BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

      Complaint No.197 of 2020

      Date of Instt. 20.07.2020

      Date of Decision: 08.11.2024

Munish Kumar s/o Surinder Pal resident of H. No.NM 31, Mohalla Krar, Ward No.6, Jalandhar.

..........Complainant

Versus

1.       Star Health & Allied Insurance Co. Ltd., 1, New Tank Street, Valluvar Kottam High School, Nungambakkam, Chennai-600034           through its Authorized Officer.

2.       Star Health & Allied Insurance Co. Ltd., EH-98, Nirmal Complex GT Road Jalandhar through its Branch Manager.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Sh. Jaswant Singh Dhillon       (Member)

Present:       Sh. R. K. Bhardwaj, Adv. Counsel for the Complainant.

                   Sh. Nitish Arora, Adv. & Smt. Aditi Kapur, Adv. Counsels for OPs.

Order

Dr. Harveen Bhardwaj (President)

1.                The instant complaint has been filed by the complainant, wherein it is alleged that the complainant had availed a health insurance policy bearing policy No.P/211215/01/2019/002815. The executives of the OP told the complainant that the health policy provided by the OP is comprehensive and includes almost all the ailments. Being lured by deceptive assurances of the agents of OPs, the complainant agreed for purchasing a health insurance policy for himself and his family and consequently the above mentioned policy was issued after receiving the premium amount by the OPS as additional policy. It is noteworthy to add here that the policy had been issued after the agents and executives of the OPs assured themselves that the complainants are hale and hearty and they are not suffering from any pre-existing disease nor they had any such pre-existing disease. Thereafter, the complainant fell ill and was admitted in DMC Hospital Ludhiana hospital on 2-10-2019 and was treated for "Pitutary Macroadenoma" and was discharged from hospital on 24-10-2017. Though, the policy was a cashless policy, however The Complainant vide letter dated 4-10-2019 denied approval of Cashless treatment and ultimately an amount of Rs.5,02887/- was billed by the hospital including medicines; copies of which had duly been supplied to the opposite parties, however, OPs had not fully satisfied the claim of the complainant to the satisfaction of complainant and wrongly and illegally without providing any opportunity of being heard and against the settled principals of law repudiated claim vide letter dated 20-12-2019 which clearly amounts to deficiency in services and negligence in duties towards the customers. After the repudiation of claim, the claimant also contacted the OP through customer care as well as by visiting the office of OP No.2, but every time OPs refused to listen to the complainant. Even Legal Notice dated 19-02-2020 has been issued, 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 entertain the claim of the complainant as per medical bills to the tune of Rs.5,02,887/- already submitted with OPs. Further, OPs be directed to pay a compensation of Rs.50,000/- for causing mental tension and harassment to the complainant and Rs.10,000/- 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 claim has been rightly repudiated by the OPs vide repudiation letter dated 20.12.2019 as per terms and conditions of the policy. As per the waiting period 3 of the terms and conditions of the policy, the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease/condition, until 48 months of continuous coverage has elapsed, since inception of the policy with the company. It is further averred that the complainant was hospitalized with the complaints of reduced vision since one month and was diagnosed with pituitary macroadenoma with spracellar and paracellar extension. It is further averred that no cause of action arisen in favour of the complainant to file the present case. The present complaint has been filed by the complainant with the malafide intention. Hence the present complaint is liable to the dismissed. It is further averred that the complainant does not fall under the definition of the consumer as per the Consumer Protection Act. The consumer forum has no jurisdiction to try and decide the present complaint of the complainant. On merits, it is admitted that the complainant has purchased the health insurance policy from the OP and the same was valid from 31.12.2018 to midnight 30.12.2019 and the basic floater sum insured was Rs.5,00,000/-. It is also admitted that the complainant was lodged a claim and the same was repudiated, 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 not filed by the complainant.

4.                In order to prove their respective versions, both the parties have produced on the file their respective evidence.

5.                We have heard the arguments from learned counsel for the respective parties and have also gone through the case file very minutely.

6.                It is admitted that the complainant has purchased the health insurance policy from the OP and the same was valid from 31.12.2018 to midnight 30.12.2019 and the basic floater sum insured was Rs.5,00,000/-. The policy has been proved as Ex.C-1 by the complainant. The complainant has alleged that he was admitted in hospital on 02.10.2019 and was treated for Pitutary Macroadenoma and was discharged from the hospital on 24.10.2019. The discharge summary has been proved as Ex.C-19. It has been admitted that the policy was cashless policy and the cashless facility was denied by the OP, vide letter dated 04.10.2019, the same has been proved as Ex.OP-5. The complainant paid the bill of Rs.5,02,887/- to the OP and lodged reimbursement claim form, which was also repudiated vide letter dated 20.12.2019. This fact has been admitted by the OP that the claim was repudiated. It has been alleged that the claim was repudiated as per terms and conditions of the policy. The complainant has also proved on record all the medical bills of the hospital.

7.                The cause for repudiation of the claim is that as per the consultant report dated 12.12.2018 of Thind Eye Hospital, the patient was diagnosed with presbyopia of both eyes. The submitted CEMRI brain report dated 23.09.2019 shows Pitutary Macroadenoma with spraceellar and paracellar extension. Pitutary Macroadenoma is benign slow growing lesion. On the basis of these findings, it was found that the insured patient has chronic longstanding disease, existing prior to inception of medical insurance policy and it is a pre-existing disease. On the basis of this ground as well as as per waiting period of condition No.3 (iii) of the insurance policy, the complainant was not held entitled for any payment.

8.                As per the report of Thind Hospital relied upon by the OP, the complainant was diagnosed with presbyopia. As per medical jurisprudence, ‘Presbyopia is a refractive error that makes it hard for middle aged and older adults to see things up close’. As per the MRI dated 23.09.2019, the complainant was found having Pitutary Macroadenoma. ‘Pitutary Macroadenoma are the tumors, which are slow growing and benign, which means that there was a tumor larger than 10MM’. The discharge summary Ex.C-19 and Ex.OP-8 shows that the complainant was diagnosed with Pitutary Macroadenoma. The entire discharge summary nowhere shows that this disease of Pitutary Macroadenoma was pre-existing i.e. no history or time of existence of this disease has been mentioned. The reason for admission has been mentioned as reduced vision by one month. This discharge summary is dated 24.10.2019 and the policy was taken by the complainant in the month of December, 2018. The OP has not produced on record any document or any receipt or medical subscription of any doctor to show that the complainant was suffering from this Pitutary Macroadenoma prior to the purchase of the policy and he has not disclosed this fact to the OP while taking the insurance policy. The onus was upon the OP to prove that there is a co-relation between Pitutary Macroadenoma and Presbyopia. The Etiology filed by the OP nowhere shows that Presbyopia is the direct cause of Pitutary Macroadenoma. The visual deficiency can be one of the reason alongwith the hormonal deficiency and other factors, but this is not the only cause. It was the OP to prove the direct nexus between Pitutary Macroadenoma and Presbyopia. So, the OP has failed to prove that the complainant was having pre-existing disease and the complainant has concealed this fact from OP at the time of taking the policy. Even otherwise, once the policy is on the yearly basis, the policy will come to an end on the expiry of a year and the period of four years (48 months) as mentioned in condition of 3 (iii) of the policy would never reach and the condition laid down of waiting period of four years becomes of no value and meaningless. It has been held by the Hon’ble State Commission, in case titled as “New India Assurance Co. Ltd and others Vs. Ravinder Pal Singh”, 2008 CTJ 769 (CP) (SCDRC) that ‘the exclusionary clause, where there is a condition of three years cannot be made basis for repudiating the claim since the policy run on yearly basis after being renewed by the holder, the condition of three years had no logic underlying it-clearly it was a continuous Good Health Mediclaim Policy.’. So, from the overall circumstances, the complainant has proved the deficiency in service and unfair trade practice on the part of the OPs and accordingly, he is entitled for the relief.  

9.                In view of the above detailed discussion, the complaint of the complainant is partly allowed and OPs are directed to pay the insured amount of Rs.5,00,000/- to the complainant with interest @ 6% per annum from the date of repudiation till its realization. Further, OPs directed to pay a compensation of Rs.20,000/- for causing mental tension and harassment to the complainant and Rs.10,000/- 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.

10.              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          Dr. Harveen Bhardwaj     

08.11.2024                      Member                               President