Haryana

Karnal

CC/258/2017

Renu Bala - Complainant(s)

Versus

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

Dheeraj Sachdeva

02 Apr 2018

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                         Complaint No.258 of 2017

                                                        Date of instt. 03.08.2017

                                                        Date of decision:02.04.2018

 

Renu Bala, age 44 years wife of Shri Mohinder Kumar, resident of 133, Prem Nagar, Karnal.

                                                                                                                                                                                                                                                                        …….Complainant.

                                        Versus

 

1. Star Health and Allied Insurance Company Limited, SCO no.242, 1^st floor, Sector-12, Urban Estate, opp. Mini Secretariat, Karnal through its Manager, Branch at Karnal.

2. Star Health and Allied Insurance Company Limited, registered office at 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600 031 through Director/authorized person.

 

                                                                …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act.    

 

Before   Shri Jagmal Singh……President.

              Ms Veena Rani…..Member

              Shri Anil Sharma……Member

 

Present  Shri Dheeraj Sachdeva Advocate for complainant.

               Shri Naveen Khaterpal Advocate for OPs.

 

ORDER:                    

 

                (Jagmal Singh President)

 

                         This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986 on the averments that complainant purchased an insurance policy from the OP no.1, vide policy no.P/211114/01/2017/001549, valid from 12.07.2016 to 11.07.2017 in the sum of Rs.3,75,000/- including recharge benefit vide which three persons namely Mohinder, Renu Bala and Kapil were insured. The said policy was got renewed on 12.07.2017 to 11.7.2018 vide policy no.P/2/11114/01/2018/002266 but the name of the complainant is deleted from the policy. It is alleged that at the time of issuance of the aforesaid policy, complainant has submitted all the requisite documents as per the instruction of the OP no.1. In September 2017, complainant fell ill and then she visited in various hospitals Sarvodaya Multispecialty Hospital, Karnal, Hospital Amritdhara, Karnal, Shri Hari Hospital, Karnal from 3.6.2017 to 9.6.2017 wherein various investigation/tests were conducted. The complainant did not get any relief from disease and Dr. Rajiv Gupta, Hospital Amritdhara Karnal referred the complainant to some higher centre for investigation and management. Thereafter, complainant went to Ganga Ram Hospital, New Delhi on 10.06.2017 and got herself admitted and she admitted in that hospital from 10.6.2017 to 17.06.2017. Complainant through her husband sent a request for cashless treatment and it was conveyed by the officials of the Star Health that the cashless approval will take some time but on 14.06.2017 a repudiation letter was sent by the OPs stating therein that due to pre-existing disease the policy stands cancel on the same day i.e.14.6.2017. Complainant wrote a letter to OPs stating therein that there is no hospitalization and pre-existing disease. During the investigation/test in the hospital, nothing had been reported by the concerned doctor that the said disease was pre-existing. After that OPs no.1 and 2 wrote letters to Ganga Ram Hospital and enquired about the pre-authorization and a reply was sent by Ganga Ram Hospital and told to the OPS that the disease is not a pre-existing one and the treatment should be given on the basis of cashless policy. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written statement raising preliminary objections with regard to limitation; jurisdiction; cause of action; mis-joinder and non-joinder of necessary parties and concealments of true and material facts. The true facts are that the insured availed Family Health Optima Insurance Policy, vide policy no.P/211114/01/2017/001549 including Mr. Mahinder-self, Ms. Renu Bala-Spouse, Kapil-dependent child for the Sum Assured of Rs.3,00,000/-. The insured patient, Renu Bala was hospitalized at Amritdhara Hospital on 7.06.2017 for the treatment of IHD and submitted pre-authorization request for cashless treatment vide claim no.CLI/2018/211114/0109383. Thereafter, the insured was referred to higher institute. Hence, the cashless authorization was denied and the same was communicated to the insured vide letter dated 9.6.2017. Subsequently, the insured has once again raised pre-authorization request for cashless treatment vide claim no.CLI/2018/211114/0114695. On perusal of the claim records, it is observed that:

As per pre Auth Form, the insured was admitted with the complaints of Fever since 1 month, shortness of breath, joint pain and malena and the provisional diagnosis was Anemia under evaluation.

The Casualty Card dated 9.6.2017 states that the insured was presented with the history of Raynaud’s phenomenon.

As per Field Visit Report, the insured himself has declared that he has the Raynaud Phenomenon since 2 years.

From the above findings, it is observed that the insured patient has been suffering from this Raynaud Phenomenon for the past 2 years and the records pertaining to it are not available. Hence the claim cannot be processed at cashless level and the claim of the complainant was repudiated, vide letter dated 16.06.2017. Hence there was 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.

3.             Complainant tendered into evidence his affidavit Ex.CW1/A and documents Ex.C1 to Ex.C27 and Annexure-28 and closed the evidence on 5.12.2017.

4.             On the other hand, OPs tendered into evidence affidavit of N.Gopalan Ex.RW1/A and documents Ex.R1 to Ex.R17 and closed the evidence on 15.02.2018.

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

6.             There is no dispute between the parties about the fact that the complainant has purchased an insurance policy no.P/211114/01/2017/001549, valid from 12.07.2016 to 11.07.2017 for Rs.3,75,000/-. It is also not disputed that complainant fell ill and she visited in various hospital from 3.6.2017 to 9.6.2017, wherein various investigations/tests were conducted. It is also not disputed that the complainant was remained admitted in Amritdhara Hospital, Karnal from 7.6.2017 to 9.6.2017, from where she was referred to some higher centre for investigation. The complainant went to Sir Ganga Ram Hospital (hereinafter referred as SGRH), New Delhi and remained admitted there from 10.06.2017 to 17.06.2017. It is also not disputed that the complainant through her husband sent request to the OPs for cashless treatment but the OPs sent repudiation letter on 14.06.2017 stating that due to pre-existing disease, the policy stand cancelled on the same day i.e. 14.06.2017.

7.             According to the complainant three person namely Mahinder, Renu Bala complainant and their son Kapil were insured under the abovesaid policy dated 12.07.2016. The said policy was got renewed from 12.07.2017 to 11.07.2018 vide policy no. P/2/11114/01/2018/002266 but the name of the complainant was deleted from the policy. It is argued that during the investigation/tests in the above hospitals, nothing had been reported by the concerned doctor that the said disease was pre-existing one. The doctors rather told that all medical bills, treatment etc. would cover under the medi-claim policy, purchased by the complainant. It is also argued that the doctor of SGRH has clearly mentioned that Raynaud Phenomenon is not a disease. He further argued that earlier the complainant was never admitted in any hospital for the disease in question nor took any treatment, so the said disease was not a pre-existing disease. He further argued that the repudiation is illegal and void. The complainant produced authorities Life Insurance Corporation of India Versus Sarojini & Anr. in Revision Petition no.3454 of 2016, date of order 17.08.2016; Jamnaben Shambhubhai Mange Digvijaya Versus Manager, Life Insurance Corporation of India in Revision Petition no.3957 of 2011, date of decision 23.3.2017; LIC of India Versus Saurabhy Aggarwal in Revision Petition no. 1496 of 2010, date of decision 02.01.2015 and Padmavathy Venkatesh Versus Oriental Insurance Company Ltd. Consumer case no.319 of 2000, date of decision 1.7.2015.

8.             On the other hand, the OPs argued that on perusal of the claim record, disease of the complainant was a pre-existing disease and the complainant has not disclosed the same at the time of proposal, so the claim has been rightly repudiated. The OPs produced authorities Star Health & Allied Ins. Co. Ltd. Vs. Jaspal Singh Soni 2014(1) CPR, Page 94 (Chandigarh State Commission) and United India Ins. Co. Ltd. Versus M/s Harchand Rai Chandan Lal (SC) Civil Appeal no.6277 of 2004 decided on 24.09.2004.

9.             It is pertinent to mention here that the claim of the complainant was repudiated vide letter dated 14.06.2017 Ex.C21-B written to the Hospital (SGRH) which runs as under:-

        “On a scrutiny of the details furnished by you, we are of the opinion that the claim of the insured-patient is not admissible under the above insurance policy issued, for the following reasons:-

We note that the insured patient has been diagnosed with Hemorrhagic Colitis.

As per the medical records submitted, it is noticed that the insured patient has history of Raynaud’s Phenomena for 2 years. However, it is observed from the proposal that this material fact has not been disclosed as a Pre-existing Disease (PED) and company was deprived of an opportunity to properly evaluate risk factor before accepting the proposal.

Hence, as per condition no.8, we regret our inability to entertain this claim even though the treatment taken is not related to the PED and consequently the request for preauthorization cannot be approved.

Kindly inform the insured accordingly to whom a copy of this communication should also be handed over.

Hence, we regret to inform you that Pre-authorization request for cashless treatment of above insured-patient is not approved.”

10.           As the OPs repudiated the claim of the complainant, so the onus to prove the reasons of repudiation was on the OPs. The OPs referred the document Ex.R-4 regarding the repudiation of the claim. On perusal of Ex.R-4, it is clear that the complainant on 9.6.2017 in SGRH gave history of Raynaud’s Phenomena in finger but there is no mention of the time of 2 years as alleged by the OPs. It is pertinent to mention here that the complainant produced on the file Ex.C-20 wherein the doctor of SGRH gave in writing to the OPs that “on retrospective history this history of Raynaud was captured however no treatment was taken for Raynaud.” It is further necessary to mention here that the doctor of SGRH has mentioned in Ex.C-21A that Raynaud Phenomenon is not a disease, so there is no question of disclosure. It is clear from the above documents that the facts mentioned is Ex.C-20 and Ex.C-21A were given to the OPs by the doctor of SGRH but the OPs have not taken into consideration these documents. The OPs have not produced on the file any such record on the basis of which the OPs observed that complainant gave history of Raynaud Phenomenon since two years. As already stated above, in Ex.R-4 no time of two years is mentioned. No doubt the doctor of SGRH stated that the Raynaud’s Phenomenon is not a disease but if for the argument sake it is presumed that the same is a disease, even then the OPs have not produce any evidence on the file vide which it can be said that the disease of the complainant was diagnosed earlier and the same was in the knowledge of the complainant and the complainant had intentionally did not disclose the same. Without such evidence it cannot be said that the complainant was having a pre-existing disease and the same was not disclosed by him. In the authorities did not disclose the same.  Without such evidence it cannot be said that the complainant has not disclose the pre-existing disease. In the authorities produced by the complainant LIC’s case (supra) & Jamnaben Shambhubhai’s case (supra), the Hon’ble National Commission held that no treatment record produced on record for the earlier period. There is no evidence on record to show whether Insured had taken medical treatment or was admitted in any hospital for any kind of treatment. The allegation of suppression against insured is not established. Similar, proposition has been held in the other two authorities produced by the complainant. These authorities are fully applicable to the facts of the present case, whereas the authorities produced by the OPs are not applicable to the facts of the present case. In these facts and circumstances of the case, we are of the considered view that the OPs have failed to prove by cogent evidence that the insured had taken any medical treatment for the Renaud’s Phenomenon before taking the policy in question or that the complainant was admitted in any hospital for any kind of treatment before the purchase of policy, therefore, the OPs have wrongly repudiated the claim of the complainant. Hence the OPs are deficient in providing services to the complainant.

11.           The complainant has claimed the amount of Rs.1,93,473/- for which she has produced the bills and the complainant was insured for Rs.3,75,000/-.So the amount claimed by complainant is less than the insured amount, hence the complainant is entitled for the amount of Rs.1,93,473/- from the OPs.

12.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.1,93,473/- to the complainant. We further direct the OPs to pay Rs.5500/- on account of mental tension, harassment and litigation expenses. This order shall be complied within 30 days from the date of receipt of copy of this order failing which complainant is entitled for interest @ 8% per annum from the date of order till its realization.  The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 02.04.2018

                                                                       

                                                                  President,

                                                          District Consumer Disputes

                                                           Redressal Forum, Karnal.

 

 

                     (Veena Rani)        (Anil Sharma)

                        Member                 Member