Haryana

Karnal

CC/191/2018

Mukesh Kumar - Complainant(s)

Versus

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

Balbir Singh Chauhan

07 Nov 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No. 191 of 2018

                                                          Date of instt. 07.08.2018

                                                          Date of Decision 07.11.2019

 

Mukesh Kumar (aged 42 years), son of Shri Baldev Raj, resident of House no.451, Sector 13 Extension, Urban Estate, Karnal.

 

                                                                        …….Complainant

                                        Versus

 

 Star Health and Allied Insurance Company Limited, having its registered and Corporate Office 1, New Tank Street, Valluvar Kotlam High Road, Nungambakam, Chennai-600034 and having its Branch Office at SCO 242, 1^st floor Sector 12, opposite Mini Secretariat Karnal, through its Branch Manager.

                                                                        …..Opposite Party.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

      Sh.Vineet Kaushik ………..Member

                Dr. Rekha Chaudhary…….Member

 

 Present:  Shri B.S. Chauhan Advocate for complainant.

                   Shri Naveen Khaterpal Advocate 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 obtained Health Cashless policy bearing no.P-211114/2017/004594, valid from 02.12.2016 to 01.12.2017 from opposite party(OP). The policy was further renewed by the complainant for one year w.e.f.19.12.2017 to 18.12.2018. Initially, the complainant got some problem and he was taken to Dr. R.K. Caroli, Caroli Cardic Clinic, C-5987, New Friends Colony, New Delhi and was checked up by the Doctor on 21.11.2017. Thereafter, on 14.02.2018, all of a sudden the complainant got the problem of hypertension and he was got admitted in Dr. Anand’s Inaging & Neurological Research Centre, New Delhi where, he was diagnosed for the disease and he remain admitted in the Hospital for one day. Thereafter, complainant was shifted to Fortis Hospital, Mohali (Punjab) on 14.02.2018 and he remain admitted there from 14.02.2018 to 18.02.2018. On being discharged from Fortis Hospital, Mohali the complainant has submitted the relevant receipts for medicines, Doctor charges, Pathological tests etc. in original to the OP with a request to release and pay the claim amounting to Rs.4,33,506/-. The claim application submitted by the complainant duly entertained by the OP as claim no.CLMG/2018/211114/0510722, but when the OP did not intimate the complainant about the progress of his claim. Thereafter, the complainant contacted the officials of the OP time and again and requested to reimburse his claim but OPs did not pay any heed to his request and lastly repudiated the claim of the complainant on the false ground. In this way there was deficiency in service on the part of the OP. 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; mis-joinder and non-joinder of necessary parties and concealment of true and material facts. On merits, it is pleaded that the complainant has availed Family Health Optima Insurance Plan from OP, covering Mr. Mukesh Kumar-self (with the PED-Diabetes Melllitus and its complications), Mrs. Preeti-Spouse and Aditya Jagga-Dependent children vide policy Nos. P/211114/01/2017/004594 for the period from 02.12.2016 to 01.12.2017 for the sum insured Rs.5,00,000/- and P/211114/01/2018/006441 for the period from 19.12.2017 to 18.12.2018 for the sum insured Rs.5,00,000/-. It is further submitted that insured submitted two claim vide claim no.CLI/2018/211114/0592450 and CLI/2018/211114/0597563.

CLI/2018/211114/0592450

The insured Mr.Mukesh Kumar was admitted in the Sanjiv Bansal Cygnus Hospital and submitted pre authorization request towards the treatment of CAD, unstable Angina and the same was denied vide letter dated 16.02.2018 since the insured patient was not admitted in the hospital.

CLI/2018/211114/0597563.

That the insured submitted pre authorization request for availing cashless treatment of CAD at Fortis Hospital Mohali-Bhabat and the same was denied and informed the insured to approach for reimbursement of medical expenses, since the etiology and duration for ailments are not known.

It is further submitted that insured submitted claim for reimbursement of medical expenses Rs.2,53,453/- towards the treatment of CAD-USA-SVD-PTCA+stent to LAD (17.02.2018), Normal LVEF 55% and Diabetes Mellitus Type 2. On scrutiny of the claim documents, it is observed that the prescription dated 14.02.2018 of Dr. Arun Kochar that the insured patient has chest pain for the past 2½ months and has consulted the doctor previously in November, 2017 which is confirmed by the consultation report dated 21.11.2017 of Dr. R.K. Caroli. Further, the insured patient has undergone myocardial perfusion scan on 23.12.2017 and ECHO on 22.12.2017 which shows evidence of long standing changes. Thus, the OP  has referred the claim to the specialist and the following were the findings:-

. On 14.02.2018, patient Mr. Mukesh Kumar consulted Dr. Arun Kochar for chest pain since 2½ month underwent TMT whch was terminated for chest pain.

.  On 03.02.2018, the patient underwent myocardial perfusion study which suggested perfusion defect.

.  On 22.12.2017, Myocardial perfusion done, which suggest Myocardial perfusion defect. Echo done on the same day also suggestive of RWMa with EF 40%.

.  Mr. Mukesh Kumar admitted at Fortis Hospital Mohali on 17.02.2018, underwent CAG, Diagnosed SVD, LAD Lesion, PTCA to LAD done. No evidence of ACS noted. ‘

With all evidence available for verification confirms, patient had previous MI before 22.12.2017.CAD presentation is not an acute presentation.

Based on these findings, it is noted that the insured patient has chronic, longstanding heart disease prior to inspection of the medical insurance policy. Hence the heart disease is a pre-existing disease. As per Waiting Period.3 (iii) 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 was repudiated and the same was informed to the insured vide letter dated 03.05.2018. There is no deficiency in service on the part of the OP. 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.C2 to Ex.C35 and closed the evidence on 18.03.2019.

4.             On the other hand, OP tendered into evidence affidavit of Rajiv Jain Ex.RW1/A and documents Ex.R1 to Ex.R23 and closed the evidence on 19.09.2019.

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 he purchased Family Health Optima Insurance Plan from the OP for the period from 02.12.2016 to 01.12.2017 for the sum insured of Rs.5,00,000/-. After expiry of the said policy, the policy was got renewed on 19.12.2017 for the period from 19.12.2017 to 18.12.2018 for the same sum insured. The complainant was shifted to Fortis Hospital Mohali (Pb) on 14.02.2018 and remain admitted from 14.02.2018 to 18.02.2018 and amount of Rs.4,33,806/- has been incurred on complainant’s treatment. The complainant lodged the claim with the OP for reimbursement of the amount spent by him on his treatment alongwith all the relevant documents but OP repudiated the claim of the complainant on the false ground. 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.             The case of the OP, in brief, is that the complainant submitted for reimbursement of medical expenses of Rs.2,53,453/- only. The claim of the insured has been repudiated by the OP on the ground insured had chronic, longstanding heart disease prior to inspection of the medical insurance policy. Hence the heart disease is a pre-existing disease. Hence the claim is not payable.

8.             As per the complainant on 14.02.2018 all of a sudden he got the problem of hypertension and he was got admitted in Dr. Anand’s Imaging & Neurological Research Centre, New Delhi where he remained for one day. Thereafter, complainant was shifted to Fortis Hosptial, Mohali on 14.02.2018 and he remained admitted there from 14.02.2018 to 18.02.2018. The complainant has spent Rs.4,33,506/- on his treatment.  After treatment the complainant submitted his claim with OPs, but on 03.05.2018 the claim of the complainant was repudiated by the OP on the ground of pre-existing disease. The claim of the complainant has been repudiated by the OP on the opinion of Dr. Arun Kochar Fortis Hospital Mohali. As per repudiation of claim Ex.R22, the insured patient has chest pain for the last 2½ month and has consulted the doctor previously in November, 2017. Repudiation letter Ex.R22 based on the treatment record Ex.R13 but in Ex.R13 Dr. Arun Kochar has mentioned that patient has chest pain for the last 1½ months. So, as per the treatment record Ex.R13 the complainant has chest pain for the last 1½ months and not for the last 2½ months as alleged by the OP. Thus, version of the OP became doubtful.

9.             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.

10.            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 OP 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.4,33,806/-  but the complainant had submitted the medical bill for the tune of Rs.2,53,453/- before the OP and as well before the Forum. Hence the complainant is only entitled to Rs.2,53,453/-

11.            Thus, as a sequel to the abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.2,53,453/- to the complainant with interest @ 9% per annum from the date of repudiation till its realization. We further direct the OP 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:07.11.2019                                                                       

                                                                      President,

                                                              District Consumer Disputes

                                                               Redressal Forum, Karnal.      

 

 

        (Vineet Kaushik)          (Dr. Rekha Chaudhary)

            Member                           Member