Haryana

Karnal

CC/820/2019

Murari Lal - Complainant(s)

Versus

Star Health And Allied Insuarnce Company Limited - Opp.Party(s)

Vineet Kapoor

13 Oct 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                Complaint no. 820 of 2019                

                                               Date of Institution: 09.12.2019

                                                Date of Decision :13.10.2021.

 

Murari Lal son of Sh. Ram Parsad, aged about 55 years, resident of House No. 3563, Anaj Mandi, Nissing, Tehsil Nissing, District Karnal.

 

                  ……Complainant.

                                        Versus.

1. Star Health & Allied Insurance Company Ltd., through its Manager, 137, 2^nd Floor, above ICICI Bank Sector 13, Urban Estate, Karnal, near Bangla Sweets, Karnal, Tehsil and District Karnal.

 

2. Star Health & Allied Insurance Company Ltd., Branch Office Rohtak, Ashok Plaza, 3^rd Floor, Delhi Road, Rohtak, Distt. Rohtak Pin-124001.  

                                                         ...…Opposite parties.

               

Complaint U/S 12 of the Consumer Protection Act, 1986 as amended under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh.Vineet Kaushik ………..Member

              

 Argued by:Shri Vineet Kapoor, counsel for complainant.

                   Shri A.K. Vohra, counsel for opposite parties.

 

                (Jaswant Singh President)

               

ORDER

 

                The complainant has been filed the present complaint under Section 12 of the Consumer Protection Act, 1986 ( as under Section 35 of C.P. Act, 2019 after amendment) against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant availed the health insurance policy bearing No.P/2111/01/2018/00585 from OPs for the period 12.5.2017 to 11.5.2018 for a sum insured amount of Rs.5,00,000/- in his name as well as in the name of his wife Smt. Raj Bala and same is in continuation since last more than three years. The said health insurance policy was again got renewed for the period 12.5.2018 to 11.5.2019 and then from 12.5.2019 to 11.5.2020 and complainant paid a sum of Rs.27,896/- towards the renewal premium to the OPs. That on 11.3.2019, the complainant was admitted in Rama Super Specialty and Critical Care Hospital, Karnal with pain where the doctor concerned told him regarding his kidney problem and due to this reason he was hospitalized for his kidney treatment from 11.3.2019 to 27.3.2019 as per discharge summary dated 27.3.2019 but the health of complainant was not at all improving so he was referred to the Max Health Care Institute situated at Saket, New Delhi where he was treated from 27.3.2019 to 6.4.2019 as per the discharge summary given by said hospital. That complainant duly informed the OPs regarding his hospitalization in both the hospitals. It is further averred that the insurance policy purchased by complainant was cashless, so the amount of the bills of above hospitals during indoor treatment of complainant were to be supplied to the OPs’ company alongwith claim form. That complainant had paid the entire bill amount including medicines, test, hospitalization charges etc. to both the above mentioned hospitals from his own. The complainant had paid an amount of Rs.1,98,000/- to Rama Super Specialty Hospital, Karnal and an amount of Rs.5,82,000/- was paid by him to Max Health Care Hospital Saket, Delhi and thus total amount of Rs.7,80,000/- had been paid by complainant to said hospitals. Thereafter, complainant approached to the OPs for reimbursement of the claim amount but the OPs started making false excuses by one way or the other and started demanding the papers from the complainant, which are not even in existence especially previous medical history of complainant with regard to any disease in any manner. It is further averred that after submitting of the claim form by complainant to the OPs’ company, the OPs sent a letter to complainant dated 7.5.2019 for the requirement of the additional documents from complainant in which all the previous investigation reports, discharge summary, all previous reports and consultation papers, letter from the treating doctor, first consultation paper, complete set of indoor case and letter from the treating doctor stating causes for right psoas hamatome were demanded. That despite the fact that complainant provided all the above mentioned documentary evidence to the OPs, he further received a letter on 13.6.2019 from OPs requiring some more additional documents and information which were also supplied by complainant. The complainant also submitted replies to the above said letters as well as reply to the query letters from concerned doctors regarding the previous history of complainant which proves that there was no previous past history of any diabetic kidney disease of complainant. That complainant after supplying of all the required documents to the OPs from time to time paid number of visits to the OPs but the OPs have been postponing the matter on one false pretext or the other and finally sent a letter dated 26.8.2019 repudiating the claim of complainant by mentioning that it has been observed that USG report dated 28.3.2019 shows small right kidney with bilateral medical renal disease and it is a pre-existing disease mellitus and further the ops’ company have ignored the clarification letter from the insured and treating doctor stating no past history of the renal failure. It is further averred that complainant is having small kidney by birth and it is totally functional and normal and prior to that no kidney problem has been occurred to the complainant in any manner and complainant is not a diabetic patient and even not taking the medicines of the alleged diabetic problem in any manner which is amply proved by the reports of the concerned doctors of above said both hospitals. But the OPs company intentionally and deliberately has not appreciated the previous history of complainant given by concerned doctors and clarification and has repudiated the claim of complainant, which is wrong, unjustified and illegal. It is further averred that above said insurance policy is continuous for a period of three years since 2017 and no claim has been taken by complainant from previous policies and in this way, total sum of Rs.2,50,000/- is also covered under this insurance policy. That request of complainant to reconsider the repudiation of claim was also turned down by OPs company. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             On notice, OPs appeared and filed written version raising preliminary objections with regard to maintainability; locus standi; jurisdiction and concealment of true and material facts. On merits, it is pleaded that the claim of complainant was duly processed, considered on merits and same was not found payable due to the fact that medical team of the OPs perused and examined the claim records and have observed that USG report dated 28.3.2019 shows small right kidney with bilateral medical renal disease and also, the insured patient is a known case of diabetes mellitus, now the insured patient is diagnosed to have diabetic kidney disease which confirms that insured patient has chronic, longstanding diabetes mellitus present prior to inception of the medical insurance policy. It is further noted that anemia, fluid overload, hyperkalemia, hypoproteinuria, metabolic encephalopathy are prepuce infection, psoas infection are secondary to diabetic kidney disease. Thus, the present admission and treatment of the complainant is for kidney disease which is a complication of pre existing diabetes mellitus. As per Exclusion No.1, the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease/ condition, until 48 months of continuous coverage has elapsed, since inception of the policy i.e. from 12.5.2017. It is further pleaded that medical claim of complainant was rejected with speaking letter dated 17.7.2019. That the insurance in question is based on utmost good faith and both the parties i.e. insured as well as the insurer are bound by the terms and conditions of the contract of insurance. The liability of the insurance company- OPs has to be within the four corners of the contract of insurance alone. However, the complainant has breached the good faith by concealing the true facts and has also violated the terms and conditions of the policy of insurance. It is further pleaded that claim of complainant was re-considered on the request of complainant and his treating doctor. The clarification letter from complainant and treating doctor stating no past history of renal failure is not acceptable as the medical team of the OPs came to the conclusion after examining the medical reports that complainant is patient of kidney disease which is a complication of pre-existing diabetes mellitus. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.            

4.             Complainant has tendered in evidence his affidavit Ex.CW1/A, copy of insurance policy Ex.C1, copy of advance premium receipt of amount of Rs.27,896/- dated 12.5.2018 Ex.C2, copy of thankful letter received from ops Ex.C3, copy of letter regarding renewal of policy dated 1.5.2019 Ex.C4, copy of policy for the period 12.5.2019 to 11.5.2020 Ex.C5, copy of premium certificate Ex.C6, copy of tax invoice dated 1.5.2019 Ex.C7, copy of discharge summary of Rama Super Specialty & Critical Care Hospital, Karnal Ex.C8, copy of discharge summary of Max Super Specialty Hospital, Saket, Delhi Ex.C9, copy of instructions of Max Hospital Ex.C10, copy of letter dated 7.5.2019 requiring additional documents/ information Ex.C11, reply against query dated 16.5.2019 Ex.C12, copy of letter dated 13.6.2019 requiring additional documents/ information Ex.C13, reply against query dated 26.7.2019 Ex.C14, reply against query Ex.C15, copy of query letter reply of Dr. Dinesh Dhanda, of Rama Super Specialty Hospital, Karnal Ex.C16 and certificate of said doctor Ex.C17, copy of certificate issued by Max Super Specialty Hospital, Saket Ex.C18, copy of application/ self statement given by complainant to ops Ex.C19, copy of repudiation letter dated 26.8.2019 Ex.C20 and copies of receipts/ bills Ex.C21 to Ex.C78, copy of Aadhar card Ex.C79 and closed the evidence on 12.11.2020 by suffering separate statement.

5.             On the other hand, OPs  tendered into evidence affidavit of Sh. Rajiv Jain, Chief Manager as Ex.OP1/A, copy of policy terms and conditions Ex.R1, copy of policy schedule Ex.R2, copy of proposal form Ex.R3, copy of pre-authorization request Ex.R4, copy of field visit report Ex.R5, copy of pre-authorization query letter dated 28.3.2019 Ex.R6, copy of pre-authorization denial letter dated 30.3.2019 Ex.R7, copy of claim form Ex.R8, copy of discharge summary Ex.R9, copy of final bill Ex.R10, copy of query and reminder letters dated 7.5.2019, 22.5.2019 and 6.6.2019 Ex.R11, copy of rejection letter dated 21.6.2019 Ex.R12, copy of field visit report Ex.R13, copy of claim form Ex.R14, copy of discharge summary dated 27.3.2019 Ex.R15, copy of discharge summary dated 6.4.2019 Ex.R16, copy of progress notes Ex.R17, copy of USG Abdomen report dated 28.3.2019 Ex.R18, copy of USG chest report dated 28.3.2019 Ex.R19, copy of final bill Ex.R20 and copy of repudiation letters dated 17.7.2019/ 26.8.2019 Ex.R21 and closed the evidence on 01.09.2021 by suffering separate statement.

6.             We have heard learned counsel for the parties and have perused the case file carefully.

7.             Admittedly, the complainant obtained health insurance policy for himself and his wife Smt. Raja Bala for the period 12.5.2017 to 11.5.2018 from OPs for sum insured amount of Rs. five lacs and said insurance policy was got renewed for the period 12.5.2018 to 11.5.2019 and then for the period 12.5.2019 to 11.5.2020 by paying premium amount of Rs.27,896/-.  On 11.3.2019 complainant was admitted in Rama Super Specialty & Critical Care Hospital, Karnal with pain where the doctor concerned told him regarding kidney problem, due to which he was hospitalized and treatment of kidney was done from 11.3.2019 to 27.3.2019. But as the health of complainant was not improving, so he was referred to higher hospital and he was taken Max Health Care Institute at Saket, New Delhi where he took treatment from 27.3.2019 to 06.04.2019. The complainant has claimed that an amount of Rs.1,98,000/- was spent by him on his treatment in Rama Super Specialty Hospital, Karnal and he spent an amount of Rs.5,82,000/- on his treatment in Max Health Care Hospital, Saket Delhi. Due intimation was given to the OPs and claim was lodged, but however, the OPs after prolonging the matter on one pretext or the other finally repudiated the claim of complainant on 26.8.2019 on the ground that it has been observed that USG report dated 28.3.2019 shows small right kidney with bilateral medical renal disease and it is a pre-existing diabetes mellitus.

8.             The OPs have not placed on record any affidavit of doctor of their medical team who examined the treatment papers of the complainant and recommended to the insurance company that complainant was having a pre-existing disease. That OPs vide their letter dated 7.5.2019 and 13.6.2019 placed on file as Ex.C11 and Ex.C13 also required additional documents/ information from complainant such as all previous investigation reports (urine report, serial creatinine, USG report) consultation papers and treatment done for CKD since its onset and all previous investigation reports, consultation papers and treatment done for diabetes mellitus. The complainant duly submitted his reply on 16.5.2019 (Ex.C12) to the OPs to the effect that he has no any previous history of CKD and Diabetes Mellitus, no fistula done, no past history of any injury, no test done in past related anemia, no any endoscopy done in past or present, no any past history of tuberculosis present. However, again vide letter dated 13.6.2019 (Ex.C13), the OPs again required additional documents/ information from complainant and the following description of documents were required:-

Sr. No.      Description of documents required

1              As per query reply in max health care dated 28.3.2019 CKG diagnosed         one month back related consultation papers with USG abdomen serum       creatinine reports.

 

2.             Discharge summary for AV fistula.

 

3.             A letter from treating doctor of max health hospital stating cause for right         PSOAS hematoma and duration of seizure disorder, any history of         tuberculosis, duration of autoimmune disease.    

 

4.           Consultation papers and treatment done for autoimmune     disease since its onset

 

5.            Consultation papers and treatment done for anemia since its

               onset

 

6.            Complete set of indoor case papers with drug chart

7.            A letter from the treating doctor stating the cause for GI bleed

              and endoscop reports done in the past.                                 

                                                                                       

9.            The above said letters of OPs were duly replied by complainant that prior to 11.3.2019 he was not having any problem of any type and he was okey and submitted all other relevant documents to the OPs. The complainant also sent a letter from treating doctor namely Dr. Dinesh Dhanda of Rama Super Specialty & Critical Care Hospital, Karnal (Ex.C16) to the OPs, which is reproduced as under:-

 Subject: Query Letter Reply for claim  no.CLI/2019/211118/0710024

                AV- Fistula not done at Rama Hospital

                First dialysis chart attached

                Patient first time consulted at Rama Hospital on 11.3.2019 so we don’t have any previous records. As per history patient diagnosed Renal failure first time on 11.3.2019. As per history patient was not diabetic.

                Patient diagnosed as Rt. Psoas hematoma at other hospital. As per history patient was not on Anti coagulant.

                Patient developed seizure episode at other hospital. As per H/o patient had no past H/o of seizure disorder.

 

10.           Further, said Dr. Dinesh Dhanda of said hospital also gave certificate dated 23.7.2019 Ex.C17 to the effect that patient Mr. Murari Lal first time consulted at Rama Super Specialty & Critical Care Hospital, Karnal on 11.3.2019. As per history had no past history of Renal failure. Furthermore, Doctor of Max Super Specialty Hospital Saket, Delhi also gave certificate Ex.C18 to the effect that AUF was not done there and no previous history of CKD and recently diagnosed. But however, OPs after demanding documents regarding previous history of diseases from the complainant time and again ultimately repudiated the claim of complainan,t vide letter dated 26.8.2019 Ex.C20 on the ground that “Our medical team has perused your representation and has noted the contents. The team which re-examined the claim records has observed that USG report dated 28.3.2019 shows small right kidney with bilateral medical renal disease and also, the insured patient is a known case of diabetes mellitus, now the insured patient is diagnosed to have diabetic kidney disease which confirms that insured patient has chronic, longstanding diabetes mellitus present prior to inception of the medical insurance policy. The present admission and treatment of the insured patient is for kidney disease which is a complication of pre-existing diabetes mellitus. Clarification letter from the insured and treating doctor stating no past history of renal failure is not acceptable.

11.           The above said repudiation of the claim of the complainant is based on only assumption and presumption and same is not supported by any documentary evidence/ proof. The OPs have not placed on file any opinion of their medical team. From the record available on file i.e. medical records of above said both the hospitals where the insured/ complainant took treatment for the period 11.3.2019 to 6.4.2019, it is not proved on record that complainant was having any pre-existing disease or past history of kidney disease rather it is proved on record that he was diagnosed with disease of kidney for the first time on 11.3.2019 when he was admitted in above said Rama Super Specialty & Critical Care Hospital, Karnal. The OPs have not placed on file any other medical record of any other hospital from which it could prove that complainant was already taking treatment for said disease. The OPs have even renewed this health policy of the complainant for further period of 12.5.2019 to 11.5.2020 by charging premium amount of Rs.27,896/-. The OPs have wrongly and illegally declined the pre-authorization request for cashless treatment of complainant vide letters dated 30.4.2019 Ex.R7 and Ex.R8. The OPs have also wrongly and illegally repudiated the genuine claim of complainant. The complainant is, therefore, entitled for reimbursement of amount incurred by him on his treatment.

12.           The complainant has alleged that he has spent an amount of Rs.7,80,000/- on his treatment. According to complainant, although the insured amount was of Rs.5,00,000/- but since complainant has taken the policy in question from year 2017 and is renewing the same, therefore, he is also entitled to the amount of Rs.2,50,000/- i.e. Rs.1,25,000/- for the period 12.5.2017 to 11.5.2018 and Rs.1,25,000/- for the renewal period as no claim bonus and said bonus amount also finds mentions in the policy Ex.C1. According to complainant, he has spent an amount of Rs.1,98,000/- in Rama Super Specialty Hospital, Karnal and spent an amount of Rs.5,82,000/- in Max Health Care Hospital, Saket Delhi and has placed on record copies of various bills of above said hospitals as Ex.C21 to Ex.C78 in this regard. On the other hand, OPs vide their bill assessment sheet Ex.R12 and Ex.R13 after making deductions on account of non payable amount have got assessed the amount of Rs.5,19,895/- and Rs.1,21,010/- but however, did not make payment of any of the amount as got assessed by the OPs which clearly amounts to deficiency in service and unfair trade practice on the part of OPs. Though, complainant has claimed an amount of Rs.7,80,000/- alongwith interest from OPs as spent by him on his treatment, however, OPs are liable to pay the amount as per insured sum as well as bonus amount as per terms and conditions of insurance policy and also as per assessment of the amount after deductions on account of hospital discount and deductions of non payable amounts.

12.           Thus, as a sequel to above discussion, we allow this complaint and direct the OPs to pay insured amount of Rs.5,00,000/- alongwith bonus amount as per terms and conditions of the policy in question to the complainant after applying deductions etc. on account of hospital discount etc. alongwith interest @9% per annum from the date of filing of repudiation of the claim till actual realization. We further direct the OPs to pay Rs.25000/- to the complainant on account of mental agony and harassment suffered by him and Rs.11000/-for litigation expenses. This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:13.10.2021                                                                     

                                                                  President,

                                                       District Consumer Disputes

                                                       Redressal Commission, Karnal.

 

 

(Vineet Kaushik)          

                     Member