Haryana

Karnal

CC/444/2019

Kuldeep Singh - Complainant(s)

Versus

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

Sanjiv Kumar Battan

15 Apr 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL  COMMISSION, KARNAL.

 

                                                          Complaint No. 444 of 2019

                                                          Date of instt.15.07.2019

                                                          Date of Decision 15.04.2021

 

Kuldeep Singh aged about 36 years son of Lajpat Rai resident of village Kaul, Kaithal.

 

                                                 …….Complainant.

                                              Versus

 

Star Health and Alied Insurance Co. Ltd. through its Authorized Signatory, Branch office 2^nd floor, SCF-137, Sector-13, Urban Estate, near ICICI Bank, Karnal.

                                                                        …..Opposite Party.

 

       Complaint u/s 12 of the Consumer Protection Act, 1986.      

 

Before:  Sh. Jaswant Singh……President.       

      Sh.Vineet Kaushik ………..Member

              Dr. Rekha Chaudhary…….Member

 

 Present:  Shri Sanjeev Kumar counsel for complainant.

                 Shri Naveen Kheterpal counsel for opposite party.

 

                (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 purchased an insurance policy no.P/211114/01/2019/006209, valid from 26.10.2018 to 25.10.2019 under the scheme 2A+2C from the opposite party (hereinafter referred as to OP). Under the policy four persons namely Kuldeep Singh (complainant), Poonam wife of Kuldeep, Harsh Sagwal and Krish Sagwall sons of Kuldeep Singh were insured. During the subsistence of the policy Poonam Rani had suffered fractured in her elbow for which she had been admitted at Anand Hospital, Kurukshetra for her medical treatment of Elbow fracture and accordingly the policy holder presented his policy before the hospital to provide cashless treatment. But the hospital refused to provide cashless treatment and force the complainant to pay the bills in cash.  The policy holder was not having cash with him at that time. The hospital did not allow the patient to leave the hospital without making the payment and kept under detention for about 24 hours. Later, the wife of complainant got the treatment for the same fracture from Bhola Hospital Kurukshetra. Complainant approached the OPs alongwith the bills and treatment record for reimbursement of the claim but OPs flatly refused to pay the claim and repudiated the same on the ground of previous medical problem to Poonam Rani. However, the wife of complainant got treatment simply for headache. For which she had visited the doctor at Karnal. The OPD slips had already provided by the complainant to the insurance company. There is no relation between the history of disease with the present fracture which occurred accidently. In this way there was deficiency in service on the part of the OP in repudiating the claim of the complainant on the false and baseless ground. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OP, who appeared and filed 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 availed Family Health Optima Insurance Plan covering Kuldeep Singh-self, Poonam Rani-spouse, Harsh Sagwal and Krish Sagwal-dependent children for the sum insured of Rs.300000/, vide policy no.P/211114/01/2019/006209, valid from 26.10.2018 to 25.10.2019. The claim was reported in the 2^nd year of the policy. The insured was admitted at Anand Orthopaedic Centre on 07.02.2019 for the treatment of fracture lower end radius right and raised pre authorization request for cashless treatment and the same was denied, vide letter dated 08.02.2019 stating that as per Discharge summary, “there is a history of Vessel Blockage in Brain” and “History of taking Blood Thinner”. Thus, the pre auth was denied and informed the insured to approach for reimbursement. It is further pleaded that the insured submitted claim records towards reimbursement of medical expenses of Rs.11,129/-. On scrutiny of the claim records, it is observed that:

As per discharge summary and indoor case paper,

a) The insured was admitted on 07.02.2019 and discharged on 08.02.2019.

b) Diagnosis: Fracture Lower and Radius Right.

c) Past/Personal history: H/O? Vessel Blockage in Brain, H/O-Taking Blood Thinner?? Record not available.

Hence, query was raised to submit the following documents vide letter dated 08.03.2019

. All the documents related to headache.

. Letter from treating doctor stating the reason for taking blood thinner and duration of illness.

. All investigation reports taken related to brain

Even after repeated reminders dated 23.03.2019, 07.04.2019 and 22.04.2019, the insured has not submitted the documents.

As per condition no.3, the insured persons 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.

Inspite of submitting the same to process the claim, the insured has filed a complaint before this Commission which is premature.  There is no deficiency in service on the part of OP. The other allegations made in the complaint have been denied an prayed for dismissal of the complaint.

3.             Complainant tendered into evidence his affidavit Ex.CW1/A, copy of policy Ex.C1, copy of OPD slip Ex.C2, copy of progress sheet Ex.C3, copy of application to OP Ex.C4, copy of invoice Ex.C5, copy of discharge summary Ex.C6 and Ex.C7, copy of OPD slips and receipts Ex.C8 to Ex.C15, copy of OPD slip Ex.C16, copy of letter dated 08.03.2019 Ex.C17 and certificate f doctor Ex.C18 and closed the evidence on 07.01.2020 by suffering separate statement.

4.             On the other hand, OP tendered into evidence affidavit of Rajiv Jain Ex.RW1/A, proposal form Ex.R1, policy Ex.R2, terms and conditions of policy Ex.R3, Request for cashless hospitalization for medical insurance policy Ex.R4, query letter Ex.R5, discharge summary Ex.R6, invoice Ex.R7, authorization for cashless treatment Ex.R8, withdrawal of pre-authorization sanctioned Ex.R9 and Ex.R10, rejection of pre-authorization Ex.R11 and Ex.R12, claim from Ex.R13, patient history Ex.R14, letters of requirement of documents Ex.R15 to Ex.R18 and calculation sheet Ex.R19 and closed the evidence on 29.01.2021 by suffering separate statement.

5.             We have heard the learned counsel of both the parties and perused the case file carefully and have also gone through the evidence led by the parties.

6.             Learned counsel for the complainant argued that the complainant purchased a health insurance policy from OP. Under the policy four persons namely Kuldeep Singh (complainant), Poonam wife of Kuldeep, Harsh Sagwal and Krish Sagwall sons of Kuldeep Singh were insured. During the subsistence of the policy Poonam Rani had suffered fractured in her elbow for which she had been admitted at Anand Hospital, Kurukshetra. Lateron the wife of complainant admitted in Bhola Hospital Kurukshetra. Complainant spent Rs.20,000/- on the treatment of his wife. After discharge from the hospital complainant approached the OPs alongwith the bills and treatment record for reimbursement of the claim but OPs flatly refused to pay the claim and repudiated the same on the ground of previous medical problem to Poonam Rani. He further argued that the wife of complainant got treatment simply for headache. For which she had visited the doctor at Karnal. The OPD slips had already provided by the complainant to the insurance company. There is no relation between the history of disease with the present fracture which occurred accidently. Learned counsel of complainant further prayed for allowing the complaint.

7.             Per contra, learned counsel of OP argued that the insured was admitted at Anand Orthopaedic Centre on 07.02.2019 for the treatment of Fracture Lower End Redius Right and raised pre authorization request for cashless treatment and the same was denied vide letter dated 08.02.2019 stating that as per discharge summary, “there is a history of Vessel Blockage in Brain’ and ‘History of taking Blood Thinners’. Thus, the pre auth was denied and informed the insured to approach for reimbursement. Learned counsel of OP further argued that the insured submitted claim records towards reimbursement of medical expenses of Rs.11,219/-. It is further argued that the claim of the complainant is not processed due to insufficient document. Even, various reminders dated 23.03.2019, 07.04.2019 and 22.04.2019 were sent to the complainant vide which OP demanded the documents but complainant failed to submit the documents, hence the claim of the complainant could not be settled and prayed for dismissal of the complaint.

8.             Admittedly, the complainant had purchased a health insurance from the OP and during subsistence of the policy, the wife of complainant Poonam Rani had suffered fractured in her elbow for which she had been admitted at Anand Hospital, Kurukshetra and thereafter she admitted in Bhola Hospital Kurukshetra. Complainant spent Rs.20,000/- on the treatment of his wife. The policy was cashless policy. Complainant raised pre authorization request for cashless treatment and the same was denied by, vide letter dated 08.02.2019  Ex.R9 stating that as per Discharge summary, “there is a history of Vessel Blockage in Brain” and “History of taking Blood Thinner”. Thus, the pre auth was denied and informed the insured to approach for reimbursement. Thereafter, complainant approached the OP for reimbursement of the claim but it was also denied on the lame excuse with regard to insufficient documents.

9.             The core question for consideration before us is that whether the claim of the complainant was rightly denied by the OP or not?

 10.          The claim of the complainant has not been settled by the OP on the ground of Vessel Blockage in Brain” and “History of taking Blood Thinner”. The complainant claimed the reimbursement of the amount on the basis of occurrence of fracture in the elbow of complainant’s wife.

11.           To prove his case OP placed on record patient history Ex.R14, which is related to Vessel Blockage in Brain. On perusal of the document Ex.R14, the doctor has mentioned the past history of patient while he was treating the patient for fracture in elbow. There is no evidence on the record which shows that any doctor has treated the patient for Vessel Blockage in Brain. This is the past history of the patient which is not treated by Dr. Himanshu Anand of Anand Orthopedic Centre Super Specialty Hospital, Kurukshetra. Hence, this being hearsay evidence, is not tenable in the eyes of law. Further, if the version of the OPs is believed then we are relying upon the authority of Hon’ble State Commission, New Delhi, titled as Life Insurance Corporation of India Versus Sudha Jain 2007 (2) CLT 423, in which Hon’ble State Commission has drawn conclusion in para 9 of the order and the relevant clause is 9 (iii), is reproduced as under:-

        “9(iii) Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in and out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.” Taking into consideration the facts of the present case and law laid down by the Hon’ble Superior Fora in the above referred cases, we are of the view that OPs were not justified in repudiating the claim of the complainant and are thus liable to pay the amount which the complainant had incurred on his treatment.

 

12.            Moreover, complainant filed the present complaint with regard to fracture in elbow of his wife as there is no nexus between the history of disease with the present fracture. Hence the plea taken by the OP has no force. The onus was upon the OP to prove its case but OP failed to prove his case by leading cogent, convincing evidence. Hence, the act of the OP amounts to deficiency in service while repudiating the claim of the complainant, which is otherwise proved genuine one. 

13.           No other point argued by the OP.

14.           Complainant’s wife has taken treatment in two hospital i.e. Anand Orthopaedic Centre, Kurukshetra and Bhola Hospital, Kurukshetra. The complainant claimed Rs.20,000/- on account of medical treatment but he has placed on  record claim form with regard to Anand Hospital, Kurukshetra Ex.C5, vide  which he claimed Rs.11,129/- and also placed on record medical bills of Ex.C8 to Ex.C16 of Bhola Hospital, Kurukshetra of Rs.6190/- hence, the complainant is entitled to Rs.17319/- (11,129+6190) alongwith compensation and litigation expenses.

15.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.17,319/- to the complainant with interest @ 9% per annum from the date of filing of complaint till its realization. We further direct the OPs to pay Rs.10,000/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied within 45 days from the receipt of copy of this order. The parties concerned be communicated the order accordingly, and the file be consigned to the record room, after due compliance.

Announced

Dated: 15.04.2021

                                                                       

                                                                    President,

                                                      District Consumer Disputes

                                                      Redressal Commission, Karnal.

 

       

 

         (Vineet Kaushik)               (Dr. Rekha Chaudhary)

            Member                              Member