DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.

Complaint Case No : CC/91/2020

Date of Institution : 02.06.2020

Date of Decision : 01.03.2021

Deepak Kumar Bansal son of Shri Rattan Chand Bansal resident of House No. B-XI/97, Opposite Easy Day, KC Road, Barnala, Tehsil and District Barnala. …Complainant

Versus

1. Star Health and Allied Insurance Company Limited, Registered and Corporate Office at 1, New Tank Street, Valluvar, Kottam High Road, Nungambakkam, Chennai-600034 through its Director.

2. State Health and Allied Insurance Company Limited, Branch Office at SCF No. 133, 2nd Floor, GT Road, Goniana Road, Bathinda through its Authorized Signatory.

3. State Health and Allied Insurance Company Limited, Branch Office at 2nd Floor, above Delhi Tractor and Combines, Opposite Punjab National Bank, Handiaya Branch, Pacca College Road, Barnala through its Branch Manager.

4. Star Health and Allied Insurance Company Limited, through Shri Vipan Kumar, Senior Sales Manager, Sukhanand Colony, Tapa Mandi, District Barnala.

5. Star Health and Allied Insurance Company Limited, through its Authorized Agent Shri Sat Pal Goyal C/o KK Laboratories, backside Truck Union, Tapa Mandi, District Barnala. 

…Opposite Parties

Complaint Under The Consumer Protection Act, 1986.

Present: Sh. AK Jindal counsel for complainant.

Sh. Lokeshwar Sewak counsel for opposite parties.

Quorum.-

1. Sh. Kuljit Singh : President

2. Sh. Tejinder Singh Bhangu : Member

 

(ORDER BY SHRI KULJIT SINGH PRESIDENT):

    The complainant Deepak Kumar Bansal filed the present complaint under the Consumer Protection Act 1986 (as amended up to date) against Star Health and Allied Insurance Company Limited, Chennai and others. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant purchased one Health Insurance Policy from the opposite parties through opposite parties No. 4 and 5 at Barnala and paid premium to the tune of Rs. 15,287/- and they issued policy No. P211217/01/2019/003135 in the name of the complainant which is valid from 31.3.2019 to midnight 30.3.2020. 

3. It is further alleged that at the time of the purchase of said policy the complainant disclosed in his declaration when the requisite application form was filled by the opposite parties No. 4 and 5 and complainant put his signatures upon the said form on 31.3.2019 and it was duly informed to the opposite parties that he is a diabetic patient and opposite parties issued the above mentioned policy in favour of the complainant. \

4. It is further alleged that on 26.12.2019 the complainant suffered from heart problem and complainant admitted in Pragma Hospital, Bathinda where he was treated and diagnosed with a deceased of CAD/ACS and after admission of complaint choreography was also conducted where it was found that the complainant suffered Distal Lad Has Moderate Disease, Distal RCA Has Sever Disease and the complainant was got operated and a stent was installed in the heart of the complainant by the doctors for the normal movement of the heart. The complainant remained admitted in Pragma Hospital, Bathinda from 26.12.2019 to 27.12.2019 and hospital charged an amount of Rs. 1,31,584/- on account of installation of the said stent in the heart of the complainant and he also consumed medicines of Rs. 1,014/- and laboratories charges of Rs. 1,552/-. 

5. It is further alleged that after recovery from the said disease by the complainant he submitted a claim application with the opposite parties to reimburse the amount of medical claim on 27.12.2019 alongwith treatment bills, discharge summary and medicine bills, receipts etc but they failed to reimburse the medical claim bill of the complainant and raised objections that the complainant was a diabetic old patient and it was not disclosed by him at the time of purchase of policy and repudiated the claim of the complainant on this ground vide letters dated 1.2.2020 and 21.3.2020.  The act of the opposite parties is deficiency in service and unfair trade practice. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to reimburse the amount of the medical claim to the tune of Rs. 1,34,150/- alongwith interest at the rate of 12% per annum till realization.  

2) To pay Rs. 50,000/- on account of compensation for mental agony and  harassment.             

3) To pay Rs. 20,000/- as litigation expenses.  

4) Any other fit relief may also be given. 

6. Upon notice of this complaint, the opposite parties filed written reply taking preliminary objections on the grounds that the complainant has no locus standi to file the present complaint and it is not maintainable. Further, complainant has not come to this Commission with clean hands and this Commission has no jurisdiction to the try and decide the present complaint.

7. On merits, it is admitted by the opposite parties admitted that the complainant purchased one Health Insurance policy from the opposite parties for sum assured of Rs. 5,00,000/- which was valid from 31.3.2019 to 30.3.2020 which was subject to conditions, clauses, warranties, exclusions etc. It is submitted that policy is contractual in nature and claims arising therein are subject to the terms and conditions forming part of the policy. The complainant accepted the policy agreeing terms and conditions thereof. The insured submitted claim documents for reimbursement towards the treatment of Rhuematic CAD-ACS TMT Postive CAG-DVD at Pragma Hospital, Bathinda dated 26.12.2019 and on scrutiny of claim documents for reimbursement, it is observed that the findings of CAG report dated 26.12.2019 shows LAD-mid LAD:severe disease, distal LAD-moderate disease; RCA-distal RCA has severe disease with the background of diabetes mellitus. Based on the CAG finding, medical team of the opinion that the insured patient has chronic, longstanding heart disease existing prior to inception of the first medical insurance policy. Hence heart disease is a pre-existing disease. The patient admission and treatment of the insured patient is for the pre existing heart i.e. coronary artery disease. As per waiting period 3 (iii) of the above policy issued to the insured, 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 31.3.2019. Rest of the contents of the complaint are denied by the opposite parties and lastly prayed for the dismissal of the present complaint with special costs.  

8. In support of his complaint, complainant tendered into evidence his own affidavit Ex.C-1, copy of proposal form Ex.C-2, copy of policy  Ex.C-3, copy of advance premium receipt Ex.C-4, copy of report dated 27.12.2019 Ex.C-5, copy of report dated 26.12.2019 Ex.C-6, copy of report dated 26.12.2019 of Singla Lab Ex.C-7, copy of receipt dated 27.12.2019  of Pragma Hospital Ex.C-8, copy of invoice dated 26.12.2019 of Cognitive Solutions Ex.C-9, copy of bill dated 27.12.2019 of Grace Pharmacy Ex.C-10, copy of bill dated 27.12.2019 of Singla Pharmacy Ex.C-11, copy of discharge summary dated 27.12.2019 of Pragma Hospital Ex.C-12, copy of claim form Ex.C-13, copy of letter dated 1.2.2020 Ex.C-14, copy of letter dated 15.2.2020 Ex.C-15, copy of letter dated 21.3.2020 Ex.C-16 and closed the evidence. 

9. To rebut the case of the complainant, the opposite parties  tendered in evidence copy of terms and conditions Ex.OPs-1, copy of policy  Ex.OPs-2, copy of proposal form Ex.OPs-3, copy of claim form Ex.OPs-4, copy of discharge summary Ex.OPs-5, copy of CAG report Ex.OPs-6, copy of final bill Ex.OPs-7, copies of letter dated 1.2.2020, 21.3.2020 Ex.OPs-8 and Ex.OPs-9 respectively, copy of bill assessment Ex.OPs-10, affidavit of Rajiv Jain Ex.OPs-11 and closed the evidence.

10. Replication also filed by the complainant in which they reiterated the allegations as mentioned in the complaint. 

11. We have heard the learned counsel for the parties and have gone through the record. Written arguments also filed by both the parties. 

12. It is admitted fact between the parties that the complainant  purchased Insurance Policy Ex.C-3 for the period from 31.3.2019 to  the midnight of 30.3.2020 from the opposite parties for sum assured of Rs. 5,00,000/-. It is also admitted by the opposite parties that the insured submitted claim documents for reimbursement towards the treatment of Rhuematic CAD-ACS TMT Postive CAG-DVD at Pragma Hospital, Bathinda dated 26.12.2019. The opposite parties further submitted in their written version that on scrutiny of claim documents for reimbursement, it is observed that the findings of CAG report dated 26.12.2019 shows LAD-mid LAD:severe disease, distal LAD-moderate disease; RCA-distal RCA has severe disease with the background of diabetes mellitus and based on the CAG finding, medical team of the opinion that the insured patient has chronic, longstanding heart disease existing prior to inception of the first medical insurance policy which is a pre-existing disease. The opposite parties further submitted in their version that the patient admission and treatment of the insured patient is for the pre existing heart i.e. coronary artery disease and as per waiting period 3 (iii) of the above policy issued to the insured, 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 31.3.2019. It is also proved on the file vide copies of letters Ex.C-14 and Ex.C-16 that the opposite parties repudiated the claim of the complainanton the ground of pre-existing disease. Now the main grievance of the complainant is that the opposite parties not reimbursed the amount of Rs. 1,34,150/- which was expended by the complainant on his treatment and for the purpose of which the complainant purchased the medical insurance policy from the opposite parties. 

13. The most important document of the present matter is copy of proposal form Ex.C-2 in which the complainant duly disclosed that he is a diabetic patient and also disclosed the medicines which he was taking for this disease. Even in this document Ex.C-2 he also mentioned that he has taken the medicine of diabetes for the last 1-1/2 years. In this way, in our view when the complainant already disclosed his disease of diabetes then it is up to the opposite parties to issue the insurance policy in his favour or not. But as the opposite parties issued the insurance policy after knowing this fact and after receiving the premium from the complainant then now the opposite parties cannot raised this objection that the complainant is the old patient of diabetes. Further, in our view if the complainant disclosed about his diabetes disease then there is no hitch for him to disclose about any heart disease if he already suffering from it. 

14. Further, the complainant purchased the policy on 31.3.2019 and  from the copy of discharge summary Ex.C-12 it is proved on the file that he was admitted in the hospital on 26.12.2019 and discharged on 27.12.2019 after a gap of almost nine months from the purchase of the mediclaim insurance policy, so it cannot say that the complainant concealed his heart disease as any disease can occur at any time. Further, the complainant already told the opposite parties that he is a diabetic patient and it is a matter of common knowledge that a diabetic patient is having much chances for suffering from heart disease. From the copy of claim form Ex.C-13 it is proved on the file that the complainant submitted the claim form on 27.12.2019 for the amount of Rs. 1,34,150/- with the opposite parties but the opposite parties have not paid any amount to the complainant. 

15. In this way as the complainant already disclosed his pre-existing disease to the opposite parties and even then they issued the insurance policy to the complainant after receiving premium from him so now the opposite parties cannot repudiate the genuine claim of the complainant and by repudiating the same is clear cut deficiency in service and unfair trade practice on the part of the opposite parties. 

16. The Hon’ble State Commission Punjab Chandigarh in case titled as Pardeep Kumar Garg versus National Insurance Company decided on 1st August 2008, wherein it has been held that Insurance Company cannot take advantage of its act of omission and commission as it is under obligation to ensure before issuing mediclaim policy whether a person is fit to be insured or not.

17. On the concept, meaning and impart of word disease, pre-existing disease in reference to medical insurance policies, we have drawn following conclusions in highly extensive, dissective manner. These are as under:-

(i) The claim of any insured should not be and cannot be repudiated by taking a clue or remote reference to any so-called disease from the discharge summary of the insured by invoking the exclusion clause or non-disclosure of pre-existing disease unless the insured had concealed his hospitalization or operation for the said disease undertaken in the reasonable near proximity as referred above.

(ii) Day to day history or history of several years of some or the other physical problem one may face occasionally without having landed for hospitalization or operation for the disease cannot be used for repudiating the claim. For instance an insured had suffered from a particular disease for which he was hospitalized or operated upon 5, 10 to 20 years ago and since then had been living healthy and normal life cannot be accused of concealment of pre-existing disease while taking mediclaim policy as after being cured of the disease, he does not suffer from any disease much less the pre-existing disease.

(iii) Non-disclosure of hospitalization/or operation for disease that too in the reasonable proximity of the date of mediclaim policy is the only ground on which insured claim can be repudiated and on no other ground.

iv) Such a disease should not only be existing at the time of taking the policy but also should have existed in the near proximity. If the insured had been hospitalized or operated upon for the said disease in the near past, say, six months or a year he is supposed to disclose the said fact to rule out the failure of his claim on the ground of concealment of information as to pre-existing disease.

18. Similarly, the case law decided by State Commission Pb. Chandigarh in case titled as Lakhwinder Singh versus United India Insurance Company decided on 7th April 2010. This case is also applicable to the facts situation of the case.

19. We are of the view that the OPs have wrongly observed that there is a pre-existing disease as OPs have failed to prove on record that the complainant had taken any treatment before inception of the policy. In the absence of any credible documentary or other evidence by the OPs on whom was the onus to prove the reasons for repudiation. In view of our conclusions on the concept of meaning and import of word disease, pre-existing disease, non disclosure of certain maladies the humanity suffer from day to day basis. Disease means a serious derangement of health or chronic deep-seated disease frequently one that is ultimately fatal for which an insured must have been hospitalized or operated upon in the near proximity of obtaining the mediclaim policy. It was duty of the OPs to produce cogent evidence with regard to previous ailment of the insured before inception of the policy. But OPs failed to produce any record showing that the insured taken any treatment for such disease before taking of the insurance policy. In the absence of any such documentary evidence it cannot be said that complainant ever suffered from such disease/problem on account of which claim of the complainant has been repudiated. The repudiation of the insurance claim of the complainant is unjustified and against the terms and conditions of the insurance policy.

20. The Hon'ble Punjab and Haryana High Court at Chandigarh in case titled New India Assurance Company Limited Versus Smt. Usha Yadav and others 2008(3) RCR (Civil) Page-111 held as under.-

“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs. 5,000/- for luxury litigation being rich.”

This citation is also fully applicable to the facts of present case as in the present matter also the opposite parties earned premium  from the complainant but at the time when complainant lodged insurance claim  with the opposite parties they repudiated his claim on the ground of pre-existing disease which was already disclosed by the complainant to the opposite parties, so the opposite parties are liable to pay the claim of the complainants. From the copy of receipt Ex.C-8 and copy of bill Ex.OPs-7 it is proved on the file that Pragma Hospital, Bathinda has received Rs. 1,31,584/- from the complainant on account of treatment charges. Further, from copies of bills Ex.C-10 and Ex.C-11 it is also proved on the file that complainant also expended Rs. 2,566/- for purchase of medicines outside from the treating hospital and totaling he spent Rs. 1,34,150/- on his treatment.

21. As a result of our above discussion, there is merit in the present complaint and same is allowed. Accordingly, the opposite parties are directed to pay Rs. 1,34,150/- to the complainant on account of insurance claim for the treatment taken by him within the validity period of the mediclaim insurance policy. The opposite parties are also directed to pay Rs. 5,000/- to the complainant on account of consolidated amount of compensation for mental tension, harassment and litigation expenses. The opposite parties are further directed to deposit Rs. 5,000/- in the Consumer Legal Aid Account maintained by this Commission. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order, failing which the opposite parties are directed to pay the above mentioned amount of Rs. 1,34,150/- to the complainant alongwith interest at the rate of 6% per annum from the date of order till actual realization. All the opposite parties jointly and severally liable to comply the above mentioned order of this Commission. Copy of this order be supplied to the parties free of costs. The file be consigned to the records after its due compliance. 

ANNOUNCED IN THE OPEN COMMISSION:

        1st Day of March 2021

 

 

            (Kuljit Singh)

            President

              

 

(Tejinder Singh Bhangu)

Member