Haryana

Kurukshetra

269/2018

KartarSingh - Complainant(s)

Versus

Star health Allianz - Opp.Party(s)

Prem Sagar

17 May 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KURUKSHETRA.

 

                                                                    Complaint No.:    269 of 2018.

                                                                   Date of institution:         06.12.2018.

                                                                   Date of decision: 17.05.2022

 

Kartar Singh s/o Shri Balbir Singh, aged 41 years, r/o House No.58, Sector -13, Urban Estate, Kurukshetra, presently residing at House No.19, Sector 3, Urban Estate, Kurukshetra.

                                                                                                …Complainant.

                                                     Versus

 

1. Star Health And Allied Insurance Company Limited, Branch office at SCO No.44, 2^nd Floor, Sector -17, Kurukshetra, through its Branch Manager.
2. Kapil Dev, Salesman/Agent of Star Health And Allied Insurance Company Limited, r/o Shop No.6B, Second Floor, Arya Samaj Market, Kurukshetra.

 

...Respondents.

 

CORAM:   NEELAM KASHYAP, PRESIDENT.    

                   NEELAM, MEMBER.

                   ISSAM SINGH SAGWAL, MEMBER.           

 

Present:       Shri Prem Sagar, Advocate for the complainant.

                   Shri Gaurav Gupta, Advocate for Opposite Party No.1.

                   Opposite Party No.2 ex-parte vide order dated 12.09.2019.

 

ORDER:

 

1.                This is a complaint under Section 12 of the Consumer Protection Act, 1986 (for short “Act”).

2.                It is alleged in the complaint that complainant had obtained policy under Family Health Optima Insurance Plan bearing No.P/21112301/2018/000881 on 11.09.2017, from OP No.1, through OP No.2 valid from 11.09.2017 to 10.09.2018 after paying the entire required premium at the time of getting the said policy. In the said policy, the complainant, his wife Pooja Saini and his children namely Milan Saini and Kshitiz Saini are insured. The limit of coverage is Rs.500000/-. At the time of obtaining the said policy, all the insured persons were hale and hearty. It has been specifically mentioned against the pre-existing disease NO PED declared. It is further stated that on 21.02.2018, wife of complainant namely Pooja Saini fell ill and taken to Jaipur Golden Hospital, New Delhi and it was found that she was suffering from Hemolytic Dnemia (Morbid OBESITY). She was admitted there from 21.2.2018 to 9.03.2018 and was treated and diagnosed there. In this regard, intimation was given to the OPs, who assured that all the medical and treatment bills of the complainant would be paid by the OP No.1, being insurer, being Jaipur Golden Hospital in the list of Hospitals of the Ops. He paid a sum of Rs.12,89,744.22 for treatment, operation and medical bills with the staff of the Hospital, but till date, the OP No.1 has failed to refund back the claim amount. He requested the OPs various times to refund the amount, but they refused to pay the same, which amounts to deficiency in services on the part of the OPs.

3.                Upon notice of complaint, OP No.1 appeared and filed its written statement, whereas, OP No.2 failed to appear before the Commission despite receipt of notice of complaint and as such, he was ordered to be proceeded against ex-parte vide order dated 12.09.2019, by this Commission.  

4.                OP No.1, in its written statement, disputed claim of the complainant, while obtaining of the insurance policy by the complainant and his family was admitted. Wife of the complainant was admitted in Jaipur Golden Hospital on 21.02.2018 and was diagnosed with GBS. Answering OP had received pre-authorization request towards the treatment of GBS. Based on the submitted documents, the claim was initially approved for an amount of Rs.15,000. Subsequently, the complainant submitted the representation for enhancement of the approved amount with the medical documents. On scrutiny of the same, it was observed that “As per case sheet, the complainant is a case of Morbid Obesity”. Thus, the OP has called for the duration of the Morbid Obesity and BMI of the complainant, vide letter dated 24.2.2018. In the reply the complainant submitted a treating doctor certificate dated 25.2.2018 stating that “as per the history given by patient herself, she noticed increasing her body weight rapidly for last approximately 6-7 months. According to her, her last measured weight was approximately 110 kg and height was 162 cm. Presently, she was not able to bear weight on legs and stand, weight could not be measured. The BMI, depending on the information given was 41.98kg/m2. From the above findings, it was noted that the complainant had a history of morbid obesity”. Though it was not related to the present admission, further evaluation was needed to ascertain the duration of morbid obesity. Thus, the pre-authorization was withdrawn, denied and informed the complainant to approach for reimbursement, vide letter dated 26.02.2018. The complainant had not submitted claim for reimbursement of medical expenses, thus the OP was not aware of the exact expenses incurred to the complainant. The cashless approval was given by the OP insurance company only on a preliminary evaluation of documents submitted by the treating hospital and it was subject to review upon the receipt of further details from the complainant. The complainant had to submit claim for reimbursement with the claim form duly completed, discharge summary, main hospital bill with break up, investigation report with X-ray films, MRI, USG, if any, medical bills with payment receipts etc., but till date, he had not submitted requisitioned documents, so no final decision has been taken by the OPs and the present complaint may kindly be dismissed being premature one.

5.                The complainant, in support of his case, tendered affidavit Ex.AW1/A along with documents Ex.A-1 to Ex.A-7 and closed his evidence.

6.                On the other hand, OP No.1 tendered affidavit Ex.RW1/A along with documents Ex.R-1 to Ex.R12 and closed its evidence.

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

8.                At the outset, the learned counsel for the OP No.1 has raised objection that the complainant had to submit the requisite documents i.e. claim form duly completed, discharge summary, main hospital bill with break up, investigation report with X-ray films, MRI, USG, if any, medical bills with payment receipts etc., for reimbursement, but till date, he had not submitted the same, so no final decision has been taken by the OPs and the present complaint be dismissed, being premature one. On the other hand, in this regard, learned counsel for the complainant contended that the complainant had already submitted all the requisite documents along with claim form with the OPs to release his claim, so the plea taken by the OPs in this regard, is totally baseless and is liable to be rejected.

9.                From of case file shows that the OP No.1 himself, in its defence evidence, attached various documents relating to the claim in question, such as, Common Proposal Form of complainant as Ex.R-1, policy documents Ex.R-2 & Ex.R-3, Pre-Authorization Request Form of complainant as Ex.R4, medical/treatment record of complainant’s wife as Ex.R-5 & Ex.R-6 etc. with the case file and carrying/attaching these documents with the case file, by OP No.l himself, means, OP No.1 has had the said requisite documents, related to the claim of the complainant with itself. It might be possible these documents were submitted/supplied by the complainant himself, as alleged by the complainant. On the one hand, the OP No.1 is alleging that the complainant had not supplied the requisite documents related to his claim with it, whereas, on the other hand, OP No.1 himself attaching/producing those documents in its defence, so, objection taken by the OP No.1, in this regard, is self-contradictory in itself. It seems that by way of raising this objection, the OP No.1 is contemplating the performance of impossibilities and shooting the arrows in the air. So, the plea taken by the OP No.1 that the complainant has not submitted the requisite documents, with it till today, as such, present complaint is premature, has no force, being self-contradictory in itself, hence rejected.  

10.              Now coming to the merits of the case.

11.              In this regard, learned counsel for the complainant argued that the complainant had obtained policy under Family Health Optima Insurance Plan bearing from OP No.1, through OP No.2 valid from  11.09.2017 to 10.09.2018. In the said policy, the complainant, his wife Pooja Saini and his children namely Milan Saini and Kshitiz Saini are insured for a sum of Rs.5,00,000/-. At the time of obtaining the said policy, all the insured persons were hale and hearty. It has been specifically mentioned against the pre-existing disease NO PED declared. It is further stated that on 21.02.2018, wife of complainant namely Pooja Saini fell ill and taken to Jaipur Golden Hospital, New Delhi and it was found that she was suffering from Hemolytic Dnemia (Morbid OBESITY). She was admitted there from 21.2.2018 to 9.03.2018 and was treated and diagnosed there. In this regard, intimation was given to the OPs. The complainant paid a sum of Rs.12,89,744.22 for treatment, operation and medical bills with the staff of the Hospital, but till date, the OP No.1 has failed to refund back the claim amount. The complainant requested the OPs various times to refund the amount, but they refused to pay the same, which amounts to deficiency in services on the part of the OPs.

12.              Contrary to it, learned counsel for the OP No.1 has argued that wife of the complainant was admitted in Jaipur Golden Hospital on 21.02.2018 and was diagnosed with GBS and the OP No.1 had received pre-authorization request towards the treatment of GBS. Based on the submitted documents, the claim was initially approved for an amount of Rs.15,000. Subsequently, the complainant submitted the representation for enhancement of the approved amount with the medical documents. On scrutiny of the same, it was observed that “As per case sheet, the complainant is a case of Morbid Obesity”. Thus, the OP has called for the duration of the Morbid Obesity and BMI of the complainant, vide letter dated 24.2.2018. In the reply the complainant submitted a treating doctor certificate dated 25.2.2018 stating that “as per the history given by patient herself, she noticed increasing her body weight rapidly for last approximately 6-7 months. According to her, her last measured weight was approximately 110 kg and height was 162 cm. Presently, she was not able to bear weight on legs and stand, weight could not be measured. The BMI, depending on the information given was 41.98kg/m2. From the above findings, it was noted that the complainant had a history of morbid obesity”. Though it was not related to the present admission, further evaluation was needed to ascertain the duration of morbid obesity. Thus, the pre-authorization was withdrawn, denied and informed the complainant to approach for reimbursement, vide letter dated 26.02.2018. The complainant had not submitted for reimbursement with the claim form duly completed, discharge summary, main hospital bill with break up, investigation report with X-ray films, MRI, USG, if any, medical bills with payment receipts etc., so no final decision has been taken by the OPs.

13.              There is no dispute that the complainant purchased a Family Health Optima Insurance policy from OP No.1, for his family covering 2 Adults + 2 children, for a sum assured of Rs.5,00,000/-, valid from 11.09.2017 to 10.09.2018, vide insurance policy Ex.A-7. There is also no dispute that wife of complainant namely Pooja Saini got admitted in Jaipur Golden Hospital, New Delhi on 21.02.2018 and discharged on 09.03.2018, vide Discharge Summary Ex.A-5.

14.              Perusal of case file shows that initially, OP No.1 gave provisional cashless approval of Rs.15,000/- for cashless treatment of wife of complainant, vide letter dated 24.2.2018 Ex.R-9, but thereafter, withdrawn the same, vide letter dated 26.02.2018 Ex.R-10 and also denied to pay the claim to the complainant, vide letter dated 26.02.2018 Ex.R-11, issued in favour Jaipur Golden Hospital as well as letter dated 26.02.2018 Ex.R-12, issued in favour of complainant. Extract part of Rejection of Pre-authorization for Cashless Treatment Ex.R-12, reads as under:-

                   “The patient is admitted for guillain baarre syndrome. As per the query reply submitted the patient has noticed increasing her body weight rapidly for past 6-7 months. The bmi as per your query reply is 41.98. Though the current ailment is not related to morbid obesity, to consider the claim as per policy terms and conditions further evaluation is needed to ascertain the duration of morbid obesity in this patient. Hence the auth is withdrawn and the claim is denied”.

  

15.               Learned counsel for the complainant alleged that the complainant paid a sum of Rs.12,89,744.22 for treatment of her wife Pooja Saini, in Jaipur Golden Hospital, New Delhi, but the OP no.1 rejected the pre-authorization request sent by the said hospital nor it refunded back the claim amount to him, till today, which amounts to deficiency in service on its part. On the other hand, the learned counsel for the OP No.1 has mainly contended that as per case-sheet, the wife of complainant Pooja Saini was a case of Morbid Obesity. Thus, the OP has called for the duration of the Morbid Obesity and BMI of the complainant and as treating doctor certificate dated 25.2.2018 submitted by complainant, she noticed increasing her body weight rapidly for last approximately 6-7 months. From the above findings, it was noted that the complainant had a history of “morbid obesity”. Though it was not related to the present admission, further evaluation was needed to ascertain the duration of morbid obesity. To corroborate this fact, firstly, the OP No.1 produced Certificate dated 25.02.2018 of Pooja Saini, issued by Jaipur Golden Hospital, New Delhi as Ex.R-6, wherein, it is mentioned that “As per history given by patient herself, she faced increasing her body weight rapidly for last approximately 6-7 months. According to her, her last measured weight was approximately 110 kg”. The OP No.1 further produced “INPATIENT HISTORY SHEET & PHYSICAL EXAMINATION RECORD” of complainant’s wife, which is second page of Ex.R-6, wherein, in Column No.3 HISTORY OF PRESENT ILLNESS, it is mentioned “DM2 & HTN”. In Column No.4 HISTORY OF PAST ILLNESS, it is mentioned “Diabetes Mellitus 1 year”. In 3^rd page of Ex.R-6, it is mentioned “morbid obesity + 120”.           

16.              From this document Ex.R-6, it is found that the OP No.1 mainly stressed that wife of complainant was known case of morbid obesity, DM2 and HTN and further evaluation was needed to ascertain the duration of morbid obesity thus, the pre-authorization was withdrawn and denied the claim of complainant. But it is pertinent to mention here that the OP No.1 had not produced any past history/medical record of wife of complainant namely Pooja Saini, on the case file, to prove that she was suffering from the illness, referred above, and taking treatment for the same, prior to taking the policy in question and that fact was in the knowledge of complainant and that she intentionally concealed the same at the time of taking the policy in question. Even also the OP No.1 insurance company did not produce any medical record to prove that which medication and for how long wife of complainant was taking medicines for those pre-existing diseases. Furthermore, affidavit of the treating doctor, who had recorded the patient history as well as who issued the certificate Ex.R-6, has not been produced on the record. It is commonly known that now-a-days a heart disease and diabetes can occur immediately to anyone. It is a well known fact that, many times the healthy person are unaware of such silent ailments of diabetes, hyper tension and heart problem etc., which come to their knowledge first time during health check-up camps or in any emergent situation. Thus, the OP(s) insurance company cannot apply a hard and fast rule to presume that the life assured was suffering from pre-existing disease prior to obtaining the insurance policy. The OP No1 has failed to prove through cogent and convincing evidence that wife of complainant was already suffering from pre-existing diseases like morbid obesity, DM2 and HTN before taking the policy in question from the OPs, and evaluation was needed to ascertain the duration of the same. In this regard we are also fortified with the observations of the Hon’ble National Commission in the case titled National Insurance Company Ltd. Vs. Raj Narain, decided on 15.01.2008 (National Commission), in which, it has been held that “If this interpretation is upheld, the Insurance Company is not liable to pay any claim, whatsoever, because every person suffers from symptoms of any disease without the knowledge of the same. This policy is not a policy at all, as it is just a contract entered only for the purpose of accepting the premium without the bonafide intention of giving any benefit to the insured under the garb of pre-existing disease. Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the insurance company relies on their clause 4.1 of the policy in a mala fide manner to repudiate all the claims. No claim is payable under the medi-claim policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him which he is genuinely unaware of them. Hindsight everyone relies much later that he should have known from some symptom. If this is so every person should do medical studies and further not take any insurance policy. Even on the facts on record, there is no material to show that the petitioner had any symptoms like chest pain, etc. prior to 11^th August, 2000. Since, there were no symptoms, the question of linking up the symptoms with a disease does not arise. In any case, it is the contention of the complainant that he was thoroughly checked up by the doctors who were nominated by the insurance company and at that time he was found hale and hearty. In such set of circumstances, it would be difficult to arrive at the conclusion that the insured had suppressed the pre-existing disease.

17.              So, from the above facts and circumstances of the case, we are of the considered view that the OP No.1 is not justified in denying the claim of the complainant, on the ground mentioned above, which amounts to deficiency in services on its part. Hence, the OP No.1 is liable to reimburse the amount, which the complainant had incurred on the treatment of her wife Pooja Saini, as per policy in question. So far as the complaint filed against OP No.2 is concerned (who was proceeded against ex-parte on 12.09.2019); from perusal of entire record, we found that neither any specific allegations have been leveled by the complainant against him, nor it has been proved, therefore, complaint qua OP No.2, is liable to be dismissed.

18.              Now the question which arises for consideration is what should be the quantum of indemnification? In the complaint, complainant contended that he spent Rs.12,89,744.22, on the treatment of her wife, and in this regard, he produced bills Ex.A-1 to Ex.A-4 respectively. In Para No.6 of his complaint, complainant himself admitted that coverage amount under policy in question is Rs.5,00,000/-. Moreover, this fact is also proved from Insurance Policy document Ex.A-7, therefore, the OP No.1 is liable to pay the sum assured of Rs.5,00,000/- to the complainant. The OP No.1 also liable to compensate the complainant for the mental agony and physical harassment suffered by him, alongwith litigations expenses.

19.              In view of our above discussion, we accept the present complaint against the OP No.1, and dismiss the same against OP N.2, and direct the OP No.1 to pay the claim amount of Rs.5,00,000/-, to the complainant. The OP No.1 is further directed to pay Rs.10,000/- to the complainant, as compensation for mental agony and physical harassment, caused to the complainant, due to an act of deficiency in service, on the part of the OP No.1, along with Rs.5,000/-, as litigation expenses. The OP No.1 is further directed to make the compliance of this order within a period of 45 days from the date of preparation of certified copy of this order, failing which, the award amount of Rs.5,00,000/- shall carry on interest @6% simple per annum, from the date of this order, till its actual realization, and the complainant shall be at liberty to initiate proceedings under Section 25/27 of the Act, against the OP No.1. 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:

Dated:17.05.2022.

    

 

                                                                                        (Neelam Kashyap)               

(Neelam)                    (Issam Singh Sagwal)                   President,

Member.                    (Member).                                     DCDRC, Kurukshetra.           
 

 

 

 

Typed by: Sham Kalra, Stenographer.