DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, CAMP COURT AT AMRITSAR, PUNJAB.

 

Complaint Case No : RBT/CC/2018/267

Date of Institution : 6.04.2018/29.11.2021

Date of Decision : 04.07.2022

Arwinder Singh son of S. Sohan Singh aged about 49 years resident of 49-A, Kot Atma Ram, Sultanwind Road, Near Harman Dairy, Amritsar.    …Complainant

Versus

1. Star Health and Allied Insurance Company Limited, 1st Floor, Himalaya House, 23, Kasturba Gandhi Marg, New Delhi-110001 through its Manager/Senior Divisional Manager/Person Over All Incharge.

2. Star Health and Allied Insurance Company Limited, having its office at SCO-25, District Shopping Complex, B-Block, Ranjit Avenue, Amritsar through its Senior Divisional Manager/Person over all Incharge.

3. Fortis Escorts Hospital, Majitha-Verka Bypass road, Amritsar-143004 through Medical Superintendent/concerned treated doctor/Person over all Incharge. 

…Opposite Parties

 

Complaint U/S 11 and 12 of The Consumer Protection Act

Present: Sh. Avtar Singh counsel for complainant.

Sh. RP Singh Adv counsel for the opposite parties No. 1&2.

Sh. Sanjeet Singh counsel for opposite party No. 3.

Quorum.-

1. Sh. Ashish Kumar Grover : President

2. Sh. Navdeep Kumar Garg  : Member

(ORDER BY ASHISH KUMAR GROVER PRESIDENT):

    The present complaint has been received by transfer from District Consumer Commission, Amritsar in compliance of the order dated 26.11.2021 of the Hon'ble State Consumer Disputes Redressal Commission, Punjab, Chandigarh. The complainant Arwinder Singh filed the present complaint under Section 11 and 12 of the Consumer Protection Act against Star Health and Allied Insurance Company Limited, New Delhi and others. (in short the opposite parties). 

2. The facts leading to the present complaint as stated by the complainant are that the complainant obtained Mediclaim Health Insurance policy from ICICI Lombard Health Insurance Company for the period of two years 2010 to 2012 covering the risk of complainant as well as his family members consisting of himself, Manpreet Kaur wife of complainant, Harminder Kaur daughter of complainant and Gurdeep Singh son of complainant up to Rs. 3,00,000/- and complainant paid premium to the said insurance company. During the validity of said policy on 30.12.2010 the son of the complainant namely Gurdeep Singh met with an accident and he immediately taken to Amandeep Hospital, Amritsar where he was diagnosed as Head Injury with lacerated wound forehead Lt. Side temporal region and got admitted in hospital where he got operated by the doctors and discharged on 15.1.2011 and under the said health insurance policy the insurance company has made the payment of medical treatment of the son of the complainant to the said hospital by admitting the claim as genuine one. Later on the complainant ported his policy with the insurance company of opposite party and policy of complainant renewed by the opposite party after porting the same covering the risk up to Rs. 5,00,000/- for the period from 17.11.2016 to 16.11.2017 against the premium amount received from the complainant. Then the same was renewed on 17.11.2017 to 16.11.2018 and opposite parties issued policy bearing No. P/700016/01/2018/005580 to the complainant. 

3. During the validity of said policy son of complainant Gurdeep Singh suffered severe headache and vertigo problem and he went to Amandeep Hospital where some test were conducted and he was referred to Fortis Escorts Hospital, Amritsar where he was admitted on 23.11.2017 and discharged on 24.11.2017. At the time of admission complainant gave card which was issued by insurance company for cashless treatment but hospital authority refused the complainant to provide cashless facility stating that the insurance company has refused to give cashless facility because patient deliberately disclosed the PED of Gurdeep Singh. The complainant spent Rs. 40,000/- on the medical treatment of his son Gurdeep Singh. Thereafter, all the bills alongwith documents have been sent to opposite parties No. 1 and 2 for reimbursement but opposite parties No. 1 and 2 have repudiated the genuine claim of complainant which is deficiency in service on the part of opposite parties. Hence, the present complaint is filed seeking the following reliefs.-

1) The opposite parties may be directed to pay a sum insured amount of Rs. 50,000/- alongwith interest at the rate of 12% per annum. 

2) To pay Rs. 25,000/- on account of compensation for mental agony and harassment. 

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

4) Any other relief to which the complainant is found entitled. 

4. Upon notice of this complaint, the opposite parties No. 1 and 2 filed written statement taking preliminary objections that the complainant availed Family Health Optima Insurance Plan cover Arvinder Singh self, Manpreet Kaur spouse, Harminder Kaur, Gurdeep Singh and Guriqbal Singh children for the sum insured of Rs. 5,00,000/- vide latest policy No. P/700016/01/2018/005580 17.11.2017 to 16.11.2018. The terms and conditions of policy were explained to the complainant. The complainant himself admitted that Gurdeep Singh son of complainant undergone treatment for head injury and got admitted in Amandeep Hospital, Amritsar from 30.12.2010 to 15.1.2011 and this fact was not disclosed by the complainant at the time of porting of policy and violated the condition No. 8 of the policy terms and conditions. When this fact has come to the notice of opposite parties the policy in respect of Gurdeep Singh has been cancelled w.e.f. 6.1.2018 and premium has been refunded. 

5. On merits, it is submitted that the complainant himself approached the opposite parties for getting the policy. The opposite parties received the pre-authorization request for treatment and after going through the medical record provided by the complainant it was found that previous treatment record was called regarding head injury vide letter dated 23.11.2017. The complainant submitted Amandeep Hospital discharge summary dated 30.12.2010 which confirmed that the insured patient has history of recurrent lica occlusion. So pre-authorization request for cashless treatment was rejected vide letter dated 24.11.2017. It is submitted that only cashless authorization was rejected and not repudiated the claim. Lastly, the opposite parties No. 1 and 2 prayed for the dismissal of the present complaint with costs. 

6. The opposite party No. 3 filed written version taking preliminary objections that the complainant is not covered under the definition of consumer. The complainant has no locus standi to file the present complaint. On merits, it is admitted that Gurdeep Singh admitted in the hospital of opposite party No. 3 on 23.11.2017 and discharged on 24.11.2017. The cashless approval was sought from opposite parties No. 1 and 2 who rejected vide intimation dated 24.11.2017. The opposite party No. 3 has nothing to do as far as approval of cashless claim is concerned. The insurance policy is agreement between the complainant and opposite parties No. 1 and 2. Lastly, the opposite party No. 3 prayed for the dismissal of the present complaint qua opposite party No. 3. 

7. In support of his complaint, the complainant tendered into evidence his affidavit Ex.CW-1/A alongwith documents Ex.C-1 to Ex.C-24 and closed the evidence. 

8. To rebut the case of the complainant, the opposite parties No. 1 and 2  tendered in evidence affidavit of PC Tripathi Ex.OP-1.2/A, copy of power of attorney Ex.OP-1.2/1, copy of letter dated 17.11.2017 Ex.OP-1.2/2, copy of cancellation of policy Ex.OP-1.2/3, copy of policy Ex.OP-1.2/4, copy of policy Ex.OP-1.2/5, copy of pre authorization request Ex.OP-1.2/6, copy of query letter dated 23.11.2017 Ex.OP-1.2/7, copy of report dated 22.11.2017 Ex.OP-1.2/8, copy of MRI report Ex.OP-1.2/9, copy of discharge summary Ex.OP-1.2/10, copy of rejection letter Ex.OP-1.2/11, copy of proposal form Ex.OP-1.2/12, copy of statement of insured Ex.OP-1.2/13, copy of terms and conditions Ex.OP-1.2/14, copy of policy Ex.OP-1.2/15, copy of potability form Ex.OP-1.2/16 and closed the evidence. Opposite party No. 3 tendered in evidence affidavit of Dinesh Vashish Ex.OP-3/1, copy of consent form Ex.OP-3/2, copy of rejection letter dated 24.11.2017 Ex.OP-3/3 and closed the evidence. 

9. We have heard the learned counsel for the parties and gone through the record on the file. 

10. The complainant alleged in the complaint that he obtained medical health insurance policy from ICICI Lombard Health Insurance Company for the period of 2010 to 2012 covering the risk of complainant as well as his family members consisting of himself, Manpreet Kaur wife of complainant, Harminder Kaur daughter of complainant and Gurdeep Singh son of complainant. The complainant alleged in the complaint that during the validity of said policy on 30.12.2010 the son of the complainant namely Gurdeep Singh met with an accident and he immediately taken to Amandeep Hospital, Amritsar where he was diagnosed as Head Injury where he got operated by the doctors and discharged on 15.1.2011 and under the said health insurance policy the ICICI Lombard Health Insurance company has made the payment of medical treatment of the son of the complainant to the said hospital by admitting the claim as genuine one. The said policy was continued with the ICICI Lombard Health Insurance Company till 2016. In the year 20167 the complainant ported his policy with the opposite party and policy of complainant renewed by the opposite party after porting the same covering the risk up to Rs. 5,00,000/- for the period from 17.11.2016 to 16.11.2017. Thereafter, the said policy was again renewed from 17.11.2017 to 16.11.2018 and opposite parties issued policy bearing No. P/700016/01/2018/005580 to the complainant. 

11. The complainant further alleged in the complaint that during the validity of the said policy son of complainant Gurdeep Singh suffered severe headache and vertigo problem and he went to Amandeep Hospital where some tests were conducted and he was referred to Fortis Escorts Hospital, Amritsar where he was admitted on 23.11.2017 and discharged on 24.11.2017. The opposite party refused the complainant to provide cashless facility because patient deliberately disclosed the PED (Pre Existing Disease) of Gurdeep Singh. The complainant spent Rs. 40,000/- on the medical treatment of his son Gurdeep Singh and applied for reimbursement but opposite parties No. 1 and 2 have repudiated the genuine claim of complainant. 

12. On the other hand the opposite parties No. 1 and 2 filed written version and admitted the insurance policy and they also admitted that the complainant ported the insurance policy and joined with the opposite parties. The opposite parties alleged in the written version that the complainant himself admitted the head injury of his son and this fact was not disclosed at the time of porting of the policy and same is the violation of condition No. 8 of the policy terms and conditions therefore, the policy of Gurdeep Singh has been cancelled w.e.f. 6.1.2018 and premium has been refunded. The opposite party mentioned in the written version that the claim was rightly repudiated by the opposite party.

13. The learned counsel for the complainant argued that the complainant has taken the said insurance policy from 2010 and the policy is continued without any obstacle. The learned counsel for the complainant also argued that it is the duty of the opposite parties to check entire record before porting the policy but the opposite parties have not taken any necessary action in this regard. The complainant has not concealed any facts from the opposite parties.

14. On the other hand the learned counsel for the opposite parties argued that the complainant concealed the material facts from the opposite parties by not disclosing the pre existing disease of his son Gurdeep Singh. The complainant has produced the medical treatment record of Gurdeep Singh which was taken by him in the year 2010. The complainant has produced the medical bill Ex.C-19 dated 15.1.2011 where the name and address of insurance company is mentioned as ICICI Lombard Health Insurance Company. The complainant alleged in the complaint that the entire payment was made by the ICICI Lombard Health Insurance Company and the said policy was renewed time to time by the ICICI Lombard Health Insurance Company. The complainant has also paid two premiums to the Star Health and Allied Insurance Company Limited and ported his policy. The learned counsel for the complainant argued that when the policy was ported all the benefits of the policy continued with the new insurance company. Learned counsel for the complainant further argued that the claim of the complainant was repudiated by the opposite parties on unreasonable grounds as the benefits of the policy remained same as per previous policy. The opposite parties have not denied this fact that ICICI Lombard Health Insurance Company made the payment of the treatment of Gurdeep singh in the year 2011. It is the duty of the insurance company to verify the entire record before porting the insurance policy. Once the   insurance policy has been ported then the benefits of the policy remained same as per the previous policy. Therefore, the opposite parties cannot denied the valid claim after ported the policy. The complainant has produced the medical bills of Fortis Escorts Hospital Ex.C-7 vide which the complainant has paid Rs. 39,091/- to the hospital. 

15. The learned counsel for the complainant argued that the claim cannot be denied as the policy is continued since 2010. The learned counsel for the complainant also submitted the judgment of Hon'ble Punjab and Haryana High Court (DB) 2012 (1) RCR (Civil)-901 in which the Hon'ble High Court 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. Single judge allowed the claim on the ground that 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. No interference called for in the order of Single Judge. Held the pre-existing condition existed in the year 2002 which was five years prior to acquiring Insurance Policy. Claim cannot be denied. 

16. From the above discussion, it established that the claim of the complainant was repudiated by the opposite parties No. 1 and 2 on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties No. 1 and 2. Therefore, present complaint is partly allowed against the opposite parties No. 1 and 2. Accordingly, opposite parties No. 1 and 2 are directed to pay Rs. 39,091/- to the complainant alongwith interest at the rate of 6% per annum from the date of filing of present complaint till actual realization. The opposite parties No. 1 and 2 are further directed to add the name of Gurdeep Singh son of the complainant in the policy w.e.f. 6.1.2018 after receiving the premium amount from the complainant from that date i.e. 6.1.2018. The opposite parties No. 1 and 2 are also directed to pay Rs. 10,000/- to the complainant as compensation for mental tension and harassment and Rs. 5,500/- as costs and litigation expenses. Both the opposite parties No. 1 and 2 jointly and severally liable to comply with the above mentioned order. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order will be supplied to the parties by the District Consumer Disputes Redressal Commission, Amritsar as per rules. File be sent back to the District Consumer Disputes Redressal Commission, Amritsar. 

ANNOUNCED IN THE OPEN COMMISSION:

        4th Day of July 2022

 

 

            (Ashish Kumar Grover)

            President

              

(Navdeep Kumar Garg)

Member