Chandigarh

DF-I

CC/416/2023

NARINDER KUMAR GARG SON OF SH. BALDEV KRISHAN GARG AGED 59 YEARS - Complainant(s)

Versus

M/S STAR HEALTH AND ALLIED INSURANCE CO. LIMITED THROUGH ITS DIRECTOR/AUTHORIZED SIGNATORY JAYASHREE - Opp.Party(s)

03 Jun 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/416/2023
Date of Institution	:	29/08/2023
Date of Decision	:	03/06/2024

 

Mr. Narinder Kumar Garg son of Sh. Baldev Krishan Garg, aged 59 years, resident of House No.2217, Super Enclave, Sector 49-C, Chandigarh 160047.

… Complainant

V E R S U S

1. M/s Star Health and Allied Insurance Co. Limited, Sri Balaji Complex, 15, Whites Road, Chennai-600014, through its Director/Authorized Signatory (Jayashree Sethuraman)

Second Address : M/s Star Health and Allied Insurance Co. Limited, Branch Office : South Delhi, B1/G6, Ground Floor, Mohan Cooperative Industrial Estate, Mathura Road, New Delhi-110044, through its Director/Authorized Signatory

… Opposite Party

2. Max Super Speciality Hospital, near Civil Hospital, Phase-6, Mohali, Punjab-160055 through its authorized signatory.

… Proforma Opposite Party

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

                                                                               

ARGUED BY	:	Complainant in person
	:	Sh. Gaurav Bhardwaj, Advocate for OP-1
	:	Sh. Ankush Aggarwal, Advocate for OP-2

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Narinder Kumar Garg, 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 Star Comprehensive Health Insurance (Hospitalisation Insurance Policy) (hereinafter referred to as “subject policy”) from OP-1/insurer which was valid w.e.f. 9.10.2022 to 8.10.2025 (three years) on payment of total premium of ₹89,770/-.  At the time of obtaining the subject policy, complainant was hale and hearty and was not suffering from any pre-existing disease.  On the late night of 9.10.2022, the complainant felt chest tightness and pain in jaw alongwith profuse sweating radiating to both sides of neck, which aggravated till the morning of 10.10.2022, as a result of which he was immediately taken to Max Super Specialty Hospital, Mohali/OP-2 (hereinafter referred to as “treating hospital”)  and was admitted on 10.10.2022 where ECG etc. were conducted and the attending doctors advised coronary angiography, which was done on the same day i.e.10.10.2022.  It was for the first time that the complainant was diagnosed with “CAD, single vessel disease” and the treating hospital had charged an amount of ₹2,31,805/-.  As certain restrictions were imposed in the subject policy, complainant did not claim the aforesaid amount from OP-1 and copy of medical record of the treating hospital is Ex.C-2.  After the aforesaid treatment, complainant was leading a healthy life.  However, on 22.5.2023, i.e. after about 8 months of the issuance of the subject policy, complainant suffered watery stool with pain in abdomen and he was again taken to the aforesaid treating hospital where he was diagnosed with “acute gastroenteritis, moderate to severe dehydration”.  The complainant had made cashless treatment request with OP-1/insurer, but, same was rejected by OP-1 vide letter dated 23.5.2023 (Ex.C-3) followed by letter dated 25.5.2023 (Ex.C-4) on the ground that complainant/insured was suffering from pre-existing disease i.e. CAD single vessel disease prior to the inception of subject policy.  However, OP-2/treating Hospital had issued certificate dated 24.7.2023 (Ex.C-5) to the effect that there was no past cardiac ailment to the complainant. The complainant tried to convince OP-1, but, instead of approving his claim, same was rejected by OP-1 vide email dated 21.8.2023 (Ex.C-7). Thereafter the complainant again approached OP-1 and made several requests through email, telephonic calls and even by visiting the office of OP-1 to reimburse the amount to the tune of ₹59,929/- paid by him, but, nothing has been done. 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. OPs 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 and concealment of facts.  However, it is admitted that the complainant had purchased the subject policy from it and the same was in existence at the relevant time.  It is further alleged that the complainant had also made request with the answering OP for cashless treatment for an amount of ₹59,929/-, but, the same was denied by it as the complainant was suffering from pre-existing disease of CAD prior to the inception of the subject policy and had undergone PTCA surgery in 2022.  It is further alleged that as the complainant has concealed material facts from the answering OP by not disclosing the same before the issuance of the subject policy, the consumer complaint of the complainant is not maintainable. 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. In its written version, OP-2, inter alia, took preliminary objections of maintainability, cause of action and mis-joinder of parties.   However, it is admitted that the complainant had approached the answering OP for the first time on 24.9.2022 and at that time he was a known case of HTN, T2 DM and was admitted and investigated thoroughly and he was found COVID-19 AG positive.  It is further alleged that on 10.10.2022, he was admitted and on seeing the health condition of complainant, his PTCA with DES to LAD was done and he was later on discharged.  Copies of discharge summary are Annexure R-2 to R-4.  It is further alleged that the complainant was again admitted to the OP-2/Hospital when he was diagnosed with loose stools and was treated on 22.5.2023 and at that time he had taken LAMA at his wish and for his treatment at different times, bills were issued in his favour. 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.
5. In separate rejoinders, 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 complainant in person, learned counsel for the OPs and also gone through the file carefully.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the subject policy (Ex.C-1) was issued to the complainant for three years, which was valid w.e.f. 9.10.2022 to 8.10.2023 and after the issuance of the same, complainant had fallen ill as he had suffered from chest tightness and pain in jaw alongwith profuse sweating radiating to both sides of neck and was admitted in the treating Hospital/OP-2 on 10.10.2022 where he was diagnosed with CAD single vessel disease and after treatment he was discharged on the next day i.e. 11.10.2022, as is also evident from the discharge summary (Ex.C-2) and the treating hospital had charged ₹2,31,805/- regarding which the complainant had not lodged any claim with OP-2 and after about eight months of the inception of the subject policy, complainant was again admitted in the treating hospital where he was diagnosed with acute gastroenteritis, moderate to severe dehydration, as is also evident from Ex.C-6 Colly. (at page 44), and the treating hospital had charged an amount of ₹59,929/- from the complainant and he had made a cashless authorization request with OP-1/insurer which was rejected by it vide letter dated 23.5.2023 on the ground of non-disclosure of pre-existing disease, the case is reduced to a narrow compass as it is to be determined if OP-1/insurer is unjustified in rejecting/ repudiating the genuine claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of complainant or if OP-1/insurer has rightly repudiated the claim 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 as well as medical record and the same is required to be scanned carefully for determining the real controversy between the parties.
   3. Perusal of the subject policy (Ex.C-1) clearly indicate that the same was issued to the complainant and the same was valid for three years w.e.f. 9.10.2022 to 8.10.2025.
   4. Ex.C-2 (colly.) is the copy of discharge summary qua the first treatment taken by the complainant from the treating hospital, after obtaining the subject policy, when he was admitted there on 10.10.2022 and was discharged on 11.10.2022 and was diagnosed with CAD single vessel disease and was treated for the same and the complainant/insured was shown to be having past medical history of T2 DM, HTN post COVID September 2022. 
   5. LAMA summary of the complainant (at page 44 of Ex.C-6 Colly.) further indicates that he was again taken to the treating hospital on 24.5.2023 when he was diagnosed with acute gastroenteritis and moderate to severe dehydration and the relevant portion of the same is reproduced below for ready reference :-

“Diagnosis:

ACUTE GASTROENTERITIS (ETIOLOGY: INFECTIVE ?VIRAL /?BACTERIAL)

MODERATE TO SEVERE DEHYDRATION

 

CAD (S/P PTCA TO LAD 2022)

HTN

DM

Presenting Complaints:

- GENERALIZED ABDOMINAL PAIN X I DAY

- LOOSE STOOLS X I DAY

- GENERALIZED WEAKNESS X 1 DAY

History of Present Illness:

PATIENT 59 YEAR OLD MALE K/C/O

S/P CAG ON 10/10/2022-CAD SINGLE VESSEL DISEASE

S/P PTCA ON 10/10/2022-PTCA WITH DES TO LAD

12 DM, HTN

POST COVID SEP, 2022

 

PRESENTED TO MSSH WITH C/O

-GENERALIZED ABDOMINAL PAIN, ACUTE ONSET CONTINUOUS IN NATURE, NON-RADIATING SINCE TODAY EARLY MORNING.

-MULTIPLE EPISODES OF LOOSE STOOLS, WATERY IN CONSISTENCY, SINCE TODAY.

-GENERALIZED WEAKNESS SINCE TODAY.

 

NO H/O FEVER/COUGH/BREATHLESSNESS

NO H/O CHEST PAIN/DIAPHORESIS/ PALPITATION

NO H/O BURNING MICTURITION/INCREASED FREQUENCY/REDUCED URINE OUTPUT

NO H/O NAUSEA/VOMITING

THE PATIENT HAS NOW BEEN ADMITTED FOR FURTHER MANAGEMENT.

History

Past Medical History:

HTN

DM

CAD (S/P PTCA TO LAD 2022)”

 

6. Thus even from the perusal of the aforesaid summary it is clear that the past medical history only refers the treatment which was given to the complainant for CAD on 10.10.2022 and 11.10.2022 i.e. after the inception of the subject policy and not prior to that.
7. It is further evident from the invoice (at page 50 of Ex.C-6 colly.) that the treating hospital had charged an amount of ₹59,929/- from the complainant and he is seeking the said claim from OP-1 in the present consumer complaint.
8. Perusal of repudiation/rejection letter dated 21.8.2023 (Ex.C-7) clearly indicates that OP-1/ insurer has repudiated the claim of the complainant on the following ground :-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of AGE

Although the present admission of the insured patient is for treatment of acute gastroenteritis (AGE), it is observed from the submitted records, the insured patient has undergone PTCA surgery in 2022 which confirms that insured patient is suffering from coronary artery disease (CAD) prior to date of commencement of first year policy.

At the time of inception of policy which is from 09/10/2022 to 04/07/2023, you have not disclosed the above mentioned medical history/health details of the insured-person in the proposal form which amounts to misrepresentation/non-disclosure of material facts. Had you disclosed the above pre existing disease/s in the proposal form we would not have issued the policy.

As per Condition No.1 of the policy issued to you, if there is any misrepresentation/non-disclosure of material facts whether by the insured person or any other person acting on his behalf, the Company is not liable to make any payment in respect of any claim.

As per Condition No.7, the policy is also liable to be cancelled and necessary action will be taken by our Corporate Office.

We therefore regret to inform you that for the reasons stated above we are unable to settle your claim under the above policy and we hereby repudiate your claim.”

 

9. From the aforesaid letter is also clear that OP-1 has repudiated the claim of the complainant on the ground of mis-representation and non-disclosure of material facts by the complainant while obtaining the subject policy as he had not disclosed about the pre-existing disease.
10. As per the case of the complainant, he was hale and hearty at the time of obtaining the subject policy and he had only suffered from CAD on the late night of 9.10.2022 when he was taken to the treating hospital and was treated there whereas it is the defence of OP-1 that as the complainant was suffering from  HTN  and CAD, making clear that he was suffering from pre-existing disease, which fact was not disclosed by him at the time of inception of the subject policy, OP-1 has rightly repudiated the claim of the complainant, especially when the discharge summary (Ex.C-2 colly.) clearly refers that the complainant was having past medical history of T2 DM and HTN post COVID September 2022. 
11. However, the certificate (Ex.C-5) issued by the treating hospital/treating doctor falsifies the defence of OP-1 that the complainant was suffering from CAD i.e. pre-existing disease before the inception of the subject policy as it has been opined that –

“There was no past cardiac ailment and the ECG on 10.10.2022 was suggestive of acute ST elevation MI in inferdateral leads.”

              making clear that the complainant was not suffering from any disease prior to the inception of the subject policy.

12. Moreover, the complainant was first time treated for CAD in the treating hospital on 10.10.2022 and he had not even lodged any claim with OP-1 for the said treatment. The complainant has only lodged the present claim qua his treatment which was taken by him for acute gastroenteritis, moderate to severe dehydration on 22.5.2023 and when he had even taken treatment for CAD after the inception of the subject policy and further it has come on record that the complainant was not suffering from any pre-existing disease prior to inception of subject policy, as discussed above, it is safe to hold that OP-1/ insurer is unjustified in repudiating the claim of the complainant.
13. Not only this, 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.”

14. 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."

 

15. 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.”

16. 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 present diseases/ailments, for which the insured patient had taken treatment from the treating hospital.  Hence, it is unsafe to hold that the OP/insurer is justified in repudiating the claim of the complainant and the present consumer complaint deserves to succeed.

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

1. to pay ₹59,929/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 21.8.2023 onwards.
2. to pay ₹15,000/- 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 proved against OP-2, the consumer complaint against it 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.

03/06/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member
	Sd/- [Suresh Kumar Sardana] Member