Punjab

Ludhiana

CC/17/123

Badri Nath - Complainant(s)

Versus

SBI Gen.Ins.Co.Ltd. - Opp.Party(s)

G.S.Marya Adv.

08 Sep 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:123 dated 17.02.2017.

                                                Date of decision: 08.09.2021.

         

Badri Nath Soni S/o. Sh. Banwari Lal, R/o.B-XIV, H. No.1882, Islam Ganj, Dholewal Chowk, Ludhiana.                                                                                                                                                             ..…Complainant

                                       Versus

1. SBI General Insurance Co. Ltd., Corporate & registered office Natraj 101, 201 & 301, Junction of Western Express Highway & Andheri, Kurla Road, Andheri East, Mumbai

2^nd Address:-

Sahni Plaza, Ground Floor, Near Dada Motors & Indian Oil Petrol Pump, G.T.Road, Delhi Road, Dholewal Chowk, Ludhiana through its Branchy head/Authorized Signatory.

2. Paramount Health Services & Insurance TPS Pvt. Ltd., Plot No.A-442, Road No.28, M.I.D.C. Industrial Area, Wagale Estate, Ram Nagar, Vithal Rukhumani Mandir, Thane-400604 through its Authorized Signatory.                                                                                                                             …..Opposite parties 

 

Complaint Under Consumer Protection Act.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. G.S. Maurya, Advocate

For OP1                         :         Sh. Vyom Bansal, Advocate.

For OP2                         :         Exparte.

ORDER

PER K.K. KAREER, PRESIDENT

1.                Shorn of the necessary details, the case of the complainant is that he purchased a family floater policy from OP1, which was valid from 01.09.2016 to 31.08.2017. The complainant and his wife Kanta Soni were covered under the policy. The complainant suffered backache with fever and weight loss for 20 days. He was admitted in CMC Hospital on 23.04.2016 and was discharged on 02.05.2016. The complainant further remained admitted in CMC Hospital from 09.05.2016 to 17.05.2016. The doctor diagnosed the complainant to be suffering from left side sacroilitis with cold abscess tubercular. The complainant incurred expenses of Rs.1,48,000/-on his treatment. Prior to his hospitalization, the complainant was absolutely normal. The complainant lodged the claim with OP1 on 23.05.2016. On receipt of the claim, OP1 appointed OP2 to investigate the claim, which was repudiated on 23.12.2016 on the ground that the complainant had history of pain in lower back since 3 years, diabetes mellitus since 1½ years, weight loss since 3 years and the current ailment is complication of the same and therefore, the disease was covered under exclusion clause-1 of the policy. The complainant made enquiry from the doctor of CMC Hospital and came to know that the said hospital had already clarified the matter in letter dated 03.04.2016 mentioning that the current illness was not related to the previous conditions. In the end, it has been requested that the OPs be directed to pay the claim of Rs.1,48,000/- along with interest @12% per annum and compensation of Rs.25,000/-.

2.                Upon notice OP2 did not appear despite service and was proceeded against exparte.

3.                The complaint has been resisted by OP1. In the written statement filed on behalf of OP1, it has been admitted that the complainant was insured under Group Health Insurance Policy for the period from 30.08.2014 to 29.08.2015 for a maximum sum of Rs.2,00,000/-. It has further been pleaded that on receipt of the claim, it was administered by OP2. After scrutinizing the documents, the cashless claim was denied on the basis of pre-existing disease. Another claim for reimbursement was received, which was registered as claim No.3131525. The second claim was also found not payable. As per the documents submitted, it was observed that the patient was admitted in hospital on 23.04.2016. The date of inception of the policy was 30.08.2014. Patient had a history of pain in lower back since 3 years, diabetes mellitus since 1½ years, weight loss since 3 years which is pre-existing in nature and the current ailment was a complication of the same. Therefore, the claim was not payable as per clause-1 of the policy. Moreover, the complainant had not disclosed the fact about the past history of pain in lower back since 3 years, diabetes mellitus since 1½ years and weight loss since 3 years. As per the terms and conditions of the policy, in the event of mis-representation, mis-description or non-disclosure  of any material facts, the policy would be void. The decision was conveyed to the complainant vide letter dated 23.12.2016. It has further been pleaded that another claim was received, which was registered as claim No.3150879, but the said claim was closed due to non-receipt of required documents such as details from the attending doctor, previous consultations, indoor case papers etc. The rest of the averments made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

4.                In evidence, the complainant submitted his affidavit as Ex. CA along with documents Ex. C1 to Ex. C17 and closed the evidence.

5.                On the other hand, the OP1 submitted affidavit Ex. RA of Sh. Manish Laxman Kerkar, Assistant Manager cum Authorized Signatory of OP1 of OPs along with documents Ex. R1 to Ex. R3 and closed the evidence.

6.                We have heard the learned counsel for the parties and have also gone through records.

7.                During the course of arguments, the counsel for the complainant has argued that the claims lodged in respect of hospitalization of the complainant from 23.04.2016 to 02.05.2016 and 09.05.2016 to 17.05.2016 have been wrongfully denied by the OPs on the ground that the complainant was suffering from lower back pain for 3 years, diabetes mellitus since 1½ years etc. The counsel for the complainant has further argued that the doctor of CMC Hospital, Ludhiana had clarified in the letter dated 30.04.2016 that the current illness for which the complainant was hospitalized was not related to any of the previous condition. In these circumstances, the repudiation of the claim cannot be justified. In support of his arguments, the counsel for the complainant has relied upon case title Life Insurance Corporation of India Vs Priya Sharma and others 2011(3) CLT 549 of Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh whereby it has been held that onus to prove that the life assured had suppressed the material facts and was suffering from pre-existing disease was on insurance company and if the doctor, who examined the life assured was also not examined as witness nor any evidence was produced regarding the alleged pre-existing disease, the claim could not be repudiated. The counsel for the complainant has further relied upon Religare Health Insurance Company Ltd. Vs Subhash Chander Aggarwal in 2017(3) CPT 140 of Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh whereby it has been held that hypertension is a common disease and it is not necessary that person suffering from hypertension would always suffer a heart attack and repudiation on account of pre-existing disease was not justified. The counsel for the complainant has further relied upon Kanwaljit Singh Vs National Insurance Company Limited in 2017(2) CLT 437 of Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh whereby it has been held that many persons have disease without knowing about the same and sometimes the diseases remain dormant in the body for years. It has further been held that some illnesses have incubation period of anywhere from years to decades and if as per the certificate given by the doctor no date for his pre-existing diseases suffered by the complainant’s son was given, the complainant was held entitled to recover medi-claim bills pertaining to his treatment.

8.                On the other hand, the counsel for OP1 has argued that as per policy terms and conditions, once the claim was not payable as the disease for which the treatment was taken was a pre-existing disease. The counsel for OP1 has referred to Ex. R2, which is the admission record of the complainant and it is clearly mentioned in the record that the complainant was a case of type-2 diabetes mellitus for 1½ years, weight loss for the last 3 years and pain in the back for 3 years, which worsened 15 days prior to hospitalization. According to the counsel for OP1, since the complainant had not disclosed about the pre-existing disease, he was not entitled for the claim which has been rightly rejected.

9.                We have weighed the contentions raised by the counsel for the parties and have also gone through the record carefully.

10.              Primarily, the medi-claim has been declined by the OPs on the ground that the complainant was suffering from diabetes mellitus since 1½ years, weight loss since 3 years and pain in lower back for 3 years. It has also been claimed by the OPs that since the diseases were pre-existing in nature which were not disclosed, the claim for hospitalization in respect of pre-existing diseases is not payable as per the terms and conditions of the policy. Now, it has to be seen as to what disease the complainant was diagnosed for. In this regard, a reference can be made to discharge summary Ex. C9 wherein it is mentioned that the complainant was finally diagnosed to have been suffering from the following diseases:

(i) Left side sacroileitus (tubercular)

(ii) Left side psoas abscess

(iii) Left pulmonary nodule

(iv) Type 2 diabetes mellitus

As per information available on internet, the sacroileitus is the inflammation of sacroiliac joint which is a common source of lower back pain or pain in buttock from thighs. Psoas abscess is known to be caused by mixed flora of enteric bacteria. Mycobacterium tuberculosis infection of the spine, is the most frequent cause of secondary psoas abscess.  Pulmonary nodule is an abnormal growth that found in the lungs. The complainant was treated at CMC Hospital, Ludhiana. As per the letter Ex. C11, Dr. Arjin Philps has given an opinion that the complainant had a pre-existing back ache secondary to spondyloarthropathy of the lumber spine. He has further mentioned in the letter Ex. C11 that the current illness of the complainant is unrelated to the previous conditions and has been present only for a duration of 3 months and the same has worsened during the last 1 week with urinary retention and constipation for 3 days and the provisional diagnosis is left sacroiliatis with illio-Psaos abscess. In the light of the opinion given by the doctor, in our considered view, the conditions in which the complainant was hospitalized are not necessarily the result of pre-existing diseases nor it can be said that the disease for which the complainant was diagnosed are nothing but aggravations of the previous existing conditions. In addition to this, it is further worth pointing out that the OPs have not lead any evidence that the complainant was ever treated for so called pre-existing diseases i.e. lower back pain, weight loss or diabetes mellitus. Apart from this, the OPs have not lead any evidence to contradict the findings of Dr. Arjin Philips given in Ex. C11. In these circumstances, the repudiation of the claim by invoking clause-1 of the policy on the ground that the diseases, for which the complainant has been treated, were pre-existing ones cannot be said to be justified.

11.              As a result of above discussion, the complaint is allowed with an order that the OP1 shall disburse the claim in respect of the hospitalization  of the complainant from 23.04.2016 to 02.05.2016 and from 09.05.2016 to 17.05.2016 strictly in accordance with terms and conditions of the policy within 40 days from the date of receipt of copy of order. The OP1 is further held liable to pay a composite costs and compensation of Rs.5,500/- (Rupees Five Thousand Five Hundred only) to the complainant. Payment of compensation shall be made within a period of 30 days from the date of the receipt of the copy of this order. However, complaint against OP2 is dismissed as OP2 is only a third party administrator. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.         

12.              Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:08.09.2021.

Gobind Ram.