DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II

U.T. CHANDIGARH

Annpurna Sharma (Bali) w/o Sh. Maneesh Bali at present residing at #2408 (First Floor) Sec.71, SAS Nagar, Mohali (Pb.)

                                      ---Complainant.

Versus

1.                 Star Health and Allied Insurance Company Limited, S.C.O 257, 2^nd Floor, Sec.44-C, Chandigarh through Branch Manager.

2.                 Star Health and Allied Insurance Company Limited, 1, New Tank Road, Valluvarkattam High Road, Nungambakkam, Chennai, 34 through General Manager;

---Opposite Parties.

BEFORE:  SMT. MADHU MUTNEJA, PRESIDING MEMBER

                   SHRI JASWINDER SINGH SIDHU, MEMBER

Argued by:  Sh. Maneesh Bali, Counsel for complainant

                        Sh. Jagjot Singh, proxy counsel for Sh. Kunal Dawar, Counsel for OPs.

PER JASWINDER SINGH SIDHU, MEMBER

1.                           In brief, the case of the complainant is that the complainant had proposed an insurance cover for her mother Smt. Meena Sharma and the same was duly insured with the opposite parties vide policy No.P/161113/01/2009/000536 vide proposal form dated 6.11.2008 and a premium was paid vide cheque No.332107 dated 6.11.2008 from the complainant’s account maintained with the HDFC Bank Ltd., SAS Nagar, Mohali.  It is claimed that the policy holder was entitled for a sum insured of Rs.1,00,000/- through this policy.  The complainant also states that at the time of subscribing for the policy, the medical status of her mother was made known by placing on record a diagnostic report dated 7.11.2008 alongwith the list of medicines which were being consumed by her on the advice of her doctor.  Copy of the diagnostic report and the list of medicines is annexed as Annexure C-4 colly. 

                   The complainant has also disclosed that she had preferred an earlier complaint bearing No.CC/808 of 2010 (Annexure C-1) but withdrew the same  with liberty to file fresh and the orders of the District Forum dated 11.8.2011 in that complaint are appended at page 31 of Annexure C-5. 

                   The complainant’s mother was admitted on 14.9.2009 with the Silver Oaks Hospital, Phase 9, Mohali for treatment and a pre-authorization request was made with the opposite party on 14.9.2009 and one Mr. Devinder Garg visited the hospital on 15.9.2009.  Thereafter, the complainant was informed that her claim application has been declined by the opposite parties.  However, the complainant went ahead with the treatment of her mother and spent nearly Rs.6,63,239/- as per para 12 of her complaint till 22.1.2010.  The complainant  thereafter approached the opposite parties for the settlement of the claim whereupon the opposite party asked the complainant to file a fresh claim application which was made on the claim form sent by the opposite party through email on 10.11.2009. The complainant thereafter made repeated representations as per Annexure C-6 Colly. and C-7.  The complainant claims that the opposite parties were deficient in rendering proper service to her for the reason that her rightful claim was rejected on the basis of the report made by Mr. Devinder Garg, representative of the opposite parties who had visited the Silver Oak Hospital without taking into consideration the report of the treating doctor. 

                   The complainant has prayed that the opposite parties be ordered to pay the insured amount against the expenditure incurred alongwith penal interest payable since September 2009.  The complainant has also prayed for compensation of Rs.1,00,000/- for having suffered mental pain, sufferings, coupled with harassment caused by the opposite parties. The complainant has also claimed litigation expenses to the tune of Rs.20,000/-

2.                           In their written statement filed by OPs, it has been pleaded that the present complaint is not maintainable on the ground that the complainant has concealed and suppressed material and relevant facts of the case with malafide and dishonest intentions.  The complainant has also twisted and distorted the facts to suit his convenience and mislead this Forum.  It is further claimed that the complainant has not acted in good faith and having come to this Forum with unclean hands deserves no relief.  While replying on merits, the fact with regard to Mrs. Meena Sharma having availed the diabetes Safe Insurance Policy from the opposite parties for the period commencing from 19.11.2008 to 18.11.2009 with maximum policy cover of Rs.1,00,000/- against premium of Rs.2,135/- is admitted.  It is also claimed that this particular policy was specifically for persons who are diagnosed with Diabetes Mellitus Type-II. The copy of the terms of the policy are appended as Annexure R-1.  The proposal form filled up by the complainant through which the policy was issued is appended as Annexure R-2.  It is claimed that the status of Mrs. Meena Sharma suffering with DM Type II was stated to be since August 2007 but at the same time, while answering to the query about her suffering from any kidney disease the same was answered as ‘NO’.  Even to the question  whether she had been treated for a renal failure  the same was also answered as ‘NO’. 

                   The opposite parties whole holding their ground of rejection of the claim of the complainant have claimed that while the request for cashless claim was made, a medical officer of the opposite parties visited the Silver Oak Hospital to complete the mandatory formalities. This medical officer in his clinical assessment has stated that the patient was suffering from the said disease since 2007/08.  It was further mentioned in the assessment that the complainant was having a renal problem since the year 2008 and was getting treatment at PGI and it is for the same problem that she was now under treatment at Silver Oak Hospital.  The opposite parties claimed that the said column of M.O’s Hospital Visit Report, containing this information was duly signed by Dr. D.K. Garg.  That on the basis of Medical Officer’s Hospital Visit Report, pre-authorization request and proposal form the claim application was rightly declined by the opposite parties.  The true copies of these documents are annexed with their reply as Annexure R-3 and R-4.   

                   The opposite parties have claimed that a person cannot suffer an acute renal failure all of a sudden and require a kidney transplant as the same is the last option for such kind of a disease which clearly implies that the complainant had suppressed material facts at the time of availing the policy from the opposite parties.  Thus, the claim is not admissible as per exclusion to pre-existing disease.  The opposite parties while denying all other allegations have prayed for the dismissal of the complaint on aforementioned grounds and also the same being frivolous and vexatious which deserves dismissal with cost.   

3.                           We have heard the learned counsel for the parties and have gone through the documents on record.

4.                           It is an admitted fact that the complainant had subscribed for a policy in the name of her mother who was a diabetic patient and was suffering from DM Type II.  The said policy, which is specially designed for such patients is also named as Diabetes Safe Insurance Policy by the opposite parties. The complainant at the time of subscribing for the policy had submitted the diagnostic report clearly defining her medical status and on accepting this diagnostic report alongwith the proposal form and having received a sum of Rs.2,135/- issued the policy bearing  No.P/161113/01/2009/000536 for the period commencing from 19.11.2008 till 18.11.2009. 

5.                           The complainant has claimed that the insured-Mrs. Meena Sharma was admitted in the Silver Oaks Hospital for treatment on 14.9.2009 and a pre-authorization request for cashless treatment was made with the opposite parties and the opposite parties after appointing an officer, who visited the patient on 15.9.2009 submitted the report with the opposite parties on the basis of which request for cashless treatment was denied. The complainant after completion of the treatment submitted the claim with the opposite parties, which too was not honoured by the opposite parties.  However, the complainant claims that the factors and reasons on the basis of which the cashless treatment as well as the insurance claim was denied were altogether wrong and the opposite parties are deficient in rendering proper service to her.  The complainant has claimed that the reasons on the basis of which the opposite parties had concluded about the PED status of the insured are altogether wrong and not based on true appreciation of the facts.  On the other hand, the opposite parties in their reply which is duly supported by detailed affidavit clearly mentions in para 8 page 8 that on the basis of the Hospital Visit Report of Medical Officer preauthorization request and proposal form the claim application was rightly declined by the opposite parties.  The true copies of the hospital visit report, preauthorization report and the proposal form are annexed as Annexures R-3, R-4 and R-2 respectively. 

6.                           We have minutely gone through the three documents namely the Hospital Visit Report, preauthorization report and the proposal form on the basis of which initially the cashless treatment facility and thereafter the claim of the complainant for the sum insured was denied.  It is pertinent to mention here that the proposal form (Annexure R-2) through which the Diabetes Safe Policy for the sum insured of Rs.1,00,000/- was proposed by the complainant and had stated submitted the diagnostic report which is Annexure C-4 clearly mentioning her diabetic Type II status thus qualifying her for the policy. 

7.                           The opposite parties while heavily relying upon hospital visit report of Mr. Devinder Garg, the Medical Officer of the opposite party, which is Annexure R-3 clearly mentions the denial of cashless as PED (Pre-existing disease).  On page 16 under the clause provisional diagnosis by this Medical officer, it is found mentioned “since year 2008 she had renal problem got investigated + treated at PGI Chandigarh.  Now admitted for renal transplant.  Date of operation fixed for 16.9.09”. Furthermore, on the next page No.17 under the heading Case File Examined Treating Medical Officers Consultation Report it is mentioned that “the patient started this problem a year back in 2008 when she started having cdrenal, got investigated and treated in PGI, Chd.”  In the final clause under investigation report it is found mentioned that “investigations being done. Put on dialysis, arranging fro blood for surgery for kidney transport on 16.9.2009.” This report is found signed by Dr. D.K. Garg. 

8.                           From the bare perusal of this report, on the basis of which the claim of the complainant was denied, the fact that the complainant’s mother was suffering from a renal problem since the year 2008 and on being investigated for the same got treatment at PGI is not found corroborated from any other document nor there is any mention as to from what source the visiting officer of the opposite parties concluded the same.  The complainant on her part has claimed that while filling up the preauthorization request which was duly filled up by the treating medical officer of Silver Oaks Hospital, the medical history clearly mentions of diabetes, hypertension, SLE but there is no mention of her having got treated at the PGI in the year 2008.  Even while going through Annexure R-2 which is the proposal form the column wherein the detail of treating doctor who was consulted for her Diabetes Mellitus Type II too does not mention about her being suffering from any kidney disease. The Medical officer who has submitted his report has also not pointed out any relation of the status of the insured suffering with kidney problem by pointing out the name of the medicine at Annexure 1 page 29 of the complaint that could be related to her problem of renal failure.  Hence, in the absence of any cogent proof, the presumptions of the Medical Officer of the opposite party having concluded that the complainant was suffering from a kidney problem, at the time of inception of the policy, which was in her knowledge, cannot be termed to be suffering from a pre-existing disease, which could disqualify her from her rightful claim, as per the terms of the policy.   

9.                           In view of the above discussion, we are of the considered opinion that the opposite parties have failed to prove their version by bringing on record any cogent, reliable and trustworthy evidence so as to substantiate that their denial of the claim of the complainant was right, just and legal.  Hence, finding the opposite parties deficient in rendering proper service, the present complaint deserves to be allowed and the same is allowed accordingly.  The opposite parties are directed to pay :-

i)                   the insured sum of Rs.1,00,000/- as per the terms and conditions of the policy;

ii)                to pay Rs.10,000/- as costs of litigation.

10.                       This order be complied with by the opposite parties, within 45 days from the date of receipt of its certified copy, failing which the amount at Sr.No.(i) shall carry interest @18% per annum from the date of this order till actual payment, besides payment of litigation costs.

11.                       Certified copy of this order be communicated to the parties, free of charge. After compliance file be consigned to record room.

Announced

20.06.2013.

 Sd/-

(MADHU MUTNEJA)

PRESIDING MEMBER

Sd/-

(JASWINDER SINGH SIDHU)

MEMBER