Jharkhand

Bokaro

CC/147/2019

Santosh Singh - Complainant(s)

Versus

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

Sanjay Kapoor

06 Sep 2023

ORDER

                                District Consumer Disputes Redressal Commission, Bokaro

Date of Filing-23-09-2019

Date of final hearing-06-09-2023

 Date of Order-06-09-2023

Case No. 147/2019

Santosh Singh Late Malkeet Singh

R/o Sector-12/C, Qr.no. 1158, Bokaro Steel City, Bokaro

                                      Vrs.

1. Star Health and Allied Insurance Co. Limited

Through its Branch manager

211 & 212 2^nd Floor, Shanti Bhawan Bank more,

Dhanbad 826001

2. The Zonal  Manager, Star Health & Allied Insurance Co. Ltd.,

4th Floor shop No. 404, Modi Heights, Opp. Air Station,

Ratu Road, Ranchi-834004

Present:-

                             Shri Jai Prakash Narayan Pandey, President

Shri Bhawani Prasad Lal Das, Sr.Member

                  Smt. Baby Kumari, Member

PER- J.P.N Pandey, President

-:Order:-

1. Complainant’s case in brief is that he purchased Family Health Optima Insurance Policy from Star Health & Allied Insurance Co. Ltd. on 28.05.2018 covering him and other four family members to the tune of Rs. 5,00,000/- each vide policy No. P/231212/01/2019/000815 valid from 28.05.2018 to 27.05.2019 and paid premium of Rs. 26,302/-. Further case is that due to illness of his daughter Amandeep Kaur, complainant contacted Dr. Rakesh Kumar to whom complainant disclosed that she is having complain of low appetite since 2-2.5 years who was operated for Appendix at BGH, Bokaro in the year 2015, accordingly said doctor prepared prescription. Further case is that complainant contacted several other local doctors having no relief hence he rushed Sir Ganga Ram Hospital, New Delhi, where his daughter was admitted on 04.09.2018 and after treatment she was discharged on 08.09.2018 for which Rs. 88,927/- was paid to the hospital towards medical expense. But inspite of submission of claim form and other required papers cashless payment was refused by the O.Ps. Hence payment was made by the complainant to the hospital. Further case is that later on complainant submitted his claim before the O.Ps. and submitted all demanded papers but his claim was repudiated, in this way there is deficiency in service by the O.Ps. Hence this case has been filed with prayer to direct the O.Ps. to pay Rs. 1,30,000/- medical expense with interest @ 12% per annum and also to pay Rs. 50,000/- as compensation and Rs. 20,000/- as litigation cost.
2. O.Ps. have filed W.S mentioning therein that all complications directly or indirectly related to the surgeries or procedures performed previously . Fact related to issuance of insurance policy and its renewal are admitted fact. Further reply is that the insurance under this policy is subject to condition, clauses, warranty, exclusions etc. Further reply is that the insured Amandeep Kaur was hospitalized on 04.09.2018 at Sir Ganga Ram Hospital for the treatment of Colonic Stricture, T.B., Inflammatory, Inflammatory cell seen, no Granulomaesophageal Diverticulum Gastric, Poly Pericaecal, Righthilar, Lymphadenophaty and discharged on 08.09.2018. Further reply is that on scrutiny of the claim the medical team of the O.Ps. perused the papers and was of the opinion that the patient was having those disease prior to inception of medical insurance policy, hence it was pre-existing disease, hence as per terms and conditions of the policy it is not admissible during first year of the policy and insured had not disclosed those pre-existing disease in the proposal form. Further reply is that the O.P. had rightly repudiated the claim which was communicated to the complainant hence complainant has suppressed the real facts regarding the health and has filed this case to get illegal compensation, hence it is prayed to dismiss the case.
3. Point for determination is whether complainant is entitled to get relief as claimed?
4. Inception of insurance policy on 28.05.2018 is not in dispute, coverage of insurance policy in respect to Amandeep Kaur is also not in dispute. The fact related to treatment of the insured, expense incurred in treatment as well as filing of the claim before the O.Ps. are also not in dispute.
5.  Only dispute is whether the treatment of Intestinal obstruction for which treatment at Sir Ganga Ram Hospital was done may be denied on the ground that it is the result of pre-existing disease i.e. Appendicitis which was operated sometime in the year 2015 at BGH and whether the health problem for which treatment was done is the result of that very operation done in the year 2015.
6.  On perusal of discharge summary of the daughter of the complainant issued by Sir Ganga Ram Hospital, New Delhi and photo copy of said document has been filed by both the parties It reveals from the record that Annexure-14 filed by the complainant is photo copy of repudiation letter dt. 07.02.2019 issued by the O.Ps. by which claim of the complainant has been repudiated on the ground that he has not submitted desired documents, however, later on, on the request of the complainant again repudiation letter dt. 04.12.2019 has been issued by the O.Ps. mentioning therein that the patient was having pre-exiting disease which was not disclosed at the time of opening of the policy and on this ground claim has been repudiated. Photo copy of said repudiation letter dt. 04.12.2019 has been filed by the O.Ps. as Annxure-6/A. It appears that in any case O.Ps. are adamant to reject the claim on any ground.
7. On perusal of the discharge summary of the Sir Ganga Ram Hospital, it appears that patient was admitted in the hospital on 04.09.2018 with chief complaints of Pain Abdominal, vomiting, constipation and decreased Appetite who has undergone Upper GI Endoscopy, Videocolonoscopy,  CECT whole Abdomen, HRCT Thorox and Double Balloon Enteroscopy and under stable condition she was discharged on 08.09.2018. As per repudiation letter dt. 04.12.2019 since patient had gone Appendicectomy on 2015 hence she was having pre-existing disease and all those complications are related to that very operation.
8. On careful scrutiny of all the papers as well as the ground for repudiation of the claim it appears that there is no any paper related to operation of Appendicectomy on 2015 filed by the O.Ps. to prove it. However, we are of the view that the complications for which patient was admitted in Sir Ganga Ram Hospital on 04.09.2018 are having no relation/nexus with the alleged operation, hence it cannot be said that there was pre-exiting disease to which claimant has not disclosed at the time of obtaining the insurance policy. O.Ps. have filed photo copy of common proposal form which is Annexure-2 and on perusal of the column related to health history of the insureds it appears that there is no any specific question regarding operation related to Appendicitis. Hence on this basis claim of the complainant cannot be rejected.
9. In light of above discussion we are of the view that there is no connection of the disease for which treatment was done and claim has been rejected on the ground related  with the operation related to Appendicitis done in the year 2015 for which there is no any evidence on record. Hence we are of the considered view that there is deficiency in service by the O.Ps. and they have wrongly repudiated the claim of the complainant. Accordingly this point is being decided in favour of the complainant.
10. Hence prayer of the complainant is being allowed in the following manner:

O.Ps. are directed to pay Rs. 88,927/- to the complainant within 60 days from receipt/production of the copy of this order failing which they shall pay interest on that very amount @ 10% per annum. Further both the O.Ps. are directed to pay Rs. 10,000/- as compensation and Rs. 5000/- as litigation cost within above mentioned period.

 

Sd/-

(J.P.N. Pandey)

                                                                                      President

 

 

Sd/-

(B.P.L Das)

   Sr. Member

                                                                  

         

                                                         Sd/-                          

  (Baby Kumari)

                                                                                       Member