BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.129 of 2019
Date of Instt. 26.04.2019
Date of Decision: 08.12.2022
Shri Ravinder Kumar son of Shri Dharam Pal, resident of House No.333/7, Central Town, Jalandhar also residing at 174/4, Central Town, Jalandhar.
..........Complainant
Versus
Oriental Insurance Company Ltd., Branch Office II, SCO 50, Jeevan Raksha, PUDA Complex, Opposite Tehsil Complex, Jalandhar through its Branch Manager.
….….. Opposite Party
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member) Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Rakesh Kanojia, Adv. Counsel for the Complainant. Sh. Brijesh Bakshi, Adv. Counsel for OP.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the complainant availed a Medical Insurance Policy No.233108/48/2018/2299 for the period from 7.10.2017 to 6.10.2018 for Rs.5,00,000.00 against medical claim from the OP and the complainant had been regularly paying the premium of the said policy up- to-date. The policy was also got renewed from 7.10.2018 to 6.10.2019. The said medical policy is in vogue which was never got cancelled or terminated by the complainant and the complainant had been regularly paying the premium. The complainant suffered some medical problem on 02.06.2018 and the complainant got him medically checked up at DMC Hospital, Ludhiana as outdoor patient till 8.6.2018 At that time, BP problem was detected. Thereafter, the complainant suffered sudden problem of breathlessness for the first time. As such, the complainant was admitted in Dayanand Medical College & Hospital, Ludhiana on 10.7.2018 where, medical treatment was started and the complainant was discharged on 21.7.2018 after the treatment During the treatment of the complainant, AICD (MEDTRONICE, SINGLE CHAMBER) was done on 16/7/2017. The complainant spent a sum of Rs.4.29,167.74 for his treatment which was covered under Medical Insurance Policy for Rs 5,00,000.00. The complainant filed his Insurance Claim for reimbursement of the medical expenses incurred by him but you illegally denied the claims of client vide letter dated 17.12.2018 on account of the following reasons:
On scrutiny of the documents and as advised by Raksha TPA, we express our inability to admit the claim under the policy and the same is being denied on account of the following:
CASE OF HYPERTHYROIDISM, DILATED CARDIOMYOPATHY- LVEF 18% AICD (MEDTRONIC, SINGLE CHAMBER) DONE.
1) PATIENT IS A KNOWN CASE OF HTN SINCE 8YEARS POLICY IS FROM 2016 ONWARDS HTN DIAGNOSED BEFORE POLICY INCEPTION SO IS PED. HTN IS A PREDISPOSING FACTOR OF CARDIOMYOPATHY PED ARE PAYABLE AFTER 3YEARS. POLICY IS IN 2ND YEAR. SO THE CLAIM IS NON PAYABLE AS PER CLAUSE 4.1.
2). EXPENCSES RELATED TO HTN ARE PAYABLE AFTER 2 YEARS POLICY IS IN 2nd YEAR SO THE CLAIM IS NON PAYABLE AS PER CLAUSE 4.2.
The following is the opinion of the Doctor of DMC, Ludhiana, who attended to the complainant:
HOSPITAL COURSE: Patient was admitted outside, due to ECG and echocardiography changes shifted to HDHI for further management. BNP was raised. Echocardiography was done which showed detailed cardiomyopathy, severe LVB systolic dysfunction, LVEF-18%, frequent VPE's noted ECG was effective of ventricular bigeminy/VPC's, brady arrhythmia, AICD (Medtronic, Single Chamber was done on 16.7.2018 Regular ASD was done under all aseptic condition. Patient was managed with antibiotics, ace-inhibitors, inctropes, i/v fluids, antiarrhythmics, amiodarone, beta ockers, druretics, PPIs and other supportive measures. Gradually patient improved and is now being discharges in stable condition. The claim of the complainant was declined alleging that the claim is not within the purview of the policy, terms and conditions, which is illegal in the eye of law and is arbitrary in nature. At the time of purchasing the policy, the complainant was quite hale and hearty. He has no family back- ground of the ailment which the complainant suffered all of a sudden. The complainant was bothered with the B.P. Problem which is not an ailment or disease as per medical guidelines. The problem started two months before the admission of the complainant in the Hospital in respect of breathlessness. The OP has wrongly repudiated the legal and genuine claim of the complainant on flimsy grounds. Under the medical insurance policy, the complainant is entitled to insurance claim and the repudiation of the claim of the complainant is illegal and unlawful. The complainant served the OP with legal notice dated 05.02.2019 for settlement of his insurance claim, but the same also did not evoke any response and as such necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OP be directed to settled the medical insurance claim of the complainant under medical insurance policy No.233108/48/2018/2299 for the period from 07.10.2017 to 06.10.2018 for Rs.5,00,000/-. Further, OP be directed to pay a sum of Rs.1,00,000/- as compensation for causing mental tension and harassment to the complainant and OP be also directed for litigation expenses.
2. Notice of the complaint was given to the OP, who filed reply and contested the complaint by taking preliminary objections that the present complaint is not maintainable under the law against the OP. The complainant has got no cause of action to file the present complaint against the OP. The claim is not maintainable and the same is not payable as per the policy terms and conditions. The complainant is guilty of concealment of material facts and has not approached the Commission with clean hands and as such is not entitled to any relief from this Commission. On merits, the factum with regard to taking medical insurance policy by the complainant from the OP is admitted, 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 to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.
6. The complainant has produced on record the medical insurance covers to show that he availed medical insurance policy for the period from 07.10.2017 till 06.10.2020 continuously on regular payment of the premium. The complainant has alleged that he suffered medical problem on 02.06.2018 and got checked up from DMC Ludhiana. Thereafter, on 10.07.2018 again he suffered sudden problem of breathlessness and was admitted in DMC, Ludhiana. He was discharged on 21.07.2018. The complainant has proved on record the bills and test reports Ex.C-2 to Ex.C-14. Package availed by the complainant from DMC Ludhiana for his treatment Ex.C-15 alongwith the details of the bills Ex.C-16 to Ex.C-23 and the bills showing the amount spent by him for medicines Ex.C-24 to Ex.C-34, discharge summary Ex.C-35, which is supported by the ECGs Ex.C-37 to Ex.C-43. Perusal of the discharge summary shows that the complainant was diagnosed for hyperthyroidism and dilated cardiomyopathy-LVEF 18%. In the history it has been mentioned that he was admitted with the complaint of breathlessness since two months prior to admission and in the discharge summary, the detail has been given of the course and the treatment given to the complainant. He also also produced on record the blood reports and report of investigation done for the treatment of the complainant Ex.C-44 to Ex.C-55. The contention of the complainant is that he submitted claim before the OPs as he was policy holder. The OPs demanded documents, which were sent to the OP. The letter has been proved as Ex.C-1. The claim of the complainant was denied, vide letter Ex.C-56. Perusal of the document Ex.C-56 shows that the claim was rejected on the ground that the same was not payable as per Clause 4.1 and 4.2 of the policy.
7. The contention of the OPs is that the complainant was suffering from hypertension for 8 years. He has proved on record the previous treatment record of the complainant Ex.OP-1, Ex.OP-3 to Ex.OP-8. It has been alleged that the policy is in the second year, therefore cashless facility cannot be accorded. The copy of the email has been proved Ex.OP-9. The claim form has been proved by the OP as Ex.OP-10 and Ex.OP-11, which was filled by the hospital. The OPs have relied upon the repudiation letter Ex.OP-13, which has been proved by the complainant as Ex.C-56. Ex.OP-13, which is consisting of the letter of the Raksha Showing that the complainant was suffering from hypertension from 8 years, second year policy and cashless facility cannot be accorded. The OPs have relied upon the history of the complainant proving the documents Ex.OP-1 and Ex.OP-3 to Ex.OP-8. Perusal of these documents show that the complainant was diagnosed for hypertension for 8 years and accordingly, he was provided medicines. The OPs have alleged that the complainant was suffering from heart muscle disease also, which causes the heart chamber to thin and stretch growing larger. The documents relied upon by the OPs are of year 2018 and the complainant was insured since 2017. At the time of renewing the policy or doing the policy initially, it was the duty of the insurance company to get the person medically checked up, so that they can come to the conclusion as to whether he is eligible for the insurance or not. The insurance companies cannot be allowed to take the premium and when the complainant suffers problem and seeks reimbursement, then they refuse on the ground that he has concealed the previous medical problem. It has been held by the Hon’ble Punjab & Haryana High Court, in Civil Revision No.2318 of 2008, decided on 22.04.2008, titled as “New India Assurance Company Limited Vs. Smt. Usha Yadav & Others”, that ‘the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy’.
8. The OPs have relied upon the Clause 4.1 and 4.2 of the policy. Clause 4.1 and 4.2 states that “All pre-existing diseases (whether treated/untreated, declared or not declared in the proposal form), which are excluded upto 36 months of the policy being in force. Pre-existing disease shall be covered only after the policy has been continuously in force for 36 months. For the purpose of applying this condition, the date of inception of the first OBC-Oriental Mediclaim policy shall be considered, provided the renewals have been continuous and without any break in the policy period. This exclusion shall also apply to any complication (s) arising from pre-existing disease. Such complications will be considered as part of the pre existing health condition or disease.
4.2 The expenses on treatment of following ailments/diseases/surgeries, if contracted and/or manifested after inception of first policy (subject to continuity being maintained), are not payable during the waiting period specified below:-
(xvii) Hypertension 2 Years
If the above diseases are pre-existing at the time of inception of first OBC-Oriental Mediclaim policy, Exclusion no.4.1 for pre-existing disease shall be applicable.
9. In the present case as per the medical record and opinion of the doctor, the complainant complained of breathlessness about two months prior to the admission in the DMC Hospital. As per 4.1, it is the duty of the OPs also to get themselves satisfied about the disease of the complainant. From the documents, it is nowhere proved that the problem or the disease of the complainant regarding heart was pre-existing problem and he was continuously on medicine. Though, the documents have been proved that he has been taking the medicine of hypertension, but hypertension is not a disease. It has been decided by the Hon’ble Supreme Court in various judgments that Hypertension is not a disease, it is a general wear and tear of the life which occurred due to the pressure of the present life style and even otherwise the disease of Hypertension and Diabetes can be cured by taking medicine.
10. More so, the policy was taken by the complainant on yearly basis and in such circumstances, the patient cannot wait for expiry of the period of two years to get the treatment, when it becomes urgent to get the treatment. 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 two years would never reach and the condition laid down of waiting period of two 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.’ In view of the above referred law and considering the facts of the case, the repudiation letter is held illegal and the same is hereby set-aside.
11. In view of the above detailed discussion, the complaint of the complainant is partly allowed and OP is directed to reimburse the amount of Rs.4,29,167/- with interest @ 9% per annum from the date of lodging of mediclaim till its realization. Further, OP is directed to pay Rs.15,000/- as compensation for causing mental tension and harassment to the complainant and Rs.5000/- 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.
12. 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 Jyotsna Dr. Harveen Bhardwaj
08.12.2022 Member Member President
