BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 192 of 2018
Date of Institution : 26.06.2018
Date of Decision : 24.04.2019
Suresh Kumar (aged about 43 years) son of Sh.Bachan Lal Bajaj, House No.107, Ward No.3, Village Chamai, Tehsil & Sirsa.
……Complainant.
Versus
- Chief Manager, Star Health & Allied Insurance Co. Ltd., 1 New Tank Street Valluvar Kottam High Road, Numgambakkam Channai-600034 through its Senior Manager/Incharge Customer Care.
- Manager, Star Helath and Allied Insurance Company Limited, Branch Office, Ground Floor, Rathore Tower, Dabwali Road, Sirsa.
- Mamta Rani, Agent, Code NO.DA0000301084, Star Health and Allied Insurance Company Ltd. Ground Floor, Rathore Tower, Dabwali Road, Sirsa.
...…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. Ravinder Monga, Advocate for the complainant.
Sh. M.K. Saini, Advocate for opposite parties No.1 & 2.
OP No.3 exparte.
ORDER
The case of the complainant, in brief, is that the complainant purchased a Family Health Optima Insurance Plan policy No.P/211121/ 01/2017/002488 and paid the premium to the tune of Rs.16343/- covering the risks from 30.03.2017 to 29.03.2018/-. The policy being basic floater was for sum insured of Rs.10 lakh only. The complainant and his entire family i.e. his wife and both the children are healthy and without any pre-existing disease. Due to some problem in teeth, the complainant visited Jan Nayak Chaudhary Devi Lal Dental College Sirsa on 20.02.2018 and on examination, the doctor observed that there was a right buccal mueosa and refer him to higher centre. In the month of February, 2018, the complainant visited Jindal Institute of Medical Science, Hisar where the doctor, after investigation, advised for Biopsy test, which was got done from Mangal Diagnostic Centre, Hisar. Thereafter, Dr.G.R.Gupta, in his report dated 03.02.2018 has diagnosed that Squamous Cell Carcinoma- Moderately Differentiated - Right, Non Specific Chronic Irritative Changes - Left. The doctor concerned admitted the complainant on 21.02.2018 in the hospital and after conducting Oncology Surgery discharged him on 26.02.2018. The complainant intimated the Ops and also provided them all the requisite documents alongwith bills. It has been further averred that about 15 years back, the complainant got treatment for the same problem from some Desi Hakim/doctor. The complainant has also cleared the ambiguities of the Ops vide acknowledgement dated 18.04.2018. All of a sudden, the Ops, have taken a hyper technical plea that the complainant has concealed pre-existing disease. Though in the letter of query, there are self contradictory pleas. In letter dated 19.02.2018 under the head of insufficient query received, wherein it has been mentioned Kindly note though it is unrelated to the present ailment, above document is mandatory for the further consideration of claim in cashless. The treating doctor Dr.Harish Sharma has endorsed petty inquiry but the Ops are bent upon and pre-determined to delay and declined the claim of the complainant, so they have involved themselves within the preview of unfair trade practice. The decision dated 21.02.2018 taken by the Ops falls within the preview of pre-determined act, against the natural justice and without affording any opportunity of hearing. The Ops have passed the said order with remarks We note that the insured patient has been diagnose carcinoma of buccal Mucosa. As per the medical record submitted, it is noticed that the insured patient K/C/O chronic liver disease with the portal hyper tension on medication since 10-15 years which is non-disclose at the time of policy inception and considered as pre-existing disease. On 18.04.2018 one of the representative/authorized person had visited the premises of complainant and inquired about 2nd pending claim. The complainant being harassed, under the pressure of financial losses and ill-health condition, could not give much time to think over the deep routed conspiracy of the Ops and wrote down the same words provided/supplied by the mediator person of the Ops. The act and conduct of the Ops clearly amounts to deficiency in service on their part.
2. On notice, Ops No.1 & 2 have filed their joint reply wherein it has been submitted that the complainant had availed Family Health Optima Insurance Policy for himself, his spouse and children vide policy No.P/211121/01/2017/002488 for the period from 30.03.2017 to 29.03.2018. The patient was hospitalized in Aadhar Health institute on 21.02.2018 and was discharged on 26.02.2018 and was diagnosed as CA BUCCAL MUCOSA. On scrutiny of claim, it was observed that he was diagnosed with CA BUCCAL MUCOSA being known case of Chronic Liver Disease, thus the pre authorization was rejected and the same was informed to the insured vide letter dated 21.02.2018. At the time of inception of the policy, the above mentioned medical history was not disclosed in proposal form which amounts to mis-representation, non-disclosure of material facts and as per condition No.8 of the policy, if there is any misrepresentation/ non- disclosure of material in that eventuality, the company is not liable for any claim. It has been further submitted that there is no provision for medical checkup upto the age of 50 years and since all the insured at the time of policy was below 50 years, no medical checkup was conducted by the Ops. Though the treatment taken by the complainant/insured has no nexus with the CLD i.e. liver disease, the insured had to disclose the material facts at the time of inception of policy, thus, the claim was rejected and the same was informed to the insured vide letter dated 05.05.2018. The complainant has not filed the present complaint with clean hands and this Forum has also got no jurisdiction to decide the present complaint. Other contentions have been contorverted and prayer for dismissal of the complaint has been made. During the proceeding of the complainant, the Op No.3 did not come present, therefore, she was proceeded against exparte vide order dated 11.03.2019.
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. Learned counsel for the complainant has contended that it is a proved case of the complainant that the complainant has purchased a Family Health Optima Insurance Plan policy issued by Branch Office Sirsa by paying a sum of Rs.16343/- as premium for the period from 30.03.2017 to 29.03.2018. In the month of January, 2018, the complainant fell ill and he got treatment from different hospitals, as he was having a problem in his right Buccal Mueosa and he was advised/refer to some higher institute. The complainant went to Jindal Institute of Medical Science, Hisar in the month of February, 2018 where the doctor advised for detail investigation and after due investigation, the doctor advised for Biposy Test. The complainant was admitted in the hospital on 21.02.2018 and was discharged on 26.02.2018 after conducting Oncology Surgery. The complainant has spent Rs.1,29,110/- on his treatment. Since the cashless claim was rejected by the Ops on 21.02.2018, therefore, the complainant had lodged the claim alognwith the bills of expenditure incurred on the treatment and medicines and the same was also declined on flimsy grounds, which clearly amounts to deficiency in service and unfair trade practice on their part. Learned counsel for the complainant has relied upon the judgments report as Satish Chander Madan Vs. M/s Bajasj Allianz General Insurance Company Limited 2016 (1) CPJ 613, Jeewan Bharti Building Vs. Syham Babu & Others 2018 (1) CPJ 198, Oriental Insurance Company Limited Vs. A.V.Subba Rao & Others 2011 (2) CPJ 452 and Bajaj Allianz General Insurance Company Limited Vs. Valso Jose 2012 (4) CPJ 839.
6. On the other hand, learned counsel for the Ops No.1 & 2 has strongly contended that the complainant was suffering from severe liver disease for the last 15 years prior to inception of the policy in question and this fact has been concealed by the complainant while furnishing declaration in the proposal form, as a result of which, on the basis of terms and conditions of the policy, the claim lodged by the complainant was repudiated, as the same was not payable. It has also been contended that the complainant has furnished self declaration, by which he has himself admitted qua the fact of pre-existing disease of liver and the Ops have rightly repudiated the claim of the complainant.
7. We have heard rival contentions of learned counsel for the parties and have gone through the case file and case laws relied upon by learned counsel for the complainant carefully.
8. The perusal of the case file reveals that in order to prove his case the complainant 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 OPD Slip Ex.C1, Emergency OPD slip Ex.C2, medical test report Ex.C3, Queries on pre-authorization Ex.C4 to Ex.C7, self declaration certificate Ex.C8, ultrasound report Ex.C9, rejection of pre-authorization for cashless treatment Ex.C10, admission/discharge record Ex.C11, case summary/discharge slip Ex.C12, claim of medical reimbursement Ex.C13, details of bills Ex.C14, letter for requirement of additional documents/ information Ex.C15, claim of medical bill reimbursement Ex.C16, reply of letter Ex.C17, repudiation letter Ex.C18, renewal notice Ex.C19 and copies of insurance plan Ex.C20 & Ex.C21. On the other hand, the opposite parties have furnished affidavit of Sh. Rajiv Jain, Chief Manager as Ex.RW1, in which, he has reiterated the averments of the written statement. The OPs have also furnished copies of documents such as terms and conditions of policy Ex.R1, notice of cancellation for non disclosure of pre-existing disease Ex.R2,policy schedule Ex.R3 & Ex.R4, proposal form Ex.R5, rejection of pre-authorization for cashless treatment Ex.R6 & Ex.R7, claim form for health insurance Ex.R8, repudiation letter Ex.R9 and request of cashless hospitalization for medical insurance policy Ex.R10.
9. The facts qua issuance of the policy by the Op No.1 as well as regarding treatment of the complainant from the different hospitals and lodging of claim of the complainant are undisputed between the parties. The only ground for repudiation of the claim of the complainant is that the complainant was suffering from pre-existing disease of liver.
10. The perusal of the evidence of the complainant reveals that the complainant in the month of January, 2018 had felt some difficulties in his teeth and he went to Jan Nayak Chaudhary Devi Lal Dental College, Sirsa on 20.02.2018 where it was observed that there is a right Buccal Mueosa and he was referred to higher institute. He went to Jindal Institute of Medical Science, Hisar and after investigation, the doctor advised for Biopsy Test. The doctor while preparing his report on 03.02.2018 has diagnosed 1.Squamous Cell Carcinoma- Moderately Differentiated- Right. 2. Non specific Chronic Irritative Changes - Left. The doctor concerned admitted the complainant on 21.02.2018 and conducted Oncology Surgery and discharged the complainant on 26.02.2018. The perusal of the complaint reveals that the complainant has claimed an amount of Rs.1,29,110/- which he spent on his treatment in addition to other claim qua compensation and litigation cost. It is further undisputed between the parties that cashless claim was declined by the Ops No.1 & 2 and thereafter the claim was lodged, after the treatment, by the complainant.
11. The perusal of the repudiation letter Ex.R9 reveals that it has been specifically mentioned therein that they have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of CA buccal Mucosa. Although the present admission and treatment of the insured patient is for CA buccal mucosa, it is observed from the claim verification report that the insured patient has chronic liver disease 15 years back; as per the USG report dated 20.02.2018, liver appears diffusely heterogeneous with surface irregularly, ill marginated hypoechogenicitie in both the lobes of liver? Due to cirrhosis. Based on these findings, our medical team is of the opinion that the insured patient has chronic, longstanding disease prior to inception of the medical insurance policy. At the time of inception of the your policy which is from 30.03.2017 to 29.03.2018, you have not disclosed the above mentioned medical history/health details of the insured person in the proposal form which amounts to misrepresentation/ non-disclosure of material facts. It is apparently clear from the letter of repudiation that treatment which the complainant had taken for the disease is for CA buccal Mucosa has no relation with the disease of liver for which complainant had been allegedly suffering from the last 15 years. So, it cannot be presumed that the amount, for which the complainant has sought reimbursement, of the claim relates to the expenditure spent on alleged pre-existing disease. The evidence of the Ops further reveals that the Ops have not placed on record any cogent and convincing evidence that the complainant was suffering from any serious liver disease about 15 years ago nor the Ops have placed on record any opinion of expert or affidavit of any expert to this effect that insured Suresh was/is still suffering from liver disease, which he was having around 15 years back. Moreover, it is a common practice in the society, as and when, who purchases any medi claim policy has to undergo a test before the approved medical practitioner of the insurance company and the approved medical practitioner of the insurance company always prefer to ask the insured to go for formal tests in order to observe the health of the proposed insured.
12. Though during the course of arguments learned counsel for the Ops has strongly relied upon the self-declaration certificate allegedly to be executed by the complainant Suresh Kumar but the perusal of the self-declaration certificate reveals that after writing the self declaration the signature of Suresh Kumar has been put after a long distance between the writing and there is distance between the writing and signature. It has been allegedly written by Suresh Kumar that he does not have any pre-existing disease. He had this problem before 15 years back and he had got the treatment then and now he has no such problem. This writing does not bear the date, month and year rather it appears that the signatures of the complainant has been procured on some blank paper which has been used lateron and it does not find any attestation by any person. So, this document alone is not sufficient to repudiate the claim of the complainant rather it appears that the Ops No.1 & 2 have repudiated the claim of the complainant in a very ordinary and casual manner, which clearly amounts to deficiency in service and unfair trade practice on their part.
13. 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 after re-opening the case file within 30 days of the receipt of the copy of this order. 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.
Announced in open Forum. President,
Dated:24.04.2019. District Consumer Disputes
Redressal Forum, Sirsa.
Member Member
DCDRF, Sirsa DCDRF, Sirsa
