Punjab

Ludhiana

CC/19/548

Avinash Goel - Complainant(s)

Versus

Oriental Insurance Co.Ltd - Opp.Party(s)

A.N.Juneja Adv.

24 Jan 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 548 dated 28.11.2019.                                                                 Date of decision: 24.01.2023.

 

Avinash Goel aged 55 years son of Shri Madan Lal Gupta, resident of House No.62-A, Aggar Nagar, Ludhiana.                                                                                                                                                                     .…Complainant

                                                Versus

1. The Oriental Insurance Company Ltd., Above Fine Furniture, Opp. Chhabra Hospital, Bus Stand Road, Ludhiana, through its Manager.        
2. M/s. Raksha TPA (P) Ltd., SCO 122, 5^th Floor, Feroze Gandhi Market, Ludhiana, through its Manager.                                                                                                                                                 …..Opposite parties 

                   Complaint under Section 12 and 14 of Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. A.N. Juneja, Advocate.

For OP1                         :         Sh. Rajeev Abhi, Advocate.

For OP2                         :         Exparte.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Briefly stated, the facts of the case are that the complainant availed the services of the opposite parties in the shape of PNB-Oriental Mediclaim Policy-2017: Group Health Insurance Product (Policy for Bank Account holders for PNB only) bearing policy No.233902/48/2019/909 w.e.f. 15.05.2018 to 14.05.2019 and paid premium of Rs.16,555/- to the opposite parties through cheque. The said policy was a family floater policy covering the complainant, his wife and son. The complainant stated that during the continuation of the policy, he suddenly suffered from life threatening chest pain and heart problem and was admitted in Jindal Heart Institute & Infertility Centre, A Unit of Bathinda Healthcare Pvt. Ltd. on 03.07.2018. The complainant disclosed about his cashless medical policy to the hospital authorities who at their own level informed about the ailment of the complainant to the opposite parties and lodged the claim. The opposite parties authorized the claim of the complainant upon which the hospital authorities started the treatment of the complainant without any advance deposit. After successful treatment, the complainant was discharged on 06.07.2018 at 01.00 PM. The hospital authorities informed the customer care of the opposite parties who asked them to discharge the complainant with the representations that the formalities will be completed in due course. Accordingly, the complainant was discharged from the hospital. However, on 11.07.2018, the complainant received a call from the hospital authorities that his claim has not yet been passed by the company and the hospital staff insisted the complainant for bill payment. The hospital authorities further informed the complainant that his claim being delayed by the opposite parties due to “Patient not found at the time of investigation, H/O illness not clear.” The complainant further submitted that the officials of the opposite parties had visited the hospital at 5.00 PM on 06.07.2018 whereas the complainant was already discharged at 01:00 PM on the same very day. No prior intimation was given by the officials of the opposite parties about their visit at 05.00 PM and there was no sufficient reason or cause for the complainant to keep sitting in the hospital waiting for the visit of officials of the opposite parties as he had recently been discharged from the hospital after his critical heart ailment. The opposite parties created another false excuse i.e. “Illness not clear” as the illness was already disclosed to them. The complainant sent one email dated 12.07.2018 to the opposite parties raising his concerns and also submitted all the requisite documents including certificate from Jindal Heart Institute & Infertility Centre, Bathinda which was duly received by the opposite parties on 23.08.2019 but despite this, the opposite parties have illegally, unauthorized and unilaterally repudiated the claim No.5565181950685 of the complainant vide their letter dated 30.01.2019. The complainant submitted that the claim has been wrongly repudiated by the opposite parties and earlier they had raised the false pleas of “Patient not found at the time of investigation” and “H/O illness not clear”. The act and conduct of the opposite parties amounts to unfair trade practice and deficiency in service which has caused physical and mental pain, agony, harassment to the complainant. In the end, the complainant has prayed for issuing direction to the opposite parties to pay the claim amount of Rs.1,65,154/- besides compensation of Rs.1,00,000/- and litigation expenses of Rs.22,000/- .

2.                Upon notice, opposite party No.1 appeared and filed  written statement. In the preliminary objections, opposite party No.1 assailed the complaint on the ground of maintainability, concealment of material facts etc. The complaint is barred under Section 26 of the Consumer Protection Act. Opposite party No.1 alleged that the complainant had obtained the PNB-Oriental Mediclaim policy 2017 for the first time from opposite party No.1 valid from 15.05.2018 to 14.05.2019, which is a Group Health Insurance Product (Policy for bank account holders of PNB only). Opposite party No.1 further alleged that the insurance policy is a contract in itself and the parties are bound by the terms and conditions of the policy. As per one of the exclusion cause of the policy having cause 4.1, “The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of any ailment/disease/injury/health condition which are pre-existing (treated/untreated/declared/not declared in the proposal form), in case of any of insured person of the family, when the cover incepts for the first time are excluded from such insured persons up to three years of this policy being in force continuously.

                   For the purpose of applying this condition, the date of inception of the first indemnity based health policy taken shall be considered provided the renewals have been continuous and without any break in period, subject to portability condition.

                   This exclusion will also apply to any complications arising from pre existing ailments/disease/injuries. Such complications shall be considered as a part of the pre-existing health condition or disease.”

Opposite party No.1 further alleged that during the subsistence of the policy as per the claim lodged, the complainant Avinash Goel was admitted in Jindal Heart Institute & Infertility Centre, 12373, Power House Road, Bathinda from 04.07.2018 to 06.07.2018 with the diagnosis of CAD/ACS VEF = 48%, DVD. The claim as such is lodged in the 1^st year of policy. Jindal Heart Institute & Infertility Centre had sent pre-authorization requests for cashless treatment of complainant. After the receipt of the said preauthorization request M/s.Raksha Health Insurance TPA Pvt. Ltd., Escort Corporation Centre, 15/5, Mathura Road, Faridabad, Haryana with one of its branch office at Ludhiana had declined the cashless authorization vide their letter dated 06.07.2018 due to reason stated below:-

          “Unstable angina, chronic ischaemic heart disease, unspecific.”

                    It is further submitted that even during visit to the hospital patient not found at the time of investigation and history of illness not clear. It is further stated in the said letter that this is not the denial of treatment but is only the denial of credit facility and the complainant can send the claim for reimbursement/for review.

                    After discharge from the hospital the complainant had lodged the claim for the reimbursement of the medical expenses incurred on his treatment at Jindal Heart Institute & Infertility Centre, Bathinda. Opposite party No.2 vide its query letter dated 13.08.2018 had called upon the complainant to supply the documents such as:-

Treating doctor’s certificate mentioning history of HTN, DM, CAD along with previous treatment record clearly specifying duration.

Opposite party No.2 had also made thorough investigation, took documents and form insured’s questionnaires duly signed by the complainant during investigation and it was stated by the insured that he is suffering from hypertension x 5 years on medication Amcard 5 mg. and asthma x 30 years. After receipt of the documents and after scrutinizing the same and after due application of mind by the doctors of Raksha Health Insurance TPA Pvt. Ltd. in terms of the insurance policy, opposite party No.2 had recommended for repudiation of the claim vide letter dated 22.12.2018 i.e. recommendation for non-payment addressed to opposite party No.1 with observation and opinion reproduced as under:-

          Observation and Opinion.

Case of CAD, TVD, CART DONE, S/O DVD, PTCA STENTING TO LAD/RCA DONE.

1. As per questionnaire filled by patient on investigation, he is a k/c/o HTN since 5 years and asthma since 30 years. HTN is a predisposing factor of CAD. Policy is in first year and pre-existing disease are payable after 3 years as per policy terms & conditions. So the claim is recommended to be non payable as per cause 4.1.
2. Discrepancy in the information provided- On query reply the letter received mentions that there is no H/O HTN but as per questionnaire filled on investigation patient is a k/c/o HTN since 5 years. So the claim is recommended to be non payable as per clause 5.20”

It has been further alleged that thereafter, opposite party No.1 repudiated the claim as no claim vide letter dated 19.06.2019 on the ground of exclusion clause 4.1 of the policy terms and conditions and on the grounds that the complainant had failed to send the reply to the pre-authorization letter dated 30.01.2019. Before repudiating the claim vide letter dated 19.06.2019 (Ex. R5), the complainant was sent pre-repudiation letter dated 30.01.2019 informing him that his claim is not tenable under clause 4.1 pre-existing health condition or disease and the complainant was given one more opportunity to substantiate his claim in view of grounds of repudiation mentioned in the said letter before the final decision is taken within two weeks from the receipt of the said letter. The complainant had failed to send any reply and the claim file of the complainant was repudiated as no claim vide letter dated 19.06.2019. Opposite party No.1  further alleged that the claim of the complainant was rightly repudiated as no claim on legal, valid, enforceable grounds and in accordance with terms and conditions of the policy. Opposite party No.1 has denied deficiency in service and negligence on its part.

                   On merits, opposite party No.1 reiterated the crux of averments made in the preliminary objections and has denied that there is any deficiency of service. The complainant is not entitled to any claim and in the end, prayed for dismissal of the complaint.

3.                Initially, Sh. Dinesh Kumar, authorized representative of opposite party No.2 appeared on 11.02.2020 but thereafter, none turned up for opposite party No.2 and as such, opposite party No.2 was proceeded against exparte vide order dated 24.02.2021.

4.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 copy of email dated 12.07.2018, Ex. C2 copy of insurance policy w.e.f. 15.05.2018 to 14.05.2019, Ex. C3 is the copy of certificate issued by Dr. Rajesh Jindal of Jindal Heart Institute & Infertility Centre, Bathinda, Ex. C4 is the copy of final bill of said Jindal Hospital, Ex. C5 is the copy of pre-repudiation letter dated 30.01.2019, Ex. C6 is the copy of letter dated 06.07.2018 of Raksha TPA to the complainant, Ex. C7 is also the letter dated 13.08.2018 written by Raksha TPA to the complainant, Ex. C8 is the copy of tax invoice, Ex. C9 is the copy of letter dated 19.06.2019 issued by insurance company to the complainant, Ex. C10 is the copy of letter dated 28.08.2018 written by Raksha TPA to the complainant, Ex. C11 is the copy of letter dated 17.08.2018 written by complainant to the Raksha TPA, Ex. C12 is the copy of policy paper, Ex. C13 and Ex. C32 are the copies of angioplasty report dated 03.07.2018 of the complainant, Ex. C14 to Ex. C19 are the copies of bills/invoices, Ex. C20 to Ex. C27 are the copies of reports of the complainant, Ex. C28 is the copy of documents checklist for claim submission, Ex. C29 is the copy of  proposal form, Ex. C30 and Ex. C31 are the copies of receipts, Ex. C32 is the copy of clinical assessment sheet, Ex. C34  and Ex. C35 are the copies of reports, Ex. C36 is the  prescription slip dated 03.07.2018, Ex. C37 is the copy of bill/invoice consisting of nine pages, Ex. C38 and Ex. C39 are the copies of intake & output chart and closed the evidence.

5.                On the other hand, counsel for opposite party No.1 tendered affidavit Ex. RA of Sh. Sukhwinder Singh, Senior Divisional Manager of opposite party No.1 and affidavit Ex. RB of Sh. Dinesh Kumar (AM) of M/s. Raksha Health Insurance TPA Pvt. Ltd. along with documents Ex. R1 is the copy of policy schedule w.e.f. 15.05.2018 to 14.05.2019, Ex. R2 is the policy terms and conditions, Ex. R3 is the copy of letter dated 06.07.2018 issued by Raksha TPA to Jindal Hospital , Ex. R4 is the copy of discharge summary, Ex. R5 is the copy of letter dated 19.06.2019 written by insurance company to the complainant regarding closing his claim, Ex. R6 is the copy of letter dated 30.01.2019 issued by the insurance company to the complainant, Ex. R7 is the copy of report of Raksha TPA, Ex. R8 is the copy of letter dated 22.12.2018 written by Raksha TPA to the insurance company, Ex. R9 is the copy of letter dated 13.08.2018 written by Raksha TPA to the complainant, Ex. R10 is the copy of questionnaire form, Ex. R11 is the copy of proposal form, Ex. R12 is the copy of clinical assessment sheet, Ex. R13 is the copy of angiography report dated 03.07.2018, Ex. R14 is the copy of angioplasty report dated 03.07.2018, Ex. R15 is he copy of echocardiography report dated 03.07.2018, Ex. R16 is the copy of hematology report, Ex. R17 to Ex. R20 are the test reports of the complainant, Ex. R21 is the copy of prescription slip dated 03.07.2018, Ex. R22 is the copy of slip, Ex. R23 is the ECG report, Ex. R24 to Ex. R27 are the treatment record of the complainant and closed the evidence.

6.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties. We have also gone through the written arguments submitted by the complainant.

7.                In the present case, the complainant the holder of policy in question (Ex. R2) got himself admitted in Jindal Heart Institute & Infertility Centre, Bathinda on 03.07.2018 and remained admitted till 06.07.2018. The hospital sent pre-authorization request for cashless treatment of the complainant which was declined on 06.07.2018 on the ground that history of illness was not clear and the patient was not found in the hospital. However, later on the claim for reimbursement was submitted and during the investigation, opposite party No.2 obtained documents and questionnaire (Ex. R10) from the complainant in which the complainant himself  stated that he had been suffering from hypertension x 5 years and asthma x 30 years and he is on medication for these ailments. Considering all the documents and admission of complainant, opposite party No.1 invoked clause 4.1 of the policy and claim file of the complainant was treated as ‘No claim’. Clause 4.1 reads as under:-

“4.1: The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of any ailment/disease/injury/health condition  which are pre-existing (treated/untreated/declared/not declared in the proposal form), in case of any of insured person of the family, when the cover incepts for the first time are excluded from such insured persons up to three years of the policy being in force continuously.

For the purpose of applying this condition, the date of inception of the first indemnity based health policy taken shall be considered provided the renewals have been continuous and without any break in period, subject to portability condition.

This exclusion will also apply to the complications arising from pre-existing ailments/diseases/injuries. Such complications shall be considered as a part of the pre-existing health condition or disease.”

Further as per clause 3.1 of the policy  defines the pre-existing health condition or disease,

“Pre Existing health condition or disease: Any condition, ailment or injury or related condition (s) for which the insured had signs or symptoms, and/or were diagnosed and/or received medical advice/treatment for suffered ailment/illness/disease/injury/accident during the currency of the policy.”

8.                Perusal of the documents shows that the claim was submitted by the complainant for the first time in the first year of the policy. So the pre-existing disease, which the complainant was suffering from asthma since last 30 years and hypertension since the last 5 years which is the root cause of CAD (Coronary Artery Disease) were not covered as the claim of these ailments was payable after 3 to 5 years respectively. The complainant was under legal obligation to disclose these pre-existing diseases at the time of availing the policy. Even a pre-authorization letter dated 30.01.2019 (Ex. C5) was sent to the complainant and he was afforded an opportunity to substantiate his claim. The medical certificate Ex. C3 dated 06.07.2018 excludes the Coronary Artery Disease (CAD) and not about Asthma or HTN. So in the given circumstances, this Commission is of the opinion that the repudiation of the claim of the complainant is justified and the complaint is liable to be dismissed.

9.                As a result of above discussion, the complaint fails the same is hereby dismissed.  However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

10.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                      President         

 

Announced in Open Commission.

Dated:24.01.2023.

Gobind Ram.

 

 

 

 

 

 

 

Avinash Goel Vs Oriental Insurance Co.                        CC/19/548

 

Present:       Sh. A.N. Juneja, Advocate for complainant.

                   Sh. Rajeev Abhi, Advocate for OP1.

                   OP2 exparte.

                   Arguments heard. Vide separate detailed order of today, the complaint fails the same is hereby dismissed.  However, there shall be no order as to costs. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                      President         

 

Announced in Open Commission.

Dated:24.01.2023.

Gobind Ram.