Punjab

Barnala

CC/187/2022

Rajesh Kumar Garg - Complainant(s)

Versus

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

Rajan Chaudhary

12 Jan 2024

ORDER

Heading1
Heading2
 
Complaint Case No. CC/187/2022
( Date of Filing : 05 Aug 2022 )
 
1. Rajesh Kumar Garg
S/o Harbans Lal Garg R/o H.No. 216, Ward No.7, Near Bus Stand Dhanaula
Barnala
Punjab
...........Complainant(s)
Versus
1. Star Health and Allied Insurance Co Ltd
SCO 133,2nd floor above Tata Motor Finance, Near Hotel Sweet Milan Goniana Road Bathinda
Bathinda
Punjab
2. Dayanand Medical College and Hospital
Civil Lines Ludhiana through its Chairman/Director/Authorized Signatory
............Opp.Party(s)
 
BEFORE: 
 HON'BLE MR. Sh.Jot Naranjan Singh Gill PRESIDENT
 HON'BLE MR. Navdeep Kumar Garg MEMBER
 
PRESENT:
 
Dated : 12 Jan 2024
Final Order / Judgement
DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
 
Complaint Case No : CC/187/2022
Date of Institution   : 05.08.2022
Date of Decision    : 12.01.2024
Rajesh Kumar Garg son of Sh. Harbans Lal Garg resident of H.No. 216, Ward No. 7, Near Bus Stand, Dhanaula, Tehsil and District Barnala.         
                          …Complainant Versus
1.Star Health and Allied Insurance Company Ltd., S.C.O 133, 2nd Floor Above Tata Motor Finance, Near Hotel Sweeet Milan, Goniana Road, Bathinda.
2.Dayanand Medical College & Hospital, Civil Lines, Ludhiana through its Chairman/Director/Authorized Signatory.  
                         …Opposite Parties
 
Complaint Under Section 35 of Consumer Protection Act, 2019.
Present: Sh. Rajan Chaudhary counsel for complainant.
Sh. Rohit Jain counsel for opposite party No. 1.
Opposite party No. 2 deleted.
Quorum:-
1. Sh. Jot Naranjan Singh Gill : President
2.Sh. Navdeep Kumar Garg : Member
 
ORDER BY JOT NARANJAN SINGH GILL, PRESIDENT:
The present complaint has been filed under Section 35 of the Consumer Protection Act 2019, (amended upto date) against Star Health and Allied Insurance Company Limited and others (hereinafter referred as opposite parties).  
2. The facts leading to the present complaint are that the complainant was insured with HDFC Ergo Medical Policy for the last three years. It is alleged that the representative of the opposite party visited the complainant and asked the complainant to port his medical insurance policy from HDFC Ergo to Star Health and Allied Insurance Company Limited. Upon believing the words the complainant port his policy to Star Health and Allied Insurance Company Limited and took the policy namely Family Health Optima Insurance 2017 Med-Pro-051 vide  policy No. P/211229/01/2022/000039 which was for the period from 23.4.2021 to 22.4.2022 and a premium of Rs. 15,287/- was charged from the complainant against insurance upto Rs. 5 lacs. It is further alleged that on 14.7.2021 the complainant was having nasal bleeding and at night time when the bleeding was increased then on 15.7.2021 the complainant was admitted to Dayanand Medical College & Hospital, Ludhiana for treatment vide admission No. 2021035126 and was discharged on 19.7.2021 and total expenditure on the treatment was Rs. 90,302/- for which the complainant could retain bills and the intimation of the claim was given to the opposite party No. 1, but on query it came to the knowledge of the complainant that the claim was rejected. It is alleged that the complainant was shocked to receive a letter dated 17.7.2021 from the opposite party No. 1 stated that the claim has been repudiated on the ground that “the insured patient has HYPERTENSION for the last 4 years and the insured has not disclosed the medical history in the proposal form and other portability forms at the time of porting the policy to us. Hence, the claim for treatment of this disease is not admissible under the policy issued to the insured”. The complainant submitted that neither the complainant had hidden any information regarding his prior disease because the complainant was not suffering from such HYPERTENSION  as alleged by the opposite party No. 1. The complainant again moved a request a letter that the decision of repudiation be reconsidered, but till date complainant has not received any reply from the opposite party No. 1. Thus, the above said act and conduct of the opposite party No. 1 falls under the deficiency in service and unfair trade practice on the part of opposite party No. 1. Hence, the present complaint is filed for seeking the following reliefs.- 
i)To pay the claim of the complainant amounting to Rs. 90,302/- alongwith interest @ 12% per annum from the date of filing the claim till realization. 
ii)To pay Rs. 50,000/- towards mental tension and harassment and Rs. 10,000/- towards counsel fee and litigation expenses.   
3. Upon notice of this complaint, the opposite party No. 1 appeared and filed written version taking preliminary objections interalia on the grounds that the complaint is false, frivolous, vague, baseless and misconceived. It is admitted in the preliminary objections that the complainant availed the Family Health Optima Insurance plan through Branch office Barnala which covering Mr. Rajesh Kumar Garg- Self (PED- Diabetes Mellitus and its complications), Mrs Raj Rani – Spouse, Jashan Garg and Shivansh -Dependent Children for the sum insured Rs. 5,00,000/- vide policy No. P/211229/01/2022/000039 for the period from 23.4.2021 to 22.4.2022. It is further alleged that earlier the complainant had medical insurance policy with HDFC ERGO General Insurance Company Limited for the period from 18.3.2016 to 22.4.2021 and subsequently ported to Star under portability. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and same were served to the complainant alongwith policy schedule. It is further alleged that the insured was hospitalized on 15.7.2021 at Dayanand Medical College and Hospital, Ludhiana for the treatment of EPISTASIS and discharged on 19.7.2021. The insured complainant raised a pre-authorization request to avail cashless facility and subsequently submitted claim documents for reimbursement of medical expenses. On scrutiny of the submitted medical documents, it is observed that;
i. As per the indoor case papers of the treating hospital, the insured patient is a known case of hypertension for 4 years which prior to our policy.
ii. Moreover, the insured has not disclosed this medical history at the time of porting the policy. 
From the above finding, it is noted that the insured patient is a known case of the above ailment prior to porting of the policy and the date of commencement of first year policy and the same was found from the claim documents submitted at the time of claim processing. Hence, it is a pre-existing disease. The present admission and treatment of the insured patient is for the complication of the non-disclosed pre-existing disease which is not payable as per 3. Exclusion Pre-Existing Disease- Code Excl 01 of the policy. It is further alleged that as per Condition No. 6 of the policy “Disclosure to information 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 or non-disclosure of any material fact by the policy holder”. It is further alleged that as per 3. Exclusion Pre-Existing Disease- Code Excl 01 of the policy, the company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer and the above said pre-existing disease is subject to waiting period of 48 months with effect from PED incorporation date 2.11.2021. Hence, the cashless request and the claim was rejected and the same was communicated to the insured vide letters dated 17.7.2021 and 6.11.2021 respectively.  
4. On merits, the opposite party No. 1 submitted that without prejudice to whatever has been stated earlier in this written statement, even assuming without conceding that the company is liable to pay the claim in terms of contract of insurance issued to the claimant-petitioner, it is respectfully submitted that the maximum quantum of liability under the terms of the policy shall be Rs. 63,952/-. All other allegations of the complaint are denied by the opposite party No. 1. Therefore, there is no deficiency in service on the part of opposite party No. 1 and prayed for the dismissal of complaint with special costs.
5. Ld. Counsel for the complainant on 12.8.2022 has suffered the statement that he withdraw the complaint qua the opposite party No. 2, so it may kindly be deleted from the arena of opposite parties. In view of the statement of Ld. Counsel for complainant the opposite party No. 2 was deleted from the arena of opposite parties.  
6. Complainant has filed rejoinder to the written reply of opposite party No. 1 and denied the averments of the opposite party No. 1. 
7. To prove his case the complainant tendered into evidence his own affidavit Ex.C-1, copy of policy Ex.C-2 (containing 14 pages), copy of discharge summary with treatment chart Ex.C-3 & Ex.C-4, copy of collection receipt Ex.C-5, In patient final bill Ex.C-6 to Ex.C-8, claim form Part A Ex.C-9, copies of rejection letters Ex.C-10 & Ex.C-11, copy of query on authorization for cashless treatment letter dated 16.7.2021 Ex.C-12, claim form Ex.C-13, claim form Part B Ex.C-14, pharmacy bills and receipts Ex.C-15 to Ex.C-32 and closed the evidence.   
8. To rebut the case of the complainant the opposite party No. 1  tendered into evidence affidavit of Sumit Kumar Sharma Ex.O.P1/1, copy of proposal form Ex.O.P1/2 (containing 4 pages), copy of probability form Ex.O.P1/3 (containing 5 pages), copy of policy Ex.O.P1/4 (containing 8 pages), copy of terms and conditions Ex.O.P1/5 (containing 6 pages), copy of endorsement schedule Ex.O.P1/6, copy of IRDA guidelines Ex.O.P1/7 (containing 20 pages), copy of request of cashless Ex.O.P1/8 (containing 5 pages), copies of letters Ex.O.P1/9 to Ex.O.P1/12, copy of claim form Ex.O.P1/13 (containing 4 pages), copy of patient admission letter Ex.O.P1/14, copy of discharge summary Ex.O.P1/15 (containing 16 pages), copy of final bill Ex.O.P1/16 (containing 3 pages), copy of repudiation letter Ex.O.P1/17 (containing 3 pages), copy of bill assessment sheet Ex.O.P1/18 (containing 3 pages) and closed the evidence.     
9. We have heard the learned counsel for the parties and have gone through the record on file.  Written arguments filed by the opposite party No. 1.
10. It is not disputed between the parties that the complainant took the policy namely Family Health Optima Insurance 2017 Med-Pro-051 vide  policy No. P/211229/01/2022/000039 which was for the period from 23.4.2021 to 22.4.2022 and a premium of Rs. 15,287/- was charged from the complainant against insurance upto Rs. 5 lacs (Ex.C-2 & Ex.O.P1/4). It is further admitted case of the complainant that the above said policy covering Mr. Rajesh Kumar Garg- Self, Mrs Raj Rani – Spouse, Jashan Garg and Shivansh -Dependent Children for the sum insured Rs. 5,00,000/-. It is further admitted case of the complainant that the complainant on 15.7.2021 was admitted to Dayanand Medical College & Hospital, Ludhiana for treatment vide admission No. 2021035126 and was discharged on 19.7.2021. 
11. Ld. Counsel for the complainant argued that on 14.7.2021 the complainant was having nasal bleeding and at night time when the bleeding was increased then on 15.7.2021 the complainant was admitted to Dayanand Medical College & Hospital, Ludhiana for treatment vide admission No. 2021035126 and was discharged on 19.7.2021 (Ex.C-3 & Ex.C-4) and total expenditure on the treatment was Rs. 90,302/-. It is further argued that the intimation of the claim was given to the opposite party No. 1, but on query it came to the knowledge of the complainant that the claim was rejected. The complainant was shocked to receive a letter dated 17.7.2021 (Ex.C-10) from the opposite party No. 1 stated that the claim has been repudiated on the ground that the insured patient has HYPERTENSION for the last 4 years and the insured has not disclosed the medical history in the proposal form and other portability forms at the time of porting the policy. It is further argued that the complainant neither had hidden any information regarding his prior disease because the complainant was not suffering from such HYPERTENSION as alleged by the opposite party No. 1. It is also argued that the complainant again moved a request a letter that the decision of repudiation be reconsidered, but till date complainant has not received any reply from the opposite party No. 1. Therefore, the above said act and conduct of the opposite party No. 1 falls under the deficiency in service and unfair trade practice on the part of opposite party No. 1.
12. On the other hand, Ld. Counsel for opposite party No. 1 argued that the insured was hospitalized on 15.7.2021 at Dayanand Medical College and Hospital, Ludhiana for the treatment of EPISTASIS and discharged on 19.7.2021. It is further argued that the complainant raised a pre-authorization request to avail cashless facility and subsequently submitted claim documents for reimbursement of medical expenses and on scrutiny of the submitted medical documents, it is observed as under;-
i. As per the indoor case papers of the treating hospital, the insured patient is a known case of hypertension for 4 years which prior to our policy.
ii. Moreover, the insured has not disclosed this medical history at the time of porting the policy. 
It is further argued that from the above finding, it is noted that the insured patient is a known case of the above ailment prior to porting of the policy and the date of commencement of first year policy and the same was found from the claim documents submitted at the time of claim processing. Hence, it is a pre-existing disease and the present admission and treatment of the insured patient is for the complication of the non-disclosed pre-existing disease which is not payable as per 3. Exclusion Pre-Existing Disease- Code Excl 01 of the policy. It is further argued that as per Condition No. 6 of the policy “Disclosure to information 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 or non-disclosure of any material fact by the policy holder”. It is further argued that as per 3. Exclusion Pre-Existing Disease- Code Excl 01 of the policy, the company shall not be liable to make any payments under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of expenses related to the treatment of a pre-existing disease and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer and the above said pre-existing disease is subject to waiting period of 48 months with effect from (PED) incorporation date 2.11.2021. Hence, the cashless request and the claim was rejected and the same was communicated to the insured vide letters dated 17.7.2021 and 6.11.2021 respectively (Ex.O.P1/11 and Ex.O.P1/17). 
13. From the perusal of the file it is established that the insured complainant was admitted in Dayanand Medical College & Hospital, Ludhiana for treatment on 15.7.2021 and was discharged on 19.7.2021. It is further established that the complainant has spent on his treatment an amount of Rs. 90,310/- which shows from the bills Ex.C-6, Ex.C-7, Ex.C-17, Ex.C-19, Ex.C-20, Ex.C-21, Ex.C-23, Ex.C-24, Ex.C-25, Ex.C-26, Ex.C-27, Ex.C-28 and Ex.C-32. On the other hand, the opposite party No. 1 has repudiated the claim of the complainant on the ground that “it is observed from the indoor case records of above hospital, the insured patient has hypertension for the past 4 years which is prior to our policy. The present admission and treatment of the insured patient is for the complication non disclosed hypertension” (Ex.O.P1/17). It is further the case of the opposite party No. 1 that as per the indoor case papers of the treating hospital, the insured patient is a known case of hypertension for 4 years which prior to our policy and the insured has not disclosed this medical history at the time of porting the policy. It is also the case of the opposite party No. 1 that from the above finding, it is noted that the insured patient is a known case of the above ailment prior to porting of the policy and the date of commencement of first year policy and the same was found from the claim documents submitted at the time of claim processing. Therefore, it is a pre-existing disease and the present admission and treatment of the insured patient is for the complication of the non-disclosed pre-existing disease which is not payable as per 3. Exclusion Pre-Existing Disease- Code Excl 01 of the policy.
14. We are of the view that the opposite party No. 1 has failed to place on record any earlier medical record of the complainant to prove the fact that the complainant has Hypertension for the past 4 years. We have perused the copy of proposal form Ex.O.P1/2 vide which at Page No. 2 it is mentioned in the column of Diabetes Mellitus, If yes, since when “Yes” for the last one year and in all the other column it is mentioned “No”. Further, we have perused copy of request for cashless hospitalization for health insurance Ex.O.P1/8 vide which at Page No. 3 in column of Mandatory Past History of any chronic illness, Diabetes is mentioned 4 years and in the column of Hypertension no year is mentioned and this document is stamped by the hospital and signed by the patient's brother not by the insured/complainant. Moreover, in discharge summary Ex.O.P1/15 in column of Diagnosis Hypertension is mentioned but it is not written that the patient has Hypertension for the past 4 years. Further, from Ex.O.P1/15 it shows that the complainant got the treatment of EPISTASIS- POST NASAL CAUTERIZATION and in Ex.O.P1/15 at Page No. 3 it is mentioned in the column of ADVICE: REGULAR HOME MONITORING OF BLOOD SUGAR.   
15. The learned counsel for complainant referred the judgment Civil Appeal No.7437 of 2011 titled as P.Vankat Naidu Vs LIC of India. The Hon'ble Supreme Court of India held that Since the respondents had come out with the case that the deceased did not disclose correct facts relating to his illness, it was for them to produce cogent evidence to prove the allegation. The appeal is allowed. Another case LPA No. 1537 of 2011 titled as Iffco Tokio General Insurance Company Ltd. Vs Permanent Lok Adalat Gurgaon and others 2012(1)R.C.R.(Civil) 901:2012(2)PLR 547 decided on 26.08.2011. The Hon'ble Punjab and Haryana High Court held that the law is well settled with regard to the standard form of contracts. When the bargaining powers of the parties is unequal and consumer has no real freedom to contract the Courts would strike down such unfair and unreasonable clause in a contract where parties are not equal in bargaining power. It was also held that claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the Policy. It was for insurance company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. Claim cannot be denied. 
16. Ld. Counsel for complainant has also relied upon the judgment In R.P. No. 4461 of 2012 in case titled Neelam Chopra Vs Life Insurance Corporation of India & Ors., decided on 8.10.2018 (NC) vide which it was held in Para No. 11 that;-
“From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases. The person insured may suffer consequences in terms of the reduced claims”. 
The Ld. Counsel for complainant further relied upon the Judgment in New India Assurance Company Ltd., Vs Usha Yadav and  others (2008) 151 PLR 313 Punjab and Haryana High Court, Chandigarh, vide which it is held that it seems that the insurance companies are only interested in earning the premiums. 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 company in such cases reply upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy.
17. So, from the above discussion, it is established that the claim of the complainant was repudiated by the opposite party No. 1 on unreasonable and unjustified grounds and there is clear cut deficiency in service on the part of opposite party No. 1. Therefore, the present complaint is partly allowed against the opposite party No. 1 and the opposite party No. 1
is directed to pay Rs. 90,310/- alongwith interest @ 7% per annum to the complainant from the date of filing the present complaint till realization. The opposite party No. 1 is further directed to pay Rs. 5,500/- on account of consolidated amount of compensation as well as litigation expenses to the complainant.
18. Compliance of the order be made within the period of 45 days from the date of the receipt of the copy of this order.
19. Copy of this order be supplied to the parties free of costs as per rules. File be consigned to the records after its due compliance. 
ANNOUNCED IN THE OPEN COMMISSION:
       12th Day of January, 2024
 
            (Jot Naranjan Singh Gill)
            President
 
(Navdeep Kumar Garg)
Member
 
 
[HON'BLE MR. Sh.Jot Naranjan Singh Gill]
PRESIDENT
 
 
[HON'BLE MR. Navdeep Kumar Garg]
MEMBER
 

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