BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 59 of 2020
Date of Institution : 04.02.2020
Date of Decision : 07.04.2023.
Ram Chander Pahwa, aged 62 years, son of Shri Sadhu Ram, resident of 87, A-Block, Near UCO Bank, Sirsa.
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Ltd., through its Branch Manager, Branch at Ground Floor Rathore Tower, Near Hotel Mehak, Dabwali Road, Sirsa, District Sirsa.
2. Star Health & Allied Insurance Company Ltd., through its Branch authorized person/ signatory Regd. & Corporate office at 1, new Tank Street, Valluvarkottam High Road, Nungambakkam, Chennai- 600034.
…….Opposite Parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA ……… MEMBER
Present: Sh. R.D. Bishnoi, Advocate for the complainant.
Sh. Mukesh Saini, Advocate for opposite parties.
ORDER
The brief and relevant facts of the present complaint are that representative and agent of the opposite parties (hereinafter referred as OPs) got purchased health insurance from ops against one time premium of Rs.29,695/-. The agent of the ops visited the house of complainant and got signed some printed forms and also received amount of Rs.29,695/- as a premium for the said policy and also assured the complainant that he will receive the policy within a few days and as such he purchased the health insurance policy. It is further averred that before issuance of the policy, the complainant completed all the required formalities as per conditions of the policy and after that ops issued the policy to the complainant vide policy No. P/211121/01/2019/ 005319, customer code AA0008259559. That in the month of November, 2019 the complainant suffered with pain over left shoulder and chest on 11.11.2019 upon which complainant went to Paras Hospital, Gurgaon for checkup and the doctor of said hospital advised him for diagnosis i.e. ACS CAG, PTCA Stent to RCA, EF 50% and after getting the report as per the recommendation of the doctor, the complainant was got admitted in the hospital where the stent to RCA done. It is further averred that complainant remained admitted in the hospital w.e.f. 12.11.2019 to 14.11.2019 and on amount of Rs.2,30,695/- was spent on his treatment. That complainant during the treatment lodged the claim with the ops’ company and also completed all the formalities required by the ops and further deposited all the documents i.e. bills, authorization letters etc. and the claim of complainant was lodged vide claim no. CLI/2020/211121/ 0638863 and complainant requested the ops to sanction the claim and to pay the bills of the hospital and treatment but ops’ company always lingered on the matter with one pretext or the other and did not pay the bills to the complainant. It is further averred that now finally without giving any sufficient reason ops have repudiated the claim of complainant vide repudiation letter dated 14.12.2019 which was received to him a week back and as a result of which inspite of purchasing the health policy under the assurance made by the ops, the complainant himself had spend the huge amount on the treatment from his own pocket and could not get the benefits of the policy. That the reason for repudiation of claim of complainant by the ops is not sufficient and they have wrongly withheld the claim of complainant and have caused unnecessary harassment and mental agony to the complainant. Hence, this complaint seeking claim amount of Rs.2,30,695/- alongwith compensation and litigation expenses.
2. On notice, opposite party appeared and filed written statement raising preliminary objections that complaint is false, frivolous and there was/is no deficiency in service on the part of ops. That true facts of the case are that insured availed family health optima insurance plan covering himself, Mrs. Sunita Rani spouse for the sum insured of Rs.5,00,000/- for the period 13.02.2019 to 12.02.2020. This policy was issued as per the terms and conditions of the insurance policy believing that the information provided by the insurer in his proposal form are true and correct. It is further 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. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and same was served to the complainant alongwith the policy schedule. Moreover, it is cleared stated in the policy schedule that the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. That claim is reported in the 9th month of the policy. As per the submitted documents insured patient was admitted on 12.11.2019 at Paras Hospital Gurgaon for treatment ACS, CAD- TVD and discharged on 14.11.2019 and claim amount is Rs.2,30,695/- as per claim form. The insured sought for the pre authorization request for cashless treatment and same was denied vide letter dated 12.11.2019 stating that the insured patient was diagnosed with CAG- PTCA. It is further submitted that it is observed that the insured patient has been diagnosed with multiple vessel disease, which is a longstanding ailment. The answering op is not able to ascertain the duration of the disease based on the documents/ details submitted by complainant. It requires further evaluation and advised the insured for reimbursement. Subsequently, the insured submitted claim documents for reimbursement of the medical expenses of Rs.2,30,695/-. On scrutiny of the documents, it is observed that the Coronary Angiogram report dated 12.11.2019 shows multiple vessel coronary artery disease with significant stenosis. Based on the CAG findings, it is noted that the insured patient has chronic, longstanding heart disease, which takes more than a year to develop, existing prior to inception of the first medical insurance policy. Hence, the heart disease is a pre existing disease. It is further submitted that present admission and treatment of the insured patient is for the pre existing heart disease. As per Waiting Period 3 (iii) of the policy, the company is not liable to make any payment in respect of expenses for treatment of pre-existing disease/ condition, until 48 months of continuous coverage has elapsed, since inception of the policy with the company on 13.02.2019. Hence, the claim was repudiated and same was communicated to the insured vide letter on 14.12.2019. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
3. Complainant in evidence has tendered affidavit Ex.CW1/A and copies of documents Ex. C1 to Ex.C4.
4. On the other hand, ops have tendered affidavit of Sh. Rajiv Jain Chief Manager as Ex. R1 and copies of documents Ex. R2 to Ex. R11.
5. We have heard learned counsel for the parties and have gone through the case file carefully.
6. Admittedly the complainant purchased health insurance policy i.e. Family Health Optima Insurance Plan from the opposite parties for the sum insured amount of Rs.5,00,000/- and complainant Ram Chander and his wife Smt. Sunita Rani were covered under the said health insurance policy. The complainant paid premium amount of Rs.29,695/- for the purchase of the policy in question and the policy was effective from 13.02.2019 to 12.02.2020. It is also proved on record that in the month of November, 2019 i.e. on 11.11.2019 after about nine months of purchase of the policy in question, the complainant suffered with pain over left shoulder and chest. The complainant went to Paras Hospital Gurgaon for checkup and doctor of said hospital advised him for diagnoses i.e. ACS CAG, PTCA stent to RCA as is evident from discharge summary of the said hospital Ex.C3. From the said discharge summary Ex.C3 it is also proved on record that complainant made complaint about pain over left shoulder and chest since 1 day associated sweating. The complainant remained admitted in the said hospital from 12.11.2019 to 14.11.2019 and stent to RCA was done as is evident from the medical record of the complainant. Accordingly claim for reimbursement of the amount of Rs.2,30695/- was submitted by the complainant to the ops but same has been repudiated by the ops vide letter dated 14.12.2019 on the ground that CAG report dated 12.11.2019 shows multiple vessel coronary artery disease with significant stenosis and based on the CAG findings, their medical team is of the opinion that the insured patient has chronic, longstanding heart disease existing prior to inception of the first medical insurance policy, hence heart disease is a pre existing disease. It has been further mentioned in the said repudiation letter that the present admission and treatment of the insured patient is for the pre existing heart disease and as per waiting period 3(iii) of the policy, the company is not liable to make any payment in respect of expenses for treatment of the pre existing disease/ condition, until 48 months of continuous coverage has elapsed, since inception of the policy with the company on 13.02.2019. However, the ops in order to justify the repudiation of the claim of the complainant have not proved on record that complainant was having pre existing heart disease. They have not placed on file any opinion of their medical team as alleged in their repudiation letter. The ops have simply placed on file the medical record of Paras Hospital, Gurgaon which has also been placed on file by the complainant and has not placed on file any other medical record regarding any previous treatment of the complainant for the heart disease. The ops have only made the basis of the said treatment record/ test reports of said hospital for repudiating the claim of the complainant but however, there is no any history of the complainant regarding said disease suffered by complainant in the past. Rather it is mentioned in the discharge summary (Ex.C3 and Ex.R8) that patient complained of pain over left shoulder and chest since one day with sweating. The ops have not proved on record through any other cogent and convincing evidence that complainant was having any pre existing heart disease. So, it is proved on record that ops in order to avoid payment of genuine claim of complainant i.e. for the reimbursement of expenses for the treatment of complainant has wrongly and illegally repudiated the claim of complainant simply on the basis of their own assumption and presumption without any supportive medical/ treatment record or any expert opinion in this regard. It is proved on record that complainant suddenly suffered heart disease in the month of November, 2019 i.e. after nine months of purchase of policy in question and it cannot be said at all that said disease of complainant was a pre existing disease and therefore, ops have wrongly and illegally repudiated the claim of complainant. The complainant has spent an amount of Rs.2,30,695/- on his treatment and has paid the said amount to Paras Hospital Gurgaon as is evident from patient bill (summary ) Ex.C2 and therefore, he is entitled to reimbursement of said amount of Rs.2,30,695/- from the ops.
7. In view of our above discussion, we allow the present complaint and direct the opposite parties to pay the claim amount of Rs.2,30,695/- to the complainant within a period of 45 days from the date of receipt of copy of this order, failing which complainant will be entitled to receive the above said amount of Rs.2,30,695/- alongwith interest @6% per annum from the ops from the date of this order till actual realization. We also direct the ops to further pay a sum of Rs.5000/- as composite compensation for harassment and litigation expenses to the complainant within above said stipulated period. The ops are also directed to renew the policy in question of the complainant as prayed for. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member Member President,
Dated: 07.04.2023. District Consumer Disputes
Redressal Commission, Sirsa.
JK
