Haryana

Karnal

CC/122/2019

Smt. Aruna Rani - Complainant(s)

Versus

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

S.S.Moonak

02 Dec 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No. 122 of 2019

                                                          Date of instt.01.03.2019

                                                          Date of Decision 02.12.2019

 

Smt. Aruna Rani, aged 35 years, wife of late Shri Mohit alias Mohit Arora, resident of Gali no.1, Vikas Colony, Ranwar Road, Karnal.

 

                                                 …….Complainant.

                                              Versus

 

Star Health and Allied Insurance Company Limited, through its Branch Manager, SCO 242, 1^st floor, opp. Mini Secretariat, Sec. 12 Karnal.

 

                                                                         …..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 S.S. Moonak Advocate for complainant.

                Shri Naveen Khatterpal 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 the husband of complainant namely, Mohit Arora was the holder of Medi claim policy no.P/211114/01/2019/000925 valid from 11.05.2018 to 10.05.2019 covering the risk of Mohit Arora (since deceased) and his wife Aruna (complainant), daughter Khushi and son Satvik Arora for a sum of Rs.6,50,000/- including recharge benefit. The husband of complainant remained in coma and was in vegetative stage and was confined to bed. He died on 06.01.2019. On 26.06.2018 in the early morning the husband of complainant was admitted in Amritdhara Hospital, Karnal. The doctor has disclosed that he has suffered shock and stroke, due to which he went to “coma”. After treatment he was discharged on 30.06.2018 from the said hospital and thereafter he was admitted in Virk Hospital, Karnal, he was got admitted and discharged on 11.07.2018 with diagnosis as “Acute Anterior Wall Mi/sudden Cardiac Arrest Post OPR Survivor/Carcinogenic Shock.” Meaning thereby, the husband of complainant had suffered intensive damage to his brain and due to some blockage in the head, he remained under treatment and after discharge from the hospital he remained on bed and remained under constant medical treatment till his death. Prior to his admission Amritdhara Hospital Mr. Mohit Arora felt uneasiness and took medicines at home, as he has no serious problem or ailment. The physical and mental condition of Mohit Arora was fit and fine as he was doing his business as usual, he has no serious problem or any type of ailment, nor visited any doctor. Thereafter, he was taken to PGI Rohtak on 13.07.2018 and on the same day he was brought back to his home due to non-availability of the bed etc. He remained lying on bed in “coma” state. He could not move his limbs, he was unable to perform his daily pursuits. Due to long confinement on bed, Mohit Arora had suffered bed soars and for this he was being looked after by doctors and was kept in home in very hygienic condition. He was given constant medical treatment, physiotherapy etc. as advised by the doctor. During the course of treatment till his death. He was given liquid diet through pipes as he was unable to move his limbs, his metabolic function of the body had also suffered a lot. Since the day of suffering from stoke in the head, Mohit Arora was being looked after by the complainant, his father Vijay Arora and other family members, beside this he was being regularly checked up by the expert doctors and para medical staff. Despite all the best efforts on behalf of the complainant and his family members, Mohit Arora could not survive and died on 06.01.2019.  A sum of Rs.15 lakhs were spent by the complainant so far on the treatment, medicines, hospitalization, special diet etc. on the treatment of her husband. Thereafter, all the relevant documents alongwith medical, treatment bills, receipt etc. were submitted to the office of OP at Karnal for the settlement of the claim, however, the claim was repudiated by the OP on 31.10.2018 without giving any opportunity to the complainant and without any plausible explanation or reasoning on part of the OP. 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 OP, who appeared and filed their written statement raising preliminary objections with regard to maintainability; jurisdiction and concealment of true and material facts. On merits, it is pleaded that the insured had availed the Family Health Optima Insurance Plan covering Mr.Mohit Arora-Self and Mrs. Aruna Rani-Spouse, Khushi Arora and Sativik Arora Dependent child for floater sum insured Rs.5,00,000/-, vide policy no.P/211114/01/2019/000925 for the period 11.05.2018 to 10.05.2019. It is further pleaded that the claim is reported in the 3^rd month of policy. The insured patient Mr. Mohit Arora was admitted in the Amritdhara My Hospital on 26.06.2018. Dagnosis:Acute Anterior Wall, MI/Sudden Cardian Arrest, Post CPR Survever/Cardiogenic Shock, Likely Hypoxic Brain Injury/Recurrent Seizures, Pulmonary Edema/Hyperpyrexia Likely Neurogenic and Diabetes Mellitus. As per the claim form, the insured submitted claim for Rs.1,73,061/-. The insured submitted a claim for reimbursement of medical expenses on 07.08.2018. On scrutiny of the claim documents and query reply, it is observed that

. As per the Discharge summary the treating hospital, the insured patient has history of chest pain on and off since 2 days and taken treatment for the same from a local hospital and referred to a higher centre from the above hospital and was diagnosed with Recurrent Seizure Disorder.

Hence, a query was raised to submit the following documents

1. Letter from the treating doctor regarding the exact duration of heart disease, seizures, DM, any past history of heart disease.

2. All the previous consultation papers including first consultation papers, investigation reports including ecg. Echo, cardiac markers , ct/mri brain prior to admission.

3. As per discharge summary recurrent seizure noted. Kindly submit all treatment records including CT/MRI brain reports regarding it.

4. Letter from the treating doctor stating current neurological status, when the first episode of seizure was noted.

5. As per discharge summary, patient took treatment from local hospital and also referred to higher centre from Amritdhara hospital. Kindly submit those documents.

6. All investigation reports including ecg, echo, cardiac enzymes regarding the admission.

7. All past hospitalization records.

8. Clear copy of final bill

9. Pan card copy of the insured person (Mr. Mohit Arora)

In reply, the insured submitted insufficient document i.e. the previous documents relating to seizure disorder and treatment taken from local hospital and referred to higher centre was not submitted by the insured. As per condition no.3 of the policy, “The insured person/s shall obtain and furnish the company with all original bills receipts and other documents upon which a claim is based and shall also give the company such additional information and assistance as the Company may require in dealing with the claim.”

The insured was suffering from Recurrent Seizure disorder and hence previous treatment documents were requested for determining the first diagnosis and the treatment taken. Even after the reminder the insured failed to submit the requested documents. Hence the claim was closed and the same was communicated vide letter dated 25.09.2018. There is no deficiency in service on the part of the OP. All 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.C115 and closed the evidence on 06.09.2019.

4.             On the other hand, OP tendered into evidence affidavit of Rajiv Jain Ex.RW1/A and documents Ex.R1 to Ex.R13 and closed the evidence on 16.10.2019.

5.             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.

6.             The case of the complainant, in brief, that he has taken the Medi-Claim Insurance Family Policy from OP, no.P/211114/01/2019/ 000925 valid from 11.05.2018 to 10.05.2019. On 26.06.2018 in the early morning the husband of complainant was admitted in Amritdhara Hospital, Karnal. The doctor has disclosed that he has suffered shock and stroke, due to which he went to “coma”. After treatment he was discharged on 30.06.2018 from the said hospital and thereafter he was admitted in Virk Hospital, Karnal, he was got admitted and discharged on 11.07.2018 with diagnosis as “Acute Anterior Wall Mi/sudden Cardiac Arrest Post OPR Survivor/Carcinogenic Shock.” Meaning thereby, the husband of complainant had suffered intensive damage to his brain and due to some blockage in the head, he remained under treatment and after discharge from the hospital he remained on bed and remained under constant medical treatment till his death A sum of Rs.15 lakhs were spent by the complainant on the treatment, medicines, hospitalization, special diet etc. on the treatment of her husband. Thereafter, all the relevant documents alongwith medical, treatment bills, receipt etc. were submitted to the office of OP at Karnal for the settlement of the claim, however, the claim was repudiated by the OP on 25.09.2018 on the false ground. Learned counsel of complainant relied upon the authorities in case  Vipin Grover & Anr. Versus New India Assurance Co. Ltd. II (2018) CPJ 374 (NC); Oriental Insurance Company Limited Versus Ramesh Kumar II (2018) CPJ 253 of Hon’ble State Commission Punjab and Santanu Roy Versus TTK Healthcare TPA Pvt. Ltd. & Ors Versus IV (2018) CPJ 19  of Hon’ble State Commission West Bengal.

7.             On the other hand, the case of the OP is that the insured had availed mediclaim policies bearing no.P/211114/01/2019/000925 valid from 11.05.2018 to 10.05.2019.The insured patient Mr. Mohit Arora was admitted in the Amritdhara My Hospital on 26.06.2018. Dagnosis:Acute Anterior Wall, MI/Sudden Cardian Arrest, Post CPR Survever/Cardiogenic Shock, Likely Hypoxic Brain Injury/Recurrent Seizures, Pulmonary Edema/Hyperpyrexia Likely Neurogenic and Diabetes Mellitus. As per the claim form, the insured submitted claim for Rs.1,73,061/-. The insured submitted a claim for reimbursement of medical expenses on 07.08.2018.  On scrutiny of the claim documents and query reply, it is observed that complainant has not provided entire requisite documents as well as information to the OP and in the absence of said documents and information, the claim cannot be processed. OP sent letter dated to the complainant while requesting him to provide the documents but complainant failed to do so. Hence, the claim of the complainant was finally denied, vide repudiation letter dated 25.09.2018.

8.             Admittedly, the husband of complainant purchased the medical claim insurance policy from OP and during the subsistence of the policy husband of complainant got admitted and taken treatment from Amritdhara Hospital, Karnal, Virk Hospital Karnal and PGI Rohtak. The claim of the complainant has been repudiated by the OP on the ground of non-submission of requisite documents.

9.             As per the version of the OP, the complainant has not provided entire requisite documents and information. The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.R13, on the ground the patient has recurrent seizure disorders. The OP had demanded pre and post hospitalization medical bills/reports. On the other hand, learned counsel of complainant submitted that complainant has not taken any treatment for recurrent seizure disorder, prior to taking the present treatment. There is no proof on the file, to prove the version of the OP. The case of the OP is relied upon the baseless allegations, once it is admitted by OP that complainant had provided the bills of Rs.1,73,061/-, there is no reason, why the complainant shall not provide other informations as desired by the OP if the same were in his custody. Thus, we are of the considered view that the claim of the complainant has been repudiated by the OP on the baseless ground.

10.            In Vipin Grover’s case (supra) the Hon’ble National Commission held that Heart attack-Hospitalization expenses-Claim repudiation on ground of suppression of pre-existing disease-Deficiency in Service-District Forum allowed complaint-State Commission allowed appeal-Hence revision-Complainants have declared in proposal form that CABG was done in 1990-Policy was renewed continuously-complainants have never availed any mediclaim benefits under existing policy-Clause 15-A entitles a person for mediclaim benefits in case one has not availed benefits and has completed four years of his continuous medi-claim benefits in case on has not availed benefits and has completed four years of his continuous mediclaim policy-Exclusion clause regarding pre-existing disease cannot be invoked under such circumstances-OP had relied upon preponderance of probability that persons who underwent CABG are prone for recurrence-Present treatment of coronary PTCA was not a consequence of any pre-existing disease-It was neither late effect of previous cardiac ailment nor was there any pre-existing condition for which patient needed angioplasty-If Insurance companies co-relate each and every disease with pre-existing condition, under such circumstances, insured i.e. helpless Consumers will never succeed to get his genuine claim from Insurance Company-Repudiation not justified. In Ramesh Kumar’s case (supra) 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. In Santanu Roy’s case (supra) the Hon’ble State Commission West Bengal held that Medical reimbursement-claim repudiated on ground that treatment might have done on OPD basis without patient being hospitalized-Alleged deficiency in service-Prescription left indication that patient needs urgent hospitalization- Hospitalization of patient cannot be questioned as motivated one-Absence of any prescribed duration is subject prescription which Respondents/OPs have taken as a plea for repudiation of claim, cannot be a feasible ground as condition of patient after medication should be determining criterion for releasing or discharging any patient-Acute infusion reaction may develop immediately or within a few hours of infusion and in case of such reaction being developed, infusion should be interrupted-Medical literature itself, most naturally is not specific as to exact time by which reaction is apprehended to occur-Hospital authority or treating physician would  be or should be best judges to decide minimum period under which patient should be kept under observation-Repudiation not justified. All the authorities are applicable to the case in hand.

11.            Keeping in view the ratio of judgment, facts and circumstances of the case, we are of the considered view that act of the OP amounts to deficiency in service.

12.            The complainant has spent Rs.15,00,000/- on the treatment of her husband which proved from the medical bills Ex.C8 to Ex.C115 but the sum assured in the policy is only Rs.6,50,000/-. Thus, the complainant is entitled only insured amount alongwith compensation and litigation expenses.

13.            Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP Rs.6,50,000/- to the complainant with interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OP to pay Rs.20,000/- to the complainant on account of mental agony and harassment and Rs.5500/- towards the litigation expenses. This order shall be complied 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:02.12.2019                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

               

        (Vineet Kaushik)          (Dr. Rekha Chaudhary)

            Member                               Member