District Consumer Disputes Redressal Commission ,Faridabad.

Consumer Complaint  No.254/2019.

 Date of Institution: 27.05.2019.

Date of Order: 28.07.2022.

 Bal Mukund, aged about 43 years son of Sh. Ram Chand deceased leaving behind the following legal heirs/successors:

(i)        Mohit – Son (Aadhar card No. 2479 1528 1502),

ii)      Ms. Pooja Rani – daughter (Aadhar card No. 9934 6732 0085),

All resident of House No. 1539, 33 Ft. Road, Tyagi Market, Dabua Colony, NIT, Faridabad, District Faridabad

                                                                   …….Complainant……..

                                                Versus

M/s. Star Health and Allied Insurance Company Limited, 8^th floor, Palm Court, Maharana Pratap Circle, Gurugram – 122001 through its Divisional Manager/Principal Officer.

2^nd address:-

M/s. Star Health and Allied Insurance Company Limited, Sector-16, Faridabad.

                                                                   …Opposite party……

Complaint under section-12 of Consumer Protection Act, 1986

Now  amended  Section 34 of Consumer protection Act 2019.

BEFORE:            Amit Arora……………..President

Mukesh Sharma…………Member.

PRESENT:                    Sh. S.N.Tomar,  counsel for the complainant.

                             Sh . O.P.Gaur, counsel for opposite parties Nos.1 & 2.

ORDER:  

                   The facts in brief of the complaint are that the complainant obtained a Medical Claim Insurance Policy bearing NO. P/161117/01/2018/0000177 covering the risk from 6.4.2017 to 5.4.2018 for a sum of  Rs.5,00,000/- duly issued by the opposite party.   On 09.01.2016 suddenly the complainant became sick, because hence he went to Apurva Hospital, 2-N/74 B.P.Near 2-3 Gole Chakkar, NIT, Faridabad, on the same day where he got admitted as an indoor patient on the same day i.,e. on 09.01.2016 and remained there upto 13.01.2016, on the basis of above said mediclaim insurance policy.    The complainant informed the opposite party immediately with regard to his ailment and hospitalization.  Accordingly, at that time, the complainant got completed each and every required formality with the opposite party.   At the time the opposite party made the payment of the claimed amount without any objection.  On 22.06.2017, suddenly the complainant was having onset right side weakness, inability to speak and altered sensoriyum since morning i.e. 11.00 a.m. hence he admitted in Metro Hospitals, Sector-16A, on the same day as an indoor patient and on the same day the complainant sent a pre-authorize request letter to the opposite party from hospital and the opposite party sent rejection of pre-authorization for cashless treatment vide its letter dated 23.6.2017, stating therein that as per submitted documents, patient K/C/O hypertension for 5 years which was  pad and not disclosed present ailment  was an complication of hypertension, hence claim rejected.  At that time, the complainant remained admitted as an indoor patient in the above said hospital upto 8^th July 2017.    At that time also, the complainant spent Rs.5,14,257/-.  The complainant again admitted in Metro Hospitals, Sector-16A, Faridabad on 23.8.2017, because he was suffering from disease of left basal ganglia bleed with extrusion into fronto-temporal lobes, for which he underwent left fronto-tampro-paiental decompressive craniotomy,  evacuation of ICH with dura-plasty and placement of bone flap in abdominal wall under G.A. on 23.8.2017.  The complainant remained admitted as an indoor patient  upto 25.8.2017.  At that time the complainant spent a sum of Rs.1,63,760/- on account of doctors fees etc.  Besides this, the complainant spent Rs.1,00,000/- on account of purchasing of medicines etc. from different medical stores.  As such the complainant spent a  total amount of Rs.8,00,000/- approximately.  Accordingly, the complainant submitted all requisite documents to the opposite party.  Inspite of submission of all requisite documents by the complainant, the opposite party had failed to release the payment of the amount in question to the complainant till date.   Previously the complainant filed a complaint under section 12 of Consumer Protection Act against the opposite party, titled as ‘Bal Mukund Versus M/s. Star Health and Allied Insurance Company Ltd.’ before this Hon’ble Forum.  During the pendency of the said complaint, the opposite party filed its written statement and evidence by way of affidavit, stating therein that “ the opposite party received a request for cashless hospitalization from the complainant and the opposite party had rejected the same” stating that pre-existing disease and the complaint is pre-mature.   On the basis of which, the Hon’ble Forum was pleased to pass an order dated 09.01.2019, with a direction to the complainant to withdraw the said complaint and to submit all requisite documents i.e. claim form and treatment record of the complainant to the opposite party and if the opposite party not reimburse the claim of  complainant, then liberty was granted to the complainant to file fresh complaint.  In compliance of the above said order, the complainant withdrew all original documents from the Hon’ble Forum and submitted the new claim form alongwith all requisite documents and medical record to the opposite party, with a request to release the payment of the claimed amount.  But the

opposite party sent a letter dated 08.02.2019 to the name of the complainant, by repudiated the claim of the complainant, on the ground of ‘pre-existing disease’.  As such the fresh cause of action to file the present complaint accrued to the complainant, after receiving the above said letter of repudiation.  Hence this complaint. The aforesaid act of opposite parties amounts to deficiency of service and hence the complaint.  The complainant has prayed for directions to the opposite parties to:

a)                pay the complainant the  above said claimed amount of Rs.10,00,000/- alongwith interest @ 18% p.a. from the date of its due till realization of whole amount.

 b)                pay Rs. 50,000/- as compensation for causing mental agony and harassment .

c)                 pay Rs. 22,000 /-as litigation expenses.

2.                Opposite party  put in appearance through counsel and filed written statement wherein Opposite party refuted claim of the complainant and submitted that  the insured had availed first time, the “Star Comprehensive Insurance Policy” vide policy No. P/161117/01/2018/000177,for the period 06.04.2017 to 05.04.2018 for covering Mr. Bal Mukund – Self for the sum insured of Rs.5,00,000 Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.  The complainant neither had any cause of action nor locus standi to file the present complaint.  It was submitted that the complainant had suppressed and concealed the true, vital and material facts and information from this Forum and thus  had not come with clean hands.  As a sequel of brief history of the matter in hand and for the purposes of facilitation of the true, vital and material facts & information by this Forum, it was submitted that the insurance company received a “Request for cashless hospitalization” on 22.06.1017 from

Metro Heart Institute with Multi Specialty, Sector 16A, Faridabad in respect of hospitalization of the patient – BalMukund.  As per the “Pre Authorization Form”, the patient was hospitalized with provisional diagnosis as “Acute CVA with Hypertension”.   As a result thereof, the insurance company sent a query letter dated  23.6.2017 to the hospital inter-alia seeking the following information and documents:-

i.                 CT Head, Blood reports and admission case sheet.

ii.                Certification from the treating doctor regarding previous hospitalization of CVA and cause of CVA.

iii.               Exact duration of history of DM (Diabetes Mellitus) and Hypertension with all previous follow-up record.

Accordingly, the hospital arranged emergency card with patient history        dated 22.06.2017 and also X-ray report of chest alongwith NCCT head dated 23.06.2017.  It was further submitted that as per the treatment history, the patient had DM (Diabetes Mellitus – II) and Hypertension since 5 years.  Accordingly, the insurance company had thoroughly and carefully investigated into the subject claim on the basis of the available documents provided by the hospital.  As a result thereof, the insurance company observed that the complainant was a known case of DM (Diabetes Meelitus –II) and hypertension since 5 years, which was pre-existing diseases and the same was not disclosed at the time of obtaining the “Star Comprehensive Insurance policy”, for the period 06.04.2017 to 05.04.2018.  It was submitted that suppression and concealment of such material facts & information, constitute misrepresentation at the time of obtaining the insurance policy in the proposal form furnished by the complainant to the insurance company. It was further submitted that hospitalization of the

 complainant with diagnosis as “Acute CVA and left ganglia bleed” was as a result of DM (Diabetes Mellitus-II) and hypertension.   Therefore, the insurance company arrived at its decision in declining the     pre-authorization for cashless request vide its letter dated 23.06.2017 being the ailment pre-existing diseases, which attached Exclusion clause NO.1 contained in the star comprehensive insurance policy.  As a matter of the judicial proceedings, the complainant lodged a complaint registered as CPA case No. 116 of 2018 titled “BalMukund Vs. Star Health & Allied Insurance Company Ltd.” which complaint stand dismissed as withdrawn vide order dated 08.01.2019 with the direction to the effect that the complainant may lodge regular claim alongwith original claim documents with the insurance company  As a result, the complainant lodged  a regular claim by tending claim form alongwith claim documents, received by the insurance company on 31.01.2019.  In furtherance of the claim, the insurance company thoroughly and carefully investigated into the subject claim.  In terms of the discharge summary for the period 22.06.2017 to 08.07.2017, issued by the Metro Heart Institute with Multispecialty, Sector-16A, Faridabad, the complainant was diagnosed as under:-

-        As per the inpatient history & physical examination of the   treatment record provided at the time of reimbursement and pre authorization query furnished during cashless processing, the insured was a known case of Diabetic Mellitus and Hypertension for the past 5 years.

-        As per the discharge summary, the insured was diagnosed with “Left Basal Ganglia Bleed with Mass Effect”.

-        The most common cause of the Left Basal Ganglia Bleed was Hypertension and the insured had hypertension prior to inception of the insurance policy, it falls under the definition of “pre-existing disease”.           

It was further submitted that the afore-listed ailment and hospitalization falls under the exclusion clause No.1 of the insurance policy.  As a result, the insurance company had repudiated the subject claim vide its letter dated 08.02.2019. Opposite party denied rest of the allegations leveled in the complaint and prayed for dismissal of the complaint.                                  

3.                The parties led evidence in support of their respective versions.

4.                We have heard learned counsel for the parties and have gone through the record on the file.

5.                In this case the complaint was filed by the complainant against opposite party – Star Health & Allied Insurance Company  with the prayer to a)                 pay the complainant the  above said claimed amount of Rs.10,00,000/- alongwith interest @ 18% p.a. from the date of its due till realization of whole amount.

 b)                pay Rs. 50,000/- as compensation for causing mental agony and harassment .

c)                 pay Rs. 22,000 /-as litigation expenses.

To establish his case the complainant  has led in his evidence Ex.C-1 to C-8,Ex.C-15 to C-17, C-20 to C-22 - Cash memos, ExC-9  to Ex.C-12, Ex.C-18 to Ex.C-19 – cash sales, Ex.C-23 – Discharge summary, Ex.C-24  & C-25 -Final Bills, Ex.C-26 – Discharge summary, Ex.C-27 -  CBC (whole blood), Ex.C-28 note written by  Metro Heart Institute with Multispecialty, EAx.C-29 Final bill, Ex.C-30 Discharge summary, Ex.C-31 – Admission form,, Ex.C-32 OPD card of Apurva Hospital,, Ex.C-33 – Discharge summary , Ex.C-34 – Star Comprehensive Insurance policy valid from 06.04.2017 to 05.04.2018, Ex.C-35 – Nominee details for the proposer.Ex.C-36 – Section 7 Accidental Death and Permanent Total Disablement, Ex.C-38 – Customer Identity Card, Ex.C-39 – Hospitalization Benefit Policy, Ex.C-40 – rejection of pre-authorization for cashless treatment,, ExC41 – order dated 08.01.2019 passed by this forum, Ex.C-42 –Claim Form, Ex.C-43 - Repudiation letter dated 08.02.2019.

                   On the other hand counsel for the opposite party strongly agitated and opposed.  As per the evidence of the opposite party, Ex.O/1 – Proposal Form dated 23.03.2017, Ex.O/2 – insurance policy, Ex.O/3 – Request for cashless, Ex.O/4 – Query on pre authorization, Eax.O/5 – NCCT, Ex.O/6 – Hospital emergency card, with inpatient history, Ex.O/7 – Discharge summary, Ex.O/8 – Rejection of pre authorization for cashless treatment, Ex.C-9 – Claim form, Ex.O/10 – Discharge summary Ex.O/11 – Final Bill dated 08.07.2017, Ex.O/12 – Discharge summary, Ex.O/13 – Final Bill, Ex.O/14 – Repudiation letter dated 08.02.2019.

6.                In this case the complainant obtained a Medical Claim Insurance Policy bearing NO. P/161117/01/2018/0000177 covering the risk from 6.4.2017 to 5.4.2018 for a sum of  Rs.5,00,000/- duly issued by the opposite party.     He suddenly became sick on 09.01.2016 and visited Apurva Hospital, NIT Faridabad at about 3.00p.m. where remained admitted upto 13.01.2016, for which he informed the insurance company. The complainant “having onset right side weakness , inability to speak and altered sensorium” on 22.06.2017, hence, admitted in Metro Hospital, Sector-16A, Faridabad upto 08.07.2017 for which the insurance company was informed for pre-authorization cashless treatment.  But the insurance company rejected the cashless treatment vide its letter dated 23.06.2017 with the reasons that the complainant is a “Known case of hypertension for 5 years, a pre-existing disease”.  However, the complainant spent a sum of Rs.5,14,257/-. The complainant was again  admitted in Metro Hospital, sEctor-16A, Faridabad for the period 23.08.2017 to 25.08.2017 with the complaint of “suffering from disease left basal ganglia bleed with extrusion fronto-temporal lobes”. The complainant spent a sum of Rs.1,63,760/- on his treatment, in addition to Rs.1,00,000/- on account of purchasing medicines etc. As such the complainant spent a  total amount of Rs.8,00,000/- approximately.  The complainant submitted all requisite documents to the opposite party but the opposite party failed to release the claim. Pursuant to order dated 09.01.2019 passed by this Forum in previous complaint titled  Bal Mukund Vs. Star Health & Allied Insurance Company”  directed the complainant to lode a regular claim with the insurance company, which was earlier not lodged and thereafter the insurance company will dispose off the same expeditiously.  As a result, the complainant lodged regular claim with the insurance company but the said claim was repudiated by the insurance company but the said claim was repudiated by the insurance company vide “letter of Repudiation” dated 08.02.2019.

7.                Opposite party had repudiated the claim of  the complainant vide letter dated 08.02.2019 Ex.O/14 on the ground that  from the inpatient history and physical examination record of the aforesaid treatment submitted during cashless processing that the insured patient is a known case of diabetes mellitus and hypertension for the past 5 years which confirms the patient has diabetes mellitus and hypertension prior to inception of the first medical insurance policy. Hence, these are pre-existing disease.  The present admission and treatment of the insured patient is for intra cerebral bleed which is a complication of pre existing hypertension.  

                   The complainant has obtained first time the “Star Comprehensive insurance policy for the period 06.04.2017 to 05.04.2018 by tending the proposal form. As per proposal form vide  Ex.O/1 , the insured has not disclosed the status of health in regards to his pre-existing disease, which constitute misrepresentation of the material facts.  Further , as per exclusion clause No.1 of the policy, the company is not liable to make any payment in respect of the pre-existing disease.  Further the insured had violated, infringed and breached the condition NO.4 of the insurance ply by not disclosing and furnishing all the requisite mandatory claim documents and the past history and details of his state of health knowingly and intentionally.    

                   As per proposal form dated 30.03.2017  Ex.O/1  for the purpose of obtaining the health insurance policy for the period 06.04.2017 to 05.04.2018 inter alia declaring his state of health against the respective column as under:

Medical History:

Have you ever suffered or suffering form

any of the diseases

a)       Diabetes Mellitus

b)      High BP Cholesterol                                   “No”

The insurance contract is based on the principle of utmost good-faith.  By compounding the aforesaid declarations made by the complainant independently, voluntarily, explicitly and willingly, the complainant had not disclosed his any pre-existing disease.  As a result, the insurance company had issued “Star Comprehensive insurance policy bearing No. P/161117/01/2018/000177 for the period of 06.04.2017 to 05.04.2018 in this behalf to the complainant vide Ex.O/2, as per the following details:-

Name                    Pre-existing                    Age                       Sum insured

Bal Mukund                   Nil                                  40 years                Rs.5,00,000/-

The Complainant lodged  a regular claim by tendering claim form alongwith claim documents, received by the insurance company on 31.01.2019.  In furtherance of the claim, the insurance company thoroughly and carefully investigated into the subject claim.  In terms of the discharge summary for the period 22.06.2017 to 08.07.2018 (Ex.O/10), issued by the Metro Heart Institute with Multispecialty, Sector-16A, Faridabad the complainant was diagnosed as under:

• As per the inpatient history & physical examination of the treatment record, furnished even during cashless processing, the insured is a known case of Diabetic Mellitus and Hypertension for the past 5 years.
• The insured has known case of  Diabetic Mellitus and Hypertension for the past 5 years, whereas, presently diagnosed with “Left Basal Ganglia Bleed with Mass Effect”.
• The most common cause of the Left Basal Ganglia Bleed is Hypertension and the insured has hypertension prior to the inception of the insurance policy, hence, it falls under the definition of pre-existing disease”.

As per discharge summary for the period 23.08.2017 to 25.08.2017 vide E.O/12, issued by Metro Heart Institute with Multispecialty Hospital, Sector-16A, Faridabad, the complainant was diagnosed as under:-

1. Follow up case of Left Basal Ganglia Bleed with Extrusion into fronto-temporal lobes.
2. Diabetes Mellitus
3. Hypertension

The insurance company thoroughly and carefully investigated into the subject claim and observed that ailment and hospitalization falls under the exclusion clause No.1 of the insurance policy.  As a result, the insurance company had arrived at its decision in treating the subject claim as “Repudiated” vide its letter dated 08.02.2019 vide Ex.O/14.

8.                After going through the evidence led by the parties, the Commission is of the opinion that it is evident from Ex.O/6 i.e inpatient history & physical examination of the treatment record mentioned in the past history that the insured is a known case of Diabetic Mellitus and Hypertension for the past 5 years which confirms the patient has diabetes mellitus and hypertension prior to inception of the first medical insurance policy. Hence, these are pre-existing disease.  The present admission and treatment of the insured patient is for intra cerebral bleed which is a complication of pre existing hypertension.  

9.                Hence no deficiency in service on the part of opposite parties is proved in the present case.

10.              Resultantly the complaint is devoid of merits and the same is dismissed. Copy of this order be given to the parties free of costs and file be consigned to record room.

Announced on: 28.07.2022                                  (Amit Arora)

                                                                                  President

                     District Consumer Disputes

           Redressal  Commission, Faridabad.

                                                  ( Mukesh Sharma)

                       Member

          District Consumer Disputes

                                                                    Redressal Commission, Faridabad.