Orissa

Sambalpur

CC/59/2019

Sanjaya Kumar Sahu - Complainant(s)

Versus

Star Health And Allied Insurance Co.Ltd. - Opp.Party(s)

Sri. S.S.Panda, P.debata, A.K.Das

06 Dec 2022

ORDER

PRESIDENT, DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SAMBALPUR

Consumer Case No- 59/2019

Present-Dr. Ramakanta Satapathy, President,

  Sri. Sadananda Tripathy, Member,

Sanjaya Kumar Sahu,

S/o-Hrukesh Sahu,,

R/O- Dharropani, Ps-Katarbaga,

Dist- Sambalpur                                         ………………..Complainant

 

Vrs.

1. Star Health and Allied Insurance Co. Ltd

Represented through its Local Branch Manager,

Sambalpur Branch, Near Kolkata Bazar,

Nayapara, Ps-Town, Dist-Sambalpur.

2. Chief Executive Officer/MD, Star Health and Allied Insurance Co. Ltd

Represented through its At-New Tank Street,

Valluvarkottam High Road,

Nungambakkam, Chennai-600034.  …...……….. ….Opp. Parties

Counsels:-

1. For the Complainant       :- Sri. S.S.Panda, Advocate & Associates. 
2. For the O.P.s                     :- Sri. B.K.Purohit, Advocate & Associates

 

Date Of Filing :04.10.2019,Date Of Hearing :07.11.2022, Date Of Judgement : 06.12.2022

Presented by Sri Sadananda Tripathy, Member.

1. The Brief fact of the Complainant is that the Complainant had taken a health insurance policy from the OPs for himself and his family on dtd. 14.03.2017 and paid a sum of Rs. 7,475/- which is a cashless policy for a sum assured worth Rs 3,00,000/-. The name of the Policy was Family Health Optima Insurance which was covering the Complainant , his wife and his daughter. The policy initially in the first year covered the period dtd. 14.03.2017 to 13.03.2018 and after that it was renewed for the period 2018-2019 and further for the year 2019-2020. The Policy was in force upto dtd. 13.03.2020. On dtd. 21.03.2019, the wife of the Complainant fell ill and was admitted in AMRI Hospital, Bhubaneswar for her treatment. The OPs were duely intimated by the hospital concerned. One of the personnel of the OPs visited the insured in the hospital and refused to meet the medical expenses of the insured. As per the terms of the policy  the insured was entitled to a cashless benefit and it is the OPs who are supposed to pay the bills of the medical expenses of the person insured, the OPs violated the terms of the agreement and refused the benefit of cashless and on dtd. 01.04.2019 the personnel of the OPs company handed over a letter of repudiation of the claim to the Complainant. In the said letter of repudiation it is noted that, the OPs company had taken a plea that the disease was found to be pre existing at the time of taking of the policy and therefore the OPs company was not liable to pay anything to the Complainant. At the time of discharge of the insured the AMRI Hospital, Bhubaneswar gave a final bill of Rs. 1,48,177/- and the Complainant had to pay the entire bill from his pocket. The Complainant suffered financial loss as well as, harassment, mental agonies due to the arbitrary and high handed actions of the OPs. The policy in question was taken in the year 2017 when all these diseases were neither detected nor known to the Complainant. Such problem can occur to anybody at anytime and it cannot be said to be the effect of any pre existing disease. There is no material on record to show that the patient suffered the ailment due to his undisclosed pre existing disease or at least the problem of the patient was connected to her undisclosed pre existing ailment. So the OPs restorted to an unfair trade practice only for unjust enrichment.  
2. The written version of O.Ps is that the Complainant took Family Health Optima Insurance Policy covering self, spouse and dependent child for sum insured Rs. 3,00,000/- . The said Mrs. Mamata Bhioi was admitted at Amri Hospitals Ltd. With diagnosis of hypothyroidism, anaemia and MCTD with pancreatitis on 21.03.2019. The Complainant initially submitted a claim for cashless treatment of approximately Rs. 93,500/- vide pre-authorisation request form. The OPs raised the query vide leter dtd. 22.03.2019, requesting to submit the following documents/details supporting the diagnosis:
   1. Exact duration of MCTD and all previous consultation records
   2. Exact duration of chronic pancreatitis and its cause. Also initial consultation papers and all previous treatment records.
   3. USG abdomen taken at the time of diagnosis.
   4. Exact duration of sickel cell trait.

The Complainant submitted USG report dtd. 22.03.2019 based on which, the OPs denied the cashless request vide letter dtd. 24.03.2019 as it was observed that “Patient is k/c/o CKD, COPD and CTD. Even after query, exact duration and all documents pertaining to it were not provided. Though it may or may not be related to present ailment, current claim cannot be processed at cashless level. Hence claim denied . Member may come for reimbursement with all above mentioned documents for reconsideration. Hence we deny the approval for cashless treatment of the above diagnosed disease”. Subsequently, the Complainant applied for reconsideration of his claim by submitting certain medical records on 24.03.2019. Based on the available medical records submitted, the OPs rejected the cashless request vide letter dtd. 27.03.2019 as it was observed that “ As per the documents received by us, it is observed that the insured patient has been suffering from pancreatitis condition for the past three years which is prior to inception of the first policy. Hence it is a pre existing disease. But the insured has failed to disclose this in the proposal form at the time of inception of the first policy. This amounts to concealment of material facts. The claim is therefore not admissible under the policy issued to the insured”. The Complainant never requested for reimbursement claim with the OPs. The Complainant covering himself, his wife and children. There was no pre-existing Disease (PED) disclosed for the Complainant as well as the child. But, insofar as the wife of the Complainant is concerned, pre-existing disease was disclosed, which was PED-Calculous diseases of hepato pancreatico-biliary system Hypertension and its complications. No other pre-existing disease was disclosed, but when the details of the previous records were asked by the Insurance Company to the Amri Hospitals, they supplied the treatment history of the patient alongwith the documents. As per the discharge note of Sanjivani Family Hospital, it was recorded that the Insured had a known case of sickle cell disease. Moreover, as per medical report dtd. 11.03.2019 of Seven Hills Hospital, the Complainant had known cases of Chronic Obstructive Pulmonary Disease (COPD), Chronic Kidney Disease(CKD) and MCTD. However, when the Complainant was requested to submit documents which would determine the exact duration of these diseases/conditions as well as the treatment sought since such diseases/conditions were first detected, the Complainant could not submit any documents. Hence due to non-submission of documents, along with the fact that diseases like COPD and CKD are declined risks, which was never disclosed in the proposal form, the claim was rejected.

103606587.  

1. Is the Complainant a Consumer of the O.Ps?
2. Is there any deficiency of service/unfair Trade practice in part of O.Ps?
3. Whether the Complainant is entitled for getting any relief from the OPs?

 

Issue No. 1

Is the Complainant a consumer of the O.Ps?

The Complainant had taken a health insurance policy of the OPs for himself and his family on dtd. 14.03.2017 and paid a sum of Rs. 7,475/- which is a cashless policy for a sum assured worth Rs 3,00,000/-. So the Complainant is the consumer of the OPs.

Issue No. 2

Is there any deficiency in service/ unfair Trade practice in part of O.Ps?

The OP in his written version mentioned that “when the details of the previous records were asked by the Insurance Company to the Amri Hospitals, they supplied the treatment history of the patient along with the documents. As per the discharge note of Sanjivani Family Hospital, it was recorded that the Insured had a known case of sickle cell disease. Moreover, as per medical report dtd. 11.03.2019 of Seven Hills Hospital, the Complainant had known cases of Chronic Obstructive Pulmonary Disease (COPD), Chronic Kidney Disease(CKD) and MCTD”. But regarding the same no evidents or documents has been submitted by the OPs. Further the OPs failed to prove that the disease was pre-existing diseases prior to the health insurance policy from the OPs by the Complainant for himself and his family on dtd. 14.03.2017. So deficiency in service/ unfair Trade practice on the part of O.Ps is found.

Issue No. 3

Whether the Complainant is entitled for getting any relief from the OPs?

From all the facts of the parties, the Complainant is entitled for getting reliefs what he claims in his complaint petition from the O.Ps

                             ORDER

The complaint is allowed on contest. The O.Ps are directed to pay jointly and severally Rs. 1,98,177.02/- toward cost of the medical expenses and Rs. 5,000/- towards cost of the petition to the Complainant within 30 days from the date of order,failing which all the amount will further carry with 9% interest per annum till realization to the complainant.

Order pronounced in the open Court today on 6^th day of Dec, 2022.

Free copies of this order to the parties are supplied.