BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.
Consumer Complaint No.531 of 2018
Date of Institution:19.7.2018
Date of Decision:4.2.2020
Mr. Narinder Vaid S/o Sh. Ajay Vaid Aged about 28 years R/o 51, Holy City, Near Swami Satyanand College, Amritsar M.No. 985597822
Complainant
Versus
- Star Health and Allied Insurance Co.Ltd. through its Chairman/Managing Director/Principal Officer, through its registered office at No. 15, Shri Balaji Complex, Ist Floor, Whites Lane, Roy Apettah, Chennai 6000014 and Branch office at SCO 25, District Shopping Complex B Block, Ranjit Avenue, Amritsar Punjab
- Fortis Escorts Hospital, Majitha Verka Byepass through its Doctor/Incharge/Proprietor/Director
Opposite Parties
Complaint under section 11 & 12 of the Consumer Protection Act, 1986.
Present: For the Complainant: In person
For the Opposite Party No.1: Sh.R.P.Singh, Advocate.
For the Opposite Party No.2 : Sh.Sanjeet Singh,Advocate
Quorum:
Sh.Charanjit Singh, President
Ms.Rachna Arora, Member
Sh. Jatinder Singh Pannu,Member
Order dictated by:
Ms.Rachna Arora, Member
1. Sh.Narinder Vaid, complainant has brought the instant complaint under section 11 & 12 of the Consumer Protection Act, 1986 on the allegations that the complainant had purchased a health Insu.policy bearing No. P/211111/01/2018/006908 on 22.11.2016 covering risk period from 22.11.2017 to 21.11.2018 at the premium of Rs. 5994/- for sum assured Rs. 5,00,000/-. During the validity of said policy, complainant was admitted to Fortis Escorts Hospital, Amritsar on 14.2.2018 due to high fever and leg pains, where the doctors advised various tests but were not able to diagnose or treat the complainant. As such complainant was discharged from the hospital on 21.2.2018 without a proper diagnosis. The complainant filed cashless claim with opposite party No.1 during his stay at the hospital but the same was rejected and the opposite party asked to file for the reimbursement of the hospital expenses with opposite party No.1. On 5.3.2018 complainant was diagnosed with stills disease by the doctors at Fortis Escorts Hospital. Stills disease is an autoimmune disorder which is very rare and hard to diagnose and such a medical certificate has been provided by the doctors at Fortis Escorts Hospital. During the stay at the hospital, complainant incurred Rs. 2,12,348/-, copy of hospital bills is Ex.C-4 pages 18. The complainant filed claim for reimbursement after submitting all the documents with opposite party No.1 but the opposite party No.1 refused the claim vide letter Ex.C-5 on the ground that the patient has similar complaints last one year back but the insured has not submitted the same. The complainant had submitted all the documents and was neither admitted in any hospital previously nor had been treated for stills disease in his entire life. The act of the opposite party No.1 in rejecting the claim amounts to deficiency in service, unfair trade practice as well as gross negligence and carelessness on the part of the opposite party No.1. Vide instant complaint, complainant has sought for the following reliefs:-
(a) Opposite party No.1 be directed to pay the sum of Rs. 2,12,348- towards the treatment of the complainant alongwith interest ;
(b) Compensation to the tune of Rs. 50000/- alongwith litigation expenses to the tune of Rs. 10000/- may also be awarded to the complainant.
Hence, this complaint.
2. Upon notice, opposite party No.1 appeared and filed written version in which it was submitted that the complainant availed Medi Classic Individual Health Insurance Policy covering the complainant for the sum assured Rs. 5,00,000/- vide policy No. P/211111/01/2017/005360 from 22.11.2016 to 21.11.2017 and P/211111/01/2018/006908 from 22.11.2017 to 21.11.2018. 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 alongwith the policy schedule. In this case the complainant was admitted at Fortis Escorts Hospital Limited, Amritsar on 14.2.2018 for the treatment of PUO/Anemia/Leucocytosis/Haemorrhoids and raised pre authorization request for cashless treatment and the same was denied on the ground that the treatment pertaining to anemia is not payable as per policy and part payment for infectious disease not possible in cashless. Thereafter the complainant submitted the documents for reimbursement of medical expenses and from the documents, it was found that the complainant was diagnosis PUO with anemia with Leucocytosis with significant weight loss. Esophatgitic Grade B, Ist degree Haemorrhoids and it was found from the inpatient history and physical record submitted by him during cashless processing the insured has similar episode of the same disease last year . On that query was raised vide letter dated 23.3.2018 requesting the complainant to submit the following documents :-
- Complete set of indoor case papers;
- Discharge summary with investigation report for admission with similar complaint one year back and dated 1.2.2018 in Mehra Medical Centre and 15.3.2017, admission date 5.2.2018 and discharge summary for all admissions prior to this admission
- Any past history of blood transfusion for anemia, present
Inspite of request the complainant till date has not provided the documents as such in absence of those documents, the opposite party is unable to process the claims and the facts mentioned above have been concealed by the complainant, therefore, he is not entitled for any claim. In view of the terms and conditions of the policy, the complainant is liable to submit the documents sought for processing the claim but in the present case the complainant has not provided the documents, therefore, the claim was repudiated vide letter dated 28.4.2018. After repudiation, the representation was made by the complainant vide letter dated 9.5.2018 alongwith medical certificate dated 8.5.2018 and same was reviewed and replied vide letter date 23.5.2018 and stated that the patient was having similar complaint one year back and request was made for furnishing the previous treatment record which was taken one year back but the insured has not submitted the same, therefore, the claim was repudiated . It was submitted that even if this Forum finds any liability upon the opposite party that may be limited to Rs. 1,96,517/- on submission of PAN card/Aadhar card as per guidelines of IRDA. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Opposite party No.2 in its written version has submitted that the complainant was admitted in opposite party No.2 hospital on 14.2.2018 and discharged on 21.2.2018. The complainant approached the answering opposite party No.2 for the treatment and cashless approval for treatment was sought by the AOP from Star Health And Allied Insu.Co. Ltd. On 14.2.2018. Opposite party No.1 sent query to answering opposite party on 14.2.2018 with the requirement of some documents which the answering opposite party submitted on 14.2.2018. Again opposite party No.1 sent second query letter to answering opposite party on 15.2.2018 which the answering opposite party No.2 replied the same with supporting documents on 15.2.2018. Again opposite party No.1 sent third query letter on 16.2.2018 which was replied on 17.2.2018. Finally opposite party No.1 vide intimation dated 17.2.2018 stated that “treatment pertaining to anemia is not payable as per policy . Part payment for infectious disease not possible in cashless. Hence, we express our inability to consider the request for cashless. However, the insured may furnish all the above documents and treatment records and seek reimbursement which shall be considered in accordance with terms and conditions of the policy.” Hence, answering opposite party has made its best efforts to do for approval of the cashless claim but the opposite party No.1 rejected the same.
4. Alongwith the complaint, complainant has filed copy of cover note Ex.C-1, copy of medical history Ex.C-2, copy of hospital bills Ex.C-4, copy of medical certificate Ex.C-3, copy of medical certificate Ex.C-6, copy of refusal letter Ex.C-5, copy of legal notice Ex.C-9, copy of email Ex.C-8.
5. Alongwith written version opposite party No.1 filed affidavit of Rajiv Jain, Chief Manager Ex.OP1/1, copy of power of attorney in favour of Rajiv Jain Ex.OP1/2, copy of policy alongwith terms and conditions Ex.OP1/3, copy of repudiation letter Ex.OP1/4, copy of proposal form Ex.OP1/5, copy of pre-authorization letter Ex.OP1/6, copy of denial of cashless request dated 17.2.2018 Ex.OP1/7, copy of query letter dated 23.3.2018 Ex.OP1/8, copy of query letter dated 16.4.2018 Ex.OP1/98, copy of claim form Ex.OP1/10, copy of discharge summary Ex.OP1/11, copy of letter dated 9.5.2018 Ex.OP1/12, copy of repudiation of representation letter dated 23.5.2018 Ex.OP1/13.
6. Opposite party No.2 alongwith written version has filed affidavit of Dinesh Vashist Facility Director Ex.OP2/A, copy of pre-authorization request form Ex.OP2/1, copy of preauthorization letter dated 14.2.2018 Ex.OP2/2, copy of pre-authorization letter dated 15.2.2018 Ex.OP2/4, copy of reply with supporting documents Ex.OP2/5, copy of query on pre-authorization letter dated 16.2.2018 Ex.OP2/6, copy of reply Ex.OP2/7, copy of denial of pre authorization for cashless treatment Ex.OP2/8, copy of consent for charges related to general admission Ex.OP2/9, copy of undertaking Ex.OP2/10.
7. We have heard the Ld.counsel for the parties and have carefully gone through the record on the file.
8. From the record i.e. pleadings of the parties as well as evidence on record, it is clear that the complainant had purchased a health Insu.policy bearing No. P/211111/01/2018/006908 covering risk period from 22.11.2017 to 21.11.2018 for sum assured Rs. 5,00,000/-. It is the case of the complainant that during the validity of the policy period, complainant was admitted to Fortis Escorts Hospital, Amritsar on 14.2.2018 and was discharged from the hospital on 21.2.2018 without a proper diagnosis. The complainant filed cashless claim with opposite party No.1 during his stay at the hospital but the same was rejected and the opposite party asked to file for the reimbursement of the hospital expenses with opposite party No.1. On 5.3.2018 complainant was diagnosed with stills disease by the doctors at Fortis Escorts Hospital. Stills disease is an autoimmune disorder which is very rare and hard to diagnose and such a medical certificate has been provided by the doctors at Fortis Escorts Hospital. During the stay at the hospital, complainant incurred Rs. 2,12,348/-, copy of hospital bills is Ex.C-4 pages 18. The complainant filed claim for reimbursement after submitting all the documents with opposite party No.1 but the opposite party No.1 refused the claim vide letter Ex.C-5 on the ground that the patient has similar complaints last one year back but the insured has not submitted the same. The complainant was neither admitted in any hospital previously nor had been treated for stills disease in his entire life. The act of the opposite party in refusing the genuine claim of the complainant amounts to deficiency in service as well as unfair trade practice.
9. On the other hand Ld.counsel for opposite party No.1 has repelled the aforesaid contention on the ground that the complainant was admitted at Fortis Escorts Hospital Limited, Amritsar on 14.2.2018 for the treatment of PUO/Anemia/Leucocytosis/Haemorrhoids and raised pre authorization request for cashless treatment and the same was denied on the ground that the treatment pertaining to anemia is not payable as per policy and part payment for infectious disease not possible in cashless. Thereafter the complainant submitted the documents for reimbursement of medical expenses and from the documents, it was found that the complainant was diagnosis PUO with anemia with Leucocytosis with significant weight loss. Esophatgitic Grade B, Ist degree Haemorrhoids and it was found from the inpatient history and physical record submitted by him during cashless processing the insured has similar episode of the same disease last year . On that query was raised vide letter dated 23.3.2018 requesting the complainant to submit the following documents :-
- Complete set of indoor case papers;
- Discharge summary with investigation report for admission with similar complaint one year back and dated 1.2.2018 in Mehra Medical Centre and 15.3.2017, admission date 5.2.2018 and discharge summary for all admissions prior to this admission
- Any past history of blood transfusion for anemia, present
Inspite of request the complainant till date has not provided the documents as such in absence of those documents, the opposite party is unable to process the claims and the facts mentioned above have been concealed by the complainant, therefore, he is not entitled for any claim. The complainant has not provided the documents, therefore, the claim was repudiated vide letter dated 28.4.2018. It was submitted that even if this Forum finds any liability upon the opposite party that may be limited to Rs. 1,96,517/- on submission of PAN card/Aadhar card as per guidelines of IRDA.
10. From the appreciation of the facts and circumstances of the case, it stands proved on record that complainant had purchased a health Insu.policy bearing No. P/211111/01/2018/006908 on 22.11.2016 covering risk period from 22.11.2017 to 21.11.2018 for the sum assured Rs. 5,00,000/-. It also stands proved on record that during the validity of said policy, complainant was admitted to Fortis Escorts Hospital, Amritsar on 14.2.2018 due to high fever and leg pains and was discharged from the hospital on 21.2.2018 without a proper diagnosis. Again on 5.3.2018 complainant was diagnosed with stills disease by the doctors at Fortis Escorts Hospital. Stills disease is an autoimmune disorder which is very rare and hard to diagnose and such a medical certificate has been provided by the doctors at Fortis Escorts Hospital. During the stay at the hospital, complainant incurred Rs. 2,12,348/-, copy of hospital bills is Ex.C-4 . The cashless claim of the complainant was rejected by the opposite party as such the complainant lodged claim for reimbursement. But the opposite party on 23.5.2018 rejected the said claim on the ground that as per case records the patient has similar complaints last one year back but the insured has not submitted the same. The only plea of the opposite party No.1 is that query was raised vide letter dated 23.3.2018 requesting the complainant to submit the following documents i.e. Complete set of indoor case papers , Discharge summary with investigation report for admission with similar complaint one year back and dated 1.2.2018 in Mehra Medical Centre and 15.3.2017, admission date 5.2.2018 and discharge summary for all admissions prior to this admission as well as any past history of blood transfusion for anemia, present . But we are not agreed with this plea of the opposite party as the onus to prove whether the complainant was earlier suffered from the same problem and got admitted himself in any hospital what to talk Mehra Medical Centre is upon the opposite party and not upon the complainant. It has been held by the Hon'ble Supreme Court of India in case P.Vankat Naidu Vs. Life Insurance Corporation of India & Anr. IV(2011) CPJ 6 (SC) that where respondent did not produce any tangible evidence to prove that deceased withheld information about his hospitalization and treatment, the opposite party respondents are not justified in repudiating the claim of the complainant. Hon'ble National Commission in case LIC Insurance Corporation of India & Anr. Vs. Naseem Bano 2013(1) CPC 491 has held that where the only ground of repudiation of claim is that insured had concealed material fact of diabetes or hypertension, held that evidence based on “bed head ticket' only not sufficient to prove concealment of disease. No other medical record was produced by the insurance company. So repudiation of the claim on this ground is not justified .Same view has been taken by the Hon'ble National Commission in case Bajaj Allainz Life Insuance Company Ltd. Vs. Sowbhagyalaxmi and Ors. 2013(1) CPC 128 that repudiation of claim on ground of pre-existing disease was unfounded on report of investigator which was not supported by any evidence or affidavit. Hon'ble National Commission in case LIC of India and Others Vs. Kunari Devi 2009(2) CPC 107 has held that only evidence relied upon by the insurance company was the history recorded in hospital's bed head ticket which cannot be treated as a material evidence. Our own Hon'ble State Commission in case Life Insurance Corporation of India & Anr. Vs. Murti Devi 2012(3) CPC 375 has held that where petitioner has not produced any record of medical treatment of the insured to prove that he had taken medical treatment from any doctor regarding disease prior to the insurance policy. It cannot be held that complainant has suppressed any material fact . The Hon'ble National Commission in case Sahara India Life Insurance Co. Ltd. & Anr Vs. Hansaben Deeepak Kumar Pandya IV(2012) CPJ 13(NC) has held that where the opposite party insurance company has failed to produce on record any evidence to show that deceased insured ever consulted doctor for taking treatment of heart disease, the repudiation of the claim on the ground of suppression of material fact is totally illegal. Moreover there was no bar on the Opposite Party to get the thorough medical check up at the time of issuance of the policy. The Opposite Party was within their right to cancel the policy if it doubted or found any information supplied by the life assured being false or wrong, but this has not been done by the Opposite Party. The investigation has been got done at the time when the claim was lodged by the complainant. It was for the Opposite Party to ensure about the health of the insured before issuance of the policy of such amount. Many times a person may not know himself/ herself if he/ he is suffering from any particular disease. Moreover, prior to issuance of the policy, it was required to check up life assured thoroughly. It was the bounden duty of the Opposite Party to make thorough investigation at the initial stage. It appears that the Opposite Party has different yard stick at the time of accepting the policy for procuring the business and different face at the time of discharge of its lawful liability. The act of the Opposite Party firstly by repudiating the claim lodged by the complainant is illegal and void and against the principles of natural justice. This is a common practice of the Insurance Companies to repudiate the claim on flimsy grounds without any justification. In this regard, we are supported with the rulings: Life Insurance Corporation of India Vs. Ambika Prasad Pandey, AIR 1999 MP 13 and Life Insurance Corporation of India Vs. Narmada Agarwalla, AIR 1993 Ori 103. In the facts of this case, ratio of the decision of Hon’ble Apex Court in case of Dharmendra Goel Vs. Oriental Insurance Co. Ltd., 2008(3) CPJ 377 (SC) is fully attracted. It was held that
“Insurance Company being in a dominant position, often acts in an unreasonable manner and after having accepted the value of a particular insured goods, disowns that very figure on one pretext or the other, when they are called upon to pay compensation. This ‘take it or leave it’, attitude is clearly unwarranted not only as being bad in law, but ethically indefensible.”
11. On this point, Hon’ble Punjab & Haryana High Court in case titled as New India Assurance Company Limited Vs. Smt.Usha Yadav & Others 2008(3) RCR (Civil) Page 111 went on to hold as under:-
“It seems that the insurance companies are only interested in earning the premiums and find ways and means to decline claims. All conditions which generally are hidden, need to be simplified so that these are easily understood by a person at the time of buying any policy. The Insurance Companies in such cases rely upon clauses of the agreement, which a person is generally made to sign on dotted lines at the time of obtaining policy. Insurance Company also directed to pay costs of Rs.5000/- for luxury litigation, being rich.
12. Regarding quantum of claim the complainant has placed on record copy of hospital bill Ex.C-4 consisting of pages 84 to 94 in which it has been duly proved on record that the complainant has incurred Rs. 2,12,349/- on his treatment and made the payment of this amount from his own pocket vide receipts of Ex.C-5 pages 95 to 102. As the sum assured of the policy in dispute is Rs.5,00,000/- and the complainant has claimed Rs. 2,12,349/- incurred on his treatment which is less than the sum assured, as such the complainant is entitled to full claim amount of Rs. 2,12,349/-.
13. In view of the above discussion, we allow the complaint with costs and the opposite party No.1 is directed to pay Rs. 2,12,349/- alongwith interest @ 9% p.a. from the date of filing of the complaint till payment. Opposite party No.1 is also directed to pay litigation expenses to the tune of Rs. 7500/- to the complainant. However, complaint against opposite party No.2 stands dismissed. Compliance of the order be made within 30 days from the date of receipt of copy of this order ; failing which complainant shall be entitled to get the order executed through indulgence of this Forum. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced in Open Forum (Charanjit Singh)
President
Dated: 4.02.2020
(Rachna Arora) (Jatinder Singh Pannu)
Member Member
