BEFORE THE DISTRICT CONSUMER DISPUTES

REDRESSAL COMMISSION, JALANDHAR.

Complaint No.45 of 2018

      Date of Instt. 29.01.2018

      Date of Decision: 30.11.2021

Sh. Madan Mohan Sharma age about 71 years S/o Late Sh. Harbans Lal Sharma Office at 8, New Adarsh Nagar, Jalandhar, Punjab.

..........Complainant

Versus

1.       Star Health and Allied Insurance Co. Ltd. office address EB-198,      Second Floor, Nirmal Complex, G. T. Road, Jalandhar, Punjab    through its Manager.

2.       Star Health and Allied Insurance Co. Ltd. Regd & Corporate   Office 1, New Tank Street, Valluvar, Kottam High Road,   Nungambakkam, Chennai-600034 through managing director.

….….. Opposite Parties

Complaint Under the Consumer Protection Act.

Before:        Dr. Harveen Bhardwaj             (President)

                   Smt. Jyotsna                            (Member)                                         

                     Sh. Jaswant Singh Dhillon       (Member)

Present:        Sh. Rajneesh Dev, Adv. Counsel for the Complainant.  

                   Sh. A. K. Arora, Adv. Counsel for the OPs No.1 & 2.

Order

Dr. Harveen Bhardwaj (President)

1.                This complaint has been filed by the complainant, wherein he has alleged that the he purchased health insurance policy under senior citizen Red Carpet Insurance vide policy No.P/161125/01/2016/002534 for the period of 07.01.2016 to 06.01.2017 self for the sum insured Rs.2,00,000/-. During the subsistence of insurance contract, the complainant paid the premium without any default or lapse under the policy cover. The complainant never contravenes any terms and conditions of the insurance contract. That suddenly complainant suffered heart problem covered under the said policy and remained admitted in Shri Ram Cardiac Centre, Kapurthala Chowk, Jalandhar treated by Senior Doctors including Sh. V. P. Sharma for the heart problem CAD, Acute AWMI with reteplase LV Dysfunction (EF-27%). He remained admitted indoor patient from 01.02.2016 to 03.02.2016 and spent huge amount for his treatment covered under the aforesaid terms and conditions of the policy. The complainant discharged on 03.02.2016 from the hospital in stable condition with instruction of the doctors for follow up. After the treatment the complainant is hale and hearty. That immediately after discharge, the complainant lodged medical for the reimbursement of medical expenses. OPs vide letter dated 01.03.2016 called certain information and documents which were supplied by the complainant. Despite the supply of said information, the OPs did not settle the claim till date with malafide and dishonest intention which amounts to unfair trade practice and deficiency in service. Even again the information was supplied vide notice dated 26.05.2017 which was replied by the OPs on 23.06.2017 again called same documents for the settlement of claim. The complainant supplied all the original documents to the OPs alongwith the claim form to the OPs, the copies of the said record was again sent with notice dated 28.08.2017 alongwith prescription slip issued by Sikka Hospital, Jalandhar 29.09.2014 as called in the letter dated 23.06.2017 by the OPs. That the complainant had a problem of Supra-ventricular Tachycardia and the doctor advised him to take Tab Diltiazem 90 mg OD, whenever a need occur. The said problem was not a heart problem or connected with the terms and conditions of the present health insurance policy. The complainant went pillar to post to settle the claim and for the reimbursement of the medical expenses suffered from 01.02.2016 till treatment submitted with the medical claim, but the OPs neither settled the claim nor repute the claim, which is unfair trade practice and deficiency in service 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 settle the claim and pay Rs.58,600/- as medical claim and further OPs be directed to pay Rs.50,000/- as compensation and Rs.11,000/- as litigation expenses.

2.                Notice of the complaint was given to the OPs, who filed reply and contested the complaint by taking preliminary objections that no cause of action arisen in favour of the complainant to file the present case. It is submitted that the OPs have acted strictly on the basis of the terms and conditions contained in the policy and as per the insurance contract. The present case is premature. It is further averred that the complaint has been filed by the complainant with malafide intention and further to grab the public money. Hence the present complaint is liable to be dismissed.  It is further averred that the relief sought in the present complaint is in violation of the terms and conditions contained in the policy. Therefore, the complaint is liable to be dismissed with exemplary costs. It is further averred that the complainant is bound by the terms and conditions of the insurance contract and which were expressly made known to the complainant/policy holder at the time of taking the policy in question. It is further averred that the complainant has approached this Commission with unclean hands by not disclosing and misrepresenting material facts. It is further averred that the present complaint is false, frivolous, misconceived and vexatious in nature and has been filed with the sole intention of harassing the OPs. The complainant has knowingly and intentionally concealed the true and material facts from this Commission. The present complaint is a gross abuse of the process of law and is liable to be dismissed with costs. It is further averred that the complainant has no locus-standi and cause of action to file the present complaint. On merits, the factum in regard to taking Senior Citizen Red Carpet insurance policy by the complainant is admitted, but 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.

3.                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-16 and then closed the evidence.

4.                In order to rebut the evidence of the complainant, the counsel for the OPs No.1 and 2 tendered into evidence affidavit Ex.OPA alongwith some documents Ex.OP-1 to Ex.OP-13 and closed the evidence.

5.                We have heard the arguments from learned counsel for the respective parties and have also gone through the case file very minutely.

6.                The complainant has sought the reimbursement of the medi-claim of Rs.58,600/- which was not paid by the OPs despite supplying the documents number of times and sending the notice to the OPs also. He has based his claim with regard to the policy No.P/161125/01/2016/002534 under Senior Citizen Red Carpet policy for the period of January, 2016 to January, 2017 for the sum insured Rs.2,00,000/-. He has produced on record the documents i.e. his policy cover Ex.C-1, copy of the proposal form Ex.C-2, discharge summary Ex.C-3, investigation report Ex.C-4, final bill Ex.C-5, summary of investigations Ex.C-6, claim letter Ex.C-7, reminder of claim Ex.C-8, legal notice Ex.C-9, Ex.C-10 & Ex.C-11 postal receipts, Ex.C-12 receipt of claim letter, Ex.C-13 rejoinder notice, Ex.C-14 postal receipt, prescription slip Ex.C-15 and certificate of Doctor Ex.C-16. Whereas the OPs have tendered into evidence the policy cover along with terms and conditions Ex.OP-1, letters written to the complainant from time to time and the reply to their letters and notice Ex.OP-2 to Ex.OP-8, claim form Ex.OP-9, copy of the bill Ex.OP-10, Ex.OP-11 proposal form and Ex.OP-12 field visit letter.

7.                The contention of the OPs is that there is no deficiency in service by the OPs. The insured/complainant had submitted only claim form along with final bill and receipts and he had never submitted discharge summary. He has further submitted that as per the field visit letter of their doctor, the complainant was found having history of PSBT and despite repeated reminders and issuing letters to the complainant, the required documents were never submitted by the complainant which are mandatory to complete the process of the claim as per terms and conditions of the policy. As per his submission, the complaint is pre-mature as the claim was being processed and the complainant was written letters to submit the documents.

8.                It is admitted case of the parties that the complainant purchased the Senior Citizen Red Carpet insurance policy which was valid from 07.01.2015 to 06.01.2016 and further renewed from 07.01.2016 to 06.01.2017. The documents produced by both the parties also proved this fact. All the documents have been annexed with the complaint by the complainant. Ex.C-9 shows that the complainant has sent all the documents sought for by the OPs. He has also produced on record the postal receipts Ex.C-10 and Ex.C-11. He has also produced on record the document i.e. Letter Ex.C-8 written to the OPs in which he has categorically mentioned that his medical bills are not being cleared on one pretext or the other and vide this letter, he has requested the OPs to send his original file back so that he can get his claim passed through the Court. The OPs have written letter Ex.C-12, in which no date has been mentioned, stating therein that the complainant has submitted only claim form along with final bill and receipts and not submitted the discharge summary. This letter was in reply to the notice given by the complainant Ex.C-9. Vide Ex.C-13 the complainant has again sent rejoinder/reply to the letter stating therein that all the original documents have been sent by the complainant and the copies of the documents sought for were again sent to the OPs. The OPs themselves are not clear which documents were sent by the complainant and which were not. In all the correspondences produced on record by the OPs, it has been alleged that the claim could not be processed due to non filing of the necessary documents, whereas the complainant has written time and again that the original file and original documents are with them and asked the same to be returned to him. In the written statement, the OPs have stated in Para No.3 on merits that the insured has submitted only claim form alongwith final bill and receipts and not submitted the discharge summary, whereas on the next page in reply to the same para, it has been specifically mentioned that it is important to mention here that the insured has submitted only the copy of the discharge summary and the insured is to supply the original bills, receipts and other documents upon which the claim is based. Only on the receipt of the original claim records, the claim could be processed. This reply clearly shows the intention of the OPs that the OPs are not to consider the claim of the complainant. On one hand, the OPs are saying that only discharge summary was not filed and other documents were filed and on the other hand they are saying that only discharge summary was filed, whereas other documents were not filed. Similarly in the letter relied upon by the OPs that the claim can be processed only on the furnishing of the original documents and on the other hand, vide letter dated 21.04.2016 Ex.OP-5 they are alleging that “since you are not interested in your claim, then they have therefore closed your claim file.” In Ex.OP-6 a letter dated 08.06.2016 again they are seeking the documents to process the claim and similarly thereafter vide Ex.OP-7 again they are seeking the original documents. Here again on the one hand they are alleging that due to non filing of original documents, the claim could not be processed and on the other hand, they are alleging that the claim has been closed and even after writing this letter to complainant, they are processing the claim. So, this claim is not pre-mature as the OPs themselves are not clear about their stand.

9.                The contention of the OPs is that the claim could not be approved as the complainant had history of supra-ventricular tachycardia as per Ex.C-16 and was on treatment for the same. It is the report of the doctor and it has been specifically mentioned that he had history of Supra-ventricular Tachycardia in the year 1986 and now the complainant was admitted in the hospital on 01.02.2016 and was discharged on 03.02.2016 as per discharge summary Ex.C-3. In this document the doctor has specifically stated that no history of DM, HTN. From 1986 till 2016, the complainant did not suffer any problem as per the record furnished by both the complainant as well as OPs. If he had history of Supra-ventricular Tachycardia 1986 for approximately 30 years ago, he did not have any problem thereafter and at the time of purchasing the insurance policy also he was fit and in the column, it has been specifically mentioned that he was not having any pre-existing disease. It has been held by the Hon’ble Delhi State Consumer Disputes Redressal Commission, in 2005 CPJ 747, titled as “National Insurance Co. Ltd. Vs. Smt. Krishna Avtar Aggarwal”, wherein his Lordship held as under:-

                   “Non-disclosure of disease for which insured was treated        about 15/20 years back, does not amount to concealment of any       disease. The word ‘existing’ means disease which exists at the           time of taking the policy.”                                                                            It has been held by the Hon’ble Punjab State Consumer Disputes Redressal Commission, in 2005 CPJ 723, titled as “National Insurance Co. Ltd. Vs. Mukesh Kumar Arora”, wherein his Lordship held as under:-

                   “Exclusion clause is not attracted where the disease prior        to the taking of policy is rectified or can be rectified by medical     treatment”.

10.              In the present case also if the complainant had history of Supra-ventricular Tachycardia in 1986 only and his disease was treated. The OPs have not proved that he continuously was suffering from this disease and was on medication during the above said 30 years, therefore it is not attracted under the exclusion clause as alleged by the OPs.

11.              Form perusal of above facts and circumstances of the case and plethora of judgments, we are of the considered opinion that the complainant is entitled for the relief and the complaint of the complainant is partly allowed and OPs are directed to pay the medical claim of Rs.58,600/- with interest @ 6% from the date of claim till realization and further OPs are directed to pay Rs.30,000/- as compensation for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses. The entire compliance be made within 45 days 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.

12.              Copies of the order be sent to the parties, as permissible, under the rules. File be indexed and consigned to the record room after due compliance.

Dated          Jaswant Singh Dhillon    Jyotsna                Dr.Harveen Bhardwaj     

30.11.2021         Member                          Member           President