Haryana

Karnal

CC/360/2019

Neki Ram - Complainant(s)

Versus

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

Sultan Singh

19 Aug 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL  COMMISSION, KARNAL.

 

                                                          Complaint No. 360 of 2019

                                                          Date of instt.18.06.2019

                                                          Date of Decision 19.08.2021

 

Neki Ram son of Shri Lila Ram, Resident of village Jamba, District Karnal.

                                                 …….Complainant.

                                              Versus

1.SBI General Insurance Company Limited, First Floor B, D international SCO no.388,389 Karan Commercial Complex, Near guru Harikishan School, Post sector 13, Karnal through its authorized Signatory, Haryana-132001, India.

2. SBI General Insurance Company Limited, Registered and Cooperate Office Natracj101, 201 & 301 Junction of Western Express Highway and Andheri Kurla Road Andheri (East), Mumbai-400069.

 

                                                                     …..Opposite Parties.

 

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 Sultan Singh counsel for complainant.

                    Shri Mohit Goyal counsel for the opposite parties.

 

                    (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 parties (hereinafter referred as to OPs) on the averments that late Vikas, son of the complainant had obtained a Group Health Insurance Policy bearing no.000000000235148 on 13.06.2018, valid from 05.06.2018 to 04.06.2019 and the sum insured was Rs.5 lakhs. Vikas was suffering from illness and he was admitted on 04.07.2018 at Shri Hari Hospital, Karnal. The complainant had spent an amount of Rs.1,43,981/- on the treatment of his son. The son of complainant died on 07.08.2018. After the death of said Vikas, complainant deposited all necessary documents alongwith death certificate of said Vikas to OPs and requested to pay the insured amount alongwith other benefits but OPs did not pay the claim and postponed the matter on one pretext or the other and lastly repudiated the claim of the complainant, vide letter dated 11.09.2018 on the ground that “Vikas was suffering from Hematoma (in this case in view of Hypertension)”. It is pertinent to mention here that in the policy issued by OPs there is no where mentioning that Hematoma is exclusion in disease as mentioned in the policy. So, the said repudiation letter is illegal, null and void and not binding on the rights of the complainant. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to OPs, who appeared and filed written version, raising preliminary objections with regard to maintainability; cause of action and concealment of true and material facts. On merits, it is pleaded that Mr. Vikas was admitted for treatment of right fronto partial bleed with intraventricular extension into right lateral ventricle causing midline shift to left side for which fronto partial craniotomy with evacuation of haematoma was done. As per consultation paper of Dr. Rohit Kumar Goel dated 18.09.2018, Hypertension seems to be secondary to raise intracranial pressure. As per documents submitted it was observed that patient was admitted on 04.08.2018. The policy inception date is 05.06.2018 and policy is still in its first year of operation. As per terms and conditions of policy, expenses related to Hypertension, Heart Disease and related complications are excluded for first year of cover from the date of commencement of policy. The claim for hospitalization falls beyond purview of policy coverage. Therefore, the claim of the complainant has been rightly repudiated. There is no deficiency in service on the part of the OPs. 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, copy of death certificate dated 23.08.2018 Ex.CW1, copy of letter dated 11.09.2018 Ex.CW2, copy of death summary Ex.CW3, copy of operation notes dated 05.08.2018 Ex.CW4, copy of CT Scan dated 04.08.2018 Ex.CW5, copy of Doctor’s initial assessment Ex.CW6, copy of Bio Chemistry dated 04.08.2018 Ex.CW7, copy of Haematology dated 04.08.2018 Ex.CW8, copy of Bio chemistry dated 05.08.2018 Ex.CW9, copy of Haematology dated 05.08.2018 Ex.CW10, copy of Bio Chemistry dated 06.08.2018 Ex.CW11, copy of indoor patient file dated 07.08.2018 Ex.CW12, copy of Trauma Centre Report Ex.CW13, copy of certificate of Doctor Shri Rohit Kumar Goel Ex.CW14, copy of monitoring chart dated 04.08.2018 Ex.CW15, copy of monitoring chart dated 05.08.2018 Ex.CW16, copy of nurses medication chart dated 04.08.2018 Ex.CW17, copy of nurses medication chart dated 06.08.2018 Ex.CW18, copy of policy Ex.CW19, terms and conditions of the policy Ex.CW20, copies of bills dated 05.08.2018 Ex.CW21 to Ex.CW24, Ex.CW26 and Ex.CW30, copies of bills dated 06.08.2018 Ex.CW25 and Ex.CW31, copy of bill dated 07.08.2018 Ex.CW27, copies of bills dated 04.08.2018 Ex.CW28  and Ex.CW29, copy of account book Ex.CW32 and copy of Aadhar card Ex.CW33 and closed the evidence on 09.01.2020 by suffering separate statement.

4.             On the other hand, OPs tendered into evidence affidavit of Jagdish Kumar Assistant Manager Ex.RW1/A, copy of policy Ex.R1, copy of certificate of Doctor Shri Rohit Kumar Goel Ex.R2, copy of repudiation letter Ex.R3 and terms and conditions of the policy Ex.R4 and closed the evidence on 01.04.2021 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 son of complainant namely Vikas (since deceased) has obtained Group Health Insurance Policy from OPs. Vikas was suffering from illness and he was admitted on 04.07.2018 at Shri Hari Hospital, Karnal. The complainant had spent an amount of Rs.1,43,981/- on the treatment of his son.. After the death of Vikas, complainant deposited all necessary documents alongwith death certificate of said Vikas to OPs and requested to pay the insured amount alongwith other benefits but OPs did not pay the claim and repudiated the same, vide letter dated 11.09.2018, on the ground that “Vikas was suffering from Hematoma (in this case in view of Hypertension)”. He further argued that in the policy issued by OPs nowhere mentioned that Hematoma in exclusion disease and prayed for allowing the complaint. Learned counsel for complainant relied upon the judgment of Hon’ble State Commission in case titled as Aegon Religare LIC Vs. Poonam Jain in First Appeal no.215 of 2015, decided on 03.04.2017; The Managing Director & Ceo Versus Navjot Singh in appeal no.670 of 2009 decided on 09.05.2011 and M/s Birla Sun Life Insurance Co. Vs. Smt. L Madhavi in First Appeal no.35/2011 decided on 27.06.2013.

7.             Per contra, learned counsel for the complainant while reiterating the contents of written version, has vehemently argued that son of complainant was admitted in the hospital for treatment of right fronto partial bleed with intraventricular extension into right lateral ventricle causing midline shift to left side for which fronto partial craniotomy with evacuation of haematoma was done. As per consultation paper of Dr. Rohit Kumar Goel dated 18.09.2018, Hypertension seems to be secondary to raise intracranial pressure. As per documents, it was observed that patient was admitted on 04.08.2018 and policy is still in its first year of operation. As per terms and conditions of policy, expenses related to Hypertension, Heart Disease and related complications are excluded for first year of cover from the date of commencement of policy. The claim for hospitalization falls beyond purview of policy coverage. Hence, the claim of the complainant was rightly repudiated and prayed for dismissal of the complaint with heavy cost.

8.             Admittedly, the son of complainant namely Vikas had purchased a health insurance from the OP and during subsistence of the policy, son of complainant was suffering from illness and was admitted on 04.07.2018 at Shri Hari Hospital, Karnal for treatment  and died on 07.08.2018.

9.             The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.R3 on the ground that:-

        “The reported claim of Mr.Vikas is for the treatment of right fronto parietal bleed with intraventricular extension into right lateral ventricle causing midline shift to left side for which fronto parietal craniotomy with evacuation of haematoma was done. As per consultation paper of Dr. Rohit Kumar Goel dated 18.09.2018, Hypertension seems to be secondary to raise intracranial pressured. As per the documents submitted it is observed that, patent was admitted on 04.08.2018. The policy inception date is 05.06.2018 and policy is still in its first year of operation. As per policy terms and condition, expenses related to Hypertension, Heart Disease and related complications are excluded for first year of cover from the date of commencement of policy. This claim for hospitalization falls beyond purview of policy coverage and hence not payable”.

 

10.           The OP has taken a plea that as per policy terms and condition, expenses related to Hypertension, Heart Disease and related complications are excluded for first year of the policy. On the other hand, as per version of complainant, at the time of issuing of the policy OPs nowhere mentioned that Hematoma is exclusion in disease.

Causes of Hematoma described as under:-

Simply put, a hematoma s caused by some type of damage to a blood vessel that causes blood to leak out into places. It has no business being. Once it pools in this new area, it begins to clot, forming a small lump. Trauma is the most common cause of hematoma but this does not include just major traumas like car accidents or falling off a building. Trauma can be as simple as a sneeze or cough that is strong enough to damage a blood vessel.

Other causes include aneurysms, medications like blood thinners, and diseases like autoimmune disorders or infections, conditions that cause the blood vessels to weaken, high blood pressure, stroke, tumors or conditions like low blood platelets (which help the blood clot). Finally, hematoma formation may be spontaneous and not linked to any direct trauma.

On perusal of causes of Hematoma, it clears that this disease occurs so many reasons not only Hypertension. Hence plea taken by the OPs has no force.

11.           The claim of the complainant has been repudiated by the OPs on the basis of certificate Ex.R2 issued by Dr. Rohit Kumar Goyal and in that certificate it has been specifically mentioned that hypertension seems to be secondary to raise intracranial pressure. The OPs have repudiated the claim of the complainant on the basis of assumption and presumption led by the aforesaid doctor in the certificate Ex.R2, which is not tenable in the eyes of law.

12.           If the version of the OPs believes that Hypertension and related ailments not payable in first year of the policy, in that case also the OPs 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.

13.           No other point argued by the parties.

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

15.           The complainant has claimed Rs.1,43,981/- and in this regard he produced on record bills Ex.C21 to Ex.C31. Thus, he is entitled for the same alongwith compensation and litigation expenses.

 16.          Thus, as a sequel to above discussion, we allow the present complaint and direct the OPs to pay Rs.1,43,981/- 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 suffered by him and Rs.5500/- for the litigation expense. 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: 19.08.2021                                                                    

                                                                      President,

                                                      District Consumer Disputes

                                                      Redressal Commission, Karnal.

 

 (Vineet Kaushik)              

      Member