Haryana

Karnal

CC/214/2018

Bir Singh - Complainant(s)

Versus

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

Rishi Chalia

25 Sep 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                          Complaint No. 214 of 2018

                                                          Date of instt. 28.08.2018

                                                          Date of Decision 25.09.2019

Bir Singh, aged 41 years, son of Shri Devi Chand, resident of V.P.O. Biana, Tehsil Indri, District Karnal.

                                                …….Complainant

                                        Versus

1. Star Health and Allied Insurance Company Limited, through its General Manager, Area office, SCO 130-131, 4^th floor, Sector 34-A, Chandigarh.

2. Star Health and Allied Insurance Company Limited, through its General Manager, no.15, Sri Balaji Complex, 1^st floor, Whites Lane, Roy Apettah, Chennai-600 014.

3. Star Health and Allied Insurance Company Limited, through its Branch Manager, SCO 242, 1^st floor, opp. Mini Secretariat, Sector 12, Karnal.

                                                                        …..Opposite Parties.

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

      Sh.Vineet Kaushik ………..Member

                Dr. Rekha Chaudhary…….Member

 

 Present:  Shri Ankit Sahni Advocate for complainant.

                   Shri Naveen Khatterpal Advocate for opposite parties.

                 

                   (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant has taken the Medi Claim Insurance Family Policy from the OP no.1, vide policy no.P/211100/01/2018/000116, valid from 18.04.2017 to 17.04.2018. The said policy was cashless policy. On 5.1.2018 the complainant suffered from some disease and complainant was got admitted in Civil Hospital, Indri, thereafter, he was admitted in Sanjeev Bansal Cygnus Hospital, Railway Road, Karnal on 15.01.2018 and discharged on 17.01.2018 from the said hospital and the OPs paid the bill to the tune of Rs.16,840/- to the Cygnus Hospital. On 24.01.2018 the complainant got again some problem in his body, then he was admitted and checked in Park Hospital, Karnal and the complainant asked for Rs.70,000/- from the OPs, then OPs assured the complainant to pay the said amount himself. The complainant was referred to Chandigarh for the treatment, the complainant was got admitted in Alchemist, Hospital Limited, Sector-21, Panchkula (Haryana) on 25.01.2018 where he was admitted and treated there and he was operated upon by the concerned doctors of Alchemist Hospital on 27.01.2018 and the complainant was discharged from the said hospital on 01.02.2018. The complainant has paid a sum of Rs.2,56,605/- as hospitalization, treatment, medicines, etc. The complainant is still under treatment. After the treatment the complainant submitted all the necessary documents i.e. bills etc. for the settlement of the claim to the OP no.1. On 20.07.2018 the complainant received a letter from the OPs in which OPs repudiated the claim of the complainant on the false grounds. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written version raising preliminary objections with regard to limitation; complainant is false and frivolous; jurisdiction; mis-joinder and non-joinder of necessary parties; complainant is estopped by his own act and conduct from filing the present complaint and concealment of true and material facts. On merits, it is pleaded that insured availed Family Health Optima Insurance covering Mr. Bir Singh-self, Mrs. Parvesh Rani-Spouse, Mr. Vivek Soni and Mrs. Nishika-Dependant Children, vide policy no.P/211100/01/2018/000116 for the period 18.04.2017 to 17.04.2018 for the sum insured Rs.3,00,000/- but cashless is only discretionary of company and it is not the right of the insured. It is further pleaded that the insured was hospitalized at Alchemist Hospital on 25.01.2018 and submitted claim for reimbursement of Rs.2,52,729/-. The insured submitted pre-authorization request towards the above mentioned treatment, on scrutiny of the same, the duration of the ailment could not be ascertained. Thus, the pre-authorization was denied and informed the insured to approach for reimbursement, vide letter dated 30.01.2018. The insured submitted claim for reimbursement of medical expenses, on receipt the claim documents, it was scrutinized and observed that the

.As per discharge summary, the insured was diagnosed with Atherosclerotic Coronary artery disease-Triple Vessel Disease, (Ejection fraction-30%)

. The CAG report dated 24.01.2018, submitted vide our claim no.0559822 shows triple vessel disease;

. The ECHO report dated 24.01.2018 shows CAD-ICMP, dilated LA and LV, severe LV dysfunction, EF 25-30%, RWMA Changes present.

.  Further as per the expert opinion, there is no evidence of Acute Coronary Syndrome.

Based on these findings, it is noted that the insured patient has chronic, longstanding heart disease prior to inception of the medical insurance policy. Hence, the heart disease is a pre-existing disease.  It is further pleaded that as per exclusion no.1 of the policy, the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease/condition, until 48 months of continuous coverage has elapsed, since date of commencement of first year policy with the company on 18.04.2017. It is further pleaded that as per the terms and conditions of the policy, the entire claim which is related to pre-existing disease, shall be payable only after 48 months of continuous coverage of the policy. Thus, the claim is not payable. Hence there is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C8 and closed the evidence on 29.07.2019.

4.             On the other hand, OPs tendered into evidence affidavit of Rajiv Jain Chief Manager Ex.RW1/A and documents Ex.R1 to Ex.R15 and closed the evidence on 09.09.2019.

5.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

6.             The case of the complainant, in brief, is that on 5.1.2018 he was got admitted in Civil Hospital Indri and, thereafter, he was admitted  in Sanjeev Bansal Cygnus Hospital Karnal and OPs paid the bill to the tune of Rs.16,840/- to the Cygnus Hospital. On 24.1.2018 the complainant was again admitted in Park Hospital Karnal and spent Rs.70,000/- in the said hospital. Thereafter, he was got admitted in Alchemist, Hospital Panchkula (Haryana) on 25.01.2018 where he was treated and he operated upon by the concerned doctors of Alchemist Hospital on 27.01.2018 and the complainant was discharged from the said hospital on 01.02.2018. The complainant has paid a sum of Rs.2,56,605/- as hospitalization, treatment, medicines, etc. After the treatment the complainant submitted all the necessary documents i.e. bills etc. for the settlement of the claim to the OP no.1 but OPs repudiated the claim of the complainant on the false grounds. Learned counsel of complainant relied upon the authorities in case Oriental Insurance Company Ltd. and Anr. Versus Mohinder Singh (DR.) 2008(4) CPJ 511 Hon’ble State Commission New Delhi, National Insurance Company Limited Versus Rajan Kumar and Anr. 2011(4) CPJ 11, LIC of India Vs. Joginder Kaur 2005, CPJ 78 of our own Hon’ble State Commission, New India Assurance Co. Ltd. Versus Commander (X) (P) Kamaldeep Singh Sandhu 2008(1) CPJ 34 of Hon’ble State Commission Punjab and Satish Chander Madan Versus M/s Bajaj Allianz General Insurance Co. Ltd. decided on 11.01.2016.

7.             On the other hand, the case of the OPs is that the insured was hospitalized at Alchemist Hospital on 25.01.2018 and submitted claim for reimbursement of Rs.2,52,729/-. The insured submitted pre-authorization request towards the above mentioned treatment, on scrutiny of the same, the duration of the ailment could not be ascertained. Thus, the pre-authorization was denied and informed the insured to approach for reimbursement, vide letter dated 30.01.2018. The insured submitted claim for reimbursement of medical expenses, on receipt the claim documents; it was observed that insured patient has chronic, longstanding heart disease prior to inception of the medical insurance policy. Hence, the heart disease is a pre-existing disease. As per exclusion no.1 of the policy, the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease/condition, until 48 months of continuous coverage has elapsed, since date of commencement of first year policy with the company on 18.04.2017. Thus, the claim is not payable.

9.             As per the complainant on 5.1.2018 he was got admitted in Civil Hospital Indri and, thereafter, he was admitted  in Sanjeev Bansal Cygnus Hospital Karnal and paid the bill to the tune of Rs.16,840/- to the Cygnus Hospital. On 24.1.2018 the complainant was again admitted in Park Hospital Karnal. Thereafter, the complainant was referred to Chandigarh for his treatment, the complainant was got admitted in Alchemist Hospital Panchkula and was operated upon by the concerned doctors. The complainant had paid a sum of Rs.2,56,605/- to the said hospital.  After treatment the complainant submitted his claim with OPs, but on 20.07.2018 the claim of the complainant was repudiated by the OPs on the ground of pre-existing disease. As per the complainant, OPs had paid the previous claim amount to the Sanjeev Bansal Cygnus Hospital Karnal to the tune of Rs.16,840/- but denied the claim amount of Rs.2,56,605/-, which was paid by the complainant in Alchemist Hospital, Panchkula on the baseless ground. The complainant has paid the said amount to the said hospital, vide bill Ex.C5. The claim of the complainant has been repudiated by the OPs, on the opinion of their Medical Team, mentioned in repudiation letter Ex.R10. There is no opinion on the file of the treated/operated doctor with regard to pre-existing heart disease of the complainant. Moreover, opinion of the Medical Team of the OPs as alleged is also not on the file. Thus, version of the OPs has gone unproved.

10.            In Mohinder Singh’s case (supra) the Hon’ble State Commission Delhi held that Medi-Claim policy-Reimbursement claim repudiated-Contention that factum of pre-existing disease not disclosed-Complaint allowed by District Forum-Appeal against-Insured leading healthy and normal life, not supposed to disclose factum of treatment/operation undertaken for particular disease 10-12 years earlier-Deceased living ordinary life, subjected to basic medical test by panel doctors of insurer-Onus on insurer to prove concealment of pre-existing disease at that time of obtaining policy, not discharged-Appeal devoid of merits, dismissed. In Rajan Kumar’s case (supra) our own Hon’ble State Commission has held that Insurance Mediclaim Policy-Claim repudiated-District Forum allowed the complaint-Hence appeal-Contention that life assured concealed her disease in the proposal form and also disease suffered by her was not cover under policy-Rejected-Opinion of doctor is not sufficient about pre-existence of disease-Insurance Company has to prove that life assured was in full knowledge of disease having been suffered by her-No case of suppression or fraud made out-Insurance Company liable to reimburse the expenses-Appeal dismissed. In Joginder Kaur’s case (supra) the Hon’ble State commission Haryana has held that the unproved case history recorded by some person on the date of admission of the patient, patient would not be cogent and convincing evidence to repudiate the case, unless it was coupled with medical record for the treatment prior to the submission of the proposal form. In Commander(X)(P) Kamaldeep Singh’ case (supra) the Hon’ble State Commission Punjab held that Angioplasty done-Repudiation of claim-on ground of concealment of pre-existing disease-Deficiency in service alleged-Complaint allowed-Appeal by Insurance Company-Held, no evidence produced regarding any treatment prior to taking of policy-Complainant’s knowledge about disease not proved-Even ECG produced at the time of taking of policy did not show anything wrong with heart-Thus, Insurance Company rightly liable to pay claim amount with interest-Order upheld-Appeal dismissed. In Satish Chander Mandan’s case (supra) the Hon’ble National Commission has held that hypertension is a common ailment and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack. The treatment for heart problem cannot be termed as a claim in respect of pre-existing disease. Claim was wrongly repudiated.

11.            Keeping in view that the ratio of the law laid down in the aforesaid judgments and the facts and circumstances of the present complaint, we are of the considered view that the insurance company has failed to prove the allegations on the basis of which they have repudiated the claim of the complainant. Thus, the repudiation of the claim done by the OPs is held to be unjustified and amounts to deficiency in service and unfair trade practice.  The complainant in his complaint alleged that he had spent Rs.70,000/- on his treatment in Park Hospital, Karnal but in this regard there is no evidence on record. Hence the complainant is only entitled to Rs.2,56,605/-

10.            Thus, as a sequel to the abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.2,56,605/- to the complainant with interest @ 9% per annum from the date of repudiation till its realization. We further direct the OPs to pay Rs.25,000/- to  the complainant on account of mental agony and harassment suffered by him and Rs.11,000/- for the litigation expenses. This order shall be complied with within 30 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:25.09.2019                                                                       

                                                                      President,

                                                              District Consumer Disputes

                                                               Redressal Forum, Karnal.      

        (Vineet Kaushik)          (Dr. Rekha Chaudhary)

            Member                           Member