BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL FORUM, JALANDHAR.
Complaint No.226 of 2018
Date of Instt. 22.05.2018
Date of Decision: 25.09.2019
Ashok Kumar Grover son of Sh. Jamna Dass, resident of H. No.66, Master Tara Singh Nagar, Jalandhar-144001.
..........Complainant
Versus
1. Star Health and Allied Insurance Co. Ltd. No.15, Sri Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai-600014 through it’s Senior Divisional Manager/Senior Branch Manager.
2. Star Health and Allied Insurance Co. Ltd. it’s branch office at EH-198, 2nd Floor, Nirmal Complex, G. T. Road, Jalandhar through its Branch Manager/Authorized Signatory.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Sh. Karnail Singh (President)
Smt. Jyotsna (Member)
Present: Sh. V. P. Sharma, Adv. Counsel for the Complainant.
Sh. A. K. Arora, Adv Counsel for the OPs.
Order
Karnail Singh (President)
1. This complaint has been filed by the complainant Ashok Kumar Grover, wherein stated that the OP No.2 is branch office of OP No.1 and representative of OP No.2 approached the complainant at his residence and persuaded complainant to purchase the Star Comprehensive Insurance-2015 i.e. Health Insurance Policy and accordingly, on the inspiration of agent of the OP No.2, the complainant got Star Comprehensive Insurance-2015-Health Insurance Policy bearing No.P/161125/01/2017003411 for Rs.5,00,000/- commencing from 23.02.2017 to 22.02.2018 after making payment of the premium of Rs.32,844/-.
2. That the complainant got admitted in the Escorts Heart Institute and Research Centre Ltd. New Delhi on 08.11.2017 due to chest pain and detected major block and advised for Coronary Artery Disease and the complainant remained admitted in the hospital for 8 days and was discharged on 15.11.2017. Thereafter, the complainant submitted an insurance claim of Rs.5,00,000/- i.e. Rs.3,77,000/- against bill No.1201/17/1/CS/0103504 dated 15.11.2017 + Rs.33,860/- against bill No.1111/17/1/CS/0105345 dated 03.11.2017 + Rs.5000/- against receipt dated 02.11.2017 and other medicines and misc. expenses with the OP, vide claim No.CLI/2018/161125/0427764. The OP repudiated the claim of the complainant on a frivolous ground by stating “although the present admission and treatment of the insured patient is for Coronary Artery Disease, it is observed from the claim verification report, the treating doctor Dr. Tarun Aggarwal from Swastik Medical Centre stated that the patient is suffering from Rheumatoid Arthritis since long time back this confirms the patient had Rheumatoid Arthritis prior to inception of the medical insurance policy. Further, the insured has not submitted the previous documents relating to Rheumatoid Arthritis inspite of our query, which amounts to non-submission of required documents”. The complainant has been unnecessarily harassed by the OP and also caused great physical and mental agony to the complainant by not accepting the insurance claim of the complainant and as such, necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to pay Rs.5,00,000/- as medical insurance claim of the complainant and further OPs be directed to pay Rs.25,000/- as compensation to the complainant and be also directed to pay litigation expenses of Rs.25,000/-.
3. Notice of the complaint was given to the OPs and accordingly, both the OPs appeared through its counsel and filed joint written reply, whereby contested the complaint by taking preliminary objections that the complainant was firstly admitted at Fortis Hospital Limited-Gurgaon on 02.11.2017 and the medical records submitted to the insurance company by the complainant revealed that the disease of the complainant is of long standing nature and the same has not been disclosed in the proposal form, therefore, pre authorization request for cashless treatment was denied by the OP. Thereafter, the insured was admitted at Escorts Heart Institute & Research Centre Limited, New Delhi on 08.11.2017 for the treatment of Coronary Artery Disease and raised pre-authorization request for cashless treatment and the same was denied, since CAG report of the complainant showed Chronic Long Standing Multi Vessel Coronary Artery Disease and further the duration of Rheumatoid Arthritis was also not clear as per the documents submitted by the complainant to the insurance company. On the scrutiny of the claim records of the complainant submitted by the complainant to the insurance company, it was observed that:
a. The investigation report shows that the insured has rheumatoid arthritis.
b. During claim verification report, the treating doctor Dr. Tarun Aggarwal from Swastik Medical Centre stated that the patient is suffering from Rheumatoid Arthritis since long time back.
The above findings confirm that the insured has not submitted the previous documents relating to Rheumatoid Arthritis inspite the query of the OP, which amounts to non submission of required documents by the complainant. Rheumatoid Arthritis is a long term autoimmune disorder disease, which is not payable as per the terms and conditions of the policy. If the insured would have disclosed the same in the proposal form, the policy would have not served to him and as such, as per condition No.9 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 company is not liable to make any payment in respect of any claim and further as per condition No.14 of the policy, the insurance policy is also liable to be cancelled by the insurance company and further submitted that the non-disclosure of these material facts at the time of taking of insurance policy from the answering OPs amount to misrepresentation by the complainant, therefore, the claim of the complainant was rightly repudiated by the answering OP and was communicated to the insured, vide repudiation letter dated 06.02.2018. The OP has also raised so many other preliminary objections and further, on merits, it is admitted that the complainant got insurance policy from the OP and thereafter, submitted a medical insurance claim, which was rightly and legally repudiated. The other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
4. In order to prove the case of the complainant, the counsel for the complainant tendered into evidence affidavit of the complainant Ex.CA alongwith some documents Ex.C-1 to Ex.C-6 and then closed the evidence.
5. Similarly, counsel for the OPs tendered into evidence affidavit Ex.OPA along with some documents Ex.OP-1 to Ex.OP-22 and closed the evidence.
6. We have heard the learned counsel for the respective parties and also gone through the case file very minutely.
7. From the pleadings as well as documents, we observed that the factum in regard to purchasing an insurance policy by the complainant known as Star Comprehensive Insurance Policy-2015, Health Insurance Policy from the OP, after paying premium of Rs.34,844/- and the period of the said policy is also admitted 23.02.2017 to 22.02.2018 is not in dispute and further the complainant remained admitted in the hospital, where-from he got Coronary Artery disease treatment and then submitted an insurance bill, which was also admittedly repudiated by the OPs and now question remains before us only whether the claim of the complainant has been repudiated by the OP as per terms and conditions of the insurance policy or not, for that purpose, first of all, we have to go through the repudiation letter, which is available on the file Ex.OP-20 and the same has been also produced on the file by the complainant Ex.C-3. In the said repudiation letter Ex.OP-20 dated 20.01.2018, the claim of the complainant has been repudiated on the ground that the complainant was suffering from Rheumatoid Arthritis disease, which is pre-existing disease prior to inception of the medical insurance policy and the said disease allegedly had not been disclosed by the complainant at the time of inception of the policy, which amounts to misrepresentation/non-disclosure of material facts and by applying condition No.9 of the insurance policy, the claim of the complainant was repudiated, vide repudiation letter Ex.OP-20 dated 20.01.2018.
8. Further, to prove that there was pre-existing disease to the complainant known as Rheumatoid Arthritis disease, the OP made reliance upon the statement of Dr. Tarun Aggarwal, who allegedly stated that the complainant/patient is suffering from Rheumatoid Arthritis disease since long time back and further made reliance upon the statement of the complainant itself, which was recorded by the Investigator, copy of the same is Ex.OP-19 and wherein the complainant categorically admitted that the prescription slip is not with him, but he was taking Recita Forte, Folvita, Folitax 7.5 mg oxyfruit capsule from August 2017 and the said medicine was prescribed by Dr. Shubhang Aggarwal and further, the OP has brought on the file report of the Investigator, which is Ex.OP-18, who also conclude that the complainant was suffering from Rheumatoid Arthritis disease for a long time back as per the evidence collected by him. So, making a base of these evidence, an insurance claim of the complainant has been repudiated by the OP.
9. First of all, we make assure from the above documentary evidence of the complainant that the evidence of the OP is whether sufficient to prove that complainant was very much aware at the time of inception of the policy that he was suffering from Rheumatoid Arthritis disease, but in order to prove these facts, there is even not iota of the evidence came on the file, where-from we can ascertain that the complainant was taking medicine of Rheumatoid Arthritis disease since the day of inception of the policy i.e. prior to 23.02.2017. Though, Dr. Tarun Aggarwal medically checked up the complainant in the month of August, 2017, as per version of the complainant that he started the said medicine in the month of August, 2017 as stated in his own statement Ex.OP-19 and if the factum in regard to disease of Rheumatoid Arthritis came to the notice of the complainant in the month of August, 2017, then we can say without any hesitation that the complainant was not aware at the time of inception of the policy or filling of the proposal form, if so, then the question of misrepresentation or concealment of any pre-existing disease does not arise at all. Further, the statement recorded by the investigator of the complainant Ex.OP-19 is also corroborated with the report submitted by the Investigator Ex.OP-18 in the last page i.e. conclusion part itself says that “The patient had the name of one medicine for Rheumatoid Arthritis in his mobile, which was saved on 22nd August, 2017. When Investigator asked him from when he was using this medicine, complainant stated that it was from August, 2017”. So, again this fact has came on the file that the said medicine for disease of Rheumatoid Arthritis has been started taking by the complainant in the month of August, 2017, whereas the policy was obtained on 23.02.2017. So, from any angle, it is not established that the complainant has concealed any pre-existing disease, being reason if the complainant is not aware about any disease at the time of inception of the policy, then how he can disclose the same, though it was discovered by the doctor later on in the month of August. So, from any angle, the version of the OP is not established and in support of this observation, we like to refer a pronouncement of our own State Commission, cited in 2007(1) C. P. J. 260, titled as “Oriental Insurance Company Limited Vs. Chain Singh and anr.”, wherein his Lordship held as under:-
“Insurance- Mediclaim policy-Policy valid from 02.10.2003 to 01.10.2004- In November 2003, complainant hospitalized in Heart Institute- Underwent CABG operation – Claim repudiated on ground that complainant was known case of coronary artery disease for last 5-6 years- complaint allowed by District Forum – Appeal against – Nothing on record that complainant ever took any medicine for said disease or underwent any test or any other investigation – As per opinion of doctor, disease not pre-existing at time when initial policy taken i.e., 01.08.1998- Order of District Forum affirmed.”
On the same point, we further like to refer an other pronouncement of Hon’ble Delhi State Commission, cited in 2004(1) C.P.J. 388, titled as “New India Assurance Co. Ltd. Vs. Pushpa Verma”, wherein his Lordship held as under:-
“Consumer Protection Act, 1986 Section 15 Insurance- Medi-claim policy- Repudiation of claim on ground of pre-existing disease – No reliable evidence adduced in support – Repudiation arbitrary- Deficiency in service proved- Damages and cost reduced in appeal”
Then again we took an opportunity to refer a pronouncement of Hon’ble National Commission, cited in 2010(1) C.P.R. 263, titled as “National Insurance Co. Ltd. Vs. P. Govindarajulu and Reddy and another”, wherein his Lordship held as under:-
“Consumer Protection Act, 1986 Sections 12 and 17 Repudiation of Medi-claim on ground of suppression of earlier disease- Insured fell down, developed severe pain in both knees and was operated by surgery incurring total expenditure of Rs.3,47,274/- -Complaint allowed by District Forum- Revision petition against – Question arises to whether there was in fact any concealment of pre-existing disease by complainant-Discharge-summary though mentioned “pain swelling stiffness both knees joints since one year, but no mention that patient was suffering from Rheumatoid Arthritis before commencement of policy- Medical opinion of orthopaedic surgeon produced by appellant got no support by affidavit and nor that surgeon had ever examined the complainant- Failure on part of OP produce any evidence regarding any treatment for that disease prior to taking policy- Surveyor appointed by appellant was bachelor in Technology and not an orthopaedic surgeon- No interference warranted”
10. If we see the complaint of the complainant in the light of above detailed discussion, then we find that the complainant is entitled for the relief claimed and accordingly, the complaint of the complainant is partly accepted and OPs are directed to pay the medical insurance claim of the complainant of Rs.5,00,000/- with interest @ 12% per annum from the date of repudiation i.e. 20.01.2018, till realization and further, OPs are directed to pay compensation to the complainant for causing mental tension and harassment, to the tune of Rs.15,000/- and OPs are also directed to pay litigation expenses of Rs.10,000/-. The entire compliance be made within one month from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
11. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jyotsna Karnail Singh
25.09.2019 Member President
