Haryana

Karnal

CC/166/2019

Parvesh - Complainant(s)

Versus

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

Rajesh Kumar

21 Jan 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                          Complaint No. 166 of 2019

                                                          Date of instt.19.03.2019

                                                          Date of Decision 21.01.2021

 

Parvesh wife of Shri Joginder Singh resident of VPO Uplana Tehsil Assandh, District Karnal.

                                                                        ……Complainant.

 

                                              Versus

 

1. Star Health and allied insurance company Ltd. SCO 242, First floor, Sector-12, opposite Mini Secretariat, Karnal through its Branch Manager.

2. Star Health and Allied Insurance Company Ltd. 1^st floor, Himalaya house, 23, Kasturba Gandhi Marg, New Delhi-110001 through its Managing Director.

                                                                        …..Opposite Parties.

 

           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 Kuldeep Singh Advocate for complainant.

                 Shri Naveen Kheterpal Advocate for opposite parties.

                                        

                (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 alongwith her husband namely Joginder Singh and children namely Sachin Rana and Shivani purchased a family Health Optima Insurance Plan, vide policy no.P/211114/01/2015/003094 from the opposite parties (hereinafter referred as to OPs) by paying a premium of Rs.13,370/- and the said policy was valid from 24.03.2015 to 23.03.2016 and sum insured was Rs.5,00,000/-. The said policy was renewed by the complainant and her family members from the OPs vide policy no.P/211114/01/2016/004999, valid from 24.03.2016 to 23.03.2017 and the sum insured under the said policy was Rs.5,00,000/-. The policy was again renewed, vide policy no.P/21111/01/2017/007404, valid from 24.03.2017 to 23.3.2018 for the sum insured of Rs.5,00,000/-.The policy further got renewed by the complainant, vide policy no.P/211114/01/2018/010396, valid from 31.03.2018 to 30.03.2019 and the sum insured was of Rs.5,00,000/-.

2.             Further, in the morning of 21.01.2018 the complainant all of sudden fell down due to non-working of right side part of her body and she was taken to a local hospital, as there was no improvement in the condition of the complainant, so, on the same day in the night at about 8.33 p.m., the complainant was taken to Max Super Specialty Hospital, near Civil hospital, Mohali, Punjab and she was admitted in the said hospital on the same night and the complainant remained admitted in the said hospital upto 30.01.2018. At the time of admission, the abovesaid policy was disclosed by the family members of the complainant to abovesaid hospital and as the abovesaid policy purchased by the complainant. From the OPs was cashless policy, so all the documents relating to said policy were handed over to the abovesaid hospital. However, the officials of the abovesaid hospital got deposited an amount of Rs.20,000/- from the family of the complainant by assuring that the same will be refunded at the time of discharge of complainant. After receiving the documents and depositing the amount of Rs.20,000/-, OPs were duly intimated regarding the admission of the complainant in the abovesaid hospital. Upon which, surveyor of the OPs visited the abovesaid hospital where the complainant was admitted and approval was given to the hospital to treat the complainant and the complainant was treated in the said hospital and remained admitted there upto 30.01.2018. At the time of discharge, the official of the hospital contacted the OPs for making the payment, the OPs refused to pay the same on the ground that:-

“as per discharge, patient presents with accelerated hypertension. When asked about the same, you are claiming that the patient was in some desi medicine for the same and reports are not available. Due to these discrepancy of statements about the duration of hypertension from your side and the accelerated hypertension from your side and the accelerated hypertension is the cause of current ailment the auth is withdrawn and the claim is denied,” which fact is without any basis and record.

3.             The complainant and her family never remained ill prior to purchase of policy. The husband of the complainant continued to talk with the OPs and requested to pay the bill of the treatment of complainant but OPs flatly refused to pay the bill and under the compelling circumstances, the complainant had to pay a sum of Rs.1,94,182/- after the discount of Rs.8678/- to the hospital. Thereafter, complainant requested the OPs so many times to reimburse the claim but OPs did not pay any heed to the request of complainant. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

4.             Notice of the complaint was given to the OPs, who appeared and filed written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action and concealment of true and material facts. On merits, it is pleaded that the insured availed Family Health Optima Insurance Plan covering Mr. Joginder Singh-self, Mrs. Parvesh-spouse, Sachin Rana and Shivani-Dependent children for the sum insured of Rs.5,00,000/-, vide policy no.P/211114/01/2015/003094 for the period from 24.03.2015 to 23.03.2016. Thereafter, same was renewed, vide policy no.P/211114/01/2016/004999 for the period from 24.03.2016 to 23.03.2017 and lastly renewed vide policy no.P/21111/01/2017/007404 for the period from 24.03.2017 to 23.03.2018. The terms and conditions explained to the complainant at the time of proposing policy and the same was served to the complainant alongwith the policy schedule. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form.

5.             Further, the insured patient i.e. complainant got hospitalized on 21.01.2018 in Max Super Specialty Hospital, Mohali and raised a  pre-authorization request for availing cashless facility for the treatment of RT HEMIPLEGIA. Based on the submitted documents, the claim was initially approved for Rs.15,000/-. Whereas, on receipt of pre authorization enhancement documents, it is observed that the insured patient was admitted for left ganglio thalamic bleed and cerebral micrbleeds and accelerated hypertension. But the insured has denied the past history of hypertension and was in some desi medicine for the same. Thus, the pre authorization of the insured was withdrawn and rejected due to discrepancy of the duration of hypertension. Later, the insured submitted claim for reimbursement of medical expenses. On scrutiny of the claim document it is observed that:-

a. As per the discharge summary, the patient is a known case of the HTN and hypertension leading to right sided weakness and the patient was on alternate system of medication for the same.

b. As per the self declaration letter dated 14.05.2018 submitted in response to our query, it is stated that the insured patient has no past history of hypertension. Thus, there is discrepancy in material facts which amounts to misrepresentation.

c. ECHO report dated 22.01.2018 shows concentric left ventricular hypertrophy which confirms the insured patient has chronic, longstanding hypertension prior to inception of the material insurance policy.

d. As per the indoor case papers and ICP, the insured is a known case of HTN.

From the above observation, there is a discrepancy and the insured has pre-existing disease hypertension. As per the exclusion no.1 of the policy, the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease/condition, until48 months of continuous coverage has elapsed, since inception of the policy. The insured has hypertension prior to the inception of the policy, which is PED and was treated for the same in the 3^rd year of policy. As per the terms and conditions, PED will be covered only after 48 months of continuous coverage. Therefore, the claim is not payable. Hence, the claim was rejected and the same was communicated to the insured vide letter dated 06.06.2018. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

6.             Complainant tendered into evidence her affidavit Ex.CW1/A, copy of policy dated 24.3.2015 Ex.C1, policy dated 24.03.2016 Ex.C2, policy dated 24.3.2017 Ex.C3, policy dated 31.3.2018 Ex.C4, copy of bill summary Ex.C5, copy of settlement receipt Ex.C6, discharge summary Ex.C7, withdrawal of authorization letter Ex.C8, rejection of pre-authorization for cashless treatment Ex.C9 and C10, copy of Aadhar card of complainant Ex.C11 and closed her evidence on 16.01.2020 vide separate statement.

7.             On the other hand, OPs tendered into evidence affidavit of Rajiv Jain Ex.RW1/A, copies of policies Ex.R1 to Ex.R3, terms and conditions of policy Ex.R4, proposal form Ex.R5, claim form Ex.R6, discharge summary Ex.R7, ECHO report Ex.R8, query on pre-authorization dated 22.01.2018 Ex.R9, authorization for cashless treatment of the insured patient Ex.R10, query reply Ex.R11 and medical report Ex.R12 and closed the evidence on 02.03.2020, vide separate statement.

8.             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.

9.             The case of the complainant, in brief, is that she had purchased family Health Optima insurance Plan for the sum assured of Rs.5,00,000/- on 24.03.2015 and same was renewed upto 23.03.2018. On 21.01.2018, complainant all of sudden fell down due to non-working of right side part of her body and was taken to Max Hospital, Mohali and spent Rs.1,94,182.93. Complainant submitted her claim but same was repudiated by the OPs without any cogent reason.

10.           Per-contra, the case of the OPs, in nutshell, is that the patient was having past history of hypertension and she had concealed this material facts from the OPs which amounts to misrepresentation. The claim of the complainant was rightly repudiated by the OPs as the complainant has violated the terms and conditions of the policy.

11.           Admittedly, complainant initially purchased a Family Health Optima Insurance Plan in the month of March 2015 from the OPs and same was renewed upto March 2018 for the sum assured of Rs.5,00,000/-. During the subsistence of the policy, the complainant got admitted in Max Hospital, Mohali and got treated from there.

12.           The claim of the complainant was rejected by the OPs on the ground, that on receipt of pre-authorization encashment documents, it was observed that insured-patient was admitted for left ganglio thalamic bleed and cerebral micrbleeds and accelerated hypertension, but the insured had denied the past history of hypertension and was on some desi medicine for the same. Thus, the pre-authorization of the insured was rejected due to discrepancy of the duration of hypertension. From the other documents it was observed by the OPs that the insured has pre-existing disease of hypertension.

13.           As per the version of the OPs that the complainant was in some desi medicine but OPs neither examined any doctor from where she was allegedly taking desi medicine nor produced any documents in order to prove its version. There is no nexus between the pre-existing disease and cause of treatment taken by the complainant. In this regard, we can rely upon the authority of Hon’ble State Commission, New Delhi case titled as Life Insurance Corporation of India Versus Sudha Jain 2007 (2) CLT 423, has drawn conclusion in para 9 of the order and the relevant clause is 9(iii), which 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. Further, in case titled as  United India Insurance Co. Ltd and another Versus S.K.Gandhi, 2015 (2) CLT 71 (NC), in which Hon’ble National Commission held that the insurance company had not placed on record either the discharge summery of the complainant or any medical document signed by the doctors who treated him in Bhatnagar Eye Centre, Karnal and Arpana Hospital, Madhuban to show that the complainant when he was admitted to the said hospital, had himself stated that he was suffering from hypertension from last 8 years. In that case it was held that it is quite possible that the complainant, despite suffering from diabetes was not actually aware of the same and he cannot be accused of mis-statement or concealment. Onus was upon the insurance company to prove that he had made a mis-representation while obtaining the insurance policy and since the insurance policy failed, it was held that it was liable to pay to the complainant to the extent a sum insured by it. Further, in case  Oriental Insurance Company Limited Versus Ramesh Kumar II (2018) CPJ 253 of Hon’ble State Commission Punjab in which the Hon’ble State Commission Punjab held that Medical reimbursement-Suppression of pre-existing disease alleged-Claim repudiated-Deficiency in service-District Forum allowed complaint-Hence appeal-Appellant/OP has not referred any document that before taking policy, complainant was having knowledge of this disease and was taking treatment-Mere reference in discharge summary is not sufficient and OP was required to lead any independent evidence to prove this fact-Repudiation not justified. Further,

14.           Keeping in view the ratio of judgments, facts and circumstances of the case, we are of the considered view that act of the OPs amounts to deficiency in service. OPs have totally failed to prove their case by producing cogent evidence that prior to date of purchasing of policy, the complainant was suffering from hypertension and was getting treatment and the same fact was in the knowledge of the complainant and she intentionally concealed the same. Hence, repudiating of the claim of complainant is not justified.

15.            The complainant has placed on record copy of bill dated 30.01.2018 Ex.C5 to the tune of Rs.1,94,182.93, issued by Max Hospital, Mohali. OPs failed to rebut the said bill. As such OPs  are liable to reimburse the amount of Rs.1,94,182.93 to the complainant. The complainant is also entitled for compensation and litigation expenses because of denial of his genuine claim by the OPs.

16.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs Rs. 1,94,182.93/- to the complainant with interest @ 9% per annum from the date of repudiation of the claim till its realization. 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 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: 21.01.2021                                                                    

                                                                    President,

                                                      District Consumer Disputes

                                                      Redressal Commission, Karnal.

 

 

 

 (Vineet Kaushik)               (Dr. Rekha Chaudhary)

      Member                               Member