Chandigarh

DF-I

CC/27/2024

GURCHARAN SINGH - Complainant(s)

Versus

STAR HEALTH AND ALLIED INSURANCE CO. LTD. - Opp.Party(s)

SUKHANDEEP SINGH

01 Aug 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/27/2024
Date of Institution	:	03/01/2024
Date of Decision	:	01/08/2024

 

Gurcharan Singh s/o Hari Singh r/o Popular Book Depot, Shop No.9, Hospital Road, Kharar, Punjab – 140301.

… Complainant

V E R S U S

Star Health and Allied Insurance Co. Ltd., Branch Office – Chandigarh, SCO 5A, 2^nd Floor, Madhya Marg, Sector 7C, Chandigarh, through the Branch Manager.

… Opposite Party

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                       

ARGUED BY	:	Sh. Sukhandeep Singh, Advocate for complainant
	:	Ms. Surabhi Grover, Advocate for OP

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Gurcharan Singh, complainant against the aforesaid opposite party (hereinafter referred to as the OP).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that on 21.12.2017, complainant had purchased a health insurance policy namely “Family Health Optima Insurance Plan” covering himself and his wife, Smt. Satwant Kaur with sum insured of ₹10.00 lacs on payment of premium of ₹25,158/- and the same was valid w.e.f. 21.12.2017 to 20.12.2018. The aforesaid policy was got renewed by the complainant annually and the sum insured was also enhanced on payment of higher premium from time to time and finally the subject policy was issued/renewed by the OP which was valid w.e.f 28.12.2022 to 27.12.2023 (Ex.C-2). Earlier the complainant had filed a consumer complaint against the OP with respect to the treatment given to his wife who had taken treatment in the Max Super Speciality Hospital, Mohali as the OP had repudiated the claim on wrong grounds and the same was allowed in his favour. 

Unfortunately, on 6.10.2023, wife of the complainant (hereinafter referred to as “insured patient”) again fell ill and was taken to Max Super Specialty Hospital (hereinafter referred to as “treating hospital”) where she was diagnosed with the problem of bronchial asthma and other respiratory problem and she remained admitted w.e.f. 6.10.2023 to 10.10.2023. The treating hospital had lodged cashless claim for treatment of the insured patient with the OP, but, the same was rejected/repudiated by the OP vide letter dated 6.10.2023 (Ex.C-4 & C-5) on the ground that the insured patient was suffering from pre-existing disease under exclusion clause 01 of the insurance policy and the claim is not admissible under the policy until expiry of 48 months from the date of inception of the first policy. Having left with no option, the complainant was forced to pay the medical treatment bills from his own pocket to the tune of ₹2,34,224/- to the treating hospital and copy of discharge summary and hospital bills are Ex.C-6 & Ex.C-7. Thereafter, complainant again approached the OP with the request to reimburse his genuine claim, but, with no result. In this manner, OP has wrongly repudiated the genuine claim of the complainant and the said act amounts to deficiency in service and unfair trade practice on its part. OP was requested several times to admit the claim, but, with no result. Hence, the present consumer complaint.

2. OP resisted the consumer complaint and filed its written version, inter alia, taking preliminary objections of maintainability, cause of action, concealment of material facts, jurisdiction and also that there is no deficiency in service or unfair trade practice on its part.  On merits, admitted that the subject policy was issued to the complainant and the same was valid at the relevant time.  However, it is alleged that as the insured patient was suffering from pre-existing disease even before the inception of the subject policy, which fact was not disclosed at that time and further the claim of the complainant is also excluded under the exclusion clause and same is only admissible after expiry of 48 months from the date of inception of the subject policy, the cashless request of the complainant was rightly repudiated/rejected by the OP and the consumer complaint is not maintainable. The facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. The complainant chose not to file rejoinder.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the subject policy was purchased by the complainant first time on 21.12.2017, regarding which reference has also been made in the subject policy (Ex.C-2) valid w.e.f. 28.12.2022 to 27.12.2023 covering the complainant and his wife, Smt. Satwant Kaur (insured patient) and she had taken treatment from the treating hospital, where she remained admitted w.e.f. 6.10.2023 to 10.10.2023, as is also evident from the discharge summary (Ex.C-6) and the cashless request made by the complainant was repudiated/rejected by the OPs, as is also evident from the cashless claim rejection letters (Ex.C-4 & C-5), the case is reduced to a narrow compass as it is to be determined if the OP is unjustified in rejecting/repudiating the genuine claim of the complainant on the ground that the disease/ condition has been incorporated as a pre-existing disease in the policy schedule and as per the waiting period/exclusion No.01, a claim for pre-existing disease is not admissible until expiry of 48 months from the date of inception of the first policy and the complainant is entitled for the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OP is justified in rejecting/repudiating the claim of the complainant and the consumer complaint, being false and frivolous, is liable to be dismissed, as is the defence of the OP.
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, medical record and the repudiation letter, and the same are required to be scanned carefully to determine the controversy between the parties.
   3. Perusal of the policy schedule (Ex.OP-3) clearly indicates that in case of pre-existing disease to the insured patient, expenses related to treatment of such disease be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy.  The relevant portion of the same is reproduced below for ready reference:-

“3. EXCLUSIONS

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,

STANDARD EXCLUSIONS

1.Pre-Existing Diseases-Code Excl 01

a. 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

xxx                   xxx                   xxx”

4. In the present case, OP insurer had sent two rejection letters of authorisation for cashless treatment (Ex.C-4 & Ex.C-5) which specifically referred to exclusion clause 01 of the policy schedule  and the relevant portion of the same is reproduced below for ready reference :-

1.The above disease/condition has been incorporated as a pre-existing disease in the policy schedule. As per waiting period/exclusion no. Excl 01 a the claim for treatment of the pre-existing disease/ condition is not admissible until expiry of 48 months from the date of inception of the first policy.”

5. The discharge summary (Ex.C-6) further indicates that the insured patient was diagnosed with acute exacerbation of bronchial asthma type II respiratory failure and the relevant portion of the discharge summary is reproduced below for ready reference :-

Final diagnosis 

Acute exacerbation of bronchial asthma

Type ii respiratory failure

CAD/Lv systolic dysfunction/Ef~40%Rwma in LAd

Af with Fvr

Seizure disorder

Presenting Complaints:

        Shortness of breath since 1 week, aggravated since 4 days

        Fever since 2 days - around 100 f

Cough since I week.

Past Medical History:

Bronchial asthma x 2 years”

6. Thus, one thing is clear from the documents, having been relied upon by both the parties in the present case, that the complainant had taken treatment for bronchial asthma on 10.10.2023 and since as per the policy schedule the said medical expenses are not covered for four years from the date of inception of the subject policy i.e. 21.12.2017 till 21.12.2021, the claim of the complainant does not fall under the aforesaid exclusion clause of the subject policy as the present treatment was taken by the complainant in the year 2023, making further clear that the OPs have wrongly misinterpreted the exclusion clause of the policy schedule and thereby rejected/ repudiated the cashless request of the complainant and the said act clearly amounts to deficiency in service and unfair trade practice on its part.
7. In view of the aforesaid discussion, it is safe to hold that the complainant has successfully proved the cause of action set up in the consumer complaint and the present consumer complaint deserves to succeed.
8. Now coming to the quantum of relief, since the complainant has proved the duplicate settlement receipt (Ex.C-7) dated 10.10.2023 through which he paid the amount of ₹2,34,224/- to the treating hospital for the treatment of the insured patient, it is safe to hold that OP/insurer is liable to pay the said amount to the complainant alongwith interest and compensation etc. for the harassment caused.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OP is directed as under :-

1. to pay ₹2,34,224/- to the complainant alongwith interest @ 9% per annum (simple) from the date of payment to the treating hospital i.e. 10.10.2023 onwards.
2. to pay ₹10,000/- to the complainant as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OP, within a period of 45 days from the date of receipt of certified copy thereof, failing which the amounts mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

01/08/2024	Sd/- [Pawanjit Singh] President
	Sd/-
	[Surjeet Kaur] Member
	Sd/-
	[Suresh Kumar Sardana] Member