BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 01 of 2021
Date of Institution : 07.01.2021
Date of Decision : 21.09.2023
Ram Swroop aged about 68 years son of Bhagwan Dass, resident of Ward No.3, Near Purana Mandir, VPO Kotli, Post Office Suchan, Tehsil and Distt. Sirsa.
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Ltd., Ground Floor, Rathore Tower, Dabwali Road, Near Mahak Hotel, Opp. Shakti Motors Sirsa through its Branch Manager/ Authorized Signatory.
2. Star Health and Allied Insurance Company Ltd., office at SCO 130-131, 4th Floor, Sector 34A Chandigarh through its AGM/ Authorized Signatory.
3. Star Health and Allied Insurance Company Ltd., Grievance Department No.1, New Tank Street, ValluvarKottam High Road, VungamBakkam Chennai- 600034 through its Managing Director.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA……….MEMBER
Present: Sh. Puneet Narang, Advocate for the complainant.
Sh. Ravinder Goyal, Advocate for opposite parties.
ORDER:-
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that complainant purchased a health care insurance policy namely Senior Citizen Red Carpet Health Insurance policy bearing No. P/211121/01/2019/007071 from op no.1 for the period 31.03.2019 to 30.03.2020 by paying premium amount of Rs.21,240/- and complainant was insured by ops for total sum insured amount of Rs. five lacs. It is further averred that in the month of July, 2019 the complainant suddenly felt pain in his chest and he immediately got checked from New Life Care Hospital, Sirsa on 13.07.2019 and Dr. Dinesh Kumar Gijwani conducted ECG, ECS and ECO but no improvement was seen in his health. On 01.08.2019 complainant got checked himself from Delhi Heart Institute and Multispecialty Hospital, Bathinda and was admitted there on 05.08.2019 and Dr. Manpreet Salooja got conducted test of “Coronary Angiography” which revealed double vessel disease. That thereafter Doctor conducted the heart surgery of complainant on 06.08.2019 and he remained under the observation of Dr. Manpreet Salooja from 05.08.2019 to 11.08.2019 and various tests were got conducted and costly drugs were given and during the treatment, an amount of Rs.1,84,085/- has been incurred by complainant including hospitalization, various tests, medicines and life saving drugs etc. It is further averred that as per terms and conditions of the policy, the complainant requested to ops for cashless treatment but ops have denied for pre authorization request for cashless treatment. That complainant was/is entitled to get indemnified his claim and accordingly complainant lodged his claim bearing number CLI/2020/211121/0302840 with the ops and requested the ops to indemnify his claim as per terms and conditions of the policy and he was required to submit some requisite documents and was assured that his claim is under process and will be indemnified. It is further averred that requisite documents were got submitted by complainant with the ops but on 11.10.2019 op no.3 issued a repudiation letter to the complainant vide which his claim has been rejected by them on the ground that it is a pre existing disease prior to inception of policy. That complainant has not been suffered from unstable angina disease prior to inception of policy and ops have wrongly repudiated his claim whereas at the time of issuance of policy, he was got medically checked/ examined by the ops and after their entire satisfaction policy was issued to him. That in this way ops have harassed the complainant and have caused deficiency in service and mental agony to him. That a legal notice was also got served by complainant upon ops but to no effect. Hence, this complaint.
3. On notice, ops appeared and filed written statement taking certain preliminary objections regarding maintainability, locus standi, cause of action, suppression of true and material facts, estoppel, that claim of complainant has been repudiated by ops vide letter dated 8.10.2019 in a legal and lawful manner and that the liability of answering ops to indemnify the insured is subject to terms and conditions as laid down in the insurance policy and that this Commission has no jurisdiction to entertain and try the present complaint. It is also submitted that insurance policy issued to the complainant is governed by limits of liability as per its clauses and in case it is found that any amount is payable to the complainant, the maximum quantum of liability under the terms of the policy shall be Rs.1,09,383/-
4. On merits, it is submitted that as per the record supplied by the complainant, it transpired that complainant was hospitalized at Delhi Heart Institute and Multispecialty Hospital on 05.08.2019 for the treatment of Unstable Angina and discharged on 11.08.2019. The insured sought for pre authorization request for cashless treatment and same was denied vide letter dated 1.8.2019 stating that insured patient has the above disease which is longstanding in nature and it requires further evaluation to ascertain the exact duration of the mentioned disease. Subsequently, the insured submitted claim documents for reimbursement of medical expenses. It is further submitted that on scrutiny of the documents supplied by complainant, it was observed by ops that as per pre authorization request form duly completed and signed by the doctor and the seal of the above mentioned hospital that the duration of the disease is mentioned as six months prior to the commencement of the policy. That ops raised a query to submit previous treatment record for which the complainant through treating doctor confirmed that he did not take any treatment, however not denied the duration. It was confirmed that insured patient had been suffering from the above mentioned disease/ condition prior to the commencement of the first medical insurance policy and hence, it is pre existing disease and present admission and treatment of the insured patient is for the pre existing disease. Therefore, as per waiting period as per clause 3(iii), the company is not liable to make any payment during the first year of operation of policy in respect of expenses for treatment of the pre-existing disease/ condition for which treatment or advice was recommended or received until 12 consecutive months of continuous coverage has elapsed since inception of the first policy on 31.03.2019. Therefore on the above ground, the claim of complainant was repudiated by ops vide letter dated 8.10.2019 in a legal and lawful manner. It is further submitted that it was/is not the observation of the ops rather it was/is the observation of doctor that the duration of the disease is six months prior to the commencement of the policy. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
5. The complainant in evidence has tendered his affidavit Ex.CW1/A and copies of documents Ex.C1 to Ex.C28.
6. On the other hand, ops have tendered affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex.R1 and copies of documents Ex.R2 to Ex.R13.
7. We have heard learned counsel for the parties and have gone through the case file carefully.
8. It is admitted fact on record that complainant purchased health insurance policy from the ops for the period 31.03.2019 to 30.03.2020 for the sum insured amount of Rs.5,00,000/- after paying premium amount of Rs.21,240/- and said fact is also proved from policy document Ex.C4. During the period of policy firstly i.e. on 13.07.2019 complainant got checked himself from New Life Care Hospital as he was having chest pain from few days and same fact is also proved from prescription slip of that hospital Ex.C8. Thereafter, on 01.08.2019 complainant got himself checked from Delhi Heart Institute and Multispecialty Hospital, Bathinda and on 05.08.2019 he was admitted in that hospital where his operation of coronary artery bypass grafting was done on 06.08.2019 and was discharged on 11.08.2019. It is also proved on record that before above said operation, pre authorization request for cashless treatment was made to the ops but said request for approval for cashless treatment was denied by the ops and it advised that insured may submit the documents seeking reimbursement of the expenses incurred relating to the treatment of said disease. According to the complainant, an amount of Rs.1,84,085/- was spent by him on his above said treatment/ operation and claim was also lodged with the ops for reimbursement of said amount but however, ops vide their letter dated 11.10.2019 repudiated the claim of complainant on the ground of pre existing disease as per waiting period clause 3(iii) of the policy. The ops in order to justify their denial regarding pre authorization request for cashless treatment and also to justify repudiation of the claim of complainant has relied upon form for cashless hospitalization Ex.R5 allegedly filled by the treating doctor in which duration of present ailment is mentioned since six months. However, we are of the considered opinion that ops have wrongly and illegally repudiated the genuine claim of complainant while relying on this very document Ex.R5. The ops have not proved on record through any cogent and convincing evidence that treating doctor Dr. K.L. Bansal himself filled the column regarding duration of the present ailment in Ex.R5. The ops have not furnished affidavit of said Dr. K.L. Bansal to prove the fact that how said Doctor came to know that duration of present ailment is from six months and whether complainant himself told the doctor that he is having said ailment since six months from 01.08.2019. The complainant only for the first time went to New Life Care Hospital on 13.07.2019 when he was having chest pain from few days and uneasiness. Although ops demanded record of previous treatment from the complainant but as complainant was not having any previous treatment record with him and only suffered chest pain on 13.07.2019 the prescription slip of which has been placed on record by complainant himself, therefore, ops have wrongly demanded previous treatment record from the complainant which was not with the complainant as prior to 13.07.2019 complainant was not treated for any type of ailment in this regard. The complainant has placed on record his treatment record which he was having and since he has not taken any treatment before 13.07.2019, therefore, repudiation of claim of complainant on the ground of pre existing disease is not justified. So, it is proved on record that ops have wrongly and illegally repudiated the claim of complainant on the ground of pre existing disease because the complainant suffered above said disease after purchasing of the policy. Moreover, the onus to prove any pre existing disease of complainant was only upon ops who are alleging pre existing disease of the complainant but ops have failed to prove the same through any cogent and convincing evidence. Further more, according to complainant before issuance of policy in question to the complainant he was got checked up/ medically examined by the ops and after satisfying with the health condition of complainant, the ops issued the policy in question to the complainant and therefore, now at this stage ops cannot repudiated the genuine claim of complainant on the ground of pre existing disease. The complainant has proved on record through bills/ receipts Ex.C10 to Ex. C12, Ex.C19 to Ex.C28 that he has spent total amount of Rs.1,84,085/- on his above said treatment/ operation but ops have submitted that their liability is limited and vide bill assessment sheet Ex.R13 they have stated that final admissible amount of Rs.1,09,383/-, but however, ops have not shown any reason for such deduction and have not justified the said deduction by relying any clause of the policy. The complainant has spent amount of Rs.1,84,085/- on his treatment and will also incur more amount on further management and medicines etc. and as policy in question has been issued for sum insured amount of Rs.5,00,000/- by the ops, therefore, complainant is entitled to total reimbursement of the amount of Rs.1,84,085/- from ops and repudiation of claim of complainant is hereby set aside. Despite the fact that complainant was having insurance policy from ops he has suffered harassment at the hands of ops for getting his genuine claim amount and as such complainant is also entitled for compensation for harassment and litigation expenses from ops.
9. In view of our above discussion, we allow the present complaint and direct the opposite parties to pay claim amount of Rs.1,84,085/- (in round figure Rs.1,84,000/-) to the complainant within a period of 45 days from the date of receipt of copy of this order, failing which complainant will be entitled to receive the said amount of Rs.1,84,000/- from ops alongwith interest at the rate of @6% per annum from the date of this order till actual payment. We also direct the ops to further pay a sum of Rs.10,000/- as compensation for harassment and Rs.6000/- as litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member Member President,
Dated: 21.09.2023. District Consumer Disputes
Redressal Commission, Sirsa.
