BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 214 of 2018
Date of Institution : 20.08.2018
Date of Decision : 11.06.2019
Padam Singh aged 46 years son of Shri Bishamber Singh resident of House No.363, Sector 20, HUDA, Sirsa District Sirsa.
……Complainant.
Versus.
- Star Health & Allied Insurance Company Ltd. Branch Office: Ground Floor, Opp. Shakti Motors, Near IDBI Bank, Sirsa, Tehsil & District Sirsa, through its Branch Manager.
- Star Health and Allied Insurance Company Limited Regd. Office: 1, New Tank Street, Valluyer Kottam High Road, Numgambakkam, Chennai-600034, through its authorized signatory.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA………………. ……PRESIDENT.
SH. ISSAM SINGH SAGWAL ………MEMBER.
MRS. SUKHDEEP KAUR……………..MEMBER.
Present: Sh. JBL Garg, Advocate for the complainant.
Sh. M.K. Saini, Advocate for opposite parties.
ORDER
The case of the complainant, in brief, is that the complainant purchased a Family Health Optima Insurance Plan for himself, his wife Alpana and sons Ayush Kushwah and Aman Kushwah vide policy No.P/211114/01/2018/005370 for the period w.e.f. 13.11.2017 to 12.11.2018 with basic floater sum assured of Rs.3 lakhs and paid premium of Rs.11,889/-. That on 11.01.2018, the complainant developed heart problem and he was taken to Delhi Heart Institute and Multispecialty Hosptial, Delhi where he remained admitted upto 14.01.2018 but on the same day due to developing of further complications, he was again taken to Delhi Heart Institute, Delhi where he remained admitted as an indoor patient and was discharged on 16.01.2018. He spent Rs. 2,60,000/- on his operation, including fee of doctors, transportation charges, costs of medicine etc. The complainant lodged claim with Ops and also deposited all the requisite documents besides completing all the formalities but the Ops have repudiated the claim on the ground that the complainant had chronic, longstanding heart disease prior to inception of medical insurance policy. and as per waiting period 3 (III) of the policy, the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease/condition until 48 months of continuous coverage has elapsed since inception of the policy from 13.11.2017. The complainant requested the Ops to make the amount incurred by him on his treatment and also got served legal notice upon the Ops but to no avail. The act and conduct of the Ops clearly amounts to deficiency in service on their part. Hence, this complaint.
2. On notice, opposite parties appeared and filed their joint written statement in which it has been submitted that the claim for amount Rs.1,04,000/- was reported in the 2nd month of the policy as the cashless treatment was denied vide letter dated 13.01.2018 stating that with the available documents, the exact duration of the ailment could not be ascertained. As per discharge summary, the insured was admitted with the complaints of hypertensive, diabetic, chest pain (On & off) associated with nausea & uneasiness for last few hours prior to admission. CAG report dated 12.01.2018 shows triple vessel disease. ECG report dated 14.01.2018 shows Old MI. The above findings confirm that the insured patient has chronic, longstanding heart disease prior to inception of the medical insurance policy and the same was pre-existing disease. As per waiting period 3 (III) of the policy, the company is not liable to make any payment in respect of expenses for treatment of the pore-existing disease/condition, until 48 months of continuous coverage has elapsed, since inception of the policy with the company from 13.11.2017. The claim has been rightly repudiated on the ground of pre-existing disease. The complainant has not come to this Forum with clean hands. It has been further submitted that the complainant has no cause of action and locus standi to file the present complaint because the insured patient had longstanding heart disease prior to the date of commencement of first year policy. There is no deficiency in service on the part of the Ops. Other contentions have been controverted and prayer for dismissal of the complaint has been made.
3. Thereafter, both the parties have led their respective evidence.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. The perusal of the case file reveals that, the complainant in order to prove his case has furnished his affidavit Ex.CW1/A wherein he has reiterated all the averments made in his complaint. The complainant has also placed on record documents such as policy schedule Ex.C1, Ex.C2, repudiation letter Ex.C3, registered letter Ex.C4, medical treatment, test reports and bills Ex.C5 to Ex.C45, legal notice Ex.C46 and postal receipts Ex.C47 & Ex.C48. On the other hand, the opposite parties have furnished affidavit of Sh. Rajiv Jain, Chief Manager as Ex.RW1/A in which he has reiterated the averments of the written statement. The OPs have also furnished copies of documents such as terms and conditions Ex.R1, common proposal form Ex.R2, policy schedule Ex.R3, discharge summary Ex.R4, request for cashless hospitalization Ex.R5, claim form Ex.R6 and query on preauthorization Ex.R7.
6. The complainant has filed this complaint with the averments that on 11.01.2018, there developed heart problem to the complainant and he was taken to Delhi Heart Institute and Multi-specialty Hospital, Delhi where he remained admitted upto 14.01.2018 but again 14.01.2018 the complainant further developed some complication and then on the same day he was again admitted in Delhi Heart Institute & Multi specialty Hospital, Delhi where he remained admitted as an indoor patient and discharged on 16.01.2018 and he spent Rs.2,60,000/- on his operation. Due intimation was given to the Ops and claim was lodged, but however, the same was repudiated. On the other hand, the Ops have taken specific plea that as per discharge summary the insured was admitted with the complaints of hypertensive, diabetic, chest pain (On & off) associated with nausea & uneasiness for last few hours prior to admission. CAG report dated 12.01.2018 shows triple vessel disease. ECG report dated 14.01.2018 shows Old MI. The above findings confirm that the insured patient has chronic, longstanding heart disease prior to inception of the medical insurance policy and the same was pre-existing disease. As per waiting period 3 (III) of the policy, the company is not liable to make any payment in respect of expenses for treatment of the pore-existing disease/condition, until 48 months of continuous coverage has elapsed, since inception of the policy with the company from 13.11.2017 and the claim has been rightly repudiated on the ground of pre-existing disease.
7. The Ops have repudiated the claim on the basis and examination of discharge summary and other documents of the complainant and they found their opinion that the complainant was suffering from pre-existing disease of heart prior to the inception of the policy. The perusal of the evidence of the opposite parties reveals that the Ops have not placed on record any document or opinion of the medical expert, who examined the record and formed their opinion that the complainant was suffering from pre-existing disease prior to inception of the policy. The Ops have also not placed on record any affidavit of those medical expert, who examined the papers and formed their opinion of pre-existing disease to the complainant. The Ops have relied upon the discharge summary of complainant Ex.R4 of Delhi Heart Institute, Delhi in which it has been reported the history of the present illness Mr.Padam Singh, 45 years old male who is hypertensive, diabetic presented with complaints of chest pain (on & off) associated with nausea and uneasiness for last few hours prior to admission. So, it appears that the Ops have failed to prove the pre-exiting disease of the complainant by leading cogent and convincing evidence. The Ops have relied upon the proposal form Ex.R2 but the same does not bear the signature of Padam Singh, complainant and it bears the signature of only agent. So, it is proved on record that the Ops have arbitrarily and wrongly repudiated the claim of the complainant and the order of repudiation deserves to be set aside
8. In view of the above discussion, we hereby allow the present complaint with a direction to the Ops to settle and pay the claim of the complainant as per terms and conditions of the policy within 45 days of the receipt of the copy of this order. In case the orders are not complied within the stipulated period then the claimed amount would carry interest @ 7 % per annum from the date of lodging of complaint till its realization. The Ops are further directed to pay Rs.5,000/- as compensation on account of harassment and Rs.2,000/- as litigation expenses to the complainant. A copy of this order be sent to both the parties free of costs. File be consigned to the record room.
Pronounced in open Forum. President,
Dated:11.06.2019. District Consumer Disputes
Redressal Forum, Sirsa.
Member Member
DCDRF, Sirsa DCDRF, Sirsa
