BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.442 of 2019
Date of Instt. 23.09.2019
Date of Decision: 22.07.2024
Mrs. Kaplidner Kaur daughter of Shri Jaspal Singh, resident of House No.271-L, Model Town, Jalandhar City.
..........Complainant
Versus
1. M/s Star Health and Allied Insurance Co. Ltd., EH-198, 2nd Floor, Nirmal Complex, G. T. Road, Jalandhar through its Branch Manager.
2. M/s Star Health and Allied Insurance Co. Ltd.,1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai through its Managing Director.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Shivam Arora, Adv. Counsel for Complainant.
Sh. A. K. Arora, Adv. Counsel for OPs.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the complainant purchased Policy for medical insurance bearing previous Policy No.P-161125/01/2015/002234 on 29.1.2015 commenced from 30.1.2015 from OP No.1 and the complainant has paid premium from time to time. The said policy was further renewed on 30.1.2016 and then on 30.1.2017 and then it was again renewed on 30.1.2018. At the time of purchase of the policy and its renewal from time to time, all the necessary verifications were conducted and the company had been accepting the premium. At the time of purchase of the Policy in the year 2015, it was specifically told that the complainant was suffering from Thyroid problem. In the month of October, 2017, the complainant suffered from stomach infection and was admitted in Mannat Hospital, Jalandhar under the supervision of Dr. Mohit Nanda. The complainant submitted the claim with the OP No.1 in order to get the benefit of the policy. Since it was a small claim of Rs.10,000.00 as such, the complainant did not press the said claim nor received any amount against the said claim. The case was closed vide letter dated 9.2.2018 issued by the OP No.1 as the complainant was not interested in getting a small claim. The complainant paid the premium for the year 2018-19 and the policy was renewed by the OPs No.1 and 2 after making necessary verification. On 09.01.2019, the complainant suffered Appendicitis suddenly and she was admitted in Dr. Shingara Singh Hospital on 09.01.2019 at 01:15pm. The complainant remained admitted there till 21.01.2019. The complainant applied for benefit of Cash Less privilege against the policy, but the OPs No.1 and 2, instead of paying the bills to the Hospital, issued letter dated 09.01.2019, wherein it was mentioned that prvious claim of Chronic Liver Disease was not settled in reimbursement although present ailment is not related to liver disease but we are unable to process the claim in cash less, requested to the patient to come in reimbursement with all the documents of liver disease and present hospitalization. Since, the complainant procured cashless policy, as such, the complainant was entitled to the benefit and the OPs were liable to pay the same to the Hospital. But the OPs No.1 and 2 illegally and unlawfully did not make the payment of the policy. However, after discharge from hospital, the cop has submitted all the bills of treatment with the OPs for settlement of her insurance claim. The complainant is not suffering from any Liver disease. Had it been so, the Doctor must have prescribed the medicine for liver disease. There is no medicine prescribed for liver disease as per discharge summary. The complainant sent letter but the OPs issued letter dated 18.03.2019 wherein, it is clearly mentioned that company may cancel the policy on the ground of misrepresentation for non disclosure of the material facts in the year 2015. Again the complainant received a letter dated 20.03.2019 issued by the OPs whereby the claim has been repudiated. The complainant sent a legal notice to the OPs, but all in vain and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to reimburse the medical insurance claim of the complainant immediately and to pay interest @18% per Annam from the date till realization. Further, OPs be directed to pay a sum of Rs.2,00,000/- as damages, on account of negligence and deficiency in service, causing trauma, mental agony, tension, undue harassment, inconvenience, loss of money and time and Rs.50,000/- as litigation expenses.
2. Notice of the complaint was sent to the OPs, who filed reply and contested the complaint by taking preliminary objections that the complaint filed by the complainant is false, frivolous, vague, baseless and misconceived because there is no deficiency in service on the part of the answering respondent, therefore, the complaint of the complainant is liable to be dismissed. It is further averred that the complaint of the complainant is not maintainable under the law and in the present form, therefore, the complaint of the complainant is liable to be dismissed. It is further averred that the complaint is barred by mis-joinder of parties. The OP No.2 submits that the reliefs are claimed against OP No.1 only and admittedly there is no personal allegation and or demand/relief claimed as against the OP No.2 in the circumstances, OP No. 2 in his personal capacity is not a necessary party to the present complaint. Hence, the present complaint is liable to be dismissed. It is further averred that no cause of action has arisen in favour of the complainant to file the present case. The OP has acted strictly on the basis to the terms and conditions contained in the policy. The present case is premature as the complainant had not submitted the required documents for the purpose of the claim despite of repeated requests by the answering OPs. The complaint has been filed by the complainant with the malafide intention and further to grab the public money. Hence, the present complaint is liable to be dismissed. It is further averred that the present complaint is in violation of the terms and conditions contained in the policy. Therefore, the complaint is liable to be dismissed with exemplary costs. It is further averred that the complaint is bound by the terms and conditions as applicable and which were expressly made known to the complainant at the time of his taking the policy in question. The OP had at the time of issuing the policy explained to the complainant the exclusion clauses and the payment plan. It is further averred that the complainant has approached the Forum with unclean hands by not disclosing and misrepresenting material facts. The present complaint is false, frivolous, misconceived and vexatious in nature and has been filed with the sole intention of harassing the OPs. It is further averred that the present complaint is the misuse of the legal process. It is further averred that the present complaint was filed only with the motive to harass the OPs. It is further averred that the complainant has no locus-standi and cause of action to file the present complaint. On merits, it is admitted that the complainant purchased medical insurance policy from the OPs bearing No.P-161125/01/2015/002234 commenced from 30.01.2015. It is also admitted that the policy was renewed from 30.01.2016 till 30.01.2018. It is also admitted that the complainant paid the premium. The factum with regard to lodging the claim and repudiation of the same is also admitted, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file as well as written arguments submitted by the counsel for both the parties very minutely.
6. It is admitted that the complainant purchased medical insurance policy from the OPs bearing No.P-161125/01/2015/002234 commenced from 30.01.2015. It is also admitted that the policy was renewed from 30.01.2016 till 30.01.2018. The policies have been proved by the OP Ex.OP-1 to Ex.OP-4. Ex.OP-2 has been proved by the complainant as Ex.C-2. It is also admitted that the complainant paid the premium. The complainant has alleged that he suffered Appendicitis on 09.01.2019 and was admitted in Dr. Shangara Hospital. He has proved on record the admission slip Ex.C-3, discharge summary Ex.C-4 and receipts for treatment Ex.C-5 to Ex.C-71. The bills have been proved as Ex.C-72 to Ex.C-155. Though, the complainant was entitled for cashless payment from the insurance company, but the cashless payment was denied and the complainant lodged the claim alongwith the bills for the settlement of claim. Perusal of the Ex.C-156 shows that the cashless pre-authorization was declined and the complainant was requested to lodge the claim for reimbursement which the complainant lodged. As per Ex.C-157, which is, the notice of cancellation due to non-disclosure of pre-existing disease. The OP has relied upon the proposal form Ex.OP-6 and alleged that there is no reference of the pre-existing disease in the proposal form. The complainant was having a Chronic Liver Disease with portal hypertension prior to the date of commencement of the policy. Vide Ex.OP-33 and Ex.OP-34, the claim of the complainant was repudiated.
7. The complainant has produced Ex.C-3 the admission slip. Perusal of this file shows that the complainant was admitted on 09.01.2019 and was discharged on 21.01.2019. The discharge summary has been proved by the complainant Ex.C-4. Perusal of Ex.C-4 shows that the complainant had alleged the pain in abdomen right side lumber and Iliac Fossa Region since 2-3 days with Nausea. H/o-CH. Liver Disease since 2017, Hypothyroidism since 18 years. NO H/O-DM/CAD/COPD/HTN/DRUG Allergy/Cough/Expectoration. The OP has alleged that she was suffering from Chronic Lever Disease and there is a concealment of fact of pre-existing disease, therefore, the claim of the complainant was repudiated. Perusal of the Ex.OP-7 shows that the complainant was admitted in the hospital in Mannat Super Specialty Hospital on 21.10.2017 and 22.10.2017 and as per this document, there is no record with liver disease as the patient was admitted on day care basis for 2-3 hours. Perusal of Ex.OP-22 shows that the complainant was admitted on 09.01.2019 in Jalandhar Nursing Home and it has simply been mentioned that earlier she was admitted in Mannat Hospital in October-November, 2017. The OP has also relied upon the prescription of the Mannat Hospital of dated 08.08.2013, 01.08.2013 and the prescription of the Mannat Hospital have been proved as Ex.OP-24 to Ex.OP-29. Perusal of all these prescription nowhere shows that she was having any problem of Appendicitis and intestine. The contention of the OP is that since she was having Chronic Liver Disease and this fact was concealed by the complainant, but this contention is not tenable. It has been held by the Union Territory Consumer Disputes Redressal Commission, Chandigarh, in (2006) CPJ 270, case titled as ‘Life Insurance Corporation of India & Ors. Vs. Shiv Singh’ that ‘insured got examined from insurance doctor, found healthy – Deceased allegedly suffered from chronic obstructive pulmonary disease and chronic asthma – No nexus between cause of death and alleged ailment of deceased – Fraudulent suppression of material facts not proved- insurer liable.’ It is well settled law that there should be nexus between the pre-existing disease and the treatment of the disease. In the present case she may be having liver disease, but there is no nexus between the liver diseases with the Appendicitis. The claim of the complainant is regarding the treatment taken by her for Appendicitis as per the admission slip as well as discharge summary Ex.C-3. The Appendicitis is directly related to intestine and not to liver. But the complainant was having no problem of Appendicitis or intestine as per the prescription slip produced by the OP. So, the claim of the complainant has been repudiated only due to the fact that the complainant was having enlarged liver with enhanced Ecopattern, but as discussed above, she was not diagnosed for liver but for Appendicitis. So, the repudiation of the claim is illegal and wrong and thus the same is hereby set-aside.
8. In view of the above detailed discussion, the complaint of the complainant is partly allowed and the OPs are directed to reimburse the medical insurance claim as per the bills submitted by the complainant with interest @ 6% per annum from the date of repudiation the claim, till its realization. Further, OPs be directed to pay a compensation of Rs.15,000/- for causing mental tension and harassment to the complainant and Rs.8000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
9. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
22.07.2024 Member Member President
