Haryana

Karnal

CC/437/2023

Bhoop Singh - Complainant(s)

Versus

Star Health And Allied Insurance Company Limited - Opp.Party(s)

Shubham Kalia

11 Jul 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.437 of 2023

                                                        Date of instt.01.08.2023

                                                        Date of Decision:11.07.2024

 

Bhoop Singh aged about 50 years son of Shri Ram Chander, resident of village Pigali, Post office Chirao, District Karnal.

 

                                                 …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance co. Ltd. #SCF-137, 2^nd floor, near ICICI Bank, Sector-13, Urban Estate, Karnal-132001, through its Branch Manager.
2. Star Health and Allied Insurance Co. Ltd. # no.15, Sri Balaji Complex, 1^st floor, Whites Lane, Royapettah, Chennai-600014 through its M.D/CEO/Authorized Signatory.

 

                                                              …..Opposite Parties.

 

Complaint Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member

 

Argued by: Shri Shubham Kalia, counsel for the complainant.

                   Shri Rajesh Singhal, counsel for the OPs.

 

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant purchased a health insurance policy from the OPs, bearing policy no.171100/01/2023/13360 by paying premium of Rs.16,980/-. The Product name Family Health Optima Insurance Plan and period of said insurance policy was commenced from 09.09.2022 upto 08.09.2023. In the aforesaid insurance policy the Basic Floater Sum Insured is Rs.3,00,000/-. Prior to purchase of aforesaid policy, the complainant was purchasing Health Insurance Policies from Universal Sompo General Insurance Company Ltd. continuously since from the year 2019 to 2022 but in the year 2022 on the instigation of the representative of OPs, complainant purchased the health policy from the OPs’ company under portability. In the month of March 2023, complainant had suffered from Acute Exerbation of Chronic Obstructive Pulmonary Disase and thereafter the complainant visited in Virk hospital, Karnal for his treatment, where the concerned doctor got admitted the complainant on 04.03.2023 and complainant was discharged from said hospital on 21.03.2023. The complainant has an amount of Rs.2,89,579/- on his treatment. After discharge from the hospital, complainant applied for reimbursement of the said amount and submitted all the required documents with the OPs for settlement of the claim. Thereafter, complainant requested the OPs so many times to settle the claim but OPs did not settle the same and lastly repudiated the genuine claim of complainant, vide letter dated 04.05.2023 on the false and frivolous ground. Then complainant sent a legal notice dated 14.07.2023 to the OPs but it also did not yield any result. In this way there is deficiency in service and unfair trade practice. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; mis-joinder and non-joinder of necessary parties and concealment of true and material facts. On merits, it is pleaded that the insured Bhoop Singh availed the Family Health Optima Insurance plan covering Bhoop Singh-self, Meena Devi- spouse, Viren Narval and Waris dependent children for the sum insured of Rs.3,00,000/-, vide policy no.P/171100/01/2023/013360 for the period from 09.09.2022 to 08.09.2023. The policy is ported from Universal Sompo General Insurance Company. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant alongwith the policy schedule. The complainant has lodged a claim of Rs.2,89,579/- with the OP on account of reimbursement of medical expenses for his treatment and after examination and verification of medical record, it was found that the complainant has not disclosed the prior medical history/health details i.e. Chronic Obstructive Pulmonry Disease (hereinafter referred as COPD) of the insured-person in the proposal form and other documents submitted to the OPs, which amounts to misrepresentation/non-disclosure of material facts. Hence, the claim for treatment of this disease is not admissible under the policy issued to the insured. It is the duty of the complainant to disclose all the material facts in proposal form at the time of purchasing the policy but at the time of inception of the policy, complainant did not disclose the abovementioned medical history/health details in the proposal form and concealment the material facts. Thus, the claim was not payable. It is further pleaded that the present admission is for Acute Exacerbation of COPD with CO2 Narcosis with Type II Respiratory Failure. As per ICP’s the patient admitted earlier from 09.03.2021 to 14.03.2021 with similar complaints with Diagnosis: Acute bronchitis, LRTI, Respiratory Failure and AKI (Acute Kidney Injury). This was not disclosed to OPs at the time of porting of policy. The present admission is related to this only and therefore, a non-disclosed PED and also a declined risk PED. The policy cancellation/ risk deletion has already been done. The patient also has CLD, which is always long-standing and is most likely related to consumption of alcohol (H/O alcohol consumption for 5 years, reformed 4-5 months back). The patient admitted by the hospital under a different UHID than the previous admission UHID. The present admission and treatment of the insured patient is for pre-existing disease. Hence, the claim was  rightly repudiated. There is no deficiency in service and unfair trade practice on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of insurance policies of Universal Sompo Insurance Company for the period from 13.08.2019 to 08.09.2022 Ex.C1, Ex.C3 and Ex.C4, copy of letter dated 19.08.2019 of Universal Sompo Insurance Company regarding complete health care insurance Ex.C2, copy of insurance policy of Star Health dated 09.09.2022 Ex.C5, copy of letter of terms and conditions Ex.C6, copy of repudiation letter dated 04.05.2023 Ex.C7 and Ex.C10(repeated), copy of letter dated 13.04.2023 regarding requirement of additional documents Ex.C8, copy of Virk Hospital Report Ex.C9, copy of letter dated 02.05.2023 regarding non-disclosure of pre-existing disease Ex.C11, copy of Family Health Optima Insurance Plan Ex.C12, copy of claim form Ex.C13, copy of list of medical bills Ex.C14, copy of discharge summary Ex.C15, copy of IPD bill Virk hospital dated 21.03.2023 Ex.C16, copy of discharge summary Ex.C17, copies of bills Ex.C18, copy of legal notice and postal receipt Ex.C19 and Ex.C20, copy of aadhar card of complainant Ex.C21 and closed the evidence on 11.01.2024 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Sumit Kumar Sharma Ex.RW1/A, copy of Family Health Optima Insurance Plan Ex.R1, copy of insurance policy Ex.R2, copy of terms and conditions of the insurance policy Ex.R3, copy of portability form Ex.R4, copy of request for cashless hospitalization for health insurance Ex.R5, copy of Field Visit Details Ex.R6, copy of letters of query on authorization for cashless treatment Ex.R7 and Ex.R8, copy of denial letter of pre-authorization request for cashless treatment Ex.R9 and Ex.R10, copy of proposal form Ex.R11, copy of discharge summary Ex.R12 and Ex.R13, copy of admission file Ex.R14, copy of clinical findings Ex.R15, copy of IPD bill Ex.R16, copy of repudiation letter dated 04.05.2023 Ex.R17, copy of claim verification report Ex.R18, copy of Family Health Optima Insurance Plan Ex.R19,  copy of bill assessment sheet Ex.R20, copy of Master Circular on Standardization of Health Insurance Products Ex.R21 and closed the evidence on 04.04.2024 by suffering separate statement.

6.             We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for the complainant, while reiterating the contents of complaint, has vehemently argued that complainant had purchased a Health Insurance Policy from the OPs under the portability scheme. Prior to purchasing policy from OPs, the complainant was having health policy from the year 2019 to 2022 from Universal Sompo General Insurance Co. Ltd. and thereafter ported the said policy to the OPs company. The sum insured under the policy is Rs.3,00,000/-. During the subsistence of the insurance policy, complainant had taken the treatment from Virk Hospital, Karnal. The pre-authorization claim of complainant was denied by the OPs. Complainant paid Rs.2,89,579/- to said hospital from his own pocket and requested the OPs for reimbursement of said amount, but OPs did not pay the said amount and repudiated the claim the of complainant on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that OPs issued a health insurance policy for the sum insured of Rs.3,00,000/- to complainant. Complainant did not disclose the prior medical history at the time of portability of the policy and concealed the material facts with regard to taking the previous treatment. Thus, the claim of the complainant was rightly repudiated by the OPs and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant has availed Health Insurance Policy Plan namely “Family Health Optima Insurance Plan” from the OPs. It is also admitted that the policy was ported from Universal Sompo General Insurance Company to OPs. It is also admitted that medical policy is without any break since 2019. It is also admitted that during the subsistence of the insurance policy the complainant has taken treatment from Virk Hosptial, Karnal and spent an amount of Rs.2,89,579/-

11.           The claim of the complainant has been repudiated by the OPs, vide letters Ex.C7/Ex.C10/Ex.R17 .on the ground, which are reproduced as under:-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of COPD.

It is observed from the medical records that the insured patient has history of respiratory failure which confirms that the insured patient has respiratory failure prior to our policy. The present admission and treatment of the insured patient is for the non-disclosed disease.

You have earlier taken medical insurance policies from M/s Universal Sompo General Insurance Company Limited and subsequently taken policy from our company from 09.09.2022 to 08.09.2023 under portability.

At the time of porting the policy, you  have not disclosed the above mentioned medical history/health details of the insured-person in the proposal form and other documents submitted to us, which amounts to misrepresentation/non-disclosure of material facts.

 

12.           The claim of the complainant has been repudiated by the OPs on the above-mentioned ground.

13.            The onus to prove its version was relied upon the OPs but OPs have miserably failed to prove the same by leading any cogent and convincing evidence. There is nothing on file to prove that complainant was having any disease prior to inception of the insurance policy from Universal Sompo General Insurance Company. Complainant is having health policy from the year 2019 to 2022 from the Universal Sompo General Insurance Company, vide policies Ex.C1, Ex.C3 and Ex.C4 and thereafter he got ported the policy with the OPs company. The said fact has been admitted by the OPs. The portability defined by the IRDA vide its circular Reference No. IRDA/HLT/MISC/CIR/209/ 09/2011) is as under:-

Portability:  Portability means the right accorded to an individual health insurance policyholder (including family cover) to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policyholder chooses to switch from one insurer to another insurer or from one plan to another plan of the same insurer, provided the previous policy has been maintained without any break.                 

14.           There is no break in the medical insurance policy issued by the Universal Sompo General Insurance Company, prior to portal of the same in the OPs company. The OPs have ported the insurance policy and issued the fresh policy Ex.C5 dated 09.09.2022. Furthermore, no treatment has been taken by the complainant prior to claim period. Thus, in view of the above, we do not find any substance in the contention of the OPs.

 15.          We further fortified with the observation of Hon’ble National Commission in case titled as Mrs. Rubi Chandra Dutta Versus M/s United India Insurance Co. Ltd., (2011) 3 scale 654, decided on 16.12.2016 wherein it is held that “It was 2 years before switching over the policy with the OPs. Therefore, once portability scheme was accepted by OPs then they had no right to decline the claim upto the amount of sum assured of previous insurance policy in case it was within the terms and conditions of the policy. The policy with New India Assurance Company was continuing since 2001 and counsel for OPs was unable to pin point how the claim to the extent of Rs.1,30,000/- allowed by the District Forum was not payable under the policy. Clause 1 of the policy speaks that under portability right accorded to an individual health insurance policy holder to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policy holder chooses to switch from the one insurer to another insurer or from one plan to another plan. Under that scheme whatever has been gained by the insured under the policy insured by the previous insured will be gained by the insured under the portability scheme. Therefore, we do not agree with the plea raised by the OPs. Even otherwise, the policy was continuing one since 2001.

16.             Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

17.           Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, the act of the OPs while repudiating the claim of the complainant amounts to deficiency in services, which is otherwise proved genuine one.

18.           The complainant has claimed Rs.2,89,579/- and in this regard he has placed on file detail of medical bills Ex.C14. The said amount neither denied nor rebutted by the OPs. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

19.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.2,89,579/- (Rs. two lakhs eighty nine thousand five hundred seventy nine only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 04.05.2023 till its realization. We further direct the OPs to pay Rs.25,000/- to the complainant on account of mental agony and harassment and Rs. 11,000/- towards the litigation expenses. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:11.07.2024                                     

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

                (Vineet Kaushik)               

                      Member