DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KEONJHAR
CONSUMER COMPLAINT CASE NO. 20 OF 2020
Pradeep kumar Mishra, aged about 53 years,
S/O-Purna Chandra Mishra
Resident of,Brundabana Vihar
P.O- Old Town. P.S-Town,
Dist-Keonjhar…………………..………………………………………………Complainant
Versus
1.Religare Health Insurance Co Ltd.
Regd Office 5th Floor,19 Chawla House
Nehru Place,New Delhi-110019.
2.Manager Religare
Health Insurance Co Ltd
Unit-604-607 6th Floor ,Tower –C,
Unitech Cyber park Sec-39,
Gurugaon Haryana -122001
3. Branch Manager,
Religare Health Insurance Co Ltd
4th Floor, Radhika Complex Plot No.738-739,
Jharapada Laxmi Sagar Bhubaneswar
(Odisha)751006……………………………..……………….………………… Opp.Parties
Present:
Biranchi Narayan Patra, President
Sri Bharat Bhusan Das (Member)
Advocate for complainant- S.K Rout & associates
Advocate for Op1, Op2 & Op3 - A.K Pattanaik & associates
Date of Filing - 30.09.2020 Date of Order- 12.08.2022
B.N Patra (President)
Brief facts of this case is that, the complainant opened a Health insurance policy on dtd.25.01.2019 for sum assured of Rs.5,00000/-.The representative of Ops motivated to complainant to open a said policy.
The complainant paid Rs.28627/- to the Ops as a single premium for one year in respect of CARE plan having policy NO.-13633418. The risk was covered from the date 25.01.2019 to 24.01.2020. During the period of policy term the complainant suddenly got chest pain on dtd.07.05.2019 at his residence . He consulted the Doctor at Keonjhar and also at Cuttack. On dtd.11.05.2019 he also got his chest pain again then he consulted doctor at Aswini Hospital, Cuttack. on the same day he was admitted at Apollo Hospital, Bhubaneswar as indoor patient .After investigation of Doctor at Apollo Hospital ,it was diagnosis that , the disease of the complainant was Coronary Artery severe triple vessel Disease . The doctor advised him to go for open heart surgery .
On the same day open heart surgery was done under CABG package worth of Rs.5,00000/-. All bills of prescribed format are submitted by complaint on dtd.31.07.2019. On dtd.07.08.2019 OP.No-3 replied on e-mail alleging the clause -4-(i)for yours waiting period for treatment of pre-existing disease .But complainant replied the Mail. On dtd.28.08.2019 OP.No-3 repudiated the claim of complainant .
In the above allegation of the complainant the case was admitted and notice was issued to Ops .All the Ops were appeared before the Commission and filed their written version with strong objection that , the case was not maintainable . The Ops denies to pay any compensation to complainant because it’s diagnosis was a complication of Diabetes which is covered after four years of the inception of policy , and it does not covere any pre-existing disease during the subsistence of very first year .
The Complainant relies on the following documents.
1. Policy certified with Insurance Manual Original
2.No registration claim(Xerox)
2.Grivance petition with reply
Op Party file the Xerox copies of policy manual.
Before coming to decide the case it is necessary to attend the following issues .
- Whether the case is maintainable or not ?
- Whether the waiting period of pre-existing disease is applicable in this case ?
- Whether the Coronary Artery Disease is outcome of Diabetes ?
- What are the opinion of Doctors regarding this ?
The complainant is within jurisdiction of this commission and cause of action arose on 25.01.2020 and on words. So it is maintainable.
It is not disputed that the OPs company had a issued a Health insurance policy bearing No.-13633418 in favor of complainant which is covered himself along with his son Abhinash Mishra and spouse Minati Mishra with effect from 25.01.2019 to 24.01.2020 with insured value of Rs.5,00000/- subject to terms and conditions , It is also admitted that complainant HAD DISCLOSED Diabetes Mellitus as Pre-existing disease for which he had paid loading charges . The claim of Rs.5,00000/- for insurance was repudiated by Ops only because the pre-existing disease is only covered after four years since the policy inception.
Clause -4 exclusions:-
- Waiting periods (iii)Pre-existing disease –Claims will not admit able for any medical expenses incurred for hospitalization in respect of diagnosis /treatment of any the existing disease until 48 months of continuous coverage as a lapsed since the inception of first policy of the company .
Ops has cited a decision of New India Assurance Co.Ltd Vrs Lekha Malhotra –National Commission 2016 (4)C.P Act 455.
In the matter at hand the insured was medical covered with a condition that any claim related to existing ailments of Diabetes and Hyper-tension will not be paid for two years from the inception of the policy . The National Commission while reversing the order of State Commission said that since admittedly the claim under policy was preferred within a period of two years and as a matter of fact within two months of obtaining the same . It was squarely covered under the exclusion of the waiting period.
But the complainant here state that, he has declared the Diabetes as pre-existing disease and gives extra charges . But on 21.08.2019 the company (OPs) have repudiated the claim of complainant and sent its through E-Mail.
Issue
Whether the complainant’s diagnosis was complication of Diabetes and Coronary Artery Disease is out come of Diabetes .
The Ops have reflected the Doctors opinion that Diabetes Mellitus is significant ,strong, and independent risk factor but the complainant says that Doctors of Apollo Hospital did not mentioned in their report about the cause of Coronary surgery was the out come of disease Diabetes but either party had not submit any cogent evidence.
Issue- Whether the complainant is entitled to any relief -: It is cleared that the policy holder is a consumer and was paying regular premium, it is not doubt that the consumer has taken a CABG policy for open heart surgery and paid Rs.5,00000/- and he has submitted all documents of medical reports and medicine bills before the Ops . But they failed to settle the claim and they repudiated the claim on the ground that condition (s) i.e pre-existing disease and complainant s dialysis of complication of Diabetes. We Discussed the citation case of {Manivasgam Vs The Branch Manager on 30 January,2014 decided}
- It is the admitted case of the petitioner that he is suffering from hypertension and diabetes. If the treatment is relating to hypertension and diabetics then it is pre existing disease and no claim can be made. However in the report it is stated that the petitioner was suffering from Coronary Artery Disease and surgery was done. Coronary Artery Disease is not a pre-existing disease at the time when the policy was issued. Therefore the claim apparently is rejected on the Misconception. The authority cannot read something more into the terms and conditions of the policy and come to the inference that one disease is relatable to other disease and therefore, medi claim is rejected.
- If the treatment to the appellant/writ petitioner is relating to diabetes or hypertension, then it is a pre-existing disease and he is not entitled to reimbursement in terms of the medi claim policy. Since the nature of the treatment is for Coronary Artery Disease. Which is not a pre-existing disease even as per the records. The Insurance Company cannot dispute the claim by giving another interpretation on the nature of the disease. There may be many reason for a pre-existing disease or ailment and it is for the doctors to identify the disease or ailment and provide the treatment. Under the terms of the medi claim policy. Interpretation of a particular disease is not permissible. No addition or deletion by way of interpretation can be done, which is what has happened in the present case.
- If the disease for which the appellant/writ petitioner was treated is not stated as pre existing disease in the policy and there are no supporting documents to show that it was a pre-existing disease on the date of issuance of the policy. the insurance is bound to honour the policy. In this case, We have no difficulty to accept the plea of the appellant/writ petitioner that Coronary Artery Disease was not a pre-existing disease when the policy was issued and that fact is not disputed by the respondent Insurance Company. The Pre-existing case in this case are hypertension and diabetes and only those disease/ailments can be excluded.
In the present case the complainant opened a health insurance policy in his family name payment was made including loading charges. Diabetes was declared as pre-existing disease for complainant. The petitioner being ill was admitted in Apollo hospital Bhubaneswar for open heart surgery from the dt 11.05.19 to 23.04.19.Where he was under gone CABG surgery then he approached Ops his policy was in force validly from 25.01.19 to 24.01.20.The Claim was repudiated for pre-existing disease diabetes which is related with coronary artery disease. In this case the company badly passed on misc conception and repudiated the claim of complainant. As per the above citation coronary artery disease is not a pre-existing disease. Ops cannot interfere the CABG is out come of diabetes. So the Insurance company is bound to honour the policy .So the Ops are liable to pay the claim amount of complainant.
Order
The Ops are jointly and severally liable to pay Rs. 500000/- to complainant within 30 days of receipt of this order and they also liable to pay Rs. 50,000/- for litigation expenses and mental agony. If failed the Ops are directed to pay entire amount of Rs .500000+Rs.50,000/- = Total Rs.550000/- with 12% interest P.A till final realization.
The order pronounced in open Commission today i.e on 12th August 2022.
Free copy be supplied to parties, if applied for.
Pronounced on 12.08.2022
I agree
( Sri B. B. Das) ( B.N Patra )
Member (President)
DCDRC,Keonjhar DCDRC,Keonjhar
Dictated & Corrected by
( B.N Patra )
(President)
DCDRC,Keonjhar
