BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 311 of 2020
Date of Institution : 02.12.2020
Date of Decision : 08.06.2023
Madhu Bala wife of late Shri Surinder Kumar son of Shri Jot Ram Gupta, resident of Khoo Wala Bazar, Mandi Kalanwali, Ward No. 7, District 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 and 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 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA……….MEMBER
Present: Sh. D.S. Bhangu, Advocate for the complainant.
Sh. Ravinder Monga, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that representative of op allured the husband of complainant to purchase health insurance policy on the assurance of providing various benefits including reimbursement for treatment. Accordingly, husband of complainant purchased policy of op vide policy no. P/211121/01/2019/ 002094 dated 04.09.2018. The representative of op got signatures on some printed forms and also received amount of Rs.15,287/- as premium for the said policy and also assured the husband of complainant that he will receive policy within a few days. That before issuance of policy, the husband of complainant underwent many tests as per policy of op and only thereafter policy was issued. It is further averred that in the month of January, 2019, her husband suffered from Generalized weakness with the diagnosis of DCMP with severe LV Dysfunction with DM-2 with ARF, upon which he was taken to Shah Satnam Singh Ji Specialty Hospital, Sirsa for checkup and his tests were got conducted there and was admitted in the hospital on 24.01.2019 and remained under treatment till 22.02.2019. That as there was no improvement in the health of Surinder Kumar, so he took treatment from Adesh Institue of Medical Science & Research Centre, Bathinda (Punjab) for long period and also remained admitted there from 20.05.2019 to 30.05.2019 but to no effect rather his condition deteriorated day by day and he could not be survived and died on 31.05.2019.
3. It is further averred that at the time of admission in the hospital, complainant handed over policy of the op to the hospital staff and as per terms and conditions of insurance company/ op also filled TPA Form and sent the same to the op. The complainant during treatment lodged claims with op both times and also completed all the formalities required by op and deposited all the documents i.e. bills, authorization letters etc. and claim was lodged with op vide claims No. CLI/2019/211121/0664137 and CLI/2020/211121/0616263 but op has failed to sanction the claim and to reimburse the bills of hospital and treatment despite her several requests. The complainant herself had spent huge amount on the treatment of her husband from own pocket and also could not get benefits of the policy. That act and conduct on the part of op amounts to mal-trade practice, deficiency in service due to which complainant has suffered unnecessary harassment and mental agony. The complainant also got served a legal notice upon op on 8.10.2020 but to no effect. Hence, this complaint
4. On notice, op appeared and filed written version raising certain preliminary objections. It is submitted that policy in question was issued for the period 04.09.2018 to 03.09.2020 covering the risk of Rs. five lacs for Surender Kumar, his wife Madhu Bala, Pankaj Gupta and Kunal Gupta sons being dependent subject to conditions, clauses, warranty and exclusion clauses etc. and terms and conditions of the same were explained to the insured Surender Kumar. The policy is contractual in nature and the claim arising therein is subject to terms and conditions forming part of the policy. It is further submitted that after carefully analyzing the documents, it is found that complainant has failed to submit/ furnish the required documents to proceed the claim. The answering op in this regard sent letters dated 01.11.2019, 16.11.2019 and 01.12.2019 with the request to furnish the documents as under:-
(a) As per prescription paper dated 07.02.2021 patient has history of Acitrom Toxicity record, kindly provide letter from treating doctor stating the exact indication for Acitrom; since when patient is taking Acitrom;
(b) Any history of DVT and history of previous hospitalization, if any
(c) All previous consultation papers advising Tracitrom
(d) Doppler report if done
(e) Complete set of indoor case paper of current admission from 24.01.2019 to 31.01.2019
(f) Submit exact duration of DM and HTM.
It is further submitted that even despite reminders, the patient could not submit the required documents and it is found that the insured was not interested for claim which amounts to sheer violation to the terms and conditions of the policy. So, the claim was rejected vide letter dated 15.12.2019 on the basis of condition clause no.3 and complaint is liable to be dismissed. It is further submitted that thereafter the insured was again hospitalized from 02.05.2019 to 30.05.2019 at Adesh Hospital, Bathinda for treatment of Diabetes, Mellitus, dilated cardio myopathy, acute LVF, cardiogenic shock, acute kidney injury, severe LV diafunctional LVEF 18%. Further on the basis of documents, it was observed that the Echo report dated 25.01.2019 shows chronic long standing diabetes cardio myopathy. Based on this finding medical team of the company observed that the insured patient has dilated cardio myopathy prior to inception of the insurance policy. Hence, the said disease was a pre existing disease. It is further submitted that entire treatment of the insured patient is for pre existing disease. Hence, as per the waiting period i.e. clause 3 (iii) of the policy issued to the insured, the company is not liable to make any payment in respect of expenses for treatment of pre-existing disease/ condition until 48 months of continuation coverage has elapsed prior to the date of commencement of first year policy on 04.09.2018. It is further submitted that upon failure of complainant to submit documents, the claim has been rejected and duly conveyed vide letter dated 16.12.2019. Both the claims have rightly been repudiated and rejected in view of the terms and conditions of the policy. That policy was issued to the insured without any pre medical screening only based on the disclosure in the proposal. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
5. The complainant in evidence has tendered her affidavit Ex. CW1/A and documents Ex.C1 to Ex.C80.
6. On the other hand, op has tendered affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex. RW1/A and documents Ex. R1 to Ex.R23.
7. We have heard learned counsel for the parties and have gone through the case file carefully.
8. It is proved on record that husband of complainant namely Surinder Kumar purchased health insurance policy from the ops for the period 01.09.2018 to 03.09.2019 for the sum insured amount of Rs.5,00,000/- and paid premium amount of Rs.15287/- to the ops and Surinder Kumar alongwith spouse Madhu Bala complainant and their dependent sons Pankaj Gupta and Kunal Gupta were insured under the policy and said facts are proved from policy schedule Ex.C1. It is also proved fact and not disputed that said Surinder Kumar insured was admitted in Shah Satnam Singh Ji Specialty Hospital on 24.01.2019 as he suffered with generalized weakness with the diagnosis of DCMP with severe LV dysfunction with DM-2 and got treatment from the said hospital up to 22.02.2019 and further he took treatment from Adesh Insitute of Medical Science & Research Centre Bathinda from 20.05.20.19 to 30.05.2019 but he could not survive and ultimately died on 31.05.2019. The claims submitted by complainant has been repudiated by the ops vide letter dated 14.12.2019 (Ex.R13) on the ground of pre-existing disease. It is mentioned in the said letter dated 14.12.2019 that ECHO reports dated 25.01.2019 shows chronic long standing dilated cardio-myopathy and based on this finding their medical team is of the opinion that the insured patient has dilated cardiomyopathy prior to inception of medical insurance policy. But however, the ops have not placed on file any echo report in this regard. The ops have also failed to prove on record that above said disease of insured Surinder kumar was a pre-existing disease. The ops have not placed on file even affidavit of the doctor who opined that it was a pre-existing disease and ops have also not proved on record that how it was concluded that insured patient had pre-existing disease and that it was chronic long standing dilated cardiomyopathy. The ops have not placed on file any treatment record of the insured Surinder Kumar prior to 24.01.2019 and have also failed to prove on record that Surinder Kumar took any treatment for the above said disease prior to the purchasing of the policy in question. The ops have also failed to prove on record that even treating doctors of the insured ever opined that insured was suffering from long standing disease. Further, the ops have also failed to prove on record that the disease suffered by deceased Surinder Kumar cannot occur with immediate effect i.e. after purchase of policy in question and in the absence of any previous treatment record of the insured, we are of the view that Surinder kumar suffered with the above said diseases only in the month of January, 2019 i.e. after purchase of policy in question. So, we are of the considered view that ops have wrongly and illegally repudiated the claims of complainant only on their imaginary grounds and on their own assumption and presumption that it was a chronic long standing disease which fact is not proved through any cogent and convincing evidence. Moreover, the complainant has specifically asserted that before issuance of the policy in question her husband Surinder Kumar was got medically examined by the ops. Though ops have denied the said fact and asserted that policy was issued to the insured without any pre medical screening and even if for the sake of arguments the plea of ops in this regard is believed, then also it is not understandable that who stopped the ops from getting the insured medically examined at the time of insurance policy in question. There was no bar to the ops for prior medical examination of the insured Surinder Kumar and now they cannot take shelter of this fact that policy was issued to the insured without any pre medical screening only based on the disclosure in the proposal form. Further, the ops are not justified while making demand of above said documents from the complainant because the required documents alongwith bills were already supplied to the ops in which names of hospitals were very much clear and the ops could ask the hospitals to provide any record from the hospitals itself and could take any opinion regarding any medicine but cannot not harass the complainant by demanding above said documents being a lady who has lost her husband and was under mental trauma due to unfortunate and untimely death of her husband. As such the repudiation of the claims of complainant is hereby set aside.
9. In view of our above discussion, we allow the present complaint and direct the opposite parties to reimburse the amounts of Rs.84,400/- and Rs.37,300/- (already claimed by complainant in the claim forms as per bill assessment sheet Ex.R14 and claim form Ex.R15 submitted to the ops alongwith bills the copies of which are also placed on file) spent by her on the treatment of her husband i.e. total amount of Rs.1,21,700/- alongwith interest @6% per annum from the date of filing of present complaint i.e. 02.12.2020 till actual realization to the complainant within a period of 45 days from the date of receipt of copy of this order. We further direct the ops to further pay a sum of Rs.10,000/- as compensation for harassment and Rs.5000/- as litigation expenses to the complainant within above said stipulated period. 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: 08.06.2023. District Consumer Disputes
Redressal Commission, Sirsa.
JK
