Haryana

Karnal

CC/307/2019

Chamkar Singh - Complainant(s)

Versus

SBI General Insurance Company Limited - Opp.Party(s)

Sudhakar Mittal

12 Aug 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL  COMMISSION, KARNAL.

 

                                                         Complaint No. 307 of 2019

                                                          Date of instt.29.05.2019

                                                          Date of Decision 12.08.2021

 

Chamkar Singh age 55 years son of Shri Iqbal Singh resident of VPO Borsham, Tehsil Nilokheri, District Karnal (Haryana)

 

                                                 …….Complainant.

                                              Versus

 

SBI General Insurance Company Ltd. through its Divisional Manager, Karnal, B.D. International, SCO no.388-389, Karan Commercial Complex, near Guru Harikishan School, Sector-13, Karnal (Hr).

 

                                                                      …..Opposite Party.

 

Complaint Under section 12 of the Consumer Protection Act, 1986 as amended Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

 

 Argued by: Shri Sudhakar Mittal counsel for complainant.

                   Shri Naveen Khetarpal counsel for opposite party.

 

                    (Jaswant Singh President)

ORDER:   

                

                        The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 as after amendment Under Section 35 of Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant has taken a comprehensive health insurance policy bearing no.0000000006476947, valid from 30.05.2017 to 29.05.2018 from the OP under the name of Arogya Premier policy. The complainant paid Rs.19030/- as premium to the OP. The OP has covered all the medi claim risk of the complainant by giving cashless facility to him. On 26.02.2018, blood starting oozing out from the nose of the complainant and he was immediately taken to Aggarwal Nursing Home, Kurukshetra, in emergency. He was treated there by the doctors and discharged on 27.02.2018 at 11.28 a.m. The complainant  has made the payment of Rs.2500/- in the hospital for his treatment. On 28.02.2018 the complainant again had a complaint of right nasal bleeding, he was taken to Aggarwal Nursing Home, Kurukshetra where he remain admitted as indoor patient from 28.02.2018 to 06.03.2018 and spent Rs.50,000/-. After one day i.e. on 08.03.2018 the complainant again had the same complication. At that time the complainant was taken to Virk Hospital, Sector-17, Kurukshetra, where he remain admitted for one day. On seeing the critical condition of the complainant, he was advised to get his further treatment from higher institution. Thereafter, complainant got himself admitted in Alchemist Hospital, sector-21, Panchkula, where he diagnosed for hypertension with epistaxis with Deviated Nasal Septu with Spur Right Allergic Rhinitis. The complainant remain admitted as indoor patient in Alchemist Hospital, Sector-21, Panchkula, from 09.03.2018 to 16.03.2018. The complainant had made the payment of Rs.85,724.47 at the time of discharge from the Hospital. The complainant has also made the payment of Rs.1,10,579/- on account of medicine and other hospital charges at the time of discharge from Alchemist Hospital, Sector-21, Panchkula. Since the complainant was having cashless mediclaim insurance policy from the OP and Alchemist Hospital was on the panel of the OP, the complainant requested the hospital authority to charge the bill directly from the insurance company (OP) but hospital authority refused and asked the complainant to deposit the amount before discharge from the hospital. The hospital authority further told the complainant that the conduct of the OP is not upto the mark, for releasing claims under cashless mediclaim insurance policy. The hospital authority forwarded the claim of the complainant under the policy to the OP but instead of making the payment to the complainant, the OP repudiated the claim, vide its letter dated 05.03.2018 on the false and frivolous ground. At the time of taking the policy, complainant had disclosed all the material facts to the OP and OP issued the policy in question after its complete satisfaction and obtaining medical report of the complainant as well as his family members.  In this way there was deficiency in service on the part of the OP. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written version, raising preliminary objections with regard to maintainability; jurisdiction; mis-joinder and non-joinder of necessary parties and concealment of true and material facts. On merits, it is pleaded that OP had issued a policy no.0000000006476947 for the period of 30.05.2017 to 29.05.2018 and coverage of complainant himself for sum insured Rs.10,00,000/-subject to policy terms and conditions. It is further pleaded that it was the first policy of complainant and in the first policy, complainant was admitted for Hypertension, Epistaxis and Deviated Nasal Septum and was treated for the same in two different hospital. Complainant applied for cashless facility and OP company, TPA duly assessed the claim of complainant and communicated that “claim is being denied on account of as per available documents we are unable to ascertain the admissibility of this claim at this juncture as present ailment is not payable in first year of policy period.” The said information was sent to the OP, vide letter dated 01.03.2018. It is further pleaded that complainant again admitted on 09.03.2018 for the treatment of Hypertension with Epistaxis with Deviated Nasal Septum with Spur Right at Alchemist Hospital, Panchkula and discharged on 16.03.2018. The complainant again applied for cashless facility for an amount of Rs.1,50,000/-. The OP duly assess the said claim and observed that the complainant treated for Hypertension with Epistaxis with Deviated Nasal Septum with Spur Right and same has not been payable in first year of the policy. There is no deficiency in service on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence, his affidavit Ex.CW1/A, receipt dated 27.02.2018 of Aggarwal Nursing Home Ex.C1, discharge summary dated 06.03.2018 of Aggarwal Nursing Home Ex.C2, report dated 06.03.2018 of Department of Pathology of Aggarwal Nursing Home Ex.C3, OPD receipt dated 01.03.2018 of Rs.300/- of Aggarwal Nursing home Ex.C4, receipt dated 06.03.2018 of Rs.20,000/- of Aggarwal Nursing Home Ex.C5, Denial of Cashless dated 01.03.2018 Ex.C6, Denial of Cashless dated 05.03.2018 Ex.C7, OPD dated 08.03.2018 of Virk Hospital, Kurukshetra Ex.C8, bill/receipts from 26.02.2018 to 06.03.2018 of Aaradhana Medicose, Kurukshetra Ex.C9 to Ex.C16, Discharge summary dated 16.03.2018 of Alchemist Hospital, Panchkula Ex.C17, bill dated 16.03.2018 of Alchemist Hospital, Panchkula Ex.C18, receipt of Alchemist Hospital, Panchkula Ex.C19 to Ex.C22, ATM/payment receipt of Rs.24,000/- of Yes Bank dated 12.03.2018 Ex.C23, receipt of Alchemist Hospital, Panchkula Ex.C24, ATM/payment receipt of Rs.48000/- of HDFC Bank dated 15.03.2015 Ex.C25, receipt of Alchemist Hospital, Panchkula Ex.C26 to Ex.C28, Financial Clearance from Alchemist Hospital, Panchkula dated 16.03.2018 Ex.C29, Medical bill dated 30.03.2018 Ex.C30, Tax invoice of Alchemist Hospital, Panchkula dated 16.03.2018 Ex.C31, Medicine bill dated 04.04.2017 Ex.C32, OPD/bill receipt of Aggarwal Nursing Home, Kurukshetra dated 05.03.2018 Ex.C33, receipt dated 05.03.2018 of Aggarwal Nursing Home Kurukshetra Ex.C34, policy health card issued by SBI Gen. Insurance commencing from 30.05.2017 Ex.C35 and insurance policy dated 31.05.2017 issued by General Insurance Co. Ltd. and closed the evidence on 10.01.2020 by suffering separate statement.

4.             On the other hand, OP tendered into evidence affidavit of Jitendra Dhabhai Deputy Manager Ex.RW1/A, treatment record of Alchemist Hospital Ex.R1, treatment record of Aggarwal Nursing Home Ex.R2, discharge summary of Aggarwal Nursing Home Ex.R3, request for cashless hospitalization for medical insurance policy Ex.R4, claim from Ex.R5 and policy with terms and condition Ex.R6 and closed the evidence on 13.04.2021 by suffering separate statement. 

5.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

6.             Learned counsel for the complainant while reiterating the contents of complaint, has vehemently argued that complainant has taken a comprehensive health insurance policy from the OPs. On 26.02.2018, blood starting oozing out from the nose of the complainant and he was taken to Aggarwal Nursing Home, Kurukshetra, and discharged on 27.02.2018. The complainant again admitted in the said hospital as indoor patient from 28.02.2018 to 06.03.2018. Thereafter, complainant went to Virk Hospital, Kurukshetra for his treatment. Then, on seeing no improvement,  complainant got himself admitted in Alchemist Hospital, Sector-21, Panchkula from 09.03.2018 to 16.03.2018 and complainant incurred Rs.2,48,803/- in all the hospitals. He further argued that at the time of purchasing of the health policy, the agent of the OP had assured the complainant that all the diseases will be covered under the policy from the date of purchase of the policy.  OP never provided/disclosed  the terms and conditions of the policy which can aware the complainant that, what diseases are covered and what are not covered under the policy and prayed for allowing the complaint.

7.             Per contra, learned counsel for the complainant while reiterating the contents of written version, has vehemently argued that the policy in question was the first year policy of the complainant and in the first year policy, complainant was admitted for Hypertension, Epistaxis and Deviated Nasal Septum and was treated for the same in three different hospitals. Complainant applied for cashless facility but cashless denied on the ground that “Hypertension and related complications are not payable in the first year of policy as per the terms and conditions of the policy”.  He further argued that the terms and conditions of the policy were sent at the address of the complainant alongwith the policy. Hence, the claim of the complainant was rightly repudiated and prayed for dismissal of the complaint with heavy cost.

8.             Admittedly, the complainant had purchased a health insurance from the OP and during subsistence of the policy, blood starting oozing out from the nose of the complainant for which he was firstly treated by the Doctor of Aggarwal Nursing Home, Kurukshetra and thereafter for the same problem he admitted in Alchemist Hospital, Sector-21, Panchkula. It is also an admitted fact that the policy was cashless policy.

 9.            As per version of the complainant he spent Rs.2,48,803/- for his treatment in all the hospitals. Complainant raised pre authorization request for cashless treatment and the same was denied by OP, vide letter dated 01.03.2018 Ex.C6  and letter dated 05.03.2018 Ex.C7.

10.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.C6 and Ex.C7 on the ground that “as per the instructions of the insurer SBI General Insurance Company Limited the claim is being denied on account of, AS PER POLICY TERMS HYPERTENSION AND RELATED AILMENTS NOT PAYABLE IN FIRST YEAR OF THE POLICY HENCE CASE IS DENIED.”

11.           As per the version of the complainant, he was assured by the agent of the OP at the time of purchasing of policy, that all the diseases will be covered under this policy from the date of purchase of the policy but OP never provided the terms and conditions of the policy, rather only cover note (policy) was issued/provided by the OP to the complainant.

12.           As per version of the OP, the terms and conditions were sent to the complainant alongwith policy, but the OP has failed to produce on record any documentary evidence to prove that OP had sent/communicated the same to the complainant at any stage. The OP has further failed to produce any receipt/acknowledgement that the terms and conditions were sent/received by the complainant. Hence, the plea taken by the OP has no force. In this regard, we relied upon case titled as New India Assurance Co. Ltd Versus Anil Manglunia 2016 (1) CPR 150 (NC),wherein Hon’ble National Commission held that OP failed to provide policy clause to the complainant and rejected genuine claim of the complainant. Hence, they do not find any merit in the revision petition and the same is hereby dismissed.

13.           Furthermore, if the terms and conditions were not provided to the complainant, then these are not applicable to the complainant. Since, the OP has failed to prove the facts on record that the terms and conditions of the policy were sent and received by the complainant, therefore, the repudiation of claim of the complainant is not justified in the eyes of law.              

14.           If the version of the OP believes that Hypertension and related ailments not payable in first year of the policy, in that case also the OP cannot repudiate the claim of the complainant as, Hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension. In this regard we are placing reliance upon the case of Hon’ble State Commission, New Delhi, titled as Life Insurance Corporation of India Versus Sudha Jain 2007 (2) CLT 423, in which Hon’ble State Commission has drawn conclusion in para 9 of the order and the relevant clause is 9 (iii), is reproduced as under:-

        “9(iii) Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.” Taking into consideration the facts of the present case and law laid down by the Hon’ble Superior Fora in the above referred cases, we are of the view that OPs were not justified in repudiating the claim of the complainant and are thus liable to pay the amount which the complainant had incurred on his treatment.

15.           No other point argued by the parties.

16.           Keeping in view the ratio of above judgments, facts and circumstances of the case, we are of the considered view that act of the OP while repudiating the claim of the complainant amounts to deficiency in service, which is otherwise proved genuine one.

17.           The complainant claimed Rs.2,48,803/- on account of medical treatment etc. but he placed on record bills Rs.2500/- Ex.C1, Rs.300/- OPD slip Ex.C4, bill of Rs.20000/- Ex.C5, bill/receipt Ex.C33 of Rs.2200/-,  receipt  Ex.C34 of Rs.10,000/- and medicines bills of Rs.3284/- Ex.C9 to Ex.C16, bill of Rs.110579/- Ex.C18 (consolidated bill of bills/receipts Ex.C19, Ex.C21, Ex.C22, Ex.C24, Ex.C26 and Ex.C27), bill of Rs.100/- Ex.C20, bill of Rs.500/- Ex.C28, bill of Rs.787/- Ex.C30, bill of Rs.420/- Ex.C31 and bill of Rs.357/- Ex.C32, totaling Rs.1,51,027/-. Hence, the complainant is entitled for the same alongwith compensation and litigation expenses etc.

18.           Thus, as a sequel to abovesaid discussion, we partly allow the present complaint and direct the OPs to pay Rs.1,51,027/- to the complainant with interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OPs to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses. This order shall be complied within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:12.08.2021

President,

                                                      District Consumer Disputes

                                                      Redressal Commission, Karnal.

 

 

 

                        (Vineet Kaushik)               

                                Member