Chandigarh

DF-I

CC/494/2023

SURESH KUMAR MITTAL - Complainant(s)

Versus

M/S CARE HEALTH INSURANCE LIMITED - Opp.Party(s)

KULDIP SINGH

03 Sep 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/494/2023
Date of Institution	:	12/10/2023
Date of Decision	:	03/09/2024

 

Suresh Kumar Mittal aged 63 years son of Sh. Ram Mittal, House No.1028, Sector 45-B, Chandigarh 160047.

… Complainant

V E R S U S

M/s Care Health Insurance Limited, through its authorised signatory, Regd. Office : 5^th Floor, 19 Chawla House, Nehru Place, New Dehi-110019.

2^nd Address : Correspondence Office : Vipul Tech Square, Tower-C, 3^rd Floor, Golf Course Road, Sector 43, Gurugram-122001 (Haryana).

… Opposite Party

 

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

 

                                                                               

ARGUED BY	:	Sh. Kuldip Singh Chaudhary, Advocate for complainant
	:	Ms. Samdisha Kaur, Advocate for OP

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Suresh Kumar Mittal, 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 on 28.12.2019, complainant had obtained a cashless health insurance policy (Annexure C-1) from the OP with sum insured of ₹10.00 lacs by disclosing about his pre-existing disease of hypertension and the same was valid w.e.f. 28.12.2019 to 27.12.2021. Thereafter the complainant got the policy renewed and finally the last policy (hereinafter referred to as the “subject policy”) was issued by the OP which was valid w.e.f. 28.12.2022 to 27.12.2023 on payment of requisite premium vide receipt (Annexure C-3). Unfortunately, on 9.2.2023, the complainant suffered heart attack and immediately he was brought to the Fortis Hospital, Mohali (hereinafter referred to as “treating hospital”) where he remained admitted and was treated and he incurred total medical expenses of ₹2,26,121/- vide bills and payment receipts (Annexure C-4 coly.).  However, when the complainant raised claim, same was rejected by the OP vide letter dated 25.3.2023 (Annexure C-5) on the ground of 48 months, waiting period for the treatment of pre-existing disease and their complication.  On 7.4.2023, the complainant was again admitted in the treating hospital where stent dilatation with 2.5 x 20mm balloon was done for which he incurred total medical expenses amounting to ₹1,68,258/- vide bills and payment receipts (Annexure C-6 colly.). Again when the complainant raised claim of the said treatment, OP repudiated the same vide letter dated 19.7.2023 (Annexure C-7).  In this manner, the aforesaid acts of the OP amount 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, non-joinder of necessary parties and also that the complainant has not approached the Commission with clean hands.  However, it is admitted that the first policy was obtained by the complainant from the OP w.e.f. 28.12.2019 to 27.12.2021 and the same was renewed through the subject policy till 27.12.2023 and as per policy schedule (Annexure 1 colly.) hypertension was marked as pre-existing disease of the complainant.  The complainant also submitted pre-authorization form (Annexure 2).  However, the claim of the complainant was rejected by the OP for his hospitalisation at Fortis Hospital, Mohali from 9.2.2023 to 11.2.2023 and further from 7.4.2023 to 8.4.2023 on account of four years waiting period of pre-existing disease (hypertension). It is further alleged that as the complainant has been suffering from the pre-existing disease prior to obtaining the subject policy and further the treatment for pre-existing disease is excluded as per the terms and conditions of the subject policy for four years waiting period, the claim of complainant was rightly repudiated by the 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.
3. 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 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 obtained a health insurance policy w.e.f. 28.12.2019 and got the same renewed upto 27.12.2023, as is also evident from Annexure C-1 to C-3, and the complainant suffered heart attack and had taken treatment from the treating hospital where stents were inserted by admitting him in the said hospital w.e.f. 9.2.2023 to 11.2.2023 and again from 7.4.2023 to 8.4.2023, as is also evident from the discharge summaries (Annexure C-4/page 26 and Annexure C-6/page 67) and the treating hospital had raised two bills i.e. first bill of ₹2,26,121/- (Annexure C-4/page 36) and second bill of ₹1,68,258/- (Annexure C-6/page 74) and both the claims of the complainant had been repudiated/rejected by the OP, as is also evident from the repudiation letters (Annexure C-5 & C-7), on the ground of four years waiting period for pre-existing disease and its complications, the case is reduced to a narrow compass as it is to be determined if the OP is unjustified in repudiating/rejecting both the claims of the complainant and he is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant or if the OP has rightly repudiated/ rejected the claims of the complainant as per the terms and conditions of the subject policy 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, repudiation letter and the medical record and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Perusal of Annexure C-1 to C-3 clearly reveals that the complainant had obtained the first policy on 28.12.2019 and got the same renewed through the subject policy which was valid upto 27.12.2023. Clause 4.1 of the subject policy schedule (Annexure 6) pertains to exclusion clauses and the relevant portion of the same is reproduced as under for ready reference :-

4.    Exclusions

4.1. Standard Exclusions:

(a) Waiting Periods:

(i) Pre-existing Disease-Code-Excl01

a. Expenses related to the treatment of a pre-existing Disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer.

 

4. Annexure C-5 is the letter dated 25.3.2021 vide which the OP had repudiated the claim of the complainant and the relevant portion of the same is reproduced below for ready reference :-

        “We hereby inform you that we are not registering your claim since the present ailment (Chronic ischaemic heart disease) for which admission has been done.

For ease of your perusal we have listed the reason for denial below:

• REJECTED-4 YEARS WAITING PERIOD FOR PED AND ITS RELATED COMPLICATIONS
• 4 Years Waiting Period.”
  5. Annexure C-7 is the letter dated 19.7.2023 vide which the OP had again repudiated the claim of the complainant and the relevant portion of the same is reproduced below for ready reference :-

“We hereby inform you that we are not registering your claim since the present ailment (Chronic ischaemic heart disease) for which admission has been done

For ease of your perusal we have listed the reason for denial below :

• REJECTED-48 MONTHS WAITING PERIOD FOR TREATMENT OF PRE EXISTING DISEASE AND ITS COMPLICATIONS-HYPERTENSION
• 4.1.(a)(i) 48 months WAITING PERIOD FOR TREATMENT OF PRE EXISTING DISEASE AND ITS COMPLICATIONS(Code Excl 01)”

 

6. Perusal of the medical record (Annexure C-4) of the complainant clearly indicates about the coronary angiography report of the complainant and the discharge summary (at page 26) makes it clear that the complainant was admitted in the treating hospital on 9.2.2023 and was discharged on 11.2.2023 and the relevant portion of the same is reproduced below for ready reference :-

“Diagnosis

• CAD, P/LWMI
• CART-DVD-LAD 90%, LCX prox 100% thrombotic occlusion
• PRIMARY PTCA + STENT TO LCX 9/2/23
• K/C/O HTN

Presenting Complaints

Patient presented with complaints of chest pain since 6:30 pm associated with sweating. Patient admitted to FHM for further evaluation and management.

Past History/Comorbidities 

K/C/O HTN

Course In The Hospital

Patient admitted with above mentioned complaints and was investigated thoroughly. Initial lab investigations showed TROP T 33.9. ECG- Normal sinus rhythm. ECHO- P/LW HK, EF 45%. ECG- ST decreased V2-3, II, III, AVF. After consent and clearance patient was taken up for CART - DVD - LAD 90%, LCX prox 100% thrombotic occlusion. PRIMARY PTCA + STENT TO LCX, done on 9/2/23. Patient had episode of NSVT, managed accordingly with optimized treatment. Patient subsequent stay in the hospital was uneventful and now patient is being discharged on optimum medical management with advice to follow up in OPD.”

7. Similarly the second discharge summary (annexed with Annexure C-6 at page 67) clearly shows that the complainant was again admitted in the treating hospital on 7.4.2023 and was discharged on 8.4.2023 and the relevant portion of the same is same reproduced below for ready reference:-

       “Diagnosis

• HYPERTENSION
• CAD, P/LWMI
• CART-DVD [LAD 90%]
• PRIMARY PTCA+STENT TO LCX (9/2/23]
• PTCA+STENT TO LAD (7/4/23]
• EF~45%, P/LW HYPOKINETIC

Presenting Complaints

63 years old male patient presented to FHM for Staged PTCA to LAD.

Past History/Comorbidities

• HYPERTENSION
• CAD, P/LWMI
• CART-DVD [LAD 90%]
• PRIMARY PTCA+STENT TO LCX [9/2/23]
• EF~45%, P/LW HYPOKINETIC

Course In The Hospital

Patient admitted for staged PTCA. After consent he underwent PTCA+STENT TO LAD on 7/4/23. There were no post procedure complications. Patient subsequent stay in the hospital was uneventful and now patient is being discharged on optimum medical management with advice to follow up in OPD.”

8. Thus, one thing is clear on record that during the first tenure of hospitalisation from 9.2.2023 to 11.2.2023, the treating hospital had done primary PTCA + stent to LCX on 9.2.2023 whereas during the second hospitalisation period the complainant was admitted for staged PTCA and had undergone PTCA + stent to LAD on 7.4.2023.
9. In this manner, it is clear from both the discharge summaries that the complainant was treated twice in the treating hospital for the stenting purpose i.e. stent to LCX (Left Circumflex Artery) and stent to LAD (Left Anterior Descending).  The discharge summary further makes it clear that when the complainant was admitted in the treating hospital on 9.2.2023, he was only found with past history of HTN and in the second discharge summary, he was also referred CAD, LAD and primary PTCA and stent to LCX (9.2.2023), making it further clear that in the second discharge summary, the treating hospital had only given reference about the primary PTCA + stent to LCX done to the complainant on 9.2.2023 in addition to hypertension, making further clear that, in fact, the complainant was found to be past history of hypertension by the treating hospital at the time of first hospitalisation and at that time no other pre-existing disease was found or referred by the treating hospital with respect to the complainant. 
10. Since it is clear from the subject policy that the complainant had already disclosed about the pre-existing disease of hypertension at the time of obtaining the first policy in the year 2019, as is also evident from the copy of policy certificate (Annexure C-1/page 10) and even at the time of renewal of the subject policy, as is also evident from policy certificate (Annexure C-1/page 18), hence it is clear that the OP was aware of the fact that the complainant has only been suffering from the pre-existing disease of hypertension and after receiving higher premium from him, the OP had opted to issue the subject policy to him.  Thus, when the OP itself had issued the subject policy to the complainant by giving reference of the pre-existing disease from which the complainant was suffering before the issuance of the subject policy i.e. hypertension, it could not have repudiated the genuine claim of the complainant on the ground that the same was excluded under the exclusion clause for 48 months of waiting period.  Here we are fortified by the judgment of the Hon’ble Apex Court in Manmohan Nanda Vs. United India Insurance Co. Ltd. & Anr., I (2022) CPJ 20 (SC) in which it was held that the prudent insurer has to gauge possible risk that policy would have to cover and accordingly decide to either accept proposal form and issue policy or decline to do so.  The relevant portion of the judgment is reproduced below for ready reference:-

“66. Viewed in the aforesaid perspective, it is held that the respondent insurance company could not have repudiated the policy on the ground that acute myocardial infraction suffered by the appellant on landing at San Francisco, USA was a “pre-existing and related complication” which was excluded under the policy. The insurer was informed about the pre-existing condition of the appellant, namely, diabetes mallitus-II and it was for insurer to gauge a related complication under the policy as a prudent insurer and then issue the policy when satisfied. In the absence of the same, the treatment availed by the appellant for acute myocardial infraction in USA could not have been termed as a direct offshoot of hyperlipidaemia and diabetes mellitus so as to be labelled as a pre- existing disease or illness which the appellant suffered from and had not disclosed the same. At any rate, the appellant had in the proposal form disclosed that he was suffering from diabetes mellitus-II and for which the medical test reports were submitted along with the proposal form which were considered by the insurance company before the policy was issued to the appellant. In fact, the appellant stated in his representation dated 16^th November, 2009, against the repudiation of the policy that he was taking lipid-lowering medicines not because he was suffering from hyperlipidaemia but as it was customary to take such medication for prevention of cardio-vascular complications in diabetics. He also stated that he had informed the physician, Dr. Jitendra Jain, who examined him prior to obtaining the policy, of the medicines he had been taking. Therefore, the insurance company was well aware of the fact that the insured was a diabetic and was taking all necessary medication for preventing further complications and controlling the disease. Hence in our view, there was no suppression of any material fact by the appellant to the insurer.

67. Further on the disclosures made by the appellant with regard to his existing disease, namely diabetes mellitus-II, the insurance company considered the same and issued the policy in question to the appellant. The respondent insurance company as a prudent insurer considered the details given by the appellant in the proposal form and issued the policy. The insurance company did not think that the medical and health condition of the appellant was such which did not warrant issuance of a mediclaim policy. The insurance company therefore did not decline the proposal of the assured as a prudent insurer.”

11. Not only this, it is also apposite to mention here that the Hon’ble State Commission, Delhi, in the case titled S.S. Jaspal Vs. National Insurance Co. Ltd. & Ors., IV (2022) CPJ 26 (Del.) has held 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.”

12. 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."

13. In view of the foregoing, it is safe to hold that the OP was unjustified in repudiating the claim of the complainant and the present consumer complaint deserves to succeed.
14. Now coming to the quantum of amount, since complainant has proved on record the first bill to the tune of ₹2,26,121/- and second bill to the tune of ₹1,68,258/- as well as receipts indicating that he had paid aforesaid amounts of ₹2,26,121+ ₹1,68,258 = ₹3,94,379/-  to the treating hospital from his own pocket, it is safe to hold that OP/ insurer is liable to pay said amount to 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 the OP is directed as under :-

1. to pay ₹3,94,379/- to the complainant alongwith interest @ 9% per annum (simple) w.e.f. 19.7.2023 (when the claim was finally repudiated) 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 the OP within a period of 45 days from the date of receipt of certified copy thereof, failing which the amounts mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
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.

03/09/2024	Sd/- [Pawanjit Singh] President
	Sd/-
	[Surjeet Kaur] Member
	Sd/-
	[Suresh Kumar Sardana] Member