Chandigarh

DF-I

CC/740/2021

Ms. Anuradha Bhalla - Complainant(s)

Versus

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

Ashish Rawal

11 Mar 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/740/2021
Date of Institution	:	27/10/2021
Date of Decision	:	11/03/2024

 

Ms. Anuradha Bhalla wife of late Sh. Bimal Bhalla resident of H.No.3117, Sector 38-D, Chandigarh.

… Complainant

V E R S U S

1. Star Health and Allied Insurance Co. Ltd. having its Regd. & Corporate Office No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai 600034 through its Chairman-cum-Managing Director.

2. The Manager/Authorised Signatory, Star Health and Allied Insurance Co. Ltd., No.15, Sri Balaji Complex, 1^st Floor, Whites Lane, Roy Apettah, Chennai-600014.

3. The Grievance Redressal Officer, Corporate Grievance Department, No. 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai – 600034.

4. The Manager, Star Health and Allied Insurance Co. Ltd. SCO- 236, Sector 20, Main Road Vegetable Market, Panchkula, Haryana – 134117.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

 

ARGUED BY	:	Sh.Ashish Rawal, Advocate for complainant (through VC)
	:	Sh. Inderjit Singh, Advocate for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Anuradha Bhalla, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that, in the year 2019, husband of the complainant namely Bimal Bhalla had obtained a health insurance policy from Apollo Munich Health Insurance Company which was valid upto 28.6.2020.  Thereafter the representatives of OPs approached him for renewing/taking health insurance policy assuring better services than the previous company.  Believing the assurances given by the said representatives, husband of complainant obtained policy namely “Family Health Optima Insurance Plan” (Annexure C-1) from the OPs on payment of premium of ₹24,143/- which was valid w.e.f. 27.6.2020 to 26.6.2021 (hereinafter referred to as “subject policy”). At that time, husband of the complainant was not having any past history or chronic disease and he was conscious about his health and was only suffering from diabetes for which he was taking regular medical advice and treatment and copy of medical record is Annexure C-2.  Suddenly, on the evening of 5.7.2020, swelling developed on the “left supra clavicular region” of the husband of complainant and immediately he alongwith the complainant rushed to Govt. Multi-Specialty Hospital, Sector 16, Chandigarh where he was examined and certain clinical tests were conducted and thereafter doctor recommended further tests such as USG neck supra clavicular region, FNAC, x-ray etc. and copy of the OPD card is Annexure C-3.  As the husband of complainant was taking regular medical advice and treatment from the Apollo Clinic in respect of diabetes, he went there on 9.7.2020 with reports of clinical and other tests where the doctor advised him to consult Dr. Jatin Sarin of Chandigarh Cancer & Diagnostic Centre (CCDC) and copy of the prescription slip is Annexure C-4.  On the same day, complainant and her husband met Dr.Jatin Sarin who, after going through the reports, for the first time diagnosed the husband of complainant to be suffering from “Lymph Node Mass Left Neck”.  On the advice of doctor, he was admitted on 11.8.2020 at Ivy Hospital, Mohali for treatment, regarding which information was also given to the officials of the OPs and as per their advice pre-hospitalisation claim (Annexure C-7) amounting to ₹2,66,719/- was submitted alongwith copies of medical prescription and test reports (Annexure C-5 Colly. & C-6 Colly.).  In this manner, aforesaid swelling on neck was noticed by the treating doctor for the first time on 5.7.2020 and accordingly further treatment was started, but, unfortunately, husband of the complainant (hereinafter referred to as “DLA”) died on 17.8.2020. Thereafter the complainant submitted final claim of ₹5,32,940/- with the OPs and on this OPs asked her to submit certain documents, which she submitted via email through her son. The complainant also approached the treating doctor of Apollo Clinic qua the aforesaid ailment regarding which he had issued certificate (Annexure C-10). Though the complainant had submitted all the medical prescriptions, bills and other documents as well as doctor’s certificate in respect of her claim, but, the OPs vide letter dated 27.10.2020 (Annexure C-11) illegally and arbitrarily rejected the genuine claim of the complainant on the ground that treating doctor had observed that the patient was under treatment for Chronic Obstructive Pulmonary Disease (COPD) and the complainant could not submit the documents as asked by the OPs.  However, despite of the fact that the complainant had replied the letter dated 20.4.2021 of the OPs through her counsel vide letter dated 27.5.2021 by stating that COPD was first detected in July 2020 alongwith the certificate of the doctor, but, nothing has been done by the OPs to reimburse the claim. In this manner, the aforesaid act of the OPs amounts to deficiency in service and unfair trade practice. OPs were requested several times to admit the claim, but, with no result. Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, concealment of facts, cause of action and also that there is no deficiency in service on their part.  However, it is admitted that the subject policy was issued to the DLA and the complainant and the same was valid w.e.f. 27.6.2020 to 26.6.2021.  It is alleged that on scrutiny of the documents filed by complainant for reimbursement of the claim, it was observed that although the insured patient (DLA) was admitted for treatment of “Lymph Node Mass Left Neck”, but, from the consultation report dated 5.7.2020 it is clear that he was suffering from COPD. The complainant was asked to furnish post treatment record and investigation report, which she could not submit and accordingly the claim of the complainant was repudiated.  Not only this, even the complainant has claimed excessive and exaggerated claim of ₹5,32,940/-.  On merits, 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. In replication, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

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, including written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant and her husband, late Sh. Bimal Bhalla i.e. the DLA, were insured vide the subject policy (Annexure C-1) w.e.f. 27.6.2020 to 26.6.2021 with Basic Floater sum insured of ₹5.00 lacs and the DLA first time visited the Govt. Multi-Specialty Hospital on 5.7.2020 with complaint of swelling of left supra clavicular region and loss of appetite and thereafter he was taken to Apollo Clinic where certain tests were conducted and thereafter he was brought to CCDC Hospital where he was examined by Dr. Jatin Sarin, as is also evident from the copy of prescription slips issued by Apollo Clinic (Annexure C-4) and by Dr. Jatin Sarin (Annexure C-5), and finally he was admitted at Ivy Hospital, Mohali where he expired on 17.8.2020, as is also evident from the copy of death summary (available at page 61-62) and the complainant has submitted the claim to the tune of ₹5,32,940/-, which was repudiated by the OPs vide letter dated 27.10.2010 on the ground that the complainant has not submitted the documents asked by the OPs qua the treatment of DLA for Chronic Obstructive Pulmonary Disease (COPD), as is also evident from Annexure C-11, the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in repudiating the genuine claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of complainant or if the OPs have rightly rejected/repudiated the claim on the ground that though the DLA was admitted for treatment of “Lymph Node Mass Left Neck”, but, from the consultation report dated 5.7.2020 it is clear that he was suffering from COPD and the complainant did not furnish the required documents and details and the consumer complaint of the complainant, 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 subject policy, medical record, having been relied upon by the OPs and claim rejection/repudiation letter and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. Perusal of copy of subject policy (Annexure C-1) clearly indicates that the same was valid w.e.f. 27.6.2020 to 26.6.2021 covering the complainant and DLA, Sh. Bimal Bhalla.
   4. Annexure C-2 is the copy of medical record of Apollo Clinic which clearly indicates that the patient (DLA) was only taking treatment for diabetes and was not having any disease till his treatment in the said hospital prior to 5.7.2020.
   5. Annexure C-3 is the prescription slip of Govt. Multi Specialty Hospital, Chandigarh which clearly indicates that swelling of left supra clavicular region and history of loss of appetite was noticed first time by the medical officer on 5.7.2020.  Annexure C-4 & C-5 are copies of medical record issued by the Apollo Clinic and CCDV Hospital where the patient was diagnosed by the doctor i.e. Dr. Jatin Sarin with neck swelling and he has further given treatment to the DLA at the Ivy Hospital.  It is further clear from the death summary (annexed at page 61 of Annexure C-5 Colly.) that the DLA was having breathing difficulty and was accordingly given treatment and he died due to cardiac arrest on 17.8.2020 at 2.20 a.m. 
   6. Annexure C-10 is copy of certificate issued by the treating doctor of Apollo Clinic and the relevant portion of the same is reproduced below for ready reference:-

        “Mr. Bimal Bhalla was in regular treatment with me for last 2 years for diabetes.

        He first consulted for neck swelling on 6 July’2020 and was further investigated for same & was diagnosed with lymphoma and 6^th July’20 only.

        He did not have any COPD prior to 6^th July, though he was smoker.  His annual check was not s/o any chest ……. He was …. for lymphnode biopsy on 11^th July ’20 in …… Hospital.”

 

7. Annexure C-11 is copy of claim repudiation letter dated 27.10.2020, which indicates that the claim of the complainant was repudiated as she had failed to submit the past treatment record and investigation reports pertaining to COPD.  The relevant portion of the said letter is reproduced below for ready reference :-

       “We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of lymph node mass left neck.

        Although the present admission of the insured patient is for treatment of lymph node mass left neck, it is observed from the consultation report dated 05.07.2020, the insured patient is under treatment for chronic obstructive pulmonary disease (COPD). Hence we requested you to furnish us past treatment records and investigation reports pertaining to it. We note that you have not furnished the required documents and details. In the absence of the above documents/details, we are not able to further process your claim.

        As per Condition No.2 of the above policy, the insured person has to submit all the required documents and details called for by us.

        We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim.”

 

8. The learned counsel for the complainant contended with vehemence that as it stands proved on record that the treatment was taken by DLA for “Lymph Node Mass Left Neck” and the same has no nexus with the earlier disease i.e. COPD, OPs have wrongly repudiated the genuine claim of the complainant and the consumer complaint deserves to succeed.
9. On the other hand, learned counsel for the OPs contended with vehemence that as it stands proved on record that the DLA concealed the factum of suffering from COPD and the complainant did not submit the past treatment record, the claim was rightly repudiated and policy was cancelled on the ground of non-disclosure and concealment of material facts as per the terms and conditions of subject policy. 
10. However, there is no force in the contention of learned counsel for the OPs as it is evident from the record that the DLA had earlier taken treatment for Chronic Obstructive Pulmonary Disease (COPD) whereas the present treatment was for “Lymph Node Mass Left Neck” and he died on account of cardiac arrest on 17.8.2020, as is also evident from the death summary, hence there is clearly no connection/nexus between the two diseases/ailments and there was no need for the OPs to ask for the past treatment records
11. The Hon’ble National Commission in case titled as Neelam Chopra Vs. Life Insurance Corporation of India & Ors., IV (2018) CPJ 321 (NC), while dealing with the question of suppression/non-disclosure of material facts, has held as under :-

     12. In the present case, clearly the cause of death is cardio respiratory arrest and this disease was not existing when the proposal form was filled. Clearly, there is no suppression of material information in respect of this disease, which is the main cause of death. The other disease of LL Hansen, which was prevailing for five weeks on the date of admission on 1.8.2003 was also not existing when the proposal was filed by the DLA. The fact of DLA having been treated in the year 2002 for LL Hansen is not supported from any direct evidence though PGI Chandigarh in its certificate has mentioned that disease was treated in 2002. Moreover, this disease does not have any correlation with the cause of death in the present case. Hon’ble Supreme Court in Sulbha Prakash Motegaonkar and Ors. v. Life Insurance Corporation of India, Civil Appeal No.8245 of 2015, decided on 5.10.2015 (SC) has held the following:

        “We have heard learned Counsel for the parties.

                It is not the case of the Insurance Company that the ailment that the deceased was suffering from was a life threatening disease which could or did cause the death of the insured. In fact, the clear case is that the deceased died due to ischaemic heart disease and also because of myocardial infarction. The concealment of lumbar spondylitis with PID with sciatica persuaded the respondent not to grant the insurance claim.

                We are of the opinion that National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim by the respondent. The death of the insured due to ischaemic heart disease and myocardial infarction had nothing to do with this lumbar spondylitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified.”

12. In view of the foregoing discussion and the ratio of law laid down above, it is clear that the OPs/insurers have not been able to connect the previous diseases/ailments with the present diseases/ailments, for which the DLA had taken treatment from the treating hospital.  Hence, it is unsafe to hold that the OPs/insurers were justified in rejecting/repudiating the claim of the complainant and the present consumer complaint deserves to succeed. 
13. Now coming to the quantum of amount to be awarded to the complainant, as per the case of complainant, she had submitted bills to the tune of ₹5,32,940/- to the OPs whereas the OPs are disputing that the complete bills were not submitted with them by the complainant. However, when the OPs themselves have acknowledged the receipt of the bills to tune of ₹5,32,940/- from the complainant vide email dated 27.2.2021 (Annexure C-16), it is safe to hold that the OPs/insurers are liable to pay the said amount to the complainant alongwith interest and compensation etc.

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

1. to pay ₹5,32,940/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 27.10.2020 onwards.
2. to pay ₹20,000/- 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 OPs within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
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.

11/03/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Suresh Kumar Sardana] Member