District Consumer Disputes Redressal Commission ,Faridabad.
Consumer Complaint No.43/2020.
Date of Institution: 17.01.2020.
Date of Order: 22.06.2022.
Mr. Dheeraj Garg S/o Shri Nem Chand R/o Prince Colony, Railway Road, Hodal, Tehsil – Hodal, Distt. Palwal.
…….Complainant……..
Versus
M/s. Star Health & Allied, Krishan Palace Ist floor, Near Ajronda Chowk, NIT, Faridabad – 121101. Through its Branch Manager.
…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. Jatinder Kaushik , counsel for the complainant.
Sh. O.P.Gaur, counsel for opposite party.
ORDER:
The facts in brief of the complaint are that the complainant had taken a Family Optima Insurance Plan vide mediclaim policy No. P/161116/01/2017/006113 from 07.02.2017 to 06.02.2018 for his family for the sum insured of Rs.5,00,000/-. The complainant renewed the said policy vide No. 2825202093763600000 from HDFC Ergo General Insurance Company Ltd. From 07.02.2018 to 06.02.2019 of sum insured of Rs.5,00,000/-. As per above policy document issued by HDFC Ergo General Insurance Company Ltd., it was considered and mentioned in the said policy that the Ist policy inception date was 07.02.2017 and also mentioned that the insured to be considered as per the policy inception date as 07.02.2017. During both the policies complainant never took any claim from any of the above said companies. The complainant got renewed the above said policy 3rd time form the opposite party timely vide policy NO. P/161116/01/2019/005328 from 07.02.2019 to 06.02.2020 for his family of the sum insured of Rs.5,00,000/-. In the above said policy it was also clearly mentioned that previous policy No. was 2825202093763600000 and inception date was 07.02.2017. So as per the above said policy documents it was clear that the complainant and his family were covered from 07.02.2017. On 26.04.2019 the complainant suddenly suffered from facial puffiness, shortness of breath, dry cough, B/L LL swelling, snoring at night & day time sleepiness, nasal blockage, increase thrust, decreased urine output, upper abdominal fullness and decreased appetite. So the complainant went in QRG hospital for check up but the doctor advised him to admit in the hospital. As per the advise of the doctor the complainant had to remained admit in hospital form 26.04.2019 to 29.04.2019 in QRG Hospital and taken the treatment as per the doctor advise. Treating hospital applied for cashless claim but the opposite party had denied for cashless and advised for reimbursement of claim. The complainant made the entire payment to the hospital and submitted all documents in the office of the opposite party for reimbursement of his claim amount. After submitting his documents for reimbursement the complainant visited many times in the office of the opposite party but the opposite party did not make the payment regarding his claim. Due to such type act and conduct of the opposite party, the complainant was in tension as the opposite party was harassing him illegally and unlawfully and not making or releasing the payment regarding his genuine claim. The complainant requested the opposite party through letters dated 21.06.2019 and 06.09.2019 to make the payment of his claim but the opposite party did not give any heed to the request of the complainant. The complainant was shocked and surprised after receiving the letter dated 11.10.2019 sent by the opposite party in which the claim of the complainant was rejected illegally and unlawfully and refused to make the payment through the above said letter. The complainant sent legal notice dated 06.11.2019 to the opposite party but all in vain. The aforesaid act of opposite party amounts to deficiency of service and hence the complaint. The complainant has prayed for directions to the opposite party to:
a) pay the amount of both the claims of Rs.36,089/- and second claim of Rs.50,552/- alongwith the interest of 18% p.a. from the date of the admission till its realization.
b) pay Rs.50,000/- as compensation for causing mental agony and harassment .
c) pay Rs.50,000/ - 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 insurance company never insured the risk or undertook to impart insurable service to the insured, in case, the insured fails to lodge regular mediclaim alongwith the complete original medical treatment record and/or to furnish the requisite mandatory claim documents and information in support of his claim to the insurance company or the ailment falls with the exclusion clause and out of the scope of the terms and conditions of the “Family Health Optima Insurance Policy..” The insured had obtained the Family Health Optima Insurance Plan vide policy No. P/161116;2019/005328 for the period 07.02.2019 to 06.02.2020 for covering the family for the sum insured of Rs.5,00,000/-. The complainant had accepted the medi policy agreeing and being fully aware of such terms and conditions, pursuant to execution, signing and furnishing the “Proposal Form” in this behalf. It was submitted that the claim of the complainant was duly processed by the opposite party in accordance with the terms and conditions of the policy and as it was found not admissible, the same had duly been communicated to the complainant vide dated 11.10.2019 against Ist claim No. CL1/57204 and vide letter dated 11.10.2019 against 2nd claim No. CL1/61809.The opposite party further submit that the policy issued to the complainant under which the dispute had been raised was governed by limit of liability as per various clauses. Without any prejudice to whatever had been stated in its written statement and without conceding that the complainant was entitled to any claim in terms of the contract of insurance issued to the insured – complainant. It might be liable to the maximum quantum of liability under the terms of the policy. It was further submitted that even if this Hon’ble Forum finds any liability upon the opposite party that could not more than admissible and payable and/or sum insured Rs.5,00,000/- strictly within the terms & conditions of the medi insurance policy but on submission of Aadhar card, PAN card and cancelled cheque as per guidelines of the insurance Regulatory Development Authority. It was submitted that the insurance company received a “Request for Cashless Hospitalization” on 26.04.2019 pertaining to patient – Dheeraj Garg form QRG Health City, Plot NO.2, Sector-16, Faridabad registered as claim NO.CL1/2020/0057204. As a result, the cashless request was examined by the medical team of the insurance company and raised a query letter dated 26.04.2019, whereby advising the hospital to arrange the following treatment record and information:-
- Detailed initial assessment case sheet on account of diagnosis of the patient as a case of “Facial Plain”.
- Exact diagnosis with detailed line of management.
- All investigation reports supporting the diagnosis.
- All previous hospitalization.
In furtherance of the query, the insurance company also sought the following additional treatment record and information vide its query letter dated 27.04.2019:-
- Etiology and duration of Liver diseases.
- USG abdomen (ECHO Report)
- Final Composite diagnosis with related investigation
- Detailed line of management.
In furtherance of process of the claim intimation, the medical team of the insurance company examined the same and observed that the insured – patient provisionally diagnosed as a case of CLD/DCMP (Facial Puffiness and Pedal Edema) which was a long standing ailment. Since the duration of the disease could not have been ascertained on the basis of available documents, the same required extensive evaluation. Accordingly, the insurance company declined the “request for cashless hospitalization “ vide its letter of denial dated 29.04.2019 but at the same time advising the patient to lodge regular claim alongwith original treatment record. It was submitted that the patient had “Chronic Heart Disease” prior to obtaining the health insurance policy for the period 07.02.2019 to 06.02.2020 which was not disclosed at the time of proposal dated 07.02.2019 tendered to the insurance company. Accordingly, the insurance company arrived at its decision that the insured had violated, infringed and breached condition No.6 of the medi insurance policy by non-disclosure of the material facts and misrepresenting the material & true facts to the insurance company at the time of porting and obtaining the med insurance policy. As a result the insurance company treated the subject claim as repudiated vide its letter dated 11.10.2019.
2nd claim No. CL1/0261809
In regards to the 2nd claim, it was submitted that the insurance company received a “Request for Cahsless hospitalization” on 17.07.2019 pertaining to patient – Dheeraj Garg form QRG Health City, Sector-16, Faridabad registered as claim NO.CL1/0261809. As a result, the same was examined by the medical team of the insurance company and observed as under:
“As per verification of previous claim NO. CL1/0057204, which was repudiated per letter dated 11.10.2019, the current claim pertains to the same disease. At this stage, the cashless cannot be provided.”
However, advising the insured to lodge regular claim subject to decision on its merits. Therefore, the request for caseless hospitalization was declined by the insurance company vide its letter dated 18.07.2019. In furtherance of the claim information, the insured lodged claim vide claim form dated 20.08.2019 for reimbursement of medical expenses at Rs.55,910/-, in regards to hospitalization for the period 17.07.2019 to 20.07.2019 9in QRG Health City, Sector-16, Faridabad. Having examined the discharge summary for the period 17.07.2019 to 20.07.2019, it was observed that the insured got admitted & diagnosed as a case of “Cardiogenic Shock, DCMP, CAG Normal Coronaries (as per report dated 19.07.2019) and LVEF : 20-25%”. In furtherance of process of the subject claim, the insurance company sought certain treatment record vide its letter dated 27.08.2019 followed with reminder letter dated 11.09.2019 & 26.098.2019 from the insured inter-alia listing herein after:-
- A letter from treating doctor stating the Etiology & duration of congestive heart disease.
- All previous cardiac consultations
- Previous Echo and ECG reports
- all the past medical records including ECG, Echo, TMT, CAG prior to the current admission.
The insurance company examined the available claim documents alongwith mediclaim file pertaining to claim NO. CL1/0057204 being hospitalization for the period 26.04.2019 to 29.04.2019 r.ead with “Repudiation letter” dated 11.10.2019 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 – M/s. star Health & Allied Insurance Company Ltd. with the prayer to : a) pay the amount of both the claims of Rs.36,089/- and second claim of Rs.50,552/- alongwith the interest of 18% p.a. from the date of the admission till its realization. b) pay Rs.50,000/- as compensation for causing mental agony and harassment . c) pay Rs.50,000/ - as litigation expenses .
To establish his case the complainant has led in his evidence Ex.CW1/A - affidavit of Dheeraj Garg,, Annx.-1 - insurance policy for the period from 07.02.2017 to 06.02.2018, Annx-2 – Adhaar card,Annx-3 – insurance policy for the period from 07.02.2018 to 06.02.2019 , Annx.-4 - insurance policy from 07.02.2019 to 06.02.2020, Annx.-5 – Discharge summary, Annx.-6 – Bill,, Annx.-7 – Discharge summary,, Annx.-8 – Final Bill, Annx-9 – statement of Shri Dheeraj Garg, Annx-10 – letter written by Minakshi to Claim department, Annx-11 – letter dated 15.07.2019 regarding rejection of reimbursement claim, Annx.-12 – letter dated 11.10.2019 regarding rejection of reimbursement claim, Annx-13 – legal notice, Annx-14 – postal receipt.
On the other hand counsel for the opposite party strongly agitated and opposed. As per the evidence of the opposite party, Ex.RW1/A – affidavit of Rajeev Jain, Chief Manager (Claims), M/s. Star health & Allied Insurance Company Ltd., New Delhi, Annx.R/1 – policy terms and condition, Annx.R-2 – portability form, Annx.R-3 – insurance policy from 07.02.2019 to 06.02.2020, Annx.R/4 – proposal form, Annx.R-6 – Pre authorization request., Annx.R-7 – Field Visit report, Annx. R-8 & 8A – copy of pre authorization query letters dated 26.04.2016 and 27.04.2019,Annx.R-9 – denial of pre-authorization letter dated 29.04.2019, Annx.R-10 – claim form, Annx.R-11 – Discharge summary,Annx.R-12 – ECHO report,, Annx.R-13 – Final Bill, Annx. R-14 –Repudiation claim, Annx.R-15 – Bill Assessment report, Annx.R-16 – Request for Cashless Hospitalization for health insurance, Annx.R-17 – Denial of preauthorization request for cashless treatment, Annx.R-18 – claim form, Annx.R-19 – Discharge summary,, Annx.R-20 – Final Bill, Annx.R-21 – ECHO report, Annx.R-2, R-22/A, R-22/B, R-22/C – Query letters dated 27.08.2019, 11.09.2019, 26.09.2019 and 11,10,2019. Annx.R-23 – Bill assessment sheet, Annx.R-24 – Gazette
notification.
6. It is evident from Annexure -1, the complainant had taken a Family Optima Insurance Plan vide mediclaim policy No. P/161116/01/2017/006113 from 07.02.2017 to 06.02.2018 for his family for the sum insured of Rs.5,00,000/-. As per Annexure-3, the complainant renewed the said policy vide No. 2825202093763600000 from HDFC Ergo General Insurance Company Ltd. From 07.02.2018 to 06.02.2019 of sum insured of Rs.5,00,000/-. As per above policy document issued by HDFC Ergo General Insurance Company Ltd., it was considered and mentioned in the said policy that the Ist policy inception date was 07.02.2017 and also mentioned that the insured to be considered as per the policy inception date as 07.02.2017. During both the policies complainant never took any claim from any of the above said companies. It is evident from Annexure -4,the complainant got renewed the above said policy 3rd time form the opposite party timely vide policy NO. P/161116/01/2019/005328 from 07.02.2019 to 06.02.2020 for his family of the sum insured of Rs.5,00,000/-. In the above said policy it is also clearly mentioned that previous policy No. was 2825202093763600000 and inception date is 07.02.2017. So as per the above said policy documents it is clear that the complainant and his family were covered from 07.02.2017. As per letter dated 29.11.2019 in which it has been stated that the insured had submitted claim records for reimbursement of medical expenses. On perusal of the claim records, it is observed as follows:
ECHO report dated 27.04.2019 shows akinetic & thinned out anterior septum, apexm IVS, Mid basal IVS, Mid lateral wall, mid anterior wall, mid basal inferior wall, LVEF: 20-25%. The above fact confirmed that the insured patient had chronic heart disease heart prior to porting the policy. At the time of porting the policy, the insured had not disclosed the above mentioned medical history/health details of the insured-person in the proposal form and other documents submitted to them which amounts to mis-representation/non-disclosure of material facts. As per condition NO.6 of the policy, “if there is any misrepresentation/no n-disclosure of material facts whether by the insured person or any other persona acting on his behalf, the complainant is not liable to make any payment in respect of any claim. Hence, the claim for reimbursement of medical expenses was repudiated.
7. After going through the evidence led by the parties, the Commission is of the opinion that the opposite party has not produced any medical evidence except ECHO report to prove his case. The claim of the complainant was repudiated on the ground of misrepresentation of condition No.6 of the policy. There is no any medical evidence against the complainant. Hence, the repudiation of the claim of the complainant is totally unjustified. Resultantly, the complaint is allowed.
8. After going through the evidence led by parties, the Commission is of the opinion that the complaint is allowed. Opposite parties are directed to process the claim of the complainant within 30 days of receipt of the copy of order and pay the due amount to the complainant along with interest @ 6% p.a. from the date of filing of complaint till its realization. The opposite party is also directed to pay Rs.2200/- as compensation on account of mental tension, agony and harassment alongwith Rs.2200/- as litigation expenses to the complainant. Copy of this order be given to the parties concerned free of costs and file be consigned to record room.
Announced on: 22.06.2022 (Amit Arora)
President
District Consumer Disputes
Redressal Commission, Faridabad.
(Mukesh Sharma)
Member
District Consumer Disputes
Redressal Commission, Faridabad.
