Haryana

Karnal

CC/623/2023

Sachin Joon - Complainant(s)

Versus

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

N.K. Zak

22 Oct 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 623 of 2023

                                                        Date of instt.30.10.2023

                                                        Date of Decision: 22.10.2024

 

Sachin Joon son of Shri Ram Mehar, resident of village Kurlan, District Karnal.

 

                                               …….Complainant.

                                              Versus

 

Star Health and Allied Insurance Company Ltd. through its Branch Manager, SCO no.94, 1^st floor, Sector-17, backside of Hotel Silver Sand, Kurukshetra.

 

…..Opposite Party.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.

              Ms. Neeru Agarwal……Member

      Ms. Sarvjeet Kaur…….Member

 

Argued by: Shri N.K. Zak, counsel for the complainant.

                   Shri Suraj Mandhan, counsel for the OP.

 

                    (Jaswant Singh, President)

ORDER

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that complainant had taken Medical Term Policy bearing no.P/211123/01/2023/002892, Gold Plan alongwith his family members on 28.06.2022, commencing from 28.06.2022 to Midnight 27.06.2023 for a basic floater sum assured Rs.5,00,000/-. Unfortunately, on 29.10.2022, while playing a Volleyball Tournament, the complainant suffered pain in right knee medial side and severe tenderness on deep palpation, for which he consulted Gauri Hospital, Gaur Enclave, Jyoti Nagar, Kurukshetra on 30.10.2022 and the complainant took treatment for some time, but got no respite from his pain. The complainant again contacted Escort Heart and Super Specialty Hospital Ltd. Sector 62, Phase-VIII, SAS Nagar, Mohali (Punjab) on 12.12.2022 and took treatment for his injured knee. The doctor advised the complainant to undergo an operation, for which, the complainant gave his consent and produced his insurance documents to the hospital. The concerned hospital sent the advice for insured sum, but the OP, vide letter dated 19.12.2022 refused to make the payment for the medical expenses to the doctor with observation that “we are not able to ascertain the duration of disease based on the document/detail submitted by the Hospital. It requires further evaluation. We, therefore, deny the approval for cashless treatment of the above diagnosed disease.” In this way, complainant was forced to get treatment for his disease by spending money from his own pocket. So, the purpose of taking the medical policy was failed as complainant was forced to spend his own money for taking treatment. The complainant spent an amount of Rs.2,00,000/- on his treatment i.e. on operation of his injured knee and also spent the money on his follow up treatment. Despite of repeated requests of complainant, OP did not pay the said amount. Due to this act and conduct of OP, complainant has suffered mental pain, agony and harassment. In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence, complainant filed the present complaint seeking direction to the OP to pay Rs.1,63,880/- as medical expenses alongwith interest @ 18% per annum from the date of denial i.e. 19.12.2022 till its realization, to pay Rs.2,00,000/- as compensation on account of mental pain, agony and harassment and to pay Rs.22000/- as litigation expenses.

2.             On notice, OP 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 Sachin Joon availed Yong Star Insurance Policy cover, Sachin Joon (self) and Jyoti (spouse) for sum insured of Rs.5,00,000/-, vide policy No.P/211123/01/2023/002892 for the period from 28.06.2022 to 27.06.2023. The insured has requested for cashless and submitted the documents for hospitalization on 24.12.2022 to 25.12.2022 in Fortis Hospital-Mohali towards the treatment of ACL Tear. Cashless request was rejected on the basis of submitted documents, as the duration of disease cannot be ascertained and it requires further evaluation. Subsequently, insured has submitted the same in reimbursement on scrutiny of claim documents, it was observed that the findings of MRI report confirm injury of the complainant is chronic and, longstanding. Based on the MRI findings, medical team of the OP company is of the opinion that the insured patient has the above injury prior to inception of the medical insurance policy. Hence, it is pre-existing injury. The present admission and treatment of the insured patient is for the pre-existing injury. As per Exclusion-Pre-existing disease-Code Excl.-01 of the policy issued to you, expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 12 months. Hence, being not maintainable as per terms and conditions of the policy, the claim of the complainant was rejected and the same was informed to the insured, vide letter dated 15.06.2023. It is pertinent to mention here that this is a fresh policy, with date of inception of policy as 28.06.2022. This is a case of pre-existing disease prior to policy inception, based on acute changes in MRI, which shows only chronic, old changes and the treatment shall be excluded until the expiry of 12 months.  It is further pleaded that insured is well aware of the past medical history and failed to disclose the same in the proposal form during the porting of policy, amounting to non-disclosure of material facts thus violating the Cardinal Principle of the insurance, making the contract of the insurance voidable and unenforceable. The insured has omitted to disclose the material facts at the time of porting of policy, which amount to non-disclosure of material facts. There is no deficiency in service and unfair trade practice on the part of the OP. 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.             Complainant has tendered into evidence his affidavit Ex.CW1/A, copy of welcome letter dated 23.06.2022 Ex.C1, copy of policy schedule dated 23.06.2022 Ex.C2, copy of ID card Ex.C3, copy of insurance policy Ex.C4, copy of letter dated 19.12.2022 denial of pre-authorization request for  cashless treatment Ex.C5, copy of medical OPD dated 30.10.2022 Ex.C6, copy of receipts dated 12.12.2022, 24.12.2022, 24.12.2022 Ex.C7 to Ex.C9, copy of medical bills dated 09.01.2023, 16.01.2023, 09.01.2023 and 16.01.2023 Ex.C10 to Ex.C13, copy of repudiation letter dated 15.06.2023  Ex.C14 and closed the evidence on 23.07.2024 by suffering separate statement.

5.             On the other hand, learned counsel for the OP has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.RW1/A, copy of proposal from Ex.R1, copy of policy schedule Ex.R2, copy of terms and conditions of the policy Ex.R3, copy of request for cashless hospitalization Ex.R4, copy of denial letter dated 19.12.2022 Ex.R5, copy of claim form Ex.R6, copy of discharge summary of Fortis Hospital Ex.R7, copy of MRI Test Report dated 12.12.2022 Ex.R8, copy of x-ray report Ex.R9, copy of patient history and physical record Ex.R10, copy of Inpatient bill Ex.R11, copy of repudiation letter dated 15.06.2023 Ex.R12 and closed the evidence on 23.08.2024 by suffering separate statement. 

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

7.             Learned counsel for the complainant, while reiterating the contents of complaint, has vehemently argued that complainant purchased a health insurance policy from the OP covering himself and his spouse. On 29.10.2022, complainant suffered knee pain and he has taken treatment from Gauri Hospital, Jyoti Nagar, Kurukshetra on 30.10.2022 but he has no relief. So, complainant admitted in Escort Heart and Super Specialty Hospital Ltd., Mohali on 12.12.2022 and took treatment for his injured knee and spent an amount of Rs.1,63,880/- on his treatment.  Complainant lodged the claim with the OP for reimbursement of the said amount but OP did not pay the claim and repudiated the same, vide repudiation letter dated 15.06.2023 on the false and frivolous ground and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OP, while reiterating the contents of written version, has vehemently argued that the argued that the claim of the complainant was rightly repudiated by the OP because the complainant has knee injury prior to inception of the insurance policy and this fact has not been disclosed by the complainant at the time of taking the policy and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, complainant purchased a health insurance policy from the OP, covering himself and his wife. It is also admitted that complainant was hospitalized in Escort Heart and Super Specialty Hospital Ltd., Mohali during the subsistence of the insurance policy and spent an amount of Rs.1,63,880/-.

11.           The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.C14/Ex.R12 dated 15.06.2023 on the ground, which is reproduced as under:-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of ACL TEAR.

It is observed that the findings of MRI report confirm chronic, longstanding injury. Based on the MRI findings, our medical team is of the opinion that the insured patient has the above injury prior to inception of the medical insurance policy. Hence, it is pre-existing injury. The present admission and treatment of the insured patient is for the pre-existing injury.

As per Exclusion-Pre-existing disease-Code Excl.-01 of the policy issued to you, expenses related to the treatment of a pre-existing disease (PED) and its direct complications shall be excluded until the expiry of 12 months.

We, therefore, regret to inform you that for the reasons stated above, we are unable to settle your claim under the above policy and we hereby repudiate your claim.”

 

12.           The claim of the complainant has been repudiated by the OP on the abovesaid ground. The onus to prove that the complainant was having pre-existing disease, prior to commencement of the policy was relied upon the OP but OP has miserably failed to prove the same by leading any cogent and convincing evidence. OP has relied upon the MRI Report Ex.R8 prepared by Dr. N. Kalra, M.B.B.S.M.D., DNB Radio-Diagnosis (Ex. Sr. PGI), on perusal of the said MRI report, it is nowhere mentioned that complainant was having any chronic and longstanding disease. OP neither examined the Doctor nor tendered his affidavit, who has issued the alleged MRI report. In this regard we are relying upon the case law titled as SBI Life Insurance Co. Ltd. Vs. Lakshiben Naginbhai Chauhan and others 2020 CJ 110 (NC) and Authorised Signatory, Hon’ble National Commission has held that Insurance-SBI Home Loan Master Policy-Repudiation of death claim on ground of concealment of pre-existing disease-Complaint allowed by fora below-Both District Forum and State Commission had reached to conclusion after going through all documents that medical papers have not been properly proved since neither doctor has been duly examined nor his affidavit has been furnished-National Commission is not expected and required to re-appreciate and re-assess evidences-where on the basis of evidences Fora below have reached to a conclusion which is a possible conclusion, then such conclusion need not be disturbed in Revision Petition-Revision petition dismissed. Further in case titled as Bajaj Allianz Life Insurance Co. Ltd. and 2 others Versus Kanduru Gangadhara Rao in Revision Petition no.1054 of 2020, decided on 07.10.2021 Hon’ble National Commission held that Insurance Law-concealment of disease-Death claim repudiated by insurer on ground that life assured suppressed her health condition of her taking treatment for  placed reliance on the treatment record, ‘Chronic non-specific cervicitis’ prior to obtaining the policy-Hence this complaint-Held, insurance company placed reliance on treatment record, which was a mere photocopy and not certified. The Doctor who treated the Life Assured was also not examined nor was his affidavit filed by the insurance company. Also, insurance company failed to satisfy this Commission that there was any co-relation between death of the Life Assured and the suppression of ailment "Chronic non-specific cervicitis". Complaint allowed.

13.           Keeping in view the ratio of law laid down in the aforesaid judgments, facts and circumstances of the case, it is proved on record that OP has wrongly and illegally repudiated the claim of complainant. Hence, plea taken by the OP, complainant was having pre-existing disease has no force.

14.           Furthermore, now a days 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”.

15.           Keeping in view, the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, the act of the OP while repudiating the claim of complainant amounts to deficiency in services and unfair trade practice, which is otherwise proved genuine one.

16.           The complainant has spent an amount of Rs.1,63,880/- on his treatment and in this regard he has placed on record,  receipts Ex.C7 to Ex.C9 and medical bills Ex.C10 to Ex.C13. The said bills and receipts  neither denied nor rebutted by the OP. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental pain, agony and harassment and litigation expenses etc.

17.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.1,63,880/- (Rs.one lakh sixty three thousand eight hundred eighty only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 15.06.2023 till its realization. We further direct the OP 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:22.10.2024

         President,

      District Consumer Disputes                           

      Redressal Commission, Karnal.

 

                   ( Neeru Agarwal)            (Sarvjeet Kaur)

                            Member                        Member