DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, JALANDHAR Complaint No.380 of 2018 Date of Instt. 14.09.2019 Date of Decision: 26.10.2021 Lovejeet Singh s/o Sh. Harvinder Singh, aged 22 years, r/o H. No.665, VPO Dakoha near Dispensary District Jalandhar. ..........Complainant Versus M/s Star Health and Allied Insurance Co. Ltd through its branch Manager, EH-1, 2nd Floor, Nirmal Complex, Opposite Narinder Cinema G.T Road, Jalandhar. ….….. Opposite Party Complaint Under the Consumer Protection Act. Before: Sh. Kuljit Singh (President) Smt. Jyotsna (Member) Present: Sh. Rakesh Trikha, Adv. Counsel for the Complainant. Sh. Nitish Arora, Adv. Counsel for the OP. Order Kuljit Singh(President) 1. The instant complaint has been filed by the complainant against OP on the averments that he has taken the group insurance policy bearing no. 87842391800000900 valid for the period from 21.02.2018 to 20.02.2019. Unfortunately, he fell sick and admitted in DMC Hospital Ludhiana from 01.03.2018 to 26.03.2018. He spent a sum of Rs.78,450/- for his treatment. He requested OP to make the payment of aforesaid insurance policy but OP is dilly dallying the matter on one pretext or the other. Due to non-reimbursement of amount of treatment, OP liable to reimburse the amount of Rs.78,450/- along with compensation for mental harassment. Due to illegal act and conduct of OP, he has filed the present complaint and prayed that OP be directed to reimburse the amount of Rs.78,450/- along with interest @ 18% per annum, besides Rs.50,000/- as compensation for mental harassment and Rs.5500/- as cost of litigation. 2. Upon notice, OP appeared and filed written reply and contested the complaint of the complainant by averring that the complainant got hospitalized on 01.03.2018 in DMC Ludhiana and availing cashless facility for the treatment of ACUTE VIRAL HEPATITIS. The insured had a history of jaundice prior to inception of the policy thus pre-authorization request was denied and same was communicated to insured vide letter dated 05.03.2018. As per Exclusion No. 4, company is not liable to make any payment in respect of expenses for treatment of pre-existing disease. The insured was hospitalized for pre-existing disease, thus claim of the complainant was rejected and same was informed to the insured vide letter dated 04.05.2018. OP has acted strictly on the basis of the terms and conditions contained in the policy. Rest of the averments made by the complainant in the complaint were denied by OP and it prayed for dismissal of the complaint. 3. The complainant has tendered in evidence his affidavit Ex.CW-1A along with copies of documents Ex.C-1 to Ex.C-55. On the other hand, OP tendered in evidence affidavit of Rajiv Jain Chief Manager as Ex.OP-1/A along with copies of documents Ex.OP-1 to Ex.OP-20 and closed the evidence. 4. We have heard learned counsel for the parties and have gone through the record very carefully as well as written arguments filed by opposite party. 5. It is an admitted fact that complainant got the treatment from DMC Hospital Ludhiana on 01.03.2018 to 26.03.2018, this fact is clear from copy of OPD Card placed on the record. The complainant alleged deficiency in service and unfair trade practice on the part of OP. He alleged that he spent Rs.78,450/- on his treatment and he claimed the amount of Rs.68,040/- for admission in the hospital from 01.03.2018 to 13.03.2018. But OP repudiated the claim of the complainant vide letter dated 04.03.2018. 6. On the other hand, OP refuted the allegations of the complainant. The learned counsel for OP pleaded that insured had a history of jaundice prior to inception of the policy, thus, pre-authorization request was denied and same was communicated to the insured vide letter dated 03.05.2018. As per Exclusion no. 4 of the policy the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease, until 48 months of continuous coverage has elapsed since inception of the policy. 7. This fact is admitted that the complainant admitted in the DMC Hospital Ludhiana for treatment of ACUTE VIRAL HEPATITIS and admitted in the above said Hospital on 01.03.2018 to 26.03.2018. This fact is clear from copy of Discharge Summary Ex.OP-13 on the record. As such, the complainant is an indoor patient. The OP repudiated the claim of the complainant on the ground of pre-existing disease. But OP has not produced any cogent evidence produced on the record to prove that the complainant/insured suffering from pre-existing disease. The complainant himself admitted in letter Ex.OP-11 that he suffering from Jaundice in 2012 but Jaundice is not a disease. As per medical literature, Jaundice is a symptom not a disease. The yellowish discoloration of the skin, mucous membranes, and sclera. This yellowish discoloration is imparted by a chemical in the blood called Bilirubin. Bilirubin is the end product of heme which is produced when red blood cells are destroyed. After red blood cell lysis, the heme is converted to bilirubin which is then transported to the liver and is made water soluble. This water-soluble bilirubin is then excreted through the biliary channels to the gut some of the bilirubin is excreted in the stools as stercobilin while some of it is reabsorbed and excreted by the Kidneys as Urobilinogen. The symptom of Jaundice increase or decrease at any time. It was duty of OP medically check up the insured at the time of filling up the proposal form. The complainant/insured suffered from the problem of Jaundice on 27.10.2018 after takng the policy, this fact is clear from copy of letter Ex.OP-3 dated 27.10.2018 which has written by complainant himself. The defence which has been taken by the insurance company/OP was having no legs to stand. We are of the view that the burden was on the OP to prove that the insured had concealed the material fact of his pre-existing disease at the time of taking the policy. The OP had failed to produce on record any document to show that insured/complainant was suffering from above said diseases. The National Consumer Disputes Redressal Commission (NCDRC) said even if the insured person was suffering from diseases and did not know about it nor was taking any treatment for the same, the claim cannot be denied by an insurance company. NCDRC said the onus to prove the pre-existing disease lies on the insurance company The commission said diabetes was a lifestyle disease and the whole insurance claim cannot be rejected only based on this ground.
8. In view of the above, we are of the considered view that the OP wrongly repudiated the claim of the complainant on baseless grounds. The complainant spent Rs.78,450/- on his treatment and he produced on record bills of expenses Ex.C-6 to Ex.C-54. The complainant has not produced on record the terms and conditions of the policy, so it seems that it is not clear that the terms and conditions supplied to the complainant or not. 9. The learned counsel for OP relied upon citation titled as Subhash B. Jatani vs. National Insurance Co. Ltd reported in 2015(1) CPR 807 by National Commission New Delhi that non-reimbursement of hospitalization charges – Myasthenia Gravis was found present and complainant was suffering from it as per history given since month of Feb. 20000 disease relates to Muscular Paralysis and it is not silent disease and patient must be experiencing and aware of it. Thus, insurance company rightly inferred after careful investigation of the case and breach committed by the complainant. The case titled as National Insurance Company Ltd vs. Ashok Kumar Gupta reported in 2012(1) CPR 380 by Hon’ble National Commission New Delhi that claim repudiated by the insurer on the ground of suppression of material facts. The case titled as Diwan Surender Lal vs. Oriental Insurance Company Ltd reported in 2009(2) CLT 142 by Hon’ble National Commission New Delhi that past illness accepted by the complainant in the hospital’s admission and not disclosed in the proposal form which was material for issue of medi-claim policy. Medical claim rightly repudiated by insurance company. Complaint dismissed. 10. The above said citations placed on record by OP is distinguishable from the factual position of the case in hand because the position in the instant case is different. The OP not produced on record any document to prove that the terms and conditions supplied to the complainant or not. The Hon’ble National Commission discussed this matter in case titled as J.R Banik versus National Insurance Company Ltd reported in 2017(2) of Hon’ble National Commission New Delhi wherein it has been held that “it was the duty of OP that terms and conditions should be supplied by the insurance company. Non-production of terms and conditions to be the insured amounts to deficiency in service and the repudiation of the claim is unjust and arbitrary. Further held- it appears that the agents of insurance companies to achieve a target of number of insurance policies, act in haste and collect premiums. The consumers are supplied either cover note only or the insurance certificate without any policy clauses or terms and conditions. If the insurance companies take a little pain to provide terms and conditions along with policy certificate, then there will be limited scope of litigation.” 11. OP repudiated the claim of the complainant vide letter dated 04.03.2018. OP pleaded that as per Exclusion clause no. 4, company is not liable to make any payment in respect of expenses for treatment of pre-existing disease. But in the present case, firstly, the OP has not prove that the terms and conditions of the policy were delivered to the complainant or not and secondly, the complainant is not suffering from pre-existing disease, the symptom of Jaundice increase or decrease at any time. It was duty of OP medically checked up the insured at the time of filling up the proposal form. 12. In the light of our above discussion and after going through the citation of Hon’ble National Commission New Delhi (supra), we are of the considered opinion that we find no substance in the submissions of the OP as such, we allow the complaint of the complainant and OP is directed to reimburse Rs.78,450/-along with interest @ 6% from the date of admission of the complainant in the hospital till its actual realization. The complainant is also entitled for Rs.5,000/- as compensation for mental harassment and Rs.3,000/- as cost of litigation. The entire compliance be made within 45 days from the date of receipt of the copy of order. 14. Copies of the order be sent to the parties, as permissible, under the rules. This complaint could not be decided within stipulated time frame due to rush of work. 15. File be indexed and consigned to the record room after due compliance. Announced in open Commission 26th of October 2021 Kuljit Singh (President) Jyotsna (Member) | 
