Naveen Puri, President;

1        The complainant has filed the present complaint under Section 12 & 13 of the Consumer Protection Act (herein after called as 'the Act') against Star Health & Alied Insurance Company Ltd. and others (Opposite parties) on the allegations of deficiency in service and negligence in service on the part of the opposite parties with further prayer to direct the opposite parties No. 1, 2 to reimburse the amount of Rs. One Lac to the complainant being expenses borne by the complainant from her own pocket besides this the complainant requests for damages and compensation of Rs. 50,000/- and Rs. 20,000/- as costs of litigation alongwith interest.

2        The case of the complainant in brief is that complainant had availed medical health insurance of the opposite party No.1 having policy No. P/211111/01/2017/003950 by paying premium to the opposite parties amounting to Rs. 11,880/- in cash through opposite party No.3 being agent of opposite parties No.1 & 2 at Jhabal Tehsil & District Tarn Taran, vide receipt No.11-01/1213004617 dated 27.09.2016 and the insurance policy is valid from 27.09.2016 to 26.09.2017 for himself and his family members including his wife Seema Arora. The medical and health insurance cover of Rs.5 Lacs was to be provided by the opposite party No.1 to the complainant and his family members. In the month of January 2017, the wife of the complainant namely Seema Arora fell on the ground and received injuries on her back bone i.e. spinal code and as such had to consult the doctor and was referred to Ajit Hospital, Green Avenue, Amritsar which deals in Neuro related problems and was referred for Surgery by doctor Ranjit Singh Randhawa. The doctor Ranjit Singh Randhawa was told by wife of the complainant that she has a health Insurance Policy with the opposite parties No.1 & 2, so the opposite parties No.1 & 2 were called for approval by the doctor and the approval was given by the opposite party representatives on the same day and surgery was conducted by the doctor and representatives and insurance was also given by the opposite party representatives that the expenses of Surgery alongwith other expenses will be borne by the opposite party, as the wife of the complainant is medically insured with it.
The doctor operated the wife of the complainant and the wife of the complainant remained admitted in the hospital but in-spite of the assurance by the opposite party representatives she had to pay all the expenses of surgery from her own pocket in-spite of being medically insured by the opposite party. The complainant after getting her wife discharged from the hospital approached the opposite parties No.1 & 2 and asked for reimbursement of expenses borne by her amounting to Rs.1 Lakh in-spite of being medically insured and the representatives of the opposite party assured that same will be reimbursed in a couple of days but in-spite of repeated visits by the complainant with the opposite party, the opposite party did not reimburse the amount of Rs. One lakh to the complainant.  The opposite parties No.1 & 2 are guilty of inefficiency, negligence, un-fair trade practice by not reimbursing the amount of Rs. 1 Lakh to the complainant being the expenses borne by the complainant from her own pocket inspite of being policy holder and insured with the opposite party. Hence complaint was filed.

3        After formal admission of the complaint, notice was issued to Opposite Parties. Opposite Parties appeared through counsel and filed written version contesting the complaint on the preliminary objections that complaint of the complainant is not legally maintainable. The complainant has not come to the Forum with clean hands and suppressed the true and material facts from this Forum, as such, he is not entitled to any relief as claimed for. The complainant is estopped by his own act and conduct from filing the present complaint. The complainant has got no cause of action to file the present complaint. In case any act done against terms and conditions of policy and due to contravention of terms and conditions of the policy, the opposite party is not liable for any claim. The complainant obtained family health Optima Insurance Plan vide policy No. P/211111/01/2017/003950 for the period from 27.9.2016 to 26.9.2017 covering complainant Gurdev Singh himself, his spouse Smt. Seema and dependent children Gurkirpal Singh and Gurpreet Singh for the sum insured for Rs. 5,00,000/-. Preamble of the policy clearly states the Proposal, Declaration and other documents, if any given by the proposer from the basis of the policy of insurance “subject to terms, conditions, exclusions and definitions contained herein or endorsed or otherwise expressed hereon, the company undertakes if the insured person shall contract any disease or suffer from any illness or sustain any bodily injury through accident and if such disease or injury shall require the insured person, upon the advise of the duty qualified physician/ medical specialist/ medical specialist/ medical practitioner or duty qualified surgeon to incur hospitalization expenses for medical/ surgical treatment at any nursing home/ Hospital in India as herein defined as an inpatient the company will pay to the insured person the amount of such expenses as are reasonably and necessarily incurred in respect by or on behalf of the insured person up to the limits indicated; That the company’s liability in respect of all claims admitted during the period of insurance shall not exceed the sum insured per family mentioned in the schedule. The terms and conditions of the Policy were explained to the complainant at the time of proposing policy and the same was served to the complainant alongwith the policy schedule. The company’s liability in respect of all claims admitted during the period of insurance shall not exceed the sum insured per family mentioned in the schedule. Terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant alongwith the policy schedule. The claim was lodged by the complainant in third month of the policy it was alleged that wife of the complainant Smt. Seema was admitted in Ajit Hospital Amritsar on 13.1.2017 for treatment of L4-L5 Extruded Disc and submitted records for reimbursement of medical expenses for Rs. 74,000/- vide claim No. CL12017/211111/0380082. On scrutiny of the claim records, it was observed that as per discharge summery, the insured patient was admitted on 13.1.2017 and discharged on 18.10.2017. She fell down one day back pain in LB since then with difficulty in standing/ working, pain and numbness in left foot since then. Diagnosis L4-L5 extruded disc. Surgery left sided interlaminar micro surgical L4-L5 discectomy under G.A. The MRI report dated 13.1.2017 states that DEGENERATIVE CHANGES IN THE LUMBAR SPINE. The Histopathology report shows the appearances are consistent with intervertebral disc. From the above findings, it is observed that the MRI dated 13.1.2017 shows degenerative changes in the lumbar spine and there is no evidence of trauma/ injury spine which confirms chronic, degenerative disc disease existing prior to inception of the medical insurance policy and it is a preexisting disease. The present admission and treatment of the insured patient is for the pre-existing disc disease. As per exclusion clause No. 1 of the policy issued to the complainant, the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease until 48 months of continuous coverage has elapsed, since inception of the policy i.e. from 27.9.2016. Hence the claim was repudiated and the same was communicated to the complainant vide letter dated 14.2.2017. In response to the repudiation letter, the complainant sent letter dated nil alongwith medical certificate dated 8.3.2017 from Dr. A.S. Randhawa, the claim of the complainant was again reviewed and in this regard letter dated 17.4.2017 was served to the complainant stating therein that the MRI an HPE report dated 13.1.2017 clearly shows degenerative changes in the lumbar spine and there is no evidence of trauma/ injury spine. These findings confirm chronic degenerative disc disease, existing prior to the inception of the medical insurance policy and it is a preexisting disease. The clarification dated 8.3.2017 given by Dr. A.S. Randhawa that there is no preexisting disease is not acceptable. As per contract of insurance, the medical history/ health details of the person proposed for insurance, are to be disclosed in the proposal form at the time of inception of the policy and since the complainant had not disclosed the above preexisting disease in the proposal form at the time of inception of the policy, it is now incorporated in the policy as preexisting disease/ condition. As such, in view of above, the claim of the complainant is not payable and the same is rightly repudiated and intimation regarding this was given to the complainant as detailed above. On merits, it is pleaded that the complaint of the complainant is false, frivolous and is not legally maintainable and the complainant is not entitled to any relief on the basis of it. The policy issued to the complainant under which the dispute has been raised is governed by limits of liability as per various clauses. Without any prejudice to whatever has been stated earlier in this written version, even admitting without conceding that the company is liable to pay the claim in terms of the contract of insurance issued to the claimant-petitioner and is respectfully submitted that the maximum quantum of liability under the terms of the policy shall be Rs. 94,130/-. The opposite parties denied all the other allegations and prayer was made for dismissal of the complaint with costs. 

4        Sufficient opportunities were granted to the parties to lead evidence in order to prove their respective case. Ld. counsel for the complainant tendered in to evidence affidavit of complainant Ex. C-1, alongwith documents Ex. C-2 to Ex. C-23, mark A and closed the evidence and thereafter, Ld. counsel for the opposite parties tendered in evidence affidavit of Sh. N.Gopalan, Chief Manager Ex. OP 1, 2, 3/1 alongwith copies documents Ex. OP 1, 2, 3/2 to Ex. OP 1,2,3/15 and closed the evidence.  

5        We have carefully examined all the documents/evidence produced on record and have also judiciously considered and perused the arguments duly put forth by the learned counsels for both the parties along with the incidental scope of adverse inference for of some of the evidentiary documents that have been somehow ignored to be produced by the contesting litigants; of course, in the very back-drop of arguments as put forth by the learned counsel(s) for the attending litigants. We observe that the prime dispute (affidavit Ex.C1) prompting the herein deposed complaint pertained to the impugned repudiation (Ex.OP1,2,3/11&12) of the complainant filed hospital-treatment medical insurance claim (Ex.OP1,2,3/8&9) seeking reimbursement of incurred hospital-expenses (Ex.C3 to C20) of Rs 100,000/- approximately by the OP insurers allegedly on account of spinal-surgery conducted on account of ‘degenerative changes’ in the lumbar spine etc that are not covered under the 1^st Year Chronicity of the related policy whereas the complainant has pleaded non-intimation of any such terms of the policy along with absence of any OP produced documentary evidence of its agreed-upon exclusion and/or dispatch to/ receipt by the complainant of the policy’s terms/ conditions pertaining to the related policy.

6        The OP insurers have simply produced its rebuttal affidavit (Ex.OP1,2,3/1) along with the copies of other evidentiary documents (Ex.OP1,2,3/2 to Ex.OP1,2,3/15) trying to prove that the medical treatment was necessitated on account of occurrences of ‘degenerative changes’ in the lumbar spine area of the insured patient and not because of any external accident injury as a result of accidental fall upon the stair-case. Somehow, we are not convinced with the pleadings of the OP insurers. It shall be pertinent here to mention that the insured individual (operated-upon patient) was not having any trouble with her lumbar spine etc as affected by the so-called ‘degenerative changes’ till she got injured in an accidental stair-fall and had to undergo the medically advised treatment/ spinal surgery etc. The insured individual was not even aware of her extruded discs etc on account of degenerative changes before the accidental-fall and thus its medical treatment need be essentially covered under the related health policy. As such, the delay caused in settlement of an otherwise valid medical-claim and its subsequent repudiation amounts to adoption of unfair trade practices coupled with deficiency in service on the part of the OP insurers and that rakes them up to an adverse statutory award under the applicable Consumer Protection Act, 1986.

7        Finally, we find here in the present case the complainant had received the medical-treatment at the insurers’ network hospital who had also applied for pre-treatment sanction (with the insurers) that was however refused for un-fairly explained reasons. And, the treating hospital thus charged Rs 100,000/- approximately @ higher individual-patient rates whereas the insurers reimburse complainant-claim @ network moderate rates could be for a less amount and presently any such difference in rates shall have to be necessarily borne by the OP insurers, themselves.

8        We get firm support to the above proposition/ finding in the light of the judgment of the honorable State Consumer Commission, Punjab; in FA # 1100 of 2010 titled Fortis Hospital, Mohali vs. Medsave Healthcare (TPA) Ltd. & Ors; wherein, paragraph ‘22’ reads as: “After producing the ID Card, respondent no. 6 was to get cashless treatment but that was not provided for the reasons known to the appellant hospital or the insurance company (appellant in other appeal). The appellant Hospital has given the treatment and obtained the expenses for the treatment and the insurance company was liable to reimburse the same, but the District Forum held the appellant hospital liable to pay the expenses, compensation and costs jointly and severally and the said order is required to be modified”.      

9        Further, we find that the impugned insurance claim has been duly filed by the complainant with the OP insurers (competent authority) who have somehow repudiated the same for arbitrarily inadvertent logic after having first refused pre-treatment sanction to treating hospital and have neither produced on record their expert opinion of their TPA (Third Party Administrator) who have been somehow ignored during these proceedings nor the impugned claim-settlement has been supported by some other cogent evidence etc. We also find that the terms and conditions of the related policy have been duly exhibited here but it does not stand proved on record that these ‘claim settlement terms’ stood communicated to the insured complainant and in the absence of the same these cannot be enforced upon him at the stage of settlement of reimbursement of claim(s).

10      In the light of the all above, we partly allow the present complaint and thus ORDER the titled opposite party (1 & 2) insurers to pay/ refund the full hospital expenses/ medical charges (as incurred and as settled under the related policy) to the complainant besides to pay him a sum of Rs 10,000/- as cost and compensation (for having suffered undue harassment) within 30 days of the receipt of the copy of these orders otherwise the awarded amount shall attract interest @ 9% PA form date of orders till actual payment.  

11      Copy of the order be communicated to the parties free of cost. After compliance, file be consigned to records.