BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.307 of 2019
Date of Instt. 05.08.2019
Date of Decision: 18.04.2023
Gian Chand Bhardwaj age 67 son of Bishan Dass, resident of 745, Urban Estate-1, Jalandhar 144022.
..........Complainant
Versus
1. Star Health and Allied Insurance Co. Limited No.15 Bala Ji Complex, White Lane 1st Floor, Royapettah, Chennai 600014
2. Star Health and Allied Insurance Co. Limited B-6/10 Model Town 1 Near Metro Station (Model Town) New Delhi 110009 Through its Manager.
3. Star Health and Allied Insurance Co. Limited Nirmal Complex, G. T. Road Above OBC Bank, Jalandhar 144001 Through its Manager.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Sh. Jaswant Singh Dhillon (Member)
Present: Sh. Anuj Mehta, Adv. Counsel for the Complainant.
Sh. Nitish Arora, Adv. Counsel for OPs No.1 to 3.
Order
Dr. Harveen Bhardwaj (President)
1. The instant complaint has been filed by the complainant, wherein it is alleged that the complainant hired the service of OPs for obtaining the medi-claim policy Earlier, the complainant obtained his medical insurance from ICICI Lombard insurance but at the instance of the officials of the OPs, who assured the complainant that their company is one of the best company in their field and they can port all the benefits of his earlier policies into the fresh policy of their company and as per their assurance complainant obtained the Senior Citizen Red Carpet Health Insurance policy from OPs. The complainant paid a last premium of Rs.26550/- against the medical policy i.e. Senior Citizen Red Carpet Health Insurance Policy, vide policy bearing no.P/161129/2019/002172, which is effective from the date 21.10.2018 to 20.10.2019. The representative of OPs also issued policy wherein it had been specifically mentioned regarding the previous policies i.e. no., 4128/HPR/94484456/01/000 of ICICI Lombard. As per terms and conditions of above said policy, the OPs No.1 and 2 assured and undertakes to the complainant that in case he suffered any medical problem during this period and paid for that, then they will reimburse all the loss and expenses to complainant. As per the terms and conditions of the said policy, OPs assured complainant to give all the medical benefits to complainant upto Rs 10,00,000/-. The complainant after obtaining the above said policy from the OPs No.1 and 2, unfortunately on date 06.12.2018 suddenly suffered with chest problem/pain and feel uneasiness, he was immediately taken and admitted to Cardice ICU ward under Dr. Sanjeev Kumar Syal vide U No.152728 and Adm. No., 167214 at S G. L Charitable Hospital, Garha Road Jalandhar, and after the treatment he was discharged on 09.12.2018 from the said Hospital. The complainant has spent an amount of Rs.87591/- in total upon his treatment, which he paid over there. The complainant had paid an amount of Rs.87591/- in total upon his treatment which includes hospital bills, medical bills and other expenses. Thereafter, the complainant lodged a claim bearing no.CLI/2019/161129/0538005 for re-imbursement of medical expenses as per the terms: and conditions of the said policy and handed over the same to the office of OP No.3 along with necessary documents as they are liable to pay the said amount to the complainant as per the terms and conditions of their policy. At that time their representatives assured complainant to pay the said amount and the same will be reimbursed to them within few days. The OP No.3, thereafter further referred the claim of the complainant to OP No.1 also seeks other documents as per letter dated 28/12/2018, which were also sent to them by complainant through Regd. Post and the employees of OP No.3 assured complainant that claim will be passed within few days. As per the information given to complainant by the officials of OP No.1, they have not settled the claim of complainant and rejected the same with the Remark ‘suffering from pre existing disease which has not disclosed’ as per letter. The complainant has sent one certificate to the opposite party that the patient Gian Chand Bhardwaj did not have any prior history of pulmonary disease which has issued by Dr. Sanjeev Kumar Syal of S.G.L. Charitable Hospital Jalandhar. Thereafter, OP just to cover their own negligence had shown their unfair trade practice by cancelling the policy and refunded the part payment of the policy premium amount by saying that the complainant was suffering from pre existing disease. It is worth mentioned here that the complainant was not suffering from any disease from the inception of the policy and even otherwise the complainant was already insured with ICICI LOMBARD for the last more than three years and on the assurance of the representative of the OPs, the complainant switched his earlier medical policy to the company of the OP that the benefits which the complainant was availing under the said policy would continue the present policy. By concealing the fact of the said policy of the complainant by the OP again shown their unfair trade practice and withheld the benefits of the complainant regarding his medical insurance. Hence the OP is liable to revive the policy of the complainant along with all benefits and in case any claim has been accrued during the said period than the OP is also liable for the same. The act and conduct of OPs clearly shows unfair trade practice on their part. The Complainant also issued legal notice to the OP, but all in vain 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 pay claim amount of Rs.87,591/- alongwith interest @ 18% per annum from the date of filing of the claim form alongwith the damages to the tune of Rs.2,00,000/- for harassment, mental agony and on account of unfair trade practice and Rs.15,000/- for cost of the case on the part of the OPs alongwith revival of his medical policy with all benefits as demanded be given to the complainant in the interest of justice, equity and fair play.
2. Notice of the complaint was given to the OPs, who filed joint written reply and contested the complaint by taking preliminary objections that the complainant had availed Senior Citizens Red Carpet Health Insurance Policy Mr. Gian Chand Bhardwaj Self vide policy No.P/161129/01/2019/002172 for the period from 21/10/2018 to 20/10/2019 for the Floater Sum Insured Rs 10,00,000/-. The said policy was ported from ICICI Lombard Insurance Co. The Senior Citizen Red Carpet Policy coverage with suitable co-payment i.e. 50% of each and every claim arising out of all pre-existing diseases as defined and 30% in case of all other claims which are to be borne by the insured. It is submitted that the Policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The Complainant has accepted the Policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form.
“The 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 along with the Policy Schedule. Moreover it is clearly stated in the policy schedule ‘the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc.,’
It is further averred that the complainant was hospitalized at SGL Charitable Hospital Alipur on 06/12/2018 for the treatment of Dtype 2 DM/AIWMI/DVD. The claimant has submitted claim for reimbursement of medical expenses for the above mentioned treatment of TYPE 2 DM/AIWMI/DVD. On scrutiny of the claim documents, it is observed from the prescription dated 06.12.2018 of the above hospital that the insured patient is a known case of coronary artery disease. Therefore the OP requested the claimant to furnish us the previous treatment records of CAD. But as the claimant failed to submit the same, the claim was repudiated as per condition No.4 of the terms and conditions of the policy due to non-submission of necessary documents. However subsequently, the claimant submitted representation along with the previous treatment records. On scrutiny of the same, it is observed that:-
As per the consultation report dated 06.12.2018, the patient is a known case of coronary artery disease.
As per the consultation report dated 18.04.2018 of Dr. Rishi K. Arya (prior to the inception of the policy - Collected vide internal verification officer), the patient was advised to take Protimet (used to reduce high blood pressure and relieve chest pain caused due to reduced blood flow to the heart), deplatt cv (Used for the treatment of patients suffering from hyperlipidemia and cardiovascular diseases) and nitrocontin 2.6 (Tablet is an effective medicine to prevent and treat chest pain (angina)) again consulted on 09/08/2018 and advised to take Protol am (Used for the treatment of high blood pressure and ischemic heart disease). Ecosprin (Used to prevent blood clots forming following a heart attack or stroke or to help prevent heart attacks and strokes in patients who have previously suffered from these conditions), Glizid M (tablet prescribed for DM). Thus, from the prescribed tablets, it is noted that the insured was consulted for heart disease and is under treatment for the same which confirms the patient has heart disease prior to our policy.
Further, the PFT report dated 08.12.2018 shows severe restriction, which clearly show that the onset of the disease is prior to the policy. From the above findings, it is confirmed that the claimant suffered from heart disease prior to the inception of the policy. Thus, it is a Pre-existing disease. It is further averred that the claimant has earlier taken medical insurance policies from 2014-15 to 2017-18 from The ICICI LOMBARD and subsequently taken policy from the OP from 21.10.2018 to 20.10.2019 under portability. This being a ported policy, as per Provisions contained in IRDA (Health Insurance) Regulations; the policyholder shall fill in the portability form along with proposal form and submit the same to the insurance company. The term ‘Proposal form’ means a form to be filled in by the prospect in written or electronic or any other format as approved by the Authority, for furnishing all material information as required by the insurer in respect of a risk, in order to enable the insurer to take informed decision in the context of underwriting the risk, and in the event of acceptance of the risk, to determine the rates, advantages, terms and conditions of the cover to be granted. At the time of porting the policy, the insured has not disclosed the above mentioned medical history/health details of the insured-person in the proposal form and other documents submitted to the opposite party which amounts to non disclosure of Information. As per Condition No.9 of the policy, the Company shall not be liable to make any payment under the policy in respect of any claim if information furnished at the time of proposal is found to be incorrect or false or such claim is in any manner fraudulent or supported by any fraudulent means or device, misrepresentation whether by the Insured Person or by any other person acting on his behalf. Hence, the reimbursement claims of the complainant were rightly repudiated as per the terms and conditions of the policy. It is further averred that no cause of action has arisen in favor of the complainant to file the present case. It is submitted that the Respondent OP has acted strictly on the basis of the terms and conditions contained in the policy. The present case is premature as the complainant had not submitted the required documents for the purpose of the claim despite of repeated requests by the answering respondents/OP. The complaint has been filed by the complainant with the mala-fide intention, and further to grab the public money. Hence, the present complaint is liable to be dismissed. It is further averred that the complaint is bound by the terms and conditions as applicable and which were expressly made known to the complainant at the time of his taking the policy in question. The OP had at the time of issuing the policy explained to the complainant the exclusion clauses and the payment plan. Therefore, the complaint is liable to be dismissed with exemplary costs. It is further averred that the complainant has approached this Forum with unclean hands by not disclosing and misrepresenting material facts. 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 Forum. 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 present complaint is the misuse of the legal process. It is further submitted that the present complaint was filed only with the motive to harass the OPs. The complainant has no locus-standi and cause of action to file the present complaint. On merits, the factum with regard to issuance of the insurance policy is admitted and it is also admitted that the complainant had availed senior citizens red carpet health insurance policy for the period from 21.10.2018 to 20.10.2019 for the floater sum insured Rs.10,00,000/-. It is also admitted that the OPs had assured the complainant to make payment of the claim as per terms and conditions of the insurance policy and the facts regarding giving insurance cover to the complainant is also admitted and the facts regarding submission of the claim by the complainant to the OPs is also 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. Rejoinder not filed by the complainant.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file as well as written arguments submitted by counsel for the OPs very minutely.
6. It is admitted that the complainant had got senior citizen Red Carpet health insurance policy from the OP effective from 21.10.2018 to 20.10.2019. The policy has been proved as Ex.C-1. It is also admitted fact that the policy has been ported from ICICI Lombard Insurance Co. to the OP. The complainant has proved the policies to show that earlier also he was having insurance policies from ICICI Lombard and these policies have been proved vide Ex.C-2. The complainant has alleged that on 06.12.2018 suddenly he suffered with chest problem and he was immediately taken and admitted to Cardiac ICU Ward at S. G. L. Charitable Hospital, Jalandhar and was discharged on 09.12.2018 as per Discharge Summary Ex.C-3 . He has proved the Coronary Angioplasty Report Ex.C-4. The complainant lodged the claim before the OPs for reimbursement of medical expenses, which have been proved by the complainant as Ex.C-5, which are bills. He sent the documents sought for passing of the claim by the OPs as Ex.C-6 to Ex.C-10, but the claim of the complainant was rejected vide letter Ex.C-11 on the ground that he was suffering from pre-existing disease, which has not been disclosed.
7. The contention of the OPs is that prior to the inception of the policy, the complainant suffered from heart disease and it is pre-existing disease. It has been alleged by the OPs that the complainant has not disclosed the medical history/health details and pre-existing disease at the time of having the policy and on this ground only the claim has been rejected.
8. Perusal of the record shows that the complainant has sent all the documents required by the OPs and as per Ex.C-11, the OPs have referred the condition No.9 of the policy, which reads that if there is any mis-representation/non-disclosure of material facts, the company is not liable to make any payment in respect of the claim. Now the thing to be seem is as to whether the complainant had any pre-existing disease or the complainant had mis-represented the OPs at the time of purchasing the policy. The OPs have relied upon the prescriptions of Dr. Rishi K. Arya, which has been proved as Ex.OP-5 and perusal of Ex.OP-5 shows that on 18.04.2018, the complainant took the treatment from Dr. Rishi K Arya and doctor prescribed the medicines Glizid M, which is for Diabetes, Deplatt i.e. Blood Thinner, Ecosprin which prevents chest pain and Protol AM, this is for high BP. In this prescription, nothing has been mentioned that the complainant was having any heart problem. The medicines prescribed are for BP and Diabetes and due to BP, the blood thinner i.e. Ecosprin has been prescribed. Perusal of Ex.C-12 shows that ‘the complainant was admitted in S.G.L. Hospital, Jalandhar on 06.12.2018 and he was diagnosed as ‘CAD acute inferior wall MI during the admission itself. He had breathing difficulty during hospital stay and hence PFT was done which showed severe restrictive pattern’. It has been certified by the Senior Consultant Dr. Sanjeev Kumar Syal that the complainant did not have any prior history of pulmonary disease. So, the ground taken by the OPs that there is a mis-representation and non-disclosure of material facts i.e. pre-existing disease is wrong and illegal. No document is there on the file to show that the complainant was having any heart disease earlier. Perusal of Ex.OP-7 shows that they have made reference of the prescription dated 06.12.2018 in which the fact is mentioned that he is known case of coronary artery disease, but Ex.C-12 shows that nothing has been mentioned in this certificate that the complainant was known case of coronary artery disease. Perusal of Ex.C-3, which is a discharge summary, shows that the complainant was feeling pain in chest (Ghabraht) with profuse sweating from last few hours. Nothing has been mentioned in this document that he is a known case of coronary artery disease. Therefore, the ground taken by the OPs for rejecting the claim is illegal and wrong. The letter Ex.OP-8 shows that it has been mentioned in it that the patient has consulted Dr. Rishi K Arya for heart disease, but again in the prescription of the Dr. Rishi K Arya, nothing has been mentioned that he consulted him for heart disease. They have taken the presumption that consultation with doctor means that the patient has heart disease prior to the policy. On what basis the opinion has been given by the medical team of the OP that the disease is prior to their policy has not been proved on record by the OPs. So far the problem of heart due to BP is concerned. It has been held by the Hon’ble Punjab State Consumer Disputes Redressal Commission, in a case titled as “Religare Health Insurance Co. Ltd. Vs. Subhash Chander Aggarwal”, which reads as under:-
“Hypertension is a common disease and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack and repudiation on account of pre-existing disease was not justified.”
It has been held by the Hon’ble National Commission, in a case, titled as “Ravinder Singh Bindra Vs. National Insurance Company Limited & Ors.”
“Concealment of hypertension has not been taken as a suppression of any material information sufficient to repudiate the claim.”
It has been held by the Hon’ble National Commission, in a case, titled as “Satish Chander Madan Vs. M/s Bajaj Allianz General Insu. Co. Ltd.”
“Fact that, petitioner prior to obtaining insurance policy was having history of hypertension. Hypertension is a common ailment and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer heart attack.”
It has been decided by the Hon’ble Supreme Court in various judgments that Hypertension is not a disease, it is a general wear and tear of the life which occurred due to the pressure of the present life style and even otherwise the disease of Hypertension and Diabetes can be cured by taking medicine and accordingly, we are of the opinion that the claim of the complainant has been wrongly and illegally repudiated by the OPs and the same is hereby set-aside and further, find that the complainant is entitled for the relief as claimed.
9. In the light of above detailed discussion, the complaint of the complainant is partly allowed and OPs are directed to revive the medical policy with all benefits as per rules and further OPs are directed to pay a compensation of Rs.10,000/- 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.
10. Copies of the order be supplied to the parties free of cost, as per Rules. File be indexed and consigned to the record room.
Dated Jaswant Singh Dhillon Jyotsna Dr. Harveen Bhardwaj
18.04.2023 Member Member President
