Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 262.
Instituted on : 28.5.2019.
Decided on : 29.04.2024
Pankaj Gupta, aged 33 years son of Sh. MahabirParsad Gupta, permanent resident of H.No.88/2, Ward no.18, SinghanMohalla, CharkhiDadri, District CharkhiDadri.
………..Complainant.
Vs.
- Star Health & Allied Insurance Company Ltd., through its MD/CEO Regd. and Corporate Office, 1 New Tank Street, ValluvarKottam High Road, Nungambakkam, Chennai-600034.
- Manager, Star Health & Allied Insurance Co. Ltd., Branch Office Ashok Plaza, 3rd Floor, Delhi Road, Rohtak-124001.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR.VIJENDER SINGH, MEMBER.
Present: Sh. PK Maina, Advocate for complainant.
Sh. Balwan Saroha&Sh.D.N.Singal Advocates for opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that the complainant had purchased a health Insurance Policy for his family members from opposite party no.2 vide policy number P/211118/01/2018/007382 with the date of commencement 30.3.2018 and limit of coverage for medical treatment was Rs.5,00,000/- for each insured person and opposite party no.2 charged Rs.24142/- towards insurance premium under the said policy. Parents of the complainant namely, MahabirParsad Gupta and Smt. Savitri Devi were insured/beneficiary under this policy. On dated 27.6.2018, father of the complainant namely, Shri MahabirParsad Gupta developed some health problem and he was immediately admitted in emergency at MedantaTheMedicity Hospital, Gurgaon. During investigation, patient was planned for CAG, Coronary angiography which was done on 28.6.2018, which showed triple vessel disease. After appropriate evaluation, relevant investigations and pre anesthesia clearance, patient underwent CABG on 02.07.2018 and was discharged on 09.07.2018, thus complainant spent more than Rs.5,50,000/- on treatment. After discharge of his father from the hospital, he submitted medical re-imbursement bill to opposite party no.2 amounting to Rs.5,00,000/- and requested to pay the same early in the month of July, 2018 and opposite party no.2 assured that claim will be paid within a month time after processing with higher offices. In the month of September, 2018, the opposite party no.2 asked the complainant to submit necessary certificate from the Hospital regarding no previous history of CAD and medications, on which he submitted the same on 22.9.2018. But the opposite parties repudiated the claim of the complainant vide their letter dated 20.10.2018 on flimsy ground without any valid reasons and justification on the plea that insured was treated for pre existing disease. Complainant requested the opposite parties to pay the claim but they did not pay the claim amount to the complainant. Hence this complaint and it is prayed that opposite parties may kindly be directed to pay Rs.5,00,000/- towards health insurance amount alongwith interest @ 24% per annum from the date of repudiation of claim and also to pay an amount of Rs.50,000/- on account of harassment as well as Rs.11,000/- on account of litigation expenses to the complainant as explained in the relief clause.
2. After registration of complaint, notices were issued to the opposite parties. Opposite parties in preliminary objections of their reply has submitted that the insured availed Family Health Optima Insurance Policy vide policy no. P/211118/01/2018/007382 for the period 30.03.2018 to 29.03.2019 covering Mr. MahabirParsad Gupta-Self ,Mrs. Savitri Devi –spouse(PED Diabetic &Hypertension and their complications) for the floater sum insured of Rs.500000/-. It is also submitted that the insured patient Mr.MahabirParsad Gupta, was hospitalized at Medanta the Medicity, Gurugram on 27.06.2018 for the treatment of CORONARY ARTERY DISEASE, LM+ TRIPLE VESSEL DISEASE, SEVERE LV DYSFUNCTION and submitted a request for pre-authorisation of cashless treatment on 27.06.2018 and subsequently submitted a claim for reimbursement of medical expenses on 08.08.2018 for a sum of Rs.552435/- in the 3rd month of the policy. On the scrutiny of the claim documents submitted by the insured, it is observed that:
- The Echo findings in discharge summary, suggested the Akineticanterioseptum, inferior, posterior wall with EF 25% dilated LV.
- As per the CAG report,
- Left Anterio Descending Ostial-90%
- Stenosis-100% occlusion
- Left circumflex-Ostial 80% Stenosis
- RCA-Proximal 70% stenosis
The above finding confirms that the insured-patient has chronic changes. The specialist also opined as follows.
- The ECHO findings suggested the
Akineticanterioseptum, inferior, posterior wall with EF25% dilated LV. Following cardiology team review patient subjected for angiogram on 28.06.2018, which showed triple vessel disease. Patient underwent CABG on 02/07/2018. - The aforementioned findings do not suggestive of acute coronary syndrome; echocardiography evidence favors old ischemic coronary events.
Thus, the opposite party based on the above findings, noted that the insured has pre-existing disease.Thus the claim was rejected as per the terms and conditions of the policy and the same was informed to the insured vide letter dated 06.04.2019. On merits, it is submitted that he complainant had earlier applied for cashless treatment, for which specific query was raised by the company through a transparent letter seeking specific replies/documents as contained in the Company’s letters dated 27.6.2018 & 28.6.2018, which the complainant failed to reply and accordingly his cashless treatment was declined. The claim had been repudiated by transparent and well specified reasons as per terms & conditions of the policy. It is also submitted that Ayushman Scheme is not for all citizens but a special Govt. of India Group Policy for special low income people with different provisions & administration having no comparison or concern with individual policy of the complainant. Hence, there is no deficiency in service on the part of opposite parties. All the other contents of the complaint were stated to be wrong and denied and opposite parties prayed for dismissal of complaint with costs.
3. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.PW1/A, documents Ex.P1 to Ex.P9 and has closed his evidence on dated 10.10.2019. On the other hand, Ld. counsel for the opposite parties has tendered affidavits Ex.RW1/A and Ex.RW1/B and documents Ex.R1 to Ex.R14 and closed his evidence on dated 14.10.2020.
4. We have heard learned counsel for the parties and have gone through the written arguments filed by ld. Counsel for the opposite parties as well as material aspects of the case very carefully.
5. In the present case, claimof the complainant has been repudiated by the opposite parties vide their letter Ex.R12 on the ground that: “It is observed that CAG report dated 27.06.2018 shows left anterio descending Ostial 90% stenosis 100% occlusion, left circumflex-Ostial 80% stenosis, RCA-Proximal 70% stenosis and MID 70% stenosis, Obtuse Marginal-1, Small branch-Ostial 70% stenosis. Bases on these findings our medical team is of the opinion that insured patient has chronic longlasting heart disease prior to date of commencement of first year policy and hence it is pre existing disease. The present admission and treatment of the insured patient is for pre existing disease heart disease”. On the other hand, contention of ld. Counsel for the complainant is that the claim has been repudiated on the flimsy grounds as the insured was never treated for the alleged disease before commencement of policy. To prove his case complainant has placed on record copy of a certificate Ex.P4 issued by Dr. Manish Bansal MD(AIIMS), DNB(Cardiology), who has submitted that : “Mr. Mahabir Parshad Gupta,, 59 years old gentleman was diagnosed to be having CAD for the first time when he was admitted at Medanta hospital on 27.06.2018. There was no previous history of CAD and he was not on any medications for the same”. Ld. Counsel for the complainant has also placed reliance upon the Revision Petition no.1696 of 2005 of Hon’ble National Commission, New Delhi titled as Praveen Damani Vs. Oriental Insurance Co. whereby Hon’ble National Commission has held that : “the insured was unaware of this disease till he suffered chest pain which is only on 18.08.2000 and not before 09.06.2000 when he took the policy. It is further held that most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the insurance company relies on their Clause 4.1 of the policy in a malafide manner to repudiate all the claims. It is further held that complainant has proved that he was unaware of the disease at the time of taking the policy and hence the complaint is allowed”. Reliance has also been placed upon the judgment of Hon’ble State commission dated 14.03.2019 titled as Virpal Nagar vs. HDFC Standard Life Insurance co. Ltd.and order dated 15.11.2017 of Hon’ble State Commission in FA No.195/2010 Oriental Insurance Company Vs. Mr. Romesh Suri.
6. We have perused the documents placed on record by both the parties. As per the discharge summary dated 09.07.2018 of Medanta-the medicity Hospital, under the head “Medical history & Presenting complaints, it is mentioned that : “Mr. Mahabir Parshad Gupta, 59 years old non hypertensive, diabetic male, known case of coronary artery disease, presented with complaints of shortness of breath and dyspnea on exertion for 2-3 days. Now he admitted here in emergency for further evaluation & management”. We have also perused the documents Ex.R13 & Ex.R14 and discharged summary Ex.R9, as per which, at the time of admission in the hospital, he was having complaint of shortness of breath and dyspnea on exertion for 2-3 days .Meaning thereby it was not within the knowledge of life assured that he was suffering from CAD. Moreover as per the certificate Ex.P4 issued by the doctor, there was no previous history of CAD of patient Mahabir Parshad Gupta and he was not on any medications for the same. Meaning thereby, at the time of inception of policy there was no complication to the life assured about the CAD. In this complaint the policy period starts from 30.03.2018 to 29.03.2019 and first time complications occurred on 27.06.2018 i.e. after 3 months of inception of policy. On the other hand, opposite parties have placed on record a document Ex.R14 of Dr. Aditi Gupta. We have minutely perused the certificate issued by Dr. Aditi Gupta. As per our observation Dr. Aditi Gupta never treated and physically examined the patient namely Mr. Mahabir Prasad Gupta . So the observations made by her cannot be believed in toto. Opposite parties have not placed on record any other document or previous history of hospitalisation of insured in any hospital prior to taking the policy. Hence the benefit of doubt goes in favour of the complainant. In view of the documents placed on record by both the parties, law cited above by ld. Counsel for the complainant which are fully applicable on the facts and circumstances of the case and the certificate Ex.P4 issued by Dr. Manish Bansal MD(AIIMS), DNB(Cardiology), we have observed that the life assured was not suffering from any disease prior to taking the policy. Hence the repudiation of claim on this ground is illegal and amounts to deficiency in service. As per the bill Ex.P6, life assured has spent an amount of Rs.551435/- on his treatment but the limit of coverage as per policy Ex.P1 is Rs.500000/-. Hence the opposite parties are liable to pay the alleged amount to the complainant.
7. In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite parties to pay Rs.500000/-(Rupees five lac only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 28.05.2019 till its realisation and shall also pay a sum of Rs.5000/-(Rupees five thousand only) on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
8. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
29.04.2024.
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Nagender Singh Kadian, President
………………………………..
TriptiPannu, Member.
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Vijender Singh, Member.
