BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 211 of 2020
Date of Institution : 21.09.2020
Date of Decision : 09.08.2024
Minakshi Setia (aged about 35 years) wife of Sh. Virender Kumar Setia, R/o Street No.10A, Near Jai Shree High School, Aggarsain Colony, Sirsa – 125055.
……Complainant.
Versus.
1. Star Health and Allied Insurance Ltd., Sri Bala Ji Complex, 15, Whites Road Lane Roy Apettah, Chennai- 600014 through its Senior Manager/ Incharge.
2. Star Health and Allied Insurance Ltd., Ground Floor, Rathore Tower, Dabwali Road, Near Hotel Mehak, Opposite Shakti Motors, Sirsa- 125055 through its Branch Manager.
…….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. Rishabh Goyal, Advocate for the complainant.
Sh. Ravinder Goyal, 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 authorized agent accompanying with op no.2 disclosed that they are having their own paneled doctor who will examine the insured person and thereafter their company could issue the insurance policy in favour of complainant. The complainant and her husband after understanding the features of the insurance policy purchased insurance policy No. P/21121/01/2018/000724 in her name and covered the complete family i..e. husband and both daughters being dependent child. The said policy was issued on 27.06.2017 commencing from 27.06.2017 to 26.06.2018 and premium amount of Rs.11,586/- was paid to ops and thereafter ops while acknowledging the payment issued customer identity card bearing No. 7281484-1 to 7281484-4 in favour of all the family members including complainant. It is further averred that due to some family problem, the complainant could not continue/ renew the policy from the ops for further year i.e. 2018-19, however, the authorized officer of the company came to the premises of complainant and informed that their company has launched a policy known as revival contract policy and he explained that as per their policy they will renew the same with the specific endorsement which amounts to continuation of the policy. It is further averred that though complainant was little bit hesitant in regards to the afore mentioned assurance but believing upon the same she had agreed to renew the policy for the coming year i.e. from 31.03.2019 to 30.03.2020 and made payment of Rs.11,889/- to the ops and ops specifically mentioned the word renewal endorsement no. P/21121/01/2019/007248 and said policy was continued with the basic floater sum insured of Rs. three lacs and ops had also given bonus of Rs.75,000/- with limit of coverage as Rs.3,75,000/-. It is further averred that on 06.11.2019 the complainant felt some medical problem and contacted with Dr. Gurdeep Shergill who advised her to go some higher hospital and as such she was admitted in Fortis Hospital, Mohali on 07.11.2019 where she remained admitted up to 16.11.2019 under Dr. Rajiv Kapoor and doctor concerned treated her with the problem of “Left Gluteal Abscess and Cellulitis and Abscess done on 09.11.2019? Psoriasis under Evaluation acute kidney injury”. The complainant approached to Dr. Rajiv Kapoor with the complaint of swelling on face, infected painful wound on upper and lower limbs and also with the complained of fever and vomiting. That this fact was also informed to the treating Doctor that the local doctor found deranged creatinine suggestive of acute kidney injury and presented to FHM for further management. The complainant remained in the hospital and spent approximately amount of Rs.7,12,000/- alongwith some other recurring expenses of Rs.80,000/- and in this manner she spent Rs.7,92,000/- on her entire treatment including all freight charges and it was assured by ops that it was a cashless policy.
3. It is further averred that complainant and her husband telephonically informed to the ops on 07.11.2019 about taking treatment in Fortis Hospital, Mohali and one of their authorized person advised to get the entire treatment from the hospital and their company shall pay entire amount whereas doctors asked to make the payment and they shall return the same to them. The husband of complainant arranged the amount and made payment of Rs.7,12,000/- before discharge of complainant. Thereafter, as per advise of ops all the original medical bills and relevant documents were submitted with the ops on 07.02.2020 for reimbursement of above said amount and ops assured that as per terms of the policy, the entire amount shall be returned to her within short period. It is further averred that complainant was shocked to receive the impugned letter dated 13.05.2020 whereby her claim was repudiated by ops with flimsy, illegal and baseless grounds. The complainant immediately contacted with the op no.2 and inquired about reason of repudiation of her claim and also informed that on an earlier step a query in regard to the claim was made by the company officer which was duly replied by the concerned doctor with satisfactory reasons. The histopathology report dated 20.11.2019 alongwith letter dated 10.02.2020 clearly reflects that treatment of complainant is covered under the policy issued by ops but the ops have issued letter of repudiation beyond terms and conditions of the policy which is wrong and illegal and same has been issued on hyper technical grounds with the sole pre determined intention to repudiate the genuine claim of complainant and have caused deficiency in service, unfair trade practice and unnecessary harassment to the complainant. Hence, this complaint.
4. On notice, ops appeared and filed written statement taking certain preliminary objections. It is submitted that claim of complainant has been repudiated by ops vide letter dated 14.02.2020 in a legal and lawful manner. As a matter of fact and in reality as per documents supplied by complainant, she was hospitalized at Fortis Hospitalm Mohali on 07.11.2019 for treatment of Gluteal abscess with DM, HTN, CKD and discharged on 16.11.2019. Initially insured requested for cashless authorization. On scrutiny of the documents, it is noted that further evaluation required to ascertain the exact onset, hence cashless was denied on 09.11.2019. Subsequently, insured has submitted the documents for reimbursement. On scrutiny of the documents it is noted that insured has renewed the policy after a break of nine months from 27.06.2018 to 31.03.2019. Although present admission of the insured patient is for treatment of gluteal abscess, it is observed from the discharge summary of above hospital that insured patient taking her treatment for psoriasis for past 1½ years which confirms that she is suffering from psoriasis during the break period of insurance. It is further submitted that at the time of renewal of policy, she has not disclosed about health details of the insured person in the declaration letter which amounts to misrepresentation/ non disclosure of material facts and as per condition no.6 of the policy, the company is not liable to make any payment in respect of any claim, hence claim was rejected vide letter dated 14.02.2020. That insured sent reconsideration letter in response to their letter dated 14.02.2020 seeking reconsideration of her claim. Their medical team perused the representation and noted the contents. The team which re-examined the claim records has observed that as per the prescription and documents, the insured patient is having psoriasis where as dermatologist letter states it is dermatitis. Thus, there is discrepancy of material facts. It is further submitted that as per discharge summary, the insured patient is taking ayurvedic drugs in past for Eczema psoriasis for 1½ years which confirms that she is suffering from psoriasis during the break period of insurance. As per the contract of insurance the proposer has to disclose the medical history/ health details of the person proposed for insurance in the Good health declaration during renewal and therefore they were unable to consider representation favourably and hence claim was rejected and conveyed to insured vide letter dated 13.05.2020. It is further submitted that policy is contractual in nature and claims arising therein are subject to terms and conditions forming part of the policy. In this case, complainant accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. The complainant has concealed and suppressed the true and material facts. It is also submitted that in case it is found that ops are liable to pay the claim in terms of the contract of insurance issued to the complainant, the maximum quantum of liability will be as per terms of the policy 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.C29.
6. On the other hand, ops have tendered affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex.R1/A and documents Ex.R1 to Ex.R18.
7. There is no dispute about issuance of health insurance policy for the period 27.06.2017 to 26.06.2018 and then renewal of same by the ops for the period 31.03.2019 to 30.03.2020 in favour of complainant and her family members for basic floater sum insured amount of Rs.3,00,000/- with bonus of Rs.75,000/- i.e. for limit of coverage of Rs.3,75,000/- with recharge benefit of Rs.75,000/- which fact is also evident from policy schedule Ex.C3. The date of inception of the policy is mentioned as 27.06.2017 in Ex.C3. There is also no dispute of the fact that complainant took treatment from Fortis Hospital, Mohali from 07.11.2019 to 16.11.2019 and she was diagnosed with Left Gluteal Abscess and cellulitis, Incision and drainage and debridement of Gluteal Cellulitis and Abscess was done on 09.11.2019 as is evident from discharge summary of that hospital Ex.C9. It is also mentioned in the discharge summary that Psoriasis under evaluation, acute kidney injury. Since the policy was issued for the period 31.03.2019 to 30.03.2020 but the complainant took treatment from 07.11.2019 to 16.11.2019 and there is nothing on file to prove that complainant suffered from said disease prior to the renewal of the policy, therefore, the repudiation of the claim of complainant is wrong and illegal. Although history of Eczema in lower limb since 1.5 year and on ayurvedic drugs 25 days back is mentioned in the discharge summary, but the ops have failed to prove on record that complainant or other insured were specifically asked about any pre existing disease prior to renewal of the policy in question and it is general tendency of the insurance companies that policies are issued without confirming from the proposed insured that whether they are suffering from any prior disease or not and their agents in routine themselves tick marks the questions about pre existing in the proposal forms in negative but after issuances of the policies when any claim is filed to the insurance companies for reimbursement of any claim amount regarding any health issue, then insurance companies takes such flimsy grounds for repudiating genuine claims. In the present case also, the ops have also done so and have rejected the claim of complainant on flimsy and baseless ground. The authority of the Hon’ble Supreme Court of India in case titled as Satwant Kaur Sandhu Versus New India Assurance Company Limited, (2009) 8 Supreme Court Cases 316 relied upon by learned counsel for ops is not applicable to the facts and circumstances of the present case. As such repudiation of the claim of complainant is set aside. Though complainant has sought claim amount of Rs.7,92,000/- spent on her treatment and has placed on file bills/ receipts Ex.C21 to Ex.C29 in this regard, but the ops vide bill assessment sheet Ex.R18 have found that final admissible amount if Rs.4,50,000/-. Since the policy in question was also issued for an amount of Rs.4,50,000/- including limited coverage of Rs.3,75,000/- with recharge benefit of Rs.75,000/-, therefore, complainant is entitled to claim amount of Rs.4,50,000/- from ops and non payment of same clearly amounts to deficiency in service on their part.
8. In view of our above discussion, we allow the present complaint and direct the opposite parties to make payment of claim amount of Rs.4,50,000/- to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 21.09.2020 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops to further pay a sum of Rs.10,000/- as composite compensation for harassment and 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: 09.08.2024. District Consumer Disputes
Redressal Commission, Sirsa.
