BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 504 of 2019
Date of Institution : 28.08.2019
Date of Decision : 06.04.2023.
1. Vinod Kumar, aged 59 years son of Shri Karam Chand, resident of # 221, behind Raghunath Mandir, Ward No.4, Rania, District Sirsa.
2. Vandana, aged 58 years wife of Shri Vinod, resident of #221, behind Raghunath Mandir, Ward No.4, Rania, District Sirsa.
……Complainants.
Versus.
Star Health and Allied Insurance Company Ltd., having its Branch Office Ground Floor, Rathore Tower, Dabwali Road, Near Hotel Mehak, Opposite Shakti Hotel, Sirsa through its Branch Manager.
…….Opposite Party.
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. A.K. Gupta, Advocate for the complainants.
Sh. Mukesh Saini, Advocate for opposite parties.
ORDER
The brief and relevant facts of the present complaint are that complainant purchased two family health optima insurance plan policy from opposite party (hereinafter referred as OP) bearing policy No. P/211121/01/2019/004784 and P/211121/01/2019/004785 with effect from 17.01.2019 to 16.01.2020 whereby the op covered the liability against all medi claim of the complainant and his wife Smt. Vandana under a star super surplus floater insurance policy against a sum of Rs.5,00,000/- i.e. in total sum of Rs.10,00,000/-. It is further averred that on 17.02.2019 complainant no.2 suffered from fever and cough and she was taken to Aadhar Health Institute at Hisar on 18.02.2019. The op was accordingly informed through hospital regarding ailment. The complainant no.2 remained admitted in the said hospital up to 19.02.2019 and thereafter Aadhar Hospital on account of respiratory distress and decreased LV function simply referred the complainant to some Higher Centre and for the time being the Aadhar Hospital gave a differential diagnosis. That on account of the seriousness, complainant was taken to NH Narayana Superspeciality Hospital, Gurugram where she was diagnosed as having suffered from swine-flue i.e. H1N1 which attacks the lungs and causes Pneumonia and was given the treatment for H1N1 disease. All the tests were performed and said hospital declared that the patient/ complainant no.2 was not having any problem of DCMP as there was no test suggestive of features of DCMP. The complainant no.2 was given the treatment for H1N1 and DCMP was totally ruled out as per the findings/ differential diagnoses of Aadhar Hospital. It is further averred that complainant also informed the Star Health op regarding the cashless facility but op refused to provide the cashless facility to the complainant no.2 and accordingly they were required to make the payment of the bills and the medicines. That during her treatment, the team of doctors had also visited NH Narayana Hospital two times for making an enquiry and op vide letter dated 20.02.2019 demanded the records of the treatment and final diagnoses and accordingly complainants sent the findings of NH Narayana Hospital dated 25.2.2019 which was issued by Dr. Swapnil Mehta treating doctor. The complainant no.2 was discharged from said hospital on 2.3.2019 and was prescribed medicines for post hospitalization treatment for H1N1. It is further averred that all the bills and medical record of both the hospitals were handed over to the op and an amount of Rs.4,58,869/- has been spent on the treatment by them. It is further averred that now the op vide letter dated 24.06.2019 has repudiated the claim on the ground that complainants had not declared dialated cardio myopahty i.e. DCMP of Mrs. Vandana and also have held that she was having pre existing DCMP at the time of taking the policy i.e. on 17.01.2019 and which amounted to non disclosure of the material facts. That op has also threatened to cancel the policy on the ground of mis representation and non disclosure of the material facts in the proposal form.
2. It is further averred that now the op vide letter dated 27.07.2019 has cancelled the policy in respect of the insurance of complainant no.2 on above said ground which is totally wrong, against law and facts and insurance company has acted in a most arbitrary manner. That complainant no.2 suffered with H1N1 swine full all of a sudden and it could not have been anticipated and there were no symptoms prior to 17.02.2019. The H1N1 infection is a bacterial attack and as such it cannot be said to be any pre-existing disease which required to be disclosed. The DCMP condition which has been made the basis for repudiating the claim was never suffered by complainant no.2 and even she has not been treated for the same in any of the hospitals. The problem of LV functioning was the result of H1N1 problem and there was no disease of DCMP to the complainant no.2 and even after cure from H1N1 the complainant has never been declared to be a DCMP patient anywhere nor she has any such problem. It is further averred that even the Aadhar Hospital where she remained admitted for overnight on account of the pulmonary problem and fever was never diagnosed as DCMP. The complainants are entitled to receive a sum of Rs.4,58,869/- alongwith interest besides compensation for harassment and mental agony at the hands of op and they are also entitled to litigation expenses. Hence, this complaint.
3. On notice, opposite party appeared and filed written statement raising preliminary objections regarding suppression of material facts, no cause of action and jurisdiction and that complainants have no locus standi to claim any alleged sum assured as the insurance policy was obtained by the insurer by misrepresenting the material acts in order to defraud the op and as such the contract of insurance is void and not tenable in the eyes of law.
- It is further submitted that policies were issued as per the terms and conditions of the insurance policy believing that information provided by the insurer in the proposal form are true and correct. The policy is contractual in nature and 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. It is further submitted that the insured has registered two claims in the 32nd day of the policy vide claim No. CLI/2019/211121/0668862 and CLI/2019/211121/0664391. That the complainant/ insured submitted claim for reimbursement of medical expenses in two claims towards the above mentioned treatment. On scrutiny of both the claim documents, it is observed that
As per the pre auth form submitted vide our claim no. 0664391 that the insured patient had a complaints of shortness of breath since 4 days which falls during the first 30 days from the date of commencement of the policy.
As per the Emergency Medicine initially assessment sheet dated 19/02/2019, the insured has high grade fever, dry cough, breathlessness since last 5 days.
As per the initially assessment sheet and discharge summary of Aadhar Hospital dated 18.02.2019, the insured has fever, cough and Sob since 3-4 days.
Further, the ECHO report dated 18.02.2019 shows dilated LV cavity with LVEF 35% suggestive of chronic long standing disease.
5. It is further submitted that from the above it is observed that the treatment of K/C HTN with B/L PNEUMONITIS with ARDS under 30 days waiting period which is not payable as per clause 3 of waiting period. It is further submitted that as per the ECHO findings, the insured has long standing heart disease, which takes more than a month to develop. Hence, it is existing prior to the inception of the policy and the same was not disclosed. Even it is not related to the present ailment, the material facts should be disclosed at the time of inception of policy. As per condition no.6 of the policy, if there is any misrepresentative/ non disclosure of material facts whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim. Hence, both the claims were rejected as per the terms and conditions of the policy. It is further submitted that insured was diagnosed and treated with H1N1 and has complaints since 4 to 5 days which is evident from the Emergency medicine initially assessment, pre auth form and initially assessment sheet and discharge summary of Aadhar Hospital. Hence, the claim related to the H1N1 is rejected under 30 days waiting period. Further, the insured was additionally diagnosed with DCMP EF 35-40%, which is evident from discharge summary of Aadhar Health Institute. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
6.Complainants in their evidence have tendered their affidavits Ex.CW1/A, Ex.CW2/A and copies of documents Ex.C1 to Ex. C29.
7.On the other hand, op has tendered affidavit of Sh. Rajiv Jain, Chief Manager as Ex.R1 and copies of documents Ex. R1 to Ex.R8.
8.We have heard learned counsel for the parties and have gone through the case file carefully.
9.Learned counsel for complainant has contended that policy in question was obtained by complainants which was effective 17.01.2019 to 16.01.2020 and sum insured was of Rs.5,00,000/ each i.e. for total amount of Rs.10,00,000/-. He has further contended that complainant no.2 Smt. Vandana suffered from fever and cough on 17.02.2019 and was taken to Aadhar Health Institute at Hisar on 18.02.2019 and thereafter she was taken to NH Naryana Super-specialty Hospital at Gurugram and was treated for swine flu i.e. H1N1 and they have spent an amount of Rs.4,58,869/- as op refused to provide cashless facility to complainant no.2 and thereafter vide letter dated 24.06.2019 the ops wrongly and illegally has repudiated the claim of the complainant and prayed for acceptance of the complaint.
- On the other hand, learned counsel for op contended that op has rightly and legally repudiated the claim of complainants on the ground of non disclosure of material facts and prayed for dismissal of the complaint.
11.We have duly considered the rival contentions of the parties. Admittedly complainant no.1 Vinod Kumar purchased Family Health Optima insurance plan from op for himself and for his wife Smt. Vandana complainant no.2 for the sum insured of Rs.5,00,000/- each whereby said Vinod Kumar and his wife Smt. Vandana complainant no.2 were covered under the health policies and the policies in question were effective from 17.01.2019 to 16.01.2020. It is also not in dispute that as complainant no.2 fell ill on 17.02.2019, therefore, Smt. Vandana firstly was taken to Aadhar Hospital at Hisar on 18.02.2019 where she remained admitted up to 19.02.2019 and then she was taken to NH Narayana Super-specialty Hospital at Gurugram and from the medical record available on file, it is proved that after various tests she was diagnosed as having suffered from swine flu i.e. H1N1 and she was discharged from the said hospital on 02.03.2019. The claim submitted by complainants has been repudiated by the opposite party vide letter dated 24.06.2019 Ex.C5 on the ground that insured not declared the details i.e. dilated cardiomyopathy relating to Mrs. Vandana which were found to be pre existing at the time of taking the policy. But however, the perusal of the record reveals that op has wrongly and illegally repudiated the genuine claim of complainants as there is nothing on file to prove that she ever suffered from dilated cardiomyopathy (DCMP). The treating doctor Sh. Swapnil Mehta of NH Naryana Super-specialty Hospital, Gurugram has declared vide certificates Ex.C9, Ex.C10 that Mrs. Vandana was getting treatment for ARDs (H1N1), B/L Pneumonia and she does not have DCMP and that echocardiography performed at Naryana Hospital is not suggestive of features of DCMP and that she has not received/ receiving any treatment for DCMP till date. Further Aadhar Hospital at Hisar vide certificate Ex.C12 has also declared that patient was presented with complain of fever, cough and SOB. So, it is proved on record that op in order to avoid payment of genuine claim of complainants i.e. for the reimbursement of expenses for the treatment of complainant no.2 has wrongly and illegally repudiated the claim of complainants simply on the basis of their own assumption and presumption without any supportive medical/ treatment record or any expert opinion in this regard.The op has also not produced on record any medical record regarding any pre existing disease of the complainant no.2 and has wrongly asserted about pre existing disease of complainant no.2 which is only based on their own presumption. From the medical record placed on file, it is proved on record that complainant no.2 was treated for fever, cough, SOB which she suddenly suffered on 17.02.2019 and thereafter on tests she was found to be suffering from H1N1 i.e. swine flu.
- Learned counsel for op has contended that as per clause 3 (i) of the Waiting periods the claim for any disease suffered by the insured person during the first 30 days from the commencement date of the policy is not payable. But however, this contention of learned counsel for op has also no substance because policy in question was purchased on 17.01.2019 and 30 days period has elapsed on 16.02.2019 whereas complainant no.2 unfortunately suffered from above said disease of fever, cough and breathlessness on 17.02.2019 and therefore, said clause is not applicable to the present case. Therefore, rejection of claim of complainants made by op is without any reasonable cause and there is deficiency in service on the part of op as they have wrongfully withheld the amount of medical expenses incurred by complainants on the treatment of complainant no.2. It is also proved on record from bills and receipts placed on file by complainants that they have spent an amount of Rs.4,58,869/- on the treatment of complainant no.2 and as such they are entitled to said claim amount from op besides compensation for harassment on account of non payment of genuine claim of complainants.
In view of our above discussion, we allow the present complaint and direct the opposite party to pay the claim amount of Rs.4,58,869/- to the complainants within a period of 45 days from the date of receipt of copy of this order, failing which complainants will be entitled to receive the above said amount of Rs.4,58,869/- alongwith interest @6% per annum from the op from the date of this order till actual realization. We also direct the op 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 op is also directed to restore the policy of complainant no.2 which has been cancelled by them on 27.07.2019. 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: 06.04.2023. District Consumer Disputes
Redressal Commission, Sirsa.
JK
