Before the District Consumer Disputes Redressal Commission, Rohtak.

                                                                   Complaint No. : 487.

                                                                   Instituted on     : 19.08.2021.

                                                                   Decided on       : 30.04.2024

Vinita w/o Lt.Hari Om Ahuja R/o House no. 623 ward no.3, GarhiMohallaRohtak.

                                                                   ………..Complainant.

                                                Vs.

1. Star Heath and Allied Insurance Company Limited Ashoka plaza 3^rd Floor, Delhi Road, Rohtak through its Branch-Manager.
2. Star Heath and allied insurance company Limited, No. 15 Sri Balaji Complex 1^stfloor, Whites lane Royapettah, Chennai 600014 Through its Manager/MD/Chairman.

……….Opposite parties.

COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.

BEFORE:  SH.NAGENDER SINGH KADIAN, PRESIDENT.

                   DR. TRIPTI PANNU, MEMBER.

                   DR.VIJENDER SINGH, MEMBER.

Present:       Sh. Kamal Gagneja, Advocate for complainant.

                   Smt. Ruchi Chawla, Advocate for opposite parties.

                                      ORDER

NAGENDER SINGH KADIAN, PRESIDENT:

1.                Brief facts of the case as per the complainant are that on dated 06/09/2019 Sh.Hariom Ahuja (since deceased) purchased a health Policy from opposite party no.1 by paying an amount of Rs.29695/- and opposite parties issued policy no. P/211118/01/2020/003981 in which Late Sh. Hariom Ahuja & Vinita (both policy holders) were covered till 05/09/2020. At the time of issuance of policy the complainant was hale and healthy and all the information about pre existing diseases were given to the insurance company. On 05/02/2020 policy holder Sh. HariomAhuja(since deceased)was feeling severe headache, orbital pain, weakness & vomiting. He was admitted at Kainos Super Speciality Hospital Rohtak for treatment and the concerned doctor diagnosed the ailment as ‘RIGHT MCAINFARCT’. The family member of policy holder/patient informed the opposite parties aboutthe illness & the opposite parties generated a claim no. CLI/2020/211118/0886180 & the hospital sent a request for cashless treatment of the patient. On dated 08/02/2020, doctor performed surgical procedure i.e. brain operation of patient Hari Om.On dated 11/02/2020 the complainant received a denial of pre authorization request for cashless treatment which was based on the baseless grounds and after denial of cashless claim by opposite parties, the complainant deposited an amount of Rs.7,75,000/- to the said hospital. On dated 18/02/2020 during the hospitalization patient Hariom Ahuja had suffered a sudden cardiac arrest and he was put on ventilator support & on dated 20/02/2020 doctor/staff informed the family members that condition is critical and the chances of recovery are very less. Thereafter all the family members decided to admit him in PGIMS Rohtak for further treatment and he was admitted at PGIMS Rohtak.On dated 23/02/2020 during the treatment at PGIMS Rohtak Sh. Hariom Ahuja was expired.Complainant submitted her insurance claim on dated 20/07/2020alongwith all original treatment documents &hospital bills amounting toRs.7,75,000/- to the office of opposite party no. 1 but the opposite party no.1 had repudiated the claim of the complainant on 23/09/2020. The act and conduct of the opposite parties is illegal and amounts to deficiencies in service. Hence this complaint and it is prayed that opposite parties may kindly be directed to pay the cost of treatment i.e Rs.7,75,000/- along with interest @18% per annum from the date of payment, to pay Rupees 50,000/- as compensation on account of harassment & deficiency in services and  Rupees 55,000as litigation expenses to the complainant.

2.                After registration of complaint, notices were issued to the opposite parties. Opposite parties in their reply has submitted that complainant opted for Family Health Optima Insurance Plan and opposite party issued policy no. P/211118/01/2020/003981 for the period 06.09.2019 to 05.09.2020covering Mr. Hari Om Ahuja-Self and Smt Vinita Spouse, for the sum insured Rs.5,00,000/-. In the 5th month of the policy, the insured submitted the claim documents for reimbursement of medical expenses of Rs.7,75,000/-. However, the complainant has submitted bills only for Rs.6,58,730/- out of which the hospital discount is Rs.1,18,080/-, hence the total amount spent by the insured is Rs.5,40,650/- towards the treatment of right MCA infarct, diabetes mellitus (DM), hypertension (HTN), dilated cardiomyopathy(DCMP) post cardiac arrest status. On scrutiny of the claim documents their medical team observed that the insured patient was known case of hypertension in which multiple tampering is noted. This amounts to misrepresentation, Further, MCA infarct is a complication of hypertension. Moreover, the insured patient has chronic, longstanding dilated cardiomyopathy. At the time of inception of the policy, the above mentioned medical history/health details of the insured-person were not disclosed in the proposal form which amounts to misrepresentation/non disclosure of material facts.Hence claim was rejected and conveyed to insured vide letter dated 23.09.2020 by the opposite parties. The sum insured of the complainant is Rs.5,00,000/- and that the Company's liability in respect of all claims admitted during the period of insurance shall not exceed the sum insured per family mentioned in the schedule. The claim of the complainant has been rightly repudiated at cashless authorization stage. There is no deficiency in service on the part of opposite parties and dismissal of complaint has been sought. However, without prejudice to the contents of the written version stated here in above, if at all the opponent is held liable to pay the claims of the Complainant, the liability of the Opponent as per the terms and conditions shall be limited to Rs.4,24,312/-, qua the admission detailed above.All the other contents of the complaint were stated to be wrong and denied and opposite parties prayed for dismissal of complaint with costs.

3.                Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C20 and has closed his evidence on dated 21.10.2022. On the other hand, ld. counsel for the opposite parties has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R17 and closed his evidence on dated 21.07.2023.

4.                We have heard learned counsel for the parties and have gone through the as  material aspects of the case very carefully.

5.                In the present case claimof the complainant has been repudiated by the opposite parties vide their letter Ex.R16 on the ground that: “It is observed from the indoor case records of the above hospital that the insured patient is a known case of hypertension in which multiple tampering is noted.  Further MCA infract is a complication of hypertension. Moreover, the insured patient has chronic, longstanding dilated cardiomyopathy. At the time of inception of the policy, the above mentioned medical history/health details of the insured-person were not disclosed in the proposal form which amounts to misrepresentation/non disclosure of material facts”. 

6.                We have minutely perused the documents Ex.C4/Ex.R12 and Ex.R6. The main contention of the insurance company is that the complainant has concealed the material fact at the time of commencement of the policy and the life assured was a known case of HTN 4-5 years. As per Ex.R6 patient was a known case of  DM-Type-II/HTN for 4-5 years/Diabetic foot Dec 2019. We have also perused the printed document summary Ex.R13 and under the head ‘history and background’ it is submitted that patient presented with severe headache for 1 day,  associated with general weakness, vomiting multiple episodes, right orbital pain. In this written history mentioned in Ex.R13, it is nowhere mentioned that life assured patient Hari Om was having history of HTN. Moreoveron documents Ex.C4/Ex.R12, there is cutting on first page on HTN FOR 4-5 years and so many pages attached with this document. This document is issued by theKainos Super SpecialityHospital in which patient life assured was admitted. Meaning thereby the HTN was wrongly written by the hospital at the time of admission of patient in the hospital and later on the same was cut by the hospital itself. On the other hand opposite parties have not placed on record any evidence i.e. affidavit of doctor or the hospital staff to prove the fact that the alleged cutting was not made by them.  It is also observed that the policy was purchased by the complainant on 06.09.2019 and as per affidavit Ex.RW1/A, it is submitted that policy was issued w.e.f. 06.09.2019 to 05.09.2020 covering Mr. Hari Om Ahuja-Self(Diabetes Mellitus and its complications) and Smt.Vinita –spouse(all complications directly or indirectly related to the surgeries or procedures performed previously cholecystectomy diseases of knew and all its related complications) for the sum insured Rs.500000/-.  Meaning thereby the complainant and her husband have disclosed about their diseases at the time of making proposal for the policy.  The life assured Hari Om(since deceased) was admitted in the hospital firstly on 05.02.2020. No previous medical record of deceased Hari Om  has been produced by the opposite parties to show that he was suffering from hypertension prior to taking the  policy. The contention of ld. Counsel for the complainant is that life assured deceased Hari Om was having history of Diabetes Mellitus  and he was diagnosed for MCA Infract, hence there is no nexus between the previous history of disease of life assured and his treatment at the hospital. Ld. Counsel for the complainant has also placed reliance upon the judgment of Hon’ble Supreme court of India in Civil Appeal No.2769-2770 of 2023 titled as Om Parkash Ahuja Vs. Reliance General Insurance Co. Ltd. Etc., judgment of Hon’ble State Commission Punjab, Chandigarh in First  appeal no.469 of 2017 titled as Branch Manager, Bajaj Allianz General Insurance Co. Ltd. Vs. Sh.Manjit Singh whereby it is held that : “Hypertension is a lifestyle disease and it cannot be made the basis of repudiation of the claim of the consumer. The Hon’ble National Commission in Satish Chander Madan Vs. Bajaj Allianz General Insurance Co. Ltd. 1(2016) CPJ 613(NC) held that hypertension is common ailment and it can be controlled by medication and it is not necessary that a person suffering from hypertension would always suffer a heart attack”. Reliance has also been placed upon the Revision Petition no.1696 of 2005 of Hon’ble National Commission, New Delhi titled as Praveen Damani Vs. Oriental Insurance Co. whereby Hon’ble National Commission has held that : “The insured was unaware of this disease till he suffered chest pain which is only on 18.08.2000 and not before 09.06.2000 when he took the policy.  It is further held that most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the insurance company relies on their Clause 4.1 of the policy in a malafide manner to repudiate all the claims.  It is further held that complainant has proved that he was unaware of the disease at the time of taking the policy and hence the complaint is allowed”.

7.                In view of the aforesaid law which are fully applicable on the facts and circumstances of the case, we have observed that repudiation of claim by the oppositeparties  is illegal and amounts to deficiency in service. Through this complaint complainant has demanded a sum of Rs.775000/- on account of treatment of deceased Hari Om and has also placed on record copies of bills Ex.C6 to Ex.C12. But as per policy Ex.C1, the limit of coverage is Rs.500000/-. Hence opposite parties are liable to pay the alleged amount to the complainant.

8.                In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite parties to pay Rs.500000/-(Rupees five lac only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 19.08.2021 till its realisation and shall also pay a sum of Rs.5000/-(Rupees five thousand only) on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.

9.                Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.

Announced in open court:

30.04.2024.

                                                          ................................................

                                                          Nagender Singh Kadian, President

                                                          ………………………………..

                                                          TriptiPannu, Member.

                                                          ………………………………..

                                                          Vijender Singh, Member.