Haryana

Kurukshetra

CC/154/2019

Rajeev - Complainant(s)

Versus

Sandeep Kumar - Opp.Party(s)

Kuldeep Tanwar

09 Aug 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION  KURUKSHETRA.

 

Consumer Complaint No.154 of  of 2019

Date of Instt.:22.04. 2019

Date of Decision: 09.08.2021.

 

1.Rajeev Thareja son of Shri Khushi Ram aged 46 years,

2. Raj Rani wife of Shri Khushi Ram aged 70 years, both residents of  House No.305/Ward No.13, Four Marla Colony, Pehowa District Kurukshetra.                             

                                                              …….Complainant.       

                                                   Versus

 

1.Mr.Sandeep Kumar, Salesman of Star Health And Allied Insurance Company Limited, c/o Star Health And Allied Insurance Company Limited SCO No.94, First Floor, Sector 17, Backside of Hotel Silver Sand, Kurukshetra.

 

2. Star Health And Allied Insurance Company Limited, SCO No.257, 2^nd Floor, Sector 44, Chandigarh through its Manager.

 

3. Star Health And Allied Insurance Company Limited SCO No.94, First Floor, Sector 17, Backside of Hotel Silver Sand, Kurukshetra..                                                                                                                                                      ….…Opposite parties.

 

                  Complaint under Section 12 of Consumer Protection Act.

Before        Smt. Neelam Kashyap, President.    

                   Shri Issam Singh Sagwal, Member.                           

 

Present:      Sh.M.S.Tanwar counsel for the complainant.

                   Sh.Gaurav Gupta Advocate for OPs No.2 and 3.

                   OP No.1 ex parte.

 ORDER

                   This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by the complainant Rajeev Thareja etc.  against Star Health And Allied Insurance Co.  etc., the opposite parties.

2.                In brief, the case of the complainant is that the complainant was approached by OP n.1 for health policy and on the assurance of OP No.1, complainant obtained medical policy bearing No.P/211123/01/2019/001366 on 10.08.2018 which was valid from 09.8.2019  from OP No.1  who is an agent of OP No.3 which is branch of OP No.2. At the time of selling the policy, OP No.1 convinced the complainants that in case of any emergency regarding the health the policy would be cashless and complainants were not supposed to spend a single penny regarding any claims.  The complainant no.2 went to Max Hospital, for a routine check up with complainant no.1 where the doctors advised complainant Raj Rani for Coronary Angiography ECG and other blood test and as per Coronary Angiography report blockage was found and due to this immediately Angioplasty and other emergent treatment were one for saving the life of the complainant Raj Rani.  It is further submitted that complainant Rajeev Thareja then contacted OP No.1 and OP No.2 for cashless treatment on which OP No.1 assured to get the amount refunded shortly on submission of bills and other documents on which complainant no.1 on seeing  emergent situation and saving the life of the complainant Raj Rani paid an amount of Rs.2,46,841/- . The complainant had already spent more than Rs.3.00 lacs on her treatment , medical surgical instruments, transportation etc. Since the date of incident, the complainant Raj Rani is being looked after by an attendant regularly. She is not in a position to do any work. The complainant requested the OPs time and again for doing needful in the matter and to reimburse the  amount paid by complainant and submitted all the relevant documents but the needful was not done by the OPs. The complainants were shocked to receive the letter dated 4.02.2019 from the OP No.2 whereby claim of the complainant was rejected on the plea that the ailment of the complainant for which treatment was taken is pre existing one and the complainant is not entitled to any claim which amounts to deficiency in services on the part of the OPs. Thus, the complainant has filed the present complaint alleging deficiency in services on the part of the OPs and prayed  that the OPs be directed to pay the claim of the complainant alongwith compensation for the mental harassment and agony caused to him and the litigation expenses.

 

3.                Notice of the complaint was given to the OPs.  OP No.1 failed to appear and contest the case despite due service of summons. Therefore, OP No.1 was proceeded against ex-parte vide order dated 13.06.2019.

 

4.                OP No.2 and 3 appeared and filed written statement disputing the claim of the complainant. It has been submitted that the insured availed  SENIOR CITIZEN RED CARPET HEALTH INSURANCE POLICY  vide no. P/211123/01/2019/001366 for the period 10.8.2018 to 9.08.2019 covering Mrs. Raj Rani for the sum insured of Rs.10,00,000/-( PED: Hypertension and its complications).The Senior Citizen  Red Carpet Policy coverage with suitable co-payment i.e. 50% of each and every claim arising out of all pre-existing diseases as defined and 30% in case of all other claims which are to be borne by the insured. It is submitted that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form.  It is again submitted that Mrs. Raj Rani was hospitalized at MAX SUPER SPECIALITY HOSPITAL, MOHALI ON  1.11.2018 (  i.e. in the third month of the policy) for the treatment of VAD/USA/CAG – DVD/HTN  and sought for a pre-authorization  of cashless treatment on 2.11.2018 for a sum of Rs.2,48,760/-.The same was denied vide letter dated 2.11.2018, since the disease appears to be of chronic nature as per documents submitted, the cashless was denied and the insured was informed to submit a claim for reimbursement of medical expenses on 2.11.2018 for a sum of Rs.2,46,841/- . On scrutiny of the claim documents submitted by the insured it was observed that

a)                The insured was admitted on 1.11.2018 and discharged on 2.11.2018

b)                Diagnosis VAD-USA   CAG-DOUBLE VESSEL DISEASZE DONE ON 1.11.2018  S/P PTCA + STENT TO LAD  DONE ON 1.11.2018 HYPERTENSION.

                   The Coronary Angiography report dated 1.11.2018 shows Coronary Artery disease and Double  vessel disease (LAD: Type III LAD, proximal plaque  present. Mid 90% lesion with thrombus and Distal 70% lesion, RCA: Non-Dominant Small Vessel, Proximal 99% lesion).

                   Hypertension and its complications are already incorporated as pre-existing disease as per Proposal Form.

                   The above findings confirms that the insured patient is longstanding disease prior to the date of commencement of first year policy. Hence, it is a pre existing disease. The present admission and treatment of the insured patient is for pre existing disease.

                   It was also submitted that as per exclusion 1 of the policy “ The company shall not be liable to make any  payments  under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of Pre-Existing  Diseases as defined in the policy until 12 consecutive months of continuous coverage have elapsed, since inception of the first policy with any insured.  Therefore, claim of the complainant was rightly repudiated vide repudiation letter dated 4.02.2019 and prayed for dismissal of the present complaint.

 

5.                The complainant in support of his case has filed affidavit Ex.CW1/A and tendered documents ERx.C-1 to Ex.C-39 and closed his evidence.

 

6.                On the other hand, OP No.2 and 3 in their evidence have filed affidavit Ex.RW1/A and tendered documents Ex.R-1 to Ex.R-17 and closed their evidence.

 

7.                We have heard the learned counsel for the parties and gone through the case file very carefully.

8.                The learned counsel for the complainant has argued that complainant obtained medical policy bearing No. P/211123/01/2019/001366 on 10.08.2018 which was valid from 09.8.2019  from OP No.1  who is an agent of OP No.3 which is branch of OP No.2. At the time of selling the policy, OP No.1 convinced the complainants that in case of any emergency regarding the health the policy would be cashless and complainants were not supposed to spend a single penny regarding any claims.  The complainant no.2 went to Max Hospital, for a routine check up with complainant no.1 where the doctors advised complainant Raj Rani for Coronary Angiography ECG and other blood test and as per Coronary Angiography report blockage was found and due to this immediately Angioplasty and other emergent treatment were one for saving the life of the complainant Raj Rani.  It is further submitted that complainant Rajeev Thareja then contacted OP No.1 and OP No.2 for cashless treatment on which OPs    assured to get the amount refunded shortly  

on submission of bills and other documents on which complainant no.1 on seeing  emergent situation and saving the life of the complainant Raj Rani paid an amount of Rs.2,46,841/- . The complainant had already spent more than Rs.3.00 lacs on her treatment , medical surgical instruments, transportation etc. Since the date of incident, the complainant Raj Rani is being looked after by an attendant regularly. She is not in a position to do any work. The complainant requested the OPs time and again for doing needful in the matter and to reimburse the  amount paid by complainant and submitted all the relevant documents but the needful was not done by the OPs. The complainants were shocked to receive the letter dated 4.02.2019 from the OP No.2 whereby claim of the complainant was rejected on the plea that the ailment of the complainant for which treatment was taken is pre existing one and the complainant is not entitled to any claim which amounts to deficiency in services on the part of the OPs. Thus, the complainant has filed the present complaint alleging deficiency in services on the part of the OPs and prayed  that the OPs be directed to pay the claim of the complainant alongwith compensation for the mental harassment and agony caused to him and the litigation expenses. Reliance has been placed on the authority Union of India and another Versus N.K.Srivasta and others Civil Appeal No.2823 of 2020 (Arising out of Special leave petition No.(c) No.28056 of 2017).

 

9.                On the other hand, learned counsel for OP No.2 and 3 while reiterating the contentions made in the written statement has argued that It has been submitted that the insured availed  SENIOR CITIZEN RED CARPET HEALTH INSURANCE POLICY  vide no. P/211123/01/2019/001366 for the period 10.8.2018 to 9.08.2019 covering Mrs. Raj Rani for the sum insured of Rs.10,00,000/-( PED: Hypertension and its complications).The Senior Citizen  Red Carpet Policy coverage with suitable co-payment i.e. 50% of each and every claim arising out of all pre-existing diseases as defined and 30% in case of all other claims which are to be borne by the insured. It is submitted that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form.  It is again submitted that Mrs. Raj Rani was hospitalized at MAX SUPER SPECIALITY HOSPITAL, MOHALI ON  1.11.2018 (  i.e. in the third month of the policy) for the treatment of VAD/USA/CAG – DVD/HTN  and sought for a pre-authorization  of cashless treatment on 2.11.2018 for a sum of Rs.2,48,760/-.The same was denied vide letter dated 2.11.2018, since the disease appears to be of chronic nature as per documents submitted, the cashless was denied and the insured was informed to submit a claim for reimbursement of medical expenses on 2.11.2018 for a sum of Rs.2,46,841/- . On scrutiny of the claim documents submitted by the insured it was observed that

a)                The insured was admitted on 1.11.2018 and discharged on 2.11.2018

b)                Diagnosis VAD-USA   CAG-DOUBLE VESSEL DISEASZE DONE ON 1.11.2018  S/P PTCA + STENT TO LAD  DONE ON 1.11.2018 HYPERTENSION.

 

                   The Coronary Angiography report dated 1.11.2018 shows Coronary Artery disease and Double vessel disease (LAD: Type III LAD, proximal plaque  present. Mid 90% lesion with thrombus and Distal 70% lesion, RCA: Non-Dominant Small Vessel, Proximal 99% lesion).

 

                   Hypertension and its complications are already incorporated as pre-existing disease as per Proposal Form.

 

                   Thus, it is argued that the insured patient was having  longstanding disease prior to the date of commencement of first year policy. Hence, it is a pre existing disease. The present admission and treatment of the insured patient is for pre existing disease and there is no deficiency in services on the part of the Ops. Reliance has been placed on the law cited in cases Surinder Kaur Vs. NIC Limited  Law Finder Doc Id # 780431, Tata AIG Life Insurance Co. Vs. Orissa State Co.Op.Bank and another  Law Finder Doc  Id # 686400, Satwant Kaur Sandhu Vs. New India Assurance Co.  Law Finder Doc Id# 203511, P.C.Chacko and another Vs. Chairman LIC and others : Law Finder Doc ID # 134190, United India Insurance Co.Limited Vs.Umrao Chand Doga and others: Law Finder Doc ID # 793376, C.N.Mohan Raj Vs. New India Assurance Co.Limited Law Finder Doc ID # 586911, M/s Industrial Promotion and Investment Corpn. Vs.New India AssuranceCo.Limited : Law Finder Doc ID # 785937, M/s Suraj Mal Ram Niwas Oil Mills Vs. United India Insurance Co.: Law Finder Doc ID # 219912, United India Insurance Co.Limited Vs. M/s Harchand Rai Chandan Lal (SC) Law Finder Doc ID # 79540.

 

10.              After hearing both the sides at length, having gone through the record available on the file and admission of the parties, it is admitted fact of this case that the complainants obtained medical policy bearing No.P/211123/01/2019/001366 on 10.08.2018 which was valid from 09.8.2019 from OP No.1  who is an agent of OP No.3 which is branch of OP No.2and the said policy was a cashless policy.  The complainant no.2 went to Max Hospital, for a routine check up with complainant no.1 where the doctors advised complainant Raj Rani for Coronary Angiography ECG and other blood test and as per Coronary Angiography report blockage was found and due to this immediately Angioplasty and other emergent treatment were one for saving the life of the complainant Raj Rani.  Then the  complainant Rajeev Thareja contacted OP No.1 and OP No.2 for cashless treatment on which OP No.1 assured to get the amount refunded shortly on submission of bills and other documents on which complainant no.1 on seeing  emergent situation and saving the life of the complainant Raj Rani paid an amount of Rs.2,46,841/-. Ex.R-1 is the proposal form and in the said proposal from the complainant no.1 has admitted the treatment taken for blood pressure and as such she has not concealed anything regarding her ailments.

                  It is also not in dispute that the insured was admitted on 1.11.2018 and discharged on 2.11.2018 and Diagnosis VAD-USA   CAG-DOUBLE VESSEL DISEASZE DONE ON 1.11.2018  S/P PTCA + STENT TO LAD  DONE ON 1.11.2018 HYPERTENSION.

 

11.              The Ops have argued that the Senior Citizen   Red Carpet policy coverage with suitable co-payment i.e. 50% each and every claim arising out of all pre existing diseases as defined and 30%  in case of all other claims which are to be borne by the insured. As per repudiation letter Ex.R-17,  the Ops  took shelter of exclusion clause No.1 that company is not liable to make any payment during the first year of operation of policy, in respect of expenses for treatment of the pre existing disease condition for which treatment or advice was recommended or received until 12  consecutive months of continuous coverage has elapse since inception of first policy on 10.8.2018. It is mentioned here that as per Ex.C-5 in the column of personal  history “No significant personal history  and No significant family history “ is mentioned .  But as per the case of the complainant The complainant no.2 went to Max Hospital, for a routine check up with complainant no.1 where the doctors advised complainant Raj Rani for Coronary Angiography ECG and other blood test and as per Coronary Angiography report blockage was found and seeing  emergent situation and saving the life of the complainant Raj Rani paid an amount of Rs.2,46,841/- and got treatment as mentioned above.  Thus, it is clear that the treatment for VAD-USA   CAG-DOUBLE VESSEL DISEASZE DONE ON 1.11.2018  S/P PTCA + STENT TO LAD  DONE cannot be said to be pre existing because the Ops have failed to prove that she ever took treatment for the said disease. So far as  Hypertension etc. are concerned, the complainant no.1 is  aged about 70 years and by lapse of time such type of disease like Hypertension often exists and appears and these problems cannot be said to be pre existing. The Hon’ble National Commission in case titled as Branch Manager, Star Health & Allied Insurance Co. Ltd. & anr. Vs. Umesh Badai & Ors. (supra) has held that “No proof has been brought on record to establish that the complainant took any treatment for pre-existing diseases- Appellants failed to establish, if there was any willful suppression of material facts on the part of the complainants- No grounds to interfere- Impugned order confirmed that insurer is also liable- Appeal dismissed.” The authorities relied upon by learned counsel for complainant are also applicable to the facts and circumstances of the present case wherein it has been held that burden of proving suppression of facts upon appellants not discharged whereas the authorities cited on behalf of OP No.2 and 3 are not applicable to the present case.

 12.                      As per document  Ex,C-15, the OP No.2 and 3 have admitted that the complainant spent Rs.2,46, 841/- on her treatment and during course of arguments, it has been admitted that the OP No.2 and 3 were ready to pay the amount of Rs.1,53,364/- but the complainant did not accepted the same. It is made clear that the present complaint was filed on 22.4.2019 and even during the course of pendency of the complaint, the OP No.2 and 3  failed to pay the said amount to the complainant and as such there is deficiency in services on the part of  OP No.2 and 3 for non payment of the claim of Rs.2,46,841/-  to the complainant no.2.

 

                   In this case, OP no.1 is merely an agent and as such no deficiency in services on the part of OP no.1 is proved. Therefore, the present complaint merits dismissal against OP no.1.However, OP No.1 was proceeded against ex-parte vide order dated:13.06.2019.

 

13.              In view of the above, we allow the present complaint and direct the OP No.2 and 3 to pay the amount of Rs.2,46,841 /- to the complainant no.2 along with interest @ 6% per annum from the date of this order i.e. 5.8.2021 till its realization. The complainant No.2 shall also be entitled for a sum of Rs.10,000/- as compensation for the mental harassment caused to  her and Rs.10000/- for the litigation expenses. The OP No.2 and 3  are   further directed to make the compliance of this order within a  period of  30 days from the date of preparation of certified copy of this order, failing which, the complainant will be at liberty to initiate proceedings under Section 22/27 of the Act against the OP No.2 and 3. The complaint qua  complainant no.1 as well as OP No.1 stands dismissed because the treatment was taken by  complainant  No.2 and not by complainant no.1 and OP No.1 is merely an agent of OP No.2 and 3. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the record-room, after due compliance.

 

Announced in open commission:

Dt.:9.08.2021                                                     (Neelam Kashyap)

                                                                                  President.

 

 

(Issam Singh Sagwal),                           

 Member