Haryana

Karnal

CC/314/2022

Gurmej Singh - Complainant(s)

Versus

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

Mohit Sachdeva

15 Apr 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 314 of 2022

                                                        Date of instt.31.05.2022

                                                        Date of Decision:15.04.2024

 

Gurmej Singh son of S. Avtar Singh, resident of house no.61-AR, Model Town, Karnal.

 

                                                                        …….Complainant.

                                              Versus

 

Star Health and Allied Insurance Company Limited, SCF-137, 2^nd floor, Sector-13, Urban Estate, near ICICI Bank, Karnal through its Branch Manager.

 

                                                                        …..Opposite Party.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member

      Dr.  Suman Singh…..Member

 

 Argued by: Shri Harish Mehta, counsel for the complainant.

                    Shri A.K. Vohra, counsel for the OP.

 

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant purchased a Family Health Optima Insurance Plan for an amount of Rs.5,00,000/- from the OP, vide policy no.12585662 on 15.11.2016. The period of said policy was 15.11.2016 to 14.11.2017. The complainant and his wife namely Kawaljeet Kaur were insured in the said policy. The complainant deposited regular annual premiums to the OP and the said insurance policy was renewed in the year 2017, 2018 and 2019, vide policy no.P/211114/01/2019/006795. In the month of April 2019,  the wife of complainant  was diagnosed Hernia, due to which the complainant and his wife visited the Max Hospital Saket, New Delhi on 16.04.2019. After thorough checkup, Dr. P.K. Chowbey advised for the surgery. The wife of complainant was got admitted in the said hospital on 16.04.2019 and discharged on 17.04.2019. Although the wife of complainant had visited in the said hospital for the hernia surgery but there she got diagnosed about the kidney stones and some issue in the uterus. The intimation regarding the admission of his wife was duly provided to the OP and surveyor of the OP visited in the hospital. The complainant had spent an amount of Rs.39,613/- on the treatment of his wife. All the original related documents regarding the treatment and claim, were submitted with the OP. The complainant received a letter dated 04.07.2019 from the OP therein demanding some documents but the claim of the complainant has been repudiated by the OP on the false and frivolous ground. Then complainant sent a legal notice dated 10.01.2022 to the OP but it also did not yield any result. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence complainant filed the present complaint.

2.             On notice, OP appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action; locus standi; jurisdiction and concealment of true and material facts. On merits, it is pleaded that the complainant had availed “Family Health Optima Insurance Plan covering Mr. Gurmej Singh (self), Mrs. Kawaljeet Kaur (spouse), Mr. Damanpreet Singh (dependent child) for a basic sum insured of Rs.5,00,000/- vide policy no.P/211114/01/2019/006795 for the period from 15.11.2018 to 14.11.2019 from the OP. The insured are policy holder since 2016. It is further pleaded that the insured patient Mrs. Kawaljeet Kaur 44 years female was admitted in Max Super Specialty Hospital, East Wing, Saket, New Delhi for the diagnosis of Paraumbilial Hernia on 16.04.2019 and discharged on 17.04.2019. The insured raised pre-authorization request to avail cashless treatment. On scrutiny of the submitted documents, it was observed that:-

.       The cashless benefit has been not utilized by the insured.

Hence, pre-authorization request was rejected and communicated to the treating hospital and to the insured, vide letter dated 21.04.2019. Subsequently, insured submitted claim documents for re-imbursement of medical expenses. On scrutiny of the claim documents, it is observed that,

.       As per discharge summary dated 16.04.2019 the insured was diagnosed for Paraumbilical Hernia.

.       As per consultation report dated 17.04.2019 that the insured patient has a history of surgery for brain tumor in the year 2012.

.       We requested the insured to furnish the previous documents relating to brain tumor surgery.

.       We note that you have not furnished the required documents and details.

.       This amounts to non-submission of required documents and non co-operation by the insured. In the absence of the above documents/details, we are not able to further process your claim.

        As per condition no.3 of the policy “the insured person/s shall obtain and furnish the company with all original bills, receipts and other documents upon which a claim is based and shall also give the company such additional information and assistance as the company may require in dealing with the claim.

        Hence, the claim was repudiated and communicated to the insured, vide letter dated 17.07.2019”.

The complainant did not disclose the previous ailment to the OP and he also did not supply the required documents in order to reach on final conclusion. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complainant.

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 policy Ex.C1, copy of letter dated 17.04.2019 of Max Health Care Ex.C2, copy of discharge summary dated 17.04.2019 Ex.C3, copies of receipts Ex.C4 to Ex.C5, copy of letter dated 04.07.2019 Ex.C6, copy of repudiation letter dated 17.07.2019 Ex.C7 and Ex.C8, copy of legal notice Ex.C9 and closed the evidence on 15.06.2023 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Sumit Kumar Sharma, Chief Manager Ex.OP1/A, copy of proposal form Ex.O1, copy of policy schedule Ex.O2, copy of terms and conditions of policy Ex.O3, copy of pre-authorization sanction request Ex.O4, copy of pre-authorization query Ex.O5, copy of rejection of pre-authorization letter Ex.O6, copy of claim form Ex.O7, copy of discharge summary Ex.O8, copy of final bill Ex.O9, copy of certificate of treating doctor Ex,.O10, copy of query letters dated 04.07.2019 Ex.O11 and Ex.O12, copy of repudiation letter dated 17.07.2019 Ex.O13, copy of bill assessment sheet Ex.O14 and closed the evidence on 18.01.2024 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 purchased a Family Health Optima Insurance Plan for an amount of Rs.5,00,000/- from the OP. The policy was continuing since the year 2016. On 16.04.2019, the wife of complainant was got admitted in the Max Hospital, Saket, New Delhi  for the Hernia Surgery but diagnosed for the Kidney Stone and some issue in Uterus. The complainant spent an amount of Rs.39,613/- on the treatment of his wife. The complainant submitted the claim with the OP for pre-authorization and lateron for reimbursement of the said amount but OP did not pay the claim amount and repudiated the claim of complainant on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that the wife of complainant diagnosed for Paraumbilial Hernia. The cashless request has been denied by the OP as the wife of complainant has  history of surgery for brain tumor in the year 2012 and the said fact has not been disclosed by the complainant at the time of purchasing the insurance policy. So, the claim of complainant was rightly rejected by the OP and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, complainant has availed the Family Health Optima Insurance Plan from the OP. It is also admitted that in the said policy complainant (self), his wife and dependent child was covered, for the sum insured of Rs.5,00,000/-. It is also admitted that during the subsistence of the insurance policy the wife of complainant has taken treatment from Max Super Specialty Hospital, Saket, New Delhi. It is also admitted that the policy in question is continued since the year 2016.

11.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.C7/Ex.R13 dated 17.07.2019 on the grounds, 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 Paraumbilical hernia.

Although the present admission and treatment of the insured patient is for hernia, it is observed from the consultation reported dated 17.04.2019 that the insured patient has a history of surgery for brain tumor in the year 2012. We requested the insured to furnish the previous documents relating to brain tumor surgery. We note that you have not furnished the required documents and details. This amounts to non-submission of required documents and non -cooperation of by the insured. In the absence of the above documents/details. We are not able to further process your claim.

As per condition no.3 of the policy, the insured person has to submit all the required documents and detailed.

We are, therefore, unable to settle your claim under the abovesaid policy and hereby repudiated the claim.”

              

 12.          The claim of the complainant has been repudiated by the OP on the abovementioned grounds. The onus to prove its case was relied upon the OP, but OP has miserably failed to prove the same by leading any cogent and convincing evidence. The case of the OP is based upon the history of surgery for brain tumor in the year 2012 but there is nothing on file to prove that insured patient has taken the treatment for brain tumor in the year 2012 as alleged by OP. It has not proved on the record that wife of complainant was having pre-existing disease and has concealed the true facts at the time of purchasing the policy. In this regard, we relied upon case titled as Sucha Singh Vs. Head Brach Office, HDFC Life and Another 2022 CJ 901 (NC) wherein Hon’ble National Commission held that death due to heart attack-claim repudiated on ground of pre-existing ailment-complaint dismissed by State Commission-Insurance Company cannot travel beyond grounds mentioned in repudiation letter-When policy has been revived, it revives from date when it was originally issued-Insurance Company had failed to prove that insured had concealed his medical conditions on the date when he took policy-There is nothing on record to show that deceased was suffering from chronic alcoholic condition and was suffering with chronic liver disease and that he submitted fake documents at the time of obtaining original policy-State Commission had adopted wrong approach while rejecting complaint-Respondent shall pay to complainant assured amount alongwith 9% interest. Further in case titled as Bajaj Allianze Life Insurance Co. Ltd. and others Vs. Vinod Kumar Kaushik (since deceased) 2021 CJ 956 (NC), Hon’ble National Commission has held that Mediclaim-Family Care First Plan (Medical Policy)- Surgery for total hip replacement- Non-settlement of claim by Insurance Company on ground of pre-existing condition-Complaint allowed by Fora below-Averments made by OP were not supported by documentary evidence-OP relied on treatment record relating to past history of insured, which were neither verified not supported by proper evidence-In absence of any evidence, it cannot be said that insured was having any past history-Petitioners have failed to point any illegality or irregularity in order passed by State Commission, warranting interference in exercise of Revision-Revision Petition dismissed. Further in case titled as SBI Life Insurance Co. Ltd. Vs. Lakshiben Naginbhai Chauhan and others 2020 CJ 110 (NC) and Authorised Signatory, Hon’ble National Commission has held that Insurance-SBI Home Loan Master Policy-Repudiation of death claim on ground of concealment of pre-existing disease-Complaint allowed by fora below-Both District Forum and State Commission had reached to conclusion after going through all documents that medical papers have not been properly proved since neither doctor has been duly examined nor his affidavit has been furnished-National Commission is not expected and required to re-appreciate and re-assess evidences-where on the basis of evidences Fora below have reached to a conclusion which is a possible conclusion, then such conclusion need not be disturbed in Revision Petition-Revision petition dismissed. Further in case titled as Bajaj Allianz Life Insurance Co. Ltd. and 2 others Versus Kanduru Gangadhara Rao in Revision Petition no.1054 of 2020, decided on 07.10.2021 Hon’ble National Commission held that Insurance Law-concealment of disease-Death claim repudiated by insurer on ground that life assured suppressed her health condition of her taking treatment for  placed reliance on the treatment record, ‘Chronic non-specific cervicitis’ prior to obtaining the policy-Hence this complaint-Held, insurance company placed reliance on treatment record, which was a mere photocopy and not certified. The Doctor who treated the Life Assured was also not examined nor was his affidavit filed by the insurance company. Also, insurance company failed to satisfy this Commission that there was any co-relation between death of the Life Assured and the suppression of ailment "Chronic non-specific cervicitis". Complaint allowed. Thus, keeping in view the ratio of law laid down in the aforesaid judgments, the repudiation of the claim is based only on the basis of presumption and assumption, which is not admissible in the eyes of law.

 13.          Furthermore, if for the sake of arguments, it be presumed that the wife of complainant has taken treatment for brain tumor in the year 2012, thus, there is also no nexus between the present treatment taken by the wife of complainant with the treatment of brain tumor as alleged by the OP. In this regard, we are fortified with the observation of Hon’ble State Commission, Delhi, in case titled as Chanda Devi Vs. LIC in complaint no.551/2016, decided on 23.11.2021 wherein it has been held that if the reason of the death is not in nexus with pre-existing disease and there is no evidence placed on record by the OP to show that the death was on account of pre-existing disease of the life assured, then the contention of the OP in the repudiation letter has no merit.

14.           The OP has also alleged that complainant has not furnished the required documents. Complainant has approached for pre-authorization request and same has been declined by the OP, thus as to why complainant has not submitted the required documents for reimbursement of claim. Furthermore, it is also unbelievable an insured whose personal interest is involved for such amount why he will not supplied the documents to the insurance company for getting his claim amount and will indulge himself in unwanted litigation. Hence, in view of the above, we found no substance in this contention of the OP.

15.  

“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.”

 

 16.          Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OP while repudiating the claim of the complainant amounts to deficiency, which is otherwise proved genuine one. 

17.           The complainant has claimed that he has spent Rs.39,613/- on the treatment of his wife and in this regard he has submitted the medical bills to the OPs. The said fact has not been disputed by the OP. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

18.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.39,613/- (Rs. thirty nine thousand six hundred thirteen only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OP to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses.  This order shall be complied with within 45 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: 15.04.2024 

  President,       

District Consumer Disputes

Redressal Commission, Karnal.

 

                  (Vineet Kaushik)              (Dr. Suman Singh)  

                       Member                             Member