Haryana

Karnal

CC/118/2018

Smt. Bharati Pandey - Complainant(s)

Versus

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

P.K. Maandi

02 Apr 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

 

                                                          Complaint No. 118 of 2018

                                                          Date of instt. 16.05.2018

                                                          Date of Decision 02.04.2019

 

Smt. Bharati Pandey wife of Shri Satyendra Kumar Pandey son of Shri Shambhu Nath Pandey resident of House no.180, Ward no.11, near Post Office, Taraori, District Karnal.

                                                                       …….Complainant

                                        Versus

 

Star Health and allied Insurance Co. Ltd. having its Regd./corporate office at 1, New Tank Street, Valluvar Kottam High Road Nungam Bakkam, Chennai and having its branch office at SCO no.242, 1^st floor, sector-12, Urban Estate, Karnal through its branch Manager.

                                                                      …..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 P.K. Mandi Advocate for complainant.

                  Shri Gaurav Gupta Advocate for OP.

 

                   (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 purchased a Family Health Optima Insurance Plan Policy bearing no.P/211114/01/2017/002355 dated 22.08.2016 from the OP. As per the terms and conditions of the said policy, all the family members of the complainant including her husband Shri Satyendra Kumar Pandey, daughter-Ms. Kirti Pandey his son-tushar Pandey were covered under the said insurance policy. In the month of June, 2017 the complainant namely Smt. Bharti Pandey was having some problem in her throat and she contacted the doctors concerned of Virk Hospital Kurukshetra. The complainant was treated in the Virk Hospital Kurukshetra and various tests were conducted including FNAC Test. The complainant was found suffering from Thyroid Cancer by the doctor concerned. After that the complainant again examined herself to Himalyan Hospital Dehradun for 2^nd opinion whereby the complainant was found suffering from the aforesaid disease. The complainant was admitted in the Action Cancer Hospital Delhi for the treatment of the said disease and the necessary surgery was conducted by the doctors concerned of Action Cancer Hospital Delhi and a sum of Rs.1.5 lacs was spent by the complainant on her treatment. The complainant approached the concerned official of the OP i.e. Insurance Co. and submitted the claim application alongwith all other necessary documents including prescription, bills and receipt etc. to the OP. Thereafter, the concerned officials of the OP-Insurance Co. again asked the complainant to furnish various other documents relating to some previous ailment as the OP in a mail sent to the complainant, specially stated that the present Cancer took place due to some pre-existing disease. The OP again informed the complainant that all the relevant documents which the complainant was having, have duly been submitted to the OP and no any other document was available with the complainant. However, the complainant again approached the Action Cancer Hospital Delhi whereby the concerned doctor issued the certificate on 8.3.2018 to the effect that the present disease has no clinical relevance with any alleged pre-existing disease of Neurofibromas over skin. Again the complainant submitted the said certificate to the OP and requested to settle the claim of the complainant and further to make the payment of the claim amount but OP did not pay any claim and lingered the matter on one pretext or the other. In this way there was deficiency in service on the part of the OP. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OP, who appeared and filed written version raising preliminary objections with regard to maintainability; jurisdiction; limitation; cause of action; mis-joinder and non-joinder of necessary parties and concealment of true and material facts. On merits, it is pleaded that the insured availed Family Health Optima Insurance Plan, vide policy no.P/211114/01/2017/002355 for the period of 22.08.2016 to 21.08.2017 covering Satendra Kumar Pandy-self, Bharti Pandey-spouce, Kirti Pandey &Tushar Pandey-Dependant children for the sum insured of Rs.5,00,000/-. The Preamble of the Policy clearly states the Proposal, Declaration and other documents, if any, given by the proposer form the basis of the policy of insurance.” Subject to terms, conditions, exclusions and definitions contained herein or endorsed or otherwise expressed hereon, the company undertakes if the insured person shall contract any disease or suffer from any illness or sustain any bodily injury through accident and if such disease or injury shall require the insured person, upon the advice of the duly qualified physician/Medical Specialist/Medical Practitioner or duly qualified Surgeon to incur Hospitalization expenses for medical/surgical treatment at any Nursing Home/Hospital in India as herein defined as an inpatient the Company will pay to the insured person the amount of such expenses as are reasonably and necessarily incurred in respect by or on behalf of the Insured Person upto the limits indicated”. It is further pleaded that the company’s liability in respect of all claims admitted during the period of insurance shall not exceed the sum insured per family mentioned in the schedule. It is further pleaded that the claim was reported in the 10^th month of the policy and claimed amount is Rs.1,96,923/-. The insured was admitted at Action Cancer Hospital-DMC(U) PART on 30.06.2017 for the treatment of CA THYROID VOCAL CORD PALSY and submitted claim records for reimbursement of medical expenses. On scrutiny of the claim records, it is observed that:

i) As per Discharge summary, the insured was admitted on 30.06.2017 and discharged on 04.07.2017.

a) Diagnosis: Carcinoma Right Lobe of Thyroid with Right Vocal Cord Palsy.

b) Operation performed:- Total thyroidectomy+right posterolateral LND+left lateral LND+CND done on 1.7.2017 under GA.

ii) As per ENT OPD consultation record of Himalayan Hospital, patient is known case of EUROFIBROMATOSIS .

        Hence, query was raised to submit the following documents, vide letter dated 1.11.2017 & 16.11.2017.

. Letter from treating doctor stating exact duration of presenting complaints. Doctor’s referral letter for admission.

. a letter from treating doctor stating its duration and submit treatment records of EUROFIBROMATOSIS and consultations for the same.

. Post operative Biopsy Report for the present admission.

. Initial assessment sheet.

. Any previous history of hospitalization.

. Pan card copy of the insured person.

It is further pleaded that insured has not furnished the required documents and details. In the absence of the above documents/details, OP is not able to further process the claim. As per condition no.4 of the policy, the insured person has to submit all the required documents and details. Hence, the claim was repudiated and the same was communicated, vide letter dated 30.11.2017. Thereafter, the insured has submitted a representation to reconsider the claim and the same was reviewed and replied vide letter dated 31.01.2018 stating that as per the consultation report dated 29.06.2017 of Himalayan Hospital it is noted that the insured patient is a known case of neurofibromatosis and has complaints for the past 1 month. Hence OP requested the complainant to furnish the previous documents relating to neurofibromatosis only. However, these are still not submitted, only papers related to thyroid disease are submitted. Hence repudiation of claim invoking condition no.4 of the policy in question. There is no deficiency in service on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Complainant tendered into evidence her affidavit Ex.CW1/A and documents Ex.C1 and Ex.C2 and closed the evidence on 22.10.2018.

4.             On the other hand, OP tendered into evidence affidavit of Rajiv Jain Ex.RW1/A and documents Ex.R1 to Ex.R12 and closed the evidence on 24.01.2019.

5.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties.

6.             The case of the complainant is that she purchased a Family Health Optima Insurance Plan Policy dated 22.08.2016 from OP. In the month of June, 2017 the complainant was having problem in the throat and she was treated in the Virk Hospital Kurukshetra. The complainant was found suffering from Thyroid Cancer by the doctor concerned. The complainant was admitted in the Action Cancer Hospital Delhi for treatment of the abovesaid disease and the necessary surgery was conducted by the doctor concerned of Action Cancer Hospital Delhi and a sum of Rs.1.5 Lakhs was spent by the complainant on her treatment. The complainant submitted the claim application alongwith all the other necessary documents including bills etc.  The claim of the complainant was repudiated on the ground of pre-existing disease.

7.             On the other hand, the case of the OP is that the claim was reported in 10^th month of the policy an d claimed amount is Rs.1,96,923/-. The insured was admitted at Action Cancer Hospital-DMC(U) PART on 30.06.2017 for the treatment of CA THYROID VOCAL CORD PALSY and submitted claim records for reimbursement of medical expenses. As per the consultation report dated 29.06.2017 of Himalayan Hospital it is noted that the insured patient is a known case of neurofibromatosis and has complaints for the past one month. Complainant failed to furnish the required documents and details. Hence, the claim was repudiated and same was communicated, vide letter dated 30.11.2017.

8.             Admittedly, the complainant purchased Family Health Optima Insurance Plan no.P/211114/01/2017/002355 for the period of 22.08.2016 to 21.08.2017 covering Satinder Kumar Pandey, self, Bhati Pandey-spouse, Kirti Pandey daughter and Tushar Pandey son for the sum insured of Rs.5,00,000/-. As per discharge summary the insured was admitted in hospital on 30.06.2017 and discharged on 04.07.2017. The claim of the insured was repudiated by the OP on the ground that the insured patient is known case of neurofibromatosis and has complaints for the past 1 month and insured has not submit all the required documents and details. The counsel of the complainant argued that complainant has already supplied all the documents as required for releasing the claim but OP harassed the complainant without any reason. Moreover, the claim of the complainant already repudiated by the OP without any reason.

9.             The claim of the complainant was repudiated by the OP on the ground of pre-existing disease. Onus to prove his case was upon the OP that disease was pre-existing but nothing has been filed by the OP on record to establish that disease was pre-existing and complainant has taken treatment or consulted to any doctor prior to inception of the policy. Treatment record produced by the OP, copy of which is Ex.R4 (discharge summary) clearly shows that complainant was first time hospitalized on 30.06.2017 in Action Cancer Hospital, Delhi and the policy in question was issued on 22.08.2016. No history of previous ailment is shown in medical treatment record. Complainant suffered suddenly from Cancer and there was no history of past treatment, OP totally failed to prove that disease was pre-existing. Hence the repudiation of the claim by the OP is illegal, unjustified and amounts to deficiency in service. As per complainant no.2 she incurred expenses of Rs.1,50,000/- on her treatment. All the medical bills were handed over to the OP by the complainant. OP produced the bills Ex.R5 & Ex.R6 in the evidence, which comes out to be of Rs.1,43,309/-only. Hence she is entitled for sum of Rs.1,43,309/-.

10.            Thus, as a sequel to above discussion, we allow the present complaint and direct the OP to pay Rs.1,43,309/- 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 suffered by her and for the litigation expense. 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:02.04.2019                                                                       

                                                                      President,

                                                              District Consumer Disputes

                                                               Redressal Forum, Karnal.      

        (Vineet Kaushik)          (Dr. Rekha Chaudhary)

            Member                              Member