Punjab

Ludhiana

CC/21/447

Puneet Bassi - Complainant(s)

Versus

Star Health and Allied Ins.Co.Ltd. - Opp.Party(s)

Yadwinder Singh

03 Apr 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:  447 dated 29.09.2021.                                                       Date of decision: 03.04.2024. 

Puneet  Bassi S/o. Late Sh. Ramesh Kumar, R/o. House No.412/4, Street No.2, Ward No.2, Near Ragunath Mandir, Panchseel Colony, Noorwala Road, Ludhiana.                                                                                                                                                                                            ..…Complainant

                                                Versus

1. Star Health and Allied Insurance Company Limited, Regd. & Corporate Office 1, New Tank Street, Valluvarkottam High Road, Nungambakkam, Chennai-60034, its Chairman/Managing Director/Director/Manager/ Authorized Person.
2. Star Health and Allied Insurance Company Limited, Area Office – Ludhiana No.3389, 4^th Floor, Sandhu Tower-II, Ferozepur Road, LLudhiana-141001 through Director/Manager/Authorized Person.

…..Opposite parties. 

Complaint Under Section 35 of the Consumer Protection Act, 2019.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Rupinder Singh, Advocate.

For OPs                          :         Sh. Rajeev Abhi, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

 

1.                Shorn of unnecessary details, the facts of the case are that on the allurement of representative of the OPs, the complainant purchased Floater Sum Insured Policy No.P/211200/01/2021/011474 for himself, Pooja Rani (wife), Khushi and Garima Bassi for a sum assured of Rs.3,00,000/- w.e.f. 10.02.2021 to 09.02.2022 on premium of Rs.10,767/-. The complainant stated that baby Garima Bassi was born on 27.01.2020 and she was one year old at the time of taking the policy. She was hale and hearty and not suffering from any type of disease. Even before purchasing the policy, the complainant disclosed the fact that at the time of her birth, baby Garima Bassi suffered from Respiratory Distress. She was treated in SPS Hospital, Ludhiana and discharged on 02.02.2020 in stable condition. Copy of discharge summary was provided to the representative of the OPs.

                   The complainant further stated that on 22.03.2021 Garima Bassi suffered from fever, vomiting and loose stool for which she was examined from SPS Hospital, Ludhiana in OPD by Dr. Pardeep Kumar Sharma by paying OPD charges of Rs.600/-. The complainant also paid Rs.1590/- for medical tests and medicine etc. On 01.04.2021, Garim Bassi was again got checked from Dr. Pardeep Kumar Sharma due to fever for 2 days, loose motion etc. by paying Rs.600/- and also paid Rs.286/- for medicines. On 02.04.2021, on the advice of Dr. Pardeep Kumar Sharma, Garima Bassi was admitted in SPS Hospital and she was discharged on 06.04.2021. At the time of her discharge, the complainant handed over cashless policy card to hospital authority but the Ops rejected the cashless claim and as such, the complainant had to pay Rs.53,152/- to SPS Hospital, Ludhiana from his own pocket. Garima Bassi was diagnosed for Acute Gastroenteritis with severe dehydration as per discharge summary. The complainant paid Rs.117/- on 06.04.2021 for medicines, Rs.500/- to Dr. Mehak Bansal for initial checkup after discharge, Rs.889/- for medicine on 12.04.2021, Rs.330/- to SPS Hospital for providing all documents on 13.04.2021 for lodging claim with the OPs. After discharge of Garima Bassi, the complainant lodged claim with OPs but they repudiated the claim vide letter dated 05.04.2021 on the ground that “We observe that you have not declared the details ‘respiratory distress (relating to Garima Bassi)  which were found to be pre-existing at the time of taking the policy for the first time during 10.02.2021 to 09.02.2022. This amounts to non-disclosure of material facts. And further mentioned that ‘you are hereby informed that as per the above clause, we intend to cancel the coverage for above mentioned person with effect from 15.05.2021.” The complainant further stated that the pre-existing disease are the disease which are continuing one and the patient is getting treatment of that disease continuously whereas Baby Garima Bassi was not suffering from any pre-existing disease as she was discharged in stable condition on 02.02.2020. Further the ailment of respiratory distress of Garima Bassi was settled and the doctors of SPS Hospital mentioned in discharge summary dated 02.02.2020 that Baby was weaned to HFNC on 30.01.2020. Distress settled. Feeds increased. Currently baby is maintaining on room air, haemodynamically stable, accepting spoon feed. So being discharge in stable condition. Further it was mentioned that respiratory distress nor heritages nor continuing one. Moreover, at the time of admission in SPS Hospital on 02.04.2021, Garima Bassi was not having any pre-existing disease as she was admitted due to Acute Gastroenteritis with severe dehydration. Even Dr. Pardeep Sharma has given certificate to the effect that “B/O Pooja (Garima Bassi) SPS ID 757925 was born at term gestation with birth weight 2.7 and required mechanical ventilation for meconium aspiration syndrome. The baby did not have any congenital malformation and was discharged in a stable condition.” Even Dr. Mehak Bansal issued certificate by certifying that “This is to certify that Garima 1 year 2 month female is admitted Acute Gastroenteritis with severe dehydration in SPS Hospital, Ludhiana on 02.04.2021. Child had meconium aspiration syndrome term AGA in new borne period and is not related to the current illness.” The complainant further stated that Garima was admitted in hospital for Acute Gastroenteritis with severe dehydration which is not a genetic disease. The OPs have repudiated the claim on flimsy ground which amounts to deficiency in service due to which the complainant suffered mental pain, agony etc. In the end, the complainant has prayed for issuing directions to the OPs to pay Rs.58,064/- along with interest and to pay compensation of Rs.1,00,000/- and litigation expenses of Rs.22,000/-.

2.                Upon notice, the OPs appeared and filed joint written statement and assailed the complaint by taking preliminary objections on the ground of maintainability; suppression of material facts; lack of cause of action; the complaint being estopped by her own act and conduct from filing the present complaint etc. The OPs stated that immediately on the receipt of the claim, it was duly registered, entertained and processed. The complainant had obtained Family Health Optima Insurance Plan for himself, his wife Pooja Rani, daughters Khushi and Garima Bassi for sum insured of Rs.3,00,000/- vide policy No.211200/01/2021/011474 valid from 10.02.2021 to 09.02.2022 for the first time. The claim was lodged in the second month of the policy. /-.  Further the insurance policy was issued on the principles uberrimae fides. Utmost good faith was a cardinal principle of insurance. The OPs further stated that the claims arising therein are subject to terms and conditions forming part of the policy. The complainants have accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Even the terms and conditions of the policy were explained to the complainants at the time of proposing policy and the same was served to the complainant along with the policy schedule. Moreover, it is clearly stated in the policy schedule "the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. attached." The complainant accepted the policy terms and conditions. It is one of the condition No.6 of the insurance policy under the head Disclosure to information of norms: The policy shall become void and all premium paid thereon shall be forfeited to the company, in the event of mis-representation, mis-description of non-disclosure of any material fact by the policy holder.

                   The OPs further stated that on 02.04.2021, the insured Baby Garima Bassi was admitted at Satguru Partap Singh Hospital, Ludhiana for treatment of AKI for which pre-authorization request for cashless treatment was sought. After perusing the submitted documents, query was raised vide letter dated 02.04.2021 to furnish the documents, which is reproduced as under:-

• Exact cause of recurrent diarrhea in this child.
• Cause of AKI in this child, submit serial CBE report, serial serum creatine report, serial serum electrolytes reports.
• Birth discharge summary, any h/o NICU admission.
• Details of delayed milestones any.

The OPs further stated that on scrutiny of pre-authorization documents, it was noticed as per discharge summary dated 02.02.2020, the insured was under NICU admission for the treatment of Respiratory Distress Intubated with Mechanical Ventilator Support. The admission was prior to commencement of the policy and the pre-existing disease was not disclosed in the proposal form. So the cashless authorization for diagnosed disease of AKI was rejected vide letter dated 05.04.2011. Thereafter, the complainant submitted claim documents for reimbursement of medical expenses of Rs.53,152/- and on scrutiny of claim documents, the medical team of the Ops observed that as per discharge summary of SPS Hospitals for the period 27.01.2020 to 02.02.2020, the baby had respiratory distress and shifted to Satguru Partap Singh Hospital, Ludhiana and was intubated and put on mechanical ventilator. However, the present admission and treatment of the insured patient was for acute gastroenteritis with severe dehydration, acute kidney injury and it was observed from discharge summary from 27.01.2020 to 02.02.2020 submitted in response to query during cashless processing that the insured was admitted in NICU and has respiratory distress, intubated with mechanical ventilator. Such medical history was prior to inception of medical insurance policy, which the complainant did not disclose in the proposal form. As per condition No.6 of the policy, if there is any misrepresentation/non-disclosure of material facts whether by the insured person or any other person acting on his behalf, the respondent is not liable to make any payment in respect of any claim. As such, the claim of the complainant was repudiated vide letter dated 06.05.2021 on legal and valid grounds.

                   On merits, the OPs reiterated the crux of averments made in the preliminary objections and facts of the case. The OPs have denied that there is any deficiency of service and has also prayed for dismissal of the complaint.

3.                In evidence, the complainant tendered his affidavit as Ex. CA and reiterated his averments of the complaint. The complainant also placed on Ex. C1 copy of insurance policy, Ex. C2 is the copy of discharge summary dated 02.02.2020, Ex. C3 to Ex. C13, Ex. C15 to Ex. C32 are the copies of medical bills/records, Ex. C14 is the copy of discharge summary dated 06.04.2021, Ex. C33 is the copy of certificate issued by Dr. Mehak Bansal, Ex. C34 is the copy of certificate issued by Dr. Pardeep Kumar Sharma, Ex. C35 is the copy of repudiation letter dated 05.04.2021 and closed the evidence.

4.                On the other hand, the learned counsel for the OPs tendered affidavit Ex. RA of Sh. Sumit Kumar Sharma, Senior Manager of the OPs as well as affidavit Ex. RB of Sh. Harpreet Singh, Zonal Underwriting Head, Tele Verification Team, Star Health & Allied Insurance Company Ltd., Miller Ganj, Ludhiana along with document Ex. R1 is the copy of proposal form, Ex. R2 is the copy of policy schedule, Ex. R3 is the copy of policy term and condition, Ex. R4 is the copy of IRDA guideline, Ex. R5 is the copy of pre-authorization request, Ex. R6 is the copy of Field Visit Report (FVR), Ex. R7 is the copy of treating doctor certificate, Ex. R8 is the copy of discharge summary dated 02.02.2020, Ex. R9 is the copy of pre-authorization query letter dated 02.04.2021, Ex. R10 is the copy of pre-authorization rejection letters dated 03.04.2021 and 05.04.2021, Ex. R11 is the copy of claim form, Ex. R12 is the copy of discharge summary dated 06.04.2021, Ex. R13 is the copy of final bill, Ex. R14 is the copy of repudiation letter dated 06.05.2021, Ex. R15 is the copy of billing assessment sheet, Ex. R16 is the copy of repudiation letter dated 05.04.2021, Ex. R17 is the copy of endorsement schedule dated 27.05.2021, Ex. R18 is the copy of CD of tele verification call (TVC) and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written statements along with affidavits and documents produced on record by the both parties.

6.                On the basis of proposal form dated 10.02.2021, the OPs issued policy bearing No. P/211200/01/2021/011474 namely Family Health Optima Insurance Plan having a sum insured of Rs.3,00,000/- for complainant, his wife and two dependent children. The insurance policy was having validity from 10.02.2021 to 09.02.2022. On 22.03.2021, daughter of the complainant namely Garima Bassi was got examined in OPD by Dr. Pardeep Kumar Sharma of Satguru Partap Singh Hospital, Ludhiana  as she was suffering from fever, vomiting and loose motion. She was again got checked up by the treating doctor on 01.04.2021 and on 02.04.2021 she was admitted in the hospital as per advice of Dr. Pardeep Kumar Sharma and was discharged on 06.04.2021 in satisfactory condition on oral antibiotics as per discharge summary dated 06.04.2021 Ex. C14 = Ex. R12. An expenditure of Rs.58,064/- were incurred by the complainant on treatment of Garima Bassi. The hospital authorities raised a cashless approval with the OPs for which the OPs sent a query letter dated 02.04.2021 Ex. R9 requiring the details/documents mentioned in the said letter. Thereafter, the pre-authorization cashless claim was rejected by the OPs vide letters dated 03.04.2021 and 05.04.2021 Ex. R10, the operative part of which reads as under:-

“We have scrutinized your request for approval for cashless treatment of above insured patient for the diagnosed disease of AKI.

                   As per the documents received by us, it is noticed that the insured patient has been suffering from          NICU ADMISSION       RESPIRATORY DISTRESS INTUBATED WITH MECHANICAL           VENTILATOR SUPPORT AS PER DISCHARGE SUMMARY DATED 02/02/2020         which is prior to inception of the first policy, but the insured has failed to disclose this pre-existing disease in the proposal form at the time of inception of the first policy. This amounts to concealment of material fact and hence the policy issued is void ab initio.

Hence, the claim for the diagnosed disease of AKI is not admissible due to concealment of material fact.

We are therefore unable to consider the approval for cashless treatment of the above diagnosed disease.”

The complainant lodged claim under the policy which was repudiated vide letter dated 06.05.2021 Ex. C35 = Ex. R14, the operative of which is reproduced as under:-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of acute gastroenteritis with severe dehydration, acute kidney injury.

Although the present admission and treatment of the insured patient is for acute gastroenteritis with severe dehydration, acute kidney injury, it is observed from the discharge summary of the above hospital for the period of hospitalization from 27.01.2020 to 02.02.2020 submitted a response to our query during cashless processing that the insured patient was admitted in NICU and has respiratory distress, intubated with mechanical ventilator. This significant medical history is prior to inception of medical insurance policy.

At the time of inception of your policy which is from 10.02.2021 to 09.02.2022, you have to disclosed the above mentioned medical history/health details of the insured-person in the proposal form which amounts to misrepresentation/non-disclosure of material facts.

As per Condition No.6 of the policy issued to you, if there is any misrepresentation/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.

We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim.

As per Condition No.10, the policy is also liable to be cancelled and necessary action will be taken by our Corporate Office.”

7.                The main basis of repudiation of the claim by the OPs is that baby Garima Bassi insured had history of Respiratory Distress and she was admitted in NICU and has respiratory distress, intubated with mechanical ventilator. The OPs did not produce any evidence in the form of medical record with regard to the diagnosis and treatment of said pre-existing disease except discharge summary dated 02.02.2020 Ex. R8. As per Ex. R8 the insured Garima Bassi born on 27.01.2020 was diagnosed of Term/AGA/MAS. The operative part of Ex. R8 reads as under:-

“Term/AGA female baby (Birth weight 2.7kg) born by LSCS on 27.01.2020, 8.25 am, Meconium present. Baby had respiratory distress. So shifted to Satguru Partap Hospital, Ludhiana NICU. Baby intubated and put on mechanical ventilator, IV fluids and supportive care. Inj. Dobtamine started. I/V antibiotics started. Gradually distress settled and OG feeds started. Baby was weaned to HFNC on 30.01.2020. Distress settled. Feeds increased. Currently baby is maintaining on room air, haemodynamically stable, accepting spoon feed. So being discharged in stable condition.”

The OPs have further produced Field Visit Report Ex. R6.  Rather on the other hand, the complainant has produced the certificate Ex. C33 of Dr. Dr. Mehak Bansal, which is reproduced as under:-

“This is to certify that Garima 1 year 2 month female is admitted Acute Gastroenteritis with severe dehydration in SPS Hospital, Ludhiana on 02.04.2021. Child had meconium aspiration syndrome term AGA in new borne period and is not related to the current illness.”

The complainant further produced certificate Ex. C34 of Dr. Pardeep Sharma of SPS Hospital, Ludhiana, which is reproduced as under:-

“B/O Pooja (Garima Bassi) SPS ID 757925 was born at term gestation with birth weight 2.7KG and required mechanical ventilation for meconium aspiration syndrome. The baby did not have any congenital malformation and was discharged in a stable condition.”

As per medical science Meconium Aspiration Syndrome (MAS) happens when a new born has trouble in breathing because meconium got into the lungs. Meconium can make it harder to breathe because it can clog the airways, irritate the airways and injury lung tissue, block surfactant, a fatty substance that helps open the lungs after birth. Further Meconium Aspiration Syndrome (MAS) is when a newborn baby breathes in a sticky substance called meconium just before or during birth. It can cause breathing problems and respiratory distress. It’s rare for MAS to cause long term complications or health conditions. Early detection and fast treatment improve the outcomes.

8.                Perusal of discharge summary Ex. C2 = Ex. R8 dated 02.02.2020 as well as certificates Ex. C33 and Ex. CC34 shows that the insured baby Garima Bassi was born on 27.01.2020 and after her birth she suffered respiratory distress due to meconium present and as such, she was admitted in NICU at SPS Hospital, Ludhiana and she was discharged in a stable condition. A conjoint reading of above said medical record and medical opinions clearly shows that Meconium Aspiration Syndrome (MAS) happens just before or during birth and generally it does not result into any long term complication or health condition. It is just a temporary medical condition. Dr. Pardeep Kumar Sharma in his certificate ex. C34 has clearly stated that the baby did not have any congenital malformation and was discharged in a stable condition. So treating the said condition as pre-existing disease by the OPs is devoid of any justification and logic. Normally such medical condition do happens at the time of during birth of babies.  So, therefore, this Commission is of the opinion that there is no concealment of facts on the part of the complainant at the time of availing insurance policy from the OPs. However, Baby Garima got treatment due to gastroenteritis and severe dehydration which has no direct connection with the earlier admission of Baby Garima at the time of her birth regarding her treatment of MAS.

9.                In the light of above said facts and circumstances, the opposite parties were not justified in repudiating the claim of the complainant and as such, there is deficiency in service on the part of the opposite parties. In the given facts and circumstances of the case, if the opposite parties are directed to settle and reimburse the claim with respect to hospitalization of insured Garima Bassi at Satguru Partap Singh Hospital, Ludhiana from 02.04.2021 to 06.04.2021 in terms of policy terms and conditions along with interest @8% per annum on the settled amount from the date of filing of complaint till its actual payment. The opposite parties are also burdened with composite costs of Rs.10,000/-.

10.              As a result of above discussion, the complaint is partly allowed with direction to the opposite parties to settle and reimburse the claim with respect to hospitalization of insured Garima Bassi at Satguru Partap Singh Hospital, Ludhiana from 02.04.2021 to 06.04.2021 in terms of policy terms and conditions along with interest @8% per annum on the settled amount from the date of filing of complaint till its actual payment within 30 days from the date of receipt of copy of order. The opposite parties shall also pay a composite costs of Rs.10,000/- (Rupees Ten Thousand only) to the complainants within 30 days from the date of receipt of copy of order.  Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.

11.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

 

(Monika Bhagat)                              (Sanjeev Batra)               Member                                         President  

Announced in Open Commission.

Dated:03.04.2024.

Gobind Ram.