and have perused the record.

8.                The Complainant has preferred the present complaint against Opposite Parties No.1 and 2; whereas, from the averments of the complaint, it is amply clear that the main grouse, on the basis of which, the present complaint has been filed, is against Opposite Party No.1, for non-payment of the claim amount for the treatment, which he had availed from Opposite Party No.2. Even during the course of arguments, learned counsel for the Complainant has stated that the Opposite Party No.2 was impleaded only as a proforma party, and the Complainant has not claimed any deficiency in service qua Opposite Party No.2. Even the relief claimed through the present complaint is only directed against Opposite Party No.1 alone. In the given situation, we are of the opinion that, the present complaint deserves to fail qua Opposite Party No.2, and the same is dismissed against it.

9.                The present complaint of the Complainant is borne out of the repudiation of the claim amounting to Rs.2,29,268/-, which was incurred on the treatment of Enetric Fever with Salmonella Hepatitis infection (Typhoid). The Complainant had undergone this treatment at the hospital of Opposite Party No.2. The Complainant had duly lodged his claim with the Opposite Party No.1, by submitting the entire records, as well as the original bills. This fact is not contested by the Opposite Party No.1. However, Opposite Party No.1 has stood its ground on the basis of its opinion, which was expressed by it, while rejecting the pre-authorization for the cashless facility, which was offered through the insurance policy to the Complainant. Meaning thereby, that when the Complainant was admitted with the Opposite Party No.2, for the treatment, a request for availing the cashless facility was duly forwarded, but the Opposite Party No.1 after seeking opinion from Opposite Party No.2, vide its letter dated 5.2.2011, denied the pre-authorization request for cashless facility to the Complainant, on the ground that the Complainant was suffering from pre-existing disease and other reasons mentioned under Part-II of the schedule under exclusion clause 3.1 and Part-III of schedule respectively.

10.              The Opposite Party No.1 though having refused the pre-authorization request of the Complainant, thereafter, failed to process the claim of the Complainant, for the same reasons for which such authorization was denied. We have gone through the documents tendered by the Opposite Party No.1, which include only the letter of denial of cashless access, and the copy of hospital records. We have failed to locate the details of the Part-II and Part-III of the Schedule of the Policy, on the basis of which the cashless authorization as well as the claim of the Complainant was denied. The Opposite Party No.1 for the reasons best known to it has failed to tender the details of these Schedules, to enable us to satisfy ourselves about the clauses on the basis of which the claim was denied. The Complainant has categorically stated in his complaint that he is a bonafide subscriber of the health policy from Opposite Party No.1 for the continuous past three years. It is a settled principle of law that while raising objections with regard to the pre-existing disease, the Insurance Company must satisfy itself about the health status of the subscriber of such policy by getting him/her medically examined. Such views are expressed by the Hon’ble State Consumer Disputes Redressal Commission, New Delhi, in the case titled as Oriental Insurance Co. Ltd. V/s Hemant Bhandari, III (2005) CPJ 418, wherein while expressing its opinion, the Hon’ble State Commission has held that if insured is not medically examined, the insurance company cannot take advantage of its wrongs – person once insured under medi-claim, company obliged to pay actual expenses incurred by the insured. Hence, in the given situation, denial of the claim of the Complainant on the ground of pre-existing disease is wrong and the same amounts to deficiency in service.  

11.              Furthermore, when the Opposite Party No.1 had sought the opinion of the treating doctor of the Opposite Party No.2, about the details of pre-existing disease, it was informed that the patient was suffering from D.M. (Type-II) for 20 years and NFN for 05 years. It is important to mention here that the Complainant had annexed Annexure C-6, which is a Certificate under the signatures of Dr. Avind Sahni of Opposite Party No.2 Hospital, who has categorically certified that the infection of Salmonella Hepatitis (Typhoid) had no relation with the Diabetic status of the Complainant. Hence, it is amply clear that the disease, for which the Complainant was treated, did not have any nexus with his being Diabetic, therefore, the opinion of Opposite Party No.1 is altogether baseless as in such circumstances, it is only the opinion of the treating doctor which carries force, and deserves to be appreciated. 

12.              In the light of above observations, we are of the concerted view that the Opposite Party No.1 is found deficient in giving proper service to the complainant. Hence, the present complaint of the Complainant deserves to succeed against the Opposite Party No.1, and the same is allowed, qua it. The Opposite Party No.1 is directed to:-

[a]     To pay a sum of Rs.2,29,268/- to the Complainant on account of the expenses incurred by him;

[b]     To pay Rs.25,000/-on account of deficiency in service and causing mental and physical harassment to the Complainant; 

[C]    To pay Rs.10,000/- as cost of litigation;

13.              The above said order shall be complied within 45 days of its receipt by the Opposite Party No.1; thereafter, it shall be liable for an interest @18% per annum on the amount mentioned in per sub-para [a] & [b] of para 12 above, apart from cost of litigation of Rs.10,000/-, from the date of institution of this complaint, till it is paid.  

14.              Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

26^th April, 2013.                                       

                                          Sd/-

(LAKSHMAN SHARMA)

PRESIDENT

Sd/-

 (MADHU MUTNEJA)

MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER