Haryana

Karnal

CC/571/2022

Manju - Complainant(s)

Versus

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

Surinder Gureja

17 Dec 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.571 of 2022

                                                        Date of instt 11.10.2022

                                                        Date of Decision: 17.12.2024

 

Manju aged about 50 years wife of Shri Jagdish Kumar, resident of house no.241, ward no.7, near Police Station, Assandh, District Karnal. Aadhar no.4411 8143 8995.

 

                                                                        …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance Company Limited having its Branch office at 2^nd floor, SCF no.137, sector-13, Urban Estate, Karnal through its Branch Manager.
2. Star Health and Allied Insurance Company Limited having its Corporate office at Sri Balaji Complex, 15, White Road, Chennai through its Managing Director.

…..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.     

      Ms. Sarvjeet Kaur…..Member

 

Argued by:  Sh. Surender Gureja, counsel for the complainant.

                    Shri Naveen Khetarpal, 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 Shri Jagdish Kumar husband of the complainant purchased a Mediclaim Policy from Oriental Bank of Commerce known with the name of Oriental Medi Claim Policy on 12.07.2019 which was valid upto 11.07.2020, vide policy no.261301/48/2020/842. After that same was renewed vide policy no.261300/48/2021/468 which was valid upto 19.07.2021. Policy was again renewed by husband of complainant, vide policy no.261300/48/2022/456, valid upto 19.07.2022. But at the time of getting renewed the said policy on 19.07.2022, the Oriental Bank of Commerce merged in the Punjab National Bank. Then Punjab National Bank got it renewed from Star Health and Allied Insurance Company Ltd. as that bank was having tie up with said company. OPs have taken over aforesaid previous policy and issued policy no.P/211114/01/2023/003990, valid from 20.07.2022 to 19.07.2023. Said policy is having mediclaim health risk cover of Rs.10.00 lakh. The OPs issued a certificate of insurance wherein it is mentioned that Star Group Health Insurance Policy-Gold (For bank customers). Said policy also risk cover about the health of the complainant being member of said Group Insurance Policy. Presently the said policy is running in its IVth year without any break. The complainant was feeling occasional pain in her knees, she used to consume Tab Dollo for getting rid from said problem. But the said problem went on increasing day by day. The complainant went to Ivy Hospital, Mohali for her treatment, the doctor concerned advised for her some of the tests conducting from Paras Hospital, Panchkula. Complainant took appointment on 16.08.2022 from Dr. Manoj Wadhwa of Paras Hospital, Panchkula. Said doctor got conducted several tests and x-rays of knees and after proper examination of knees, the doctors advised for both knees replacement. Thereafter, complainant visited Ivy Hospital, Mohali for her further treatment and treating doctors also advised for knee replacement. The complainant showed her medi-claim policy to the hospital authorities. The authority concerned forwarded request to OPs for getting approval for treatment of the complainant and then OPs issued cashless Authorization Letter for knees replacement, vide letter dated 26.08.2022 with initial authorized amount of Rs.1.00 lakh, vide claim no.CIG/2023/211114/0669955. The authorization was valid upto 01.09.2022. After that both knees of the complainant were replaced from said hospital on 29.08.2022 and the hospital authorities referred the matter to the OPs for the payment of an amount of Rs.382628/-but to the utter surprise of the complainant when on 09.02.2022, the OPs withdrawn the said cashless authorization letter by taking the plea that “As per the document received by us, the patient has been suffering from this OA Knee since 120 days which is prior to the portability, hence it is pre-existing disease/condition. It is further stated that the insured has failed to disclose this in his/her proposal form at the time of inception of first policy. As per the waiting period/exclusion no.Exc.01 of the policy, the claim for treatment of the disease/condition is not admissible until the expiry of 36 months from the date of admission after 1^st October, 2020. The abovesaid plea taken by the OPs is quite illegal, null and void and is against the conditions mentioned in the policy itself- it is specifically mentioned in the policy that Pre-existing disease as defined in the policy until 36 consecutive months of continuous coverage have elapsed since inception of first individual health insurance policy. In case of the complainant, the first policy was incepted on 12.07.2019 and 36 months completed on 11.07.2022, hence complainant was having pre-existing diseases. At the time of discharge from the hospital complainant has paid Rs.382628/- from her own pocket. Besides this complainant has spent an amount of Rs.16000/- on physiotherapy which was conducted from 03.09.2022 to 22.09.2022 from Physiocare C.P. and Rehabilitation Centre, Karnal and also spent Rs.10825/- on post treatment medicines, she also has to pay Rs.5500/- on pre-operation tests. Thus, in this way complainant has spent an amount of Rs.414953/- which is to be paid by the OPs. Complainant approached the OPs and requested to make payment of the aforesaid amount but OPs started postponing the matter on one pretext or the other. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence complainant filed the present complaint seeking direction to the OPs to pay Rs.414953/- i.e. amount spent by complainant on her treatment pre-tests, physiotherapy, post treatment medicines alongwith interest @ 18% per annum, to pay Rs.50,000/- as compensation for mental pain, agony and harassment and Rs.22000/- towards the litigation expenses.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the insured  availed Star Group Health Insurance Policy-Gold (for bank customers) under portability through Branch officer covering Mr. Jagdish Kumar-self, Manju-spouse, Grima and Keshav dependent children, for sum insured Rs.10,00,000/-, vide policy no.P/211114/01/2023/003990, valid from 20.07.2022 to 19.07.2023. It is further pleaded that information was sought from the insurer on PED (Pre-existing disease) if any, for a specific query the insured answered in the negative. The exact information on queries and reply given by the insured is reproduced below:-

“Any other medical condition/disability/physical deformity/diagnostic testing/routine Health Checkup/ investigation/prior history of accident:- No.

The insured answering-“No” for the above specific questions relating to medical history in the proposal amounts to non-disclosure of material fact making the contract of insurance voidable.  It is further pleaded that complainant raised request for a cashless authorization on 39^th days of ported policy with Star Health for the medical expenses towards the treatment OA Both.B/L Knee at Ivy Multi Specialty Hospital and Cancer on dated 28.08.2022. As per the cashless request for which is duly signed and seal by the treating hospital received by OP, it is noted that patient was suffering from this OA knee since 120 days which is prior to the portability. Hence, it is pre-existing disease/condition. The insured has failed to disclose this in his /her proposal form at the time of port of the policy with OP. As per the waiting period/exclusion no.Excl 01 the company shall not be liable to make any payment under this policy in respect of any expenses what so ever incurred by the insured person in connection with or in respect of expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 36 months of continuous coverage after the date of inception of the first policy with insurer. Hence, cashless claim was rejected and conveyed to the insured, vide letter dated 02.09.2022. The insured has not submitted the claim documents for reimbursement. 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 policy valid upto 19.07.2023 Ex.C1, copy of insurance policy valid upto 11.07.2020 Ex.C2, copy of insurance policy valid upto 19.07.2021 Ex.C3, copy of insurance policy valid upto 19.07.2022 Ex.C4, copy of cashless authorization letter dated 26.08.2022 Ex.C5, copy of cashless authorization withdrawal letter dated 02.09.2022 Ex.C6, copies of medical bills Ex.C7 to Ex.C19, copy of aadhar card of complainant Ex.C20 and closed the evidence on 08.05.2023 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.RW1/A, copy of proposal form Ex.R1, copy of Portability form Ex.R2, copy of policy schedule Ex.R3, copy of policy terms and conditions Ex.R4, copy of guidelines for relevant portion Ex.R5, copy of pre-authorization request Ex.R6, copy of cashless authorization letter dated Ex.R7, copy of discharge summary dated 02.09.2022 Ex.R8, copy of withdrawal of cashless authorization and rejection letter dated 02.09.2022 Ex.R9, copy of bill assessment sheet Ex.R10 and closed the evidence on 09.07.2024 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 complainant, while reiterating the contents of the complaint, has vehemently argued that husband of complainant purchased a Health Insurance Policy from the OPs. The sum insured under the policy is Rs.10,00,000/-. On 29.08.2022, during the subsistence of the policy, complainant has taken the treatment of knee replacement from Ivy Hospital, Mohali and has spent an amount of Rs.414953/- on her entire treatment. Intimation was given to the OPs by the hospital for cashless claim, initially, the same was approved but lateron same has been rejected by the OPs. Thereafter, complainant lodged the claim with the OPs and submitted all the required documents for reimbursement of the said amount but OPs did not pay the claim and rejected the same 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 on receipt of cashless pre-authorization request of the complainant, case was duly processed but cashless request has rightly been denied as complainant has taken the treatment of pre-existing disease. Thereafter, insured has never submitted the claim form alongwith documents for reimbursement of the claim and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, husband of complainant purchased a Star Group Health Insurance Policy-Gold from the OPs and in the said policy the complainant was also covered. It is also admitted that the policy has been ported from Oriental Bank of Commerce to OPs. It is also admitted that medical policy is without any break since 2019. It is also admitted that during the subsistence of insurance policy the insured (complainant) has taken treatment of knee replacement from Ivy Multi Specialty Hospital and Cancer, Mohali (Punjab).

11.           The cashless claim of the complainant regarding hospitalization in Ivy Multi Specialty Hospital and Cancer, Mohali has been denied by the OPs, vide letter Ex.C6/Ex.R8 dated 02.09.2022, on the grounds, which are reproduced as under:-

“As per documents received by us, the patient has been suffering from this oa knee since 120 days which is prior to the portability. Hence it is a pre-existing disease/condition.

The insured has failed to disclose this in his/her proposal form at the time of inception of the first policy. As per the waiting period/exclusion no.Excl.01 of the policy, the claim for treatment of the disease/condition is not admissible until the expiry of 36 months from the date of admission after 1^st October, 2020.

Hence, authorization is withdrawn and stands null and void.”

 12.          The claim of the complainant has been denied by the OPs on the abovesaid ground. The OPs have alleged that insured raised a request for a cashless authorization on 39^th days of the ported policy. During investigation, it is noted that complainant has been suffering from OA Knee since 120 days which is prior to the portability and it is pre-exist disease.

13.           The policy has been ported from Oriental Bank of Commerce to OPs company and OPs have issued insurance policy Ex.C1. In the said policy, at page no.7, the OPs have waived off the waiting period of the insured person, which are reproduced as under:-

Sr. No.	Name of the insured person	ID card no.	30 days waiting period	1st year exclusion	2nd year exclusion	Pre-existing disease
1.	Manju	CB000007874600399020580	Waived	Waived	Waived	covered
2.	Garima	CB000007874600399020581	Waived	Waived	Waived	covered
3.	Keshav Chhabra	CB000007874600399020582	Waived	Waived	Waived	covered

14.           The OPs have itself waived off the waiting period of the insured persons and the name of the complainant  has also falls in the abovesaid table, hence the plea taken by the OPs that insured has taken the treatment of pre-exist disease is not tenable in the eyes of law. Moreover, insured purchased the insurance policy from the Oriental Bank of Commerce since 2019 and got ported the same on 20.07.2022 without any break.

15.           OPs have also alleged that complainant has not approached the OPs for reimbursement of the claim amount. Complainant has specifically mentioned in her complaint as well as in her affidavit that she has lodged the claim with the OPs. Moreover, it is also unbelievable an insured whose personal interest is involved for such huge amount why he/she will not lodged the claim to the insurance company for getting his/her claim amount and will indulge him/her in unwanted litigations. Hence, the plea taken by the OPs has no force.      

16.           Furthermore, nowadays it has become a trend of insurance companies, they issue the policies by giving false assurances and when insured amount is claimed, they make such type of excuses. Thus, the denial of the claim of complainant is arbitrary and unjustified. In this regard, we place reliance on the judgment of Hon’ble Punjab and Haryana High Court titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, wherein the Hon’ble Punjab and Haryana High Court 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 that the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, the act of the OPs while repudiating the claim of complainant amounts to deficiency in services and unfair trade practice, which is otherwise proved genuine one.

18.           The complainant has spent an amount of Rs.4,14,953/- on her treatment and in this regard she has submitted the bills Ex.C7 to Ex.C19, the said amount neither denied nor rebutted by the OPs.  Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental pain, agony 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.414953/- (Rs.four lakhs fourteen thousand nine hundred fifty three only) alongwith interest @ 9% per annum from the date of filing the complaint i.e.11.10.2022 till its realization to the complainant. 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. This order shall be complied within 45 days from the date of receipt of copy of the order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated: 17.12.2024    

                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

                    (Sarvjeet Kaur)

                       Member