Complaint No: 487 of 2018.
Date of Institution: 07.12.2018.
Date of order: 18.10.2023.
Naresh Kumar aged about 53 years Son of Sh. Om Parkash Verma resident of House No. 10-8/235, Ward No. 3, Mohalla Prem Nagar, Dara Salam, Batala, Tehsil Batala, District Gurdaspur.
…....Complainant.
VERSUS
1. Star Health & Allied Insurance Co. Ltd. Branch Office - Amritsar-II, SCO 25, 2nd Floor, Ranjit Avenue, District Shopping Complex, Amritsar, Tehsil & District Amritsar – 143001.
2. Star Health & Allied Insurance Co. Ltd. Head Office & Corporate Office - 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai.
3. Dr. Raman Chawla c/o Care Max Superspeciality Hospital Guru Nanak Mission Chowk, Near Petrol Pump, Jalandhar, Tehsil and District Jalandhar.
….Opposite parties.
Complaint U/s 12 of the CPA, 1986.
Present: For the Complainant: Sh.Gaurav Verma, Advocate.
For the Opposite Parties No.1 and 2: Sh.Sandeep Ohri, Advocate.
Opposite Party No.3: Exparte.
Quorum: Sh.Lalit Mohan Dogra, President, Sh.Bhagwan Singh Matharu, Member.
ORDER
Lalit Mohan Dogra, President.
Naresh Kumar, Complainant (here-in-after referred to as complainant) has filed this complaint under section 12 of The Consumer Protection Act, 1986 (here-in-after referred to as 'Act') against Star Health & Allied Ins. Co. Ltd. Etc. (here-in-after referred to as 'opposite parties).
2. Briefly stated, the case of the complainant is that the OP’s No.1 and 2 are the insurance company and the OP No.3 is a private doctor working at Care Max Superspeciality Hospital, Jalandhar. It is further pleaded that on dated 27.03.2018, the complainant took one insurance policy from the OP No.1, which is known as Family Health Optima Insurance Plan under which any type of medical treatment and medical expenses are covered of the persons connected with the said policy, as the said policy is the family insurance policy. It is further pleaded that complainant and his wife namely Parvesh Rani both are insured with the said policy. It is further pleaded that above said policy is also called medi-claim policy and this policy is valid for only one year and remains after the expiry of its one year time period. It is further pleaded that the complainant paid Rs.19,417/- in cash to the OP No.1 as premium amount at the time of taking the policy and get the policy No. P/211214/01/2018/000839. It is further pleaded that after making the payment to the OP No.1, the complainant becomes the customer / consumer of the OP No.1. It is further submitted that the wife of the complainant namely Parvesh Rani was got admitted in the hospital of the OP No.3 on 28.07.2018, as she was suffering from the complaint of palpitation and sweating. It is further pleaded that OP No.3 attended the patient and after examining the above said patient, the OP No.3 came to know that she had a problem of SVT i.e. Supraventricular Tachycardia disease and when the OP No.3 enquired from the complainant regarding the above said disease that from how much time the patient had this problem, then the complainant replied that the patient was suffering from this problem from the last "9-10 days" and she never face such like problem earlier in her life. It is further pleaded that actually the daughter of the complainant is married in Jalandhar and was pregnant at that time period both the complainant and his wife went to Jalandhar on 25.07.2018 in the matrimonial house of their daughter for her care and on 28.07.2018 at about 11:00 A.M. during the medical checkup of the daughter the doctor asked them that the delivery of their daughter has very complicated and referred to C-Section (Operate). It is further pleaded that after listening the same the patient got tensed and came under stress which results in the above disease happened with her. It is further pleaded that the OP No.3 mentioned in his report wrongly "10 years" instead of "10 days" by mistake. It is further pleaded that complainant had no knowledge about the above said mistake done by the OP No.3 in his report. It is further pleaded that on dated 30.07.2018 the patient Parvesh Rani took discharge from the hospital as she felt good, conscious and able to go back to her home but the OP No.3 never allows to discharge the patient. It is further pleaded that by insisting the OP No.3 through complainant, the OP No.3 become fed up and irritatingly behaved with the attendants/complainant and angrily ordered for the discharge of the patient and then make wrong report of the patient on the discharge summary. It is further pleaded that the OP No.3 in the discharge report of the patient mentioned that the condition at the time of discharge is PLAMA i.e. Patient Left Against Medical Advice and also mentioned in writing that "Patient advised further evaluation but attendants were not willing and insisted for discharge". It is further pleaded that complainant made the total payment of Rs.30,909/- for the treatment of the patient which includes room charges, medicine expenses, doctor fees etc. It is further pleaded that on 08.08.2018 the complainant approached the OP No.1 and requested to settle the claim of Rs.30,909/- but on 11.08.2018 the OP No.1 rejected the claim of the complainant by issuing a letter in which the OP No.1 mentioned the reason as "Non-Disclosure of Pre-Existing Disease" and also as per the report of the OP No.3 in which he mentioned that the patient suffering from the disease from the last 10 years. It is further pleaded that on 14.09.2018, the complainant also sent the E-mail for settle the claim to the OP No.1 and also give the reply to the OP No.1 of the letter dated 11.08.2018 in which the complainant mentioned the reason and give his assurance that the complainant had not conceal any material fact but the OP No.1 cancelled the policy on 14.09.2018 and issued a new policy by deleting the name of Parvesh Rani specifically from the said policy and they sent the same to the complainant by issuing a new policy. It is further alleged that due to the act and conduct of the OP No.3, the OP No.1 rejected the claim of the complainant only on the basis of wrong report prepared by the OP No.3 in which he mentioned that "the patient suffering from disease for the last 10 years" which is totally wrong and incorrect. It is further pleaded that OP No.3 has no proof or any medical record to prove the patient was already suffering from the said disease from the last "10 years". This was all done by the OP No.3 with the malafide intention because the OP No. 3 wants the patient to remain in the hospital under treatment for more days in order to increase the bill of patient and for hospital income. It is further pleaded that due to this illegal act and conduct of the opposite parties the complainant has suffered great loss and also suffered mental agony, Physical harassment and inconvenience. It is further pleaded that there is a clear cut deficiency in services on the part of the opposite parties.
On this backdrop of facts, the complainant has alleged deficiency and negligence in services and unfair trade practice on the part of the opposite parties and prayed that necessary directions may kindly be issued to the opposite party No.1 to pay the double of the claim amount i.e. Rs.30,909/- along with interest @18% P.A. and Rs.10,000/- as litigation charges with costs and also order the opposite parties No.1 and 2 to renew the earlier policy of the complainant by cancelling the new policy and also pass the order for cancel the license of the OP No.3 who prepared the false report and play with the feelings of the innocent and poor people to grab the huge amount from them in the interest of justice and fair play.
3. Upon notice, the opposite parties No.1 and 2 appeared through counsel and contested the complaint and filing their written reply by taking the preliminary objections that the complainant has no cause of action to file the present complaint and the complainant has no locus standi to file the present complaint. It is further pleaded that there is no deficiency in services on the part of the opposite parties. It is pleaded that the insured availed Family Health Optima covering Mr. Naresh Kumar Self and Parvesh Rani Spouse for the sum insured of Rs.5,00,000/- vide Policy No. P/211214/01/2018/000839 for a period from 27.03.2018 to 26.03.2019. It is further pleaded that terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant alongwith the policy schedule. It is further pleaded that it is clearly stated in the policy schedule that the Insurance under the Policy is subject to conditions, Clauses, warranties, exclusions etc. It is further pleaded that the insurance is a contract between the two parties based on utmost good faith. It is further pleaded that complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. It is further pleaded that in the 4th month of the policy, the insured sought for approval of cashless treatment of DM Non HTN SCT reverted with adenosine towards the hospitalized in Care Max Super-specialty Hospital - Jalandhar on 28.07.2018. It is further pleaded that on scrutiny of the claim documents, it is observed that as per Authorization request, the insured patient has SVT (Supraventricular Tachycardia) since 10 years. As per ICP, the insured has a past history of increased HR present, On Tab. Metolar, so irregularly (on and off). It is further pleaded that it has been observed that the patient has heart disease since 10 years, whereas the policy is 4 month old, thus it is a PED and as such the pre - authorization was rejected and the same was informed to the insured vide letter dated 30.07.2018. It is further pleaded that the insured submitted claim for reimbursement of medical expenses of Rs.30,010/- for the above mentioned treatment. It is further pleaded that on scrutiny of the same, it is observed that as per the pre authorization form, the insured patient has SVT since 10 years and the same was not disclosed in the proposal form. It is further pleaded that as such at the time of inception of policy which is from 27.03.2018 to 26.03.2019, the insured have not disclosed the medical history / health details in the proposal form, which amounts to misrepresentation / non-disclosure of material facts. It is further pleaded that as per Condition No.6 of the Terms and conditions of the policy, if there is any misrepresentation whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in any claim, hence the claim has been rejected and the same was informed to the insured vide letter dated 14.09.2018. It is further pleaded that as per Condition No.12, the policy was liable to be cancelled and as such the policy coverage for Parvesh Rani also stand cancelled w.e.f. 20.09.2018 due to non-disclosure of Pre-existing disease. It is further pleaded that there is no deficiency in services on the part of the Opposite Parties and it is the complainant who is at fault and failed to fulfill his part of obligation.
On merits, the opposite parties No.1 and 2 have reiterated their stand as taken in legal objections and denied all the averments of the complaint and there is no deficiency in services on the part of the opposite parties. In the end, the opposite parties prayed for dismissal of complaint with costs.
4. Opposite party No.3 did not appear despite the service of notice and was proceeded against exparte vide order date 05.03.2019.
5. Learned counsel for the complainant has tendered into evidence affidavit of Naresh Kumar, (Complainant) as Ex.C-1/A alongwith other documents as Ex.C-1 to Ex.C-22.
6. Learned counsel for the opposite parties No.1 and 2 has tendered into evidence affidavit of Sh. Rajiv Jain, (Chief Manager, Authorized Signatory of Star Health & Allied Ins. Co. Ltd., New Delhi) as Ex.OP-1/A alongwith other documents as Ex.OP-1,2/1 to Ex.OP-1,2/11.
7. Rejoinder filed by the complainant.
8. Written arguments not filed by complainant and opposite parties no.1 and 2.
9. Counsel for the complainant has argued that during the continuation of health policy of insurance, wife of the complainant was suffering from palpitation and sweating on 28.07.2018 and on admission with opposite party No.3 she was found suffering from Supraventricular Tachycardia disease. It is further argued that complainant had disclosed the assertion of said disease 9-10 days but the opposite party No.3 had wrongly written the same as 10 years. It is further argued that complainant had to make payment of Rs.30,909/- for the treatment of his wife. However, claim lodged by the complainant repudiated by opposite parties No.1 and 2 on ground of concealment of disease from which she was suffering for the last 10 years.
10. On the other hand counsel for the opposite parties No.1 and 2 has argued that the insured sought for approval of cashless treatment of DM Non HTN SCT reverted with adenosine towards the hospitalization in Max Super-Specialty Hospital Jalandhar. It is further argued that on scrutiny of the claim document the insured suffering with SVT (Supraventricular Tachycardia) since 10 years and it was observed that patient had heart disease since 10 years and the policy was only 4 month old. As such pre-authorization was rejected vide letter dated 30.07.2018 and reimbursement was also declined by the opposite parties.
11. Opposite party No.3 remained exparte.
12. We have heard the Ld. counsels for the complainant and opposite parties No.1 and 2 and gone through the record. It is admitted fact that complainant had purchased family health opting insurance plan Ex.C1 from opposite parties No.1 and 2. It is further admitted fact that wife of the complainant Parvesh Rani was also covered under the said policy. It is further admitted fact that wife of the complainant remained admitted with opposite party No.3 hospital for treatment of DM Non HTN SCT reverted. It is further admitted fact that complainant had spent amount of Rs.30,909/- on the treatment of his wife. It is further admitted fact that pre-authorization was rejected by the opposite parties No.1 and 2 vide letter dated 30.07.2018 on the ground that wife of the complainant was suffering from the said disease for the last 10 years. It is further admitted fact that reimbursement of medical expenses was also declined on the ground that the insured has SVT since 10 years. The only disputed question before this Commission is whether the repudiation of claim by the opposite parties No.1 and 2 on the ground of concealment of previous ailments was justified or not. The only reason for repudiation of the claim by the opposite parties No.1 and 2 is that the patient had SVT since 10 years and on account of said fact the claim was repudiated but we are of the view that opposite parties No.1 and 2 have not been able to prove this fact that the wife of the complainant was suffering from SVT since 10 years by producing any document, any treatment record or record of medical history in respect of Parvesh Rani. The opposite parties No.1 and 2 having been able to prove the said SVT since 10 years by producing any affidavit of the doctor from whom the said insured Parvesh Rani took treatment. As such repudiation of the claim on the ground of SVT for the last 10 years only a reference given by opposite party No.3 is totally unjustified. Complainant has already raised number of allegations against opposite party No.3 but opposite party No.3 has not dared to come present before this Commission to deny the said allegations. As such no liability can be placed on the reference given by opposite party No.3 in respect of SVT since 10 years.
13. We have reliance upon the judgment of Hon'ble Supreme Court of India 2023(2) Law Herald (SC) 1560 titled as Om Parkash Ahuja Vs. Reliance General Insurance Co. Ltd. Etc. wherein it was held by the Hon'ble Supreme Court of India as under:-
"Consumer Insurance Health Insurance Non-mentioning of disease from which the deceased suffered at the time of purchasing the policy was not material, as the death was caused from a different disease all together Both had no relation with each other Insurance Company directed to pay".
As per this judgment it was held by the Hon'ble Supreme Court of India that non mentioning of disease from which wife of the applicant was suffering at the time purchasing policy is not material and the death was caused from different disease all together.
14. Further, reliance is be placed on another judgment of Hon'ble Supreme Court of India reported in 2018(1) Law Herald (SC) 832 wherein it was held by Hon'ble Supreme Court of India as under:-
"Insurance Life Insurance Premium accepted without conducting of medical examination Amounts to waiving off condition precedent in proposal form Insurer held liable to pay".
The ground of the opposite parties regarding non settlement and payment of the claim is previous history of hypertension but this Commission is of the view that hypertension is a common life style disease and it is not necessary that person suffering from hypertension would always suffer from some other disease or heart disease. More over Hypertension is common life style disease and every third person might have suffered from the same at some point of his life. This Commission has placed reliance an order of Hon'ble Punjab State Consumer Dispute Redressal Commission, Chandigarh reported in 2017(3) CLT 140 wherein it was held as under:-
"Hypertension is a common disease and it can be controlled by medication".
15. We are of the view that the opposite parties cannot refuse to settle the claim of the complainant by referring to the record of previous ailments with which the present disease has no connection or nexus. Moreover, the opposite parties have renewed the policy of insurance from time to time receiving premium. As such having renewed the policy of insurance from time to time without having availed medical examination of the complainant prior to renewal of the policy amounts to waiver and as such opposite parties cannot refuse to settle the clam by referring to the documents regarding previous ailment with which the present ailment has no concern. We are of the view that insurance companies are only interested in procuring business this way or the other but at the time of the settlement they find one excuse or the other some of which are totally ignorable.
16. We placed reliance upon judgment of Hon'ble Supreme Court of India reported in 2022 LiveLaw (SC) 506 wherein it was held by the Hon'ble Supreme Court of India as under:-
"Insurance - Insurance companies refusing claim on flimsy grounds and/or technical grounds - While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control. (Para 4.1)".
17. This Commission is of the view that it was obligatory on the part of the opposite parties before renewal of the policy of insurance must had insisted for medical examination of the complainant and his family members and since the opposite parties have failed to get them medically examined before renewal, as such opposite parties have no right to take any such ground later on. Even, in the present case opposite parties have failed to place on record any evidence or affidavit of any doctor regarding previous ailment in respect of which documents are being demanded.
18. We also placed reliance upon judgment of Hon'ble Punjab State Consumer Dispute Redressal Commission, Chandigarh reported in 2014(3) C.P.J. 13 : 2014(87) R.C.R.(Civil) 264 wherein it was held as under:-
"Insurance Company failed to produce any evidence to show that appellant was suffering from said disease at the time of taking policy - No affidavit of any doctor or person who recorded history of patient".
19. We have also placed reliance upon the judgment of Hon'ble Supreme Court of India in case titled as Om Parkash Ahuja Vs. Reliance General Insurance Co. Ltd. etc. reported in Law Herald (SC) 2023(2) Page 1560 wherein in it has held as under:-
"Insurance Health Insurance Complainant had taken health insurance for his family which was renewed time to time His wife suffered from cancer of ovary and took treatment Claim for reimbursement of medical expenses was repudiated on the ground that wife of complainant was suffering from heart disease and it was not disclosed at the initial time of taking policy Medical Certificate establishes that rheumatic heart disease and carcinoma ovary are not related to each other Thus, non-mentioning of disease from which the wife of appellant suffered at the time of purchasing the policy was not material, as the death was cause from a different disease all together Both had no relation with each other Insurance Company directed to pay the claim amount with interest".
In the said judgment the Hon'ble Supreme Court of India has very categorically held that rheumatic heart disease and carcinoma ovary are not related to each other and as such repudiation of the claim by insurance company was held to be illegal.
20. We are of the further view that it was the duty of the opposite parties No.1 and 2 to have compelled the complainant and his family members to undergo medical examination from the prescribed doctor of opposite parties No.1 and 2 before issuance of health policy of insurance and since the opposite parties No.1 and 2 failed to get the insured medical examination before issuance of policy. As such opposite parties No.1 and 2 cannot deny the claim by taking excuse of pre-existing disease and concealment of facts. Accordingly, it is held that repudiation of the claim and subsequently cancellation of policy qua Parvesh Rani is totally unjustified.
21. Accordingly, present complaint is partly allowed with following directions:-
i) Opposite parties No.1 and 2 are directed to pay the admitted amount of Rs.24,885/- to the complainant alongwith interest @ 9% P.A. from the date of filing of complaint till realization.
ii) Opposite parties No.1 and 2 are further directed to pay Rs.5,000/- for mental tension and harassment and Rs.5,000/- as litigation expenses to the complainant.
iii) Opposite parties No.1 and 2 are also directed to revive the health policy qua insured Parvesh Rani with all benefits.
Entire exercised will be completed within 30 days from the date of receipt of copy of this order.
22. The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases, vacancies in the office and due to pandemic of Covid-19.
23. Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record room.
(Lalit Mohan Dogra)
President
Announced: (B.S.Matharu)
Oct. 18, 2023 Member
*YP*
