Haryana

Karnal

CC/711/2023

Virender Adlakha - Complainant(s)

Versus

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

Virender Adlakha

12 Sep 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.711 of 2023

                                                        Date of instt 21.12.2023

                                                        Date of Decision: 12.09.2024

 

Virender Adlakha son of Shri Parkash Lal, resident of 37, Nayapuri, Karnal, tehsil and District Karnal.

 

                                                                        …….Complainant.

                                              Versus

 

1. Star Health and Allied Insurance Company Limited, through its Managing Director, 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034.
2. Star Health and Allied Insurance Company Limited, through its Branch Manager, 2^nd floor, SCF 137, Sector 13, Urban Estate, near ICICI Bank, Karnal.
3. Reetu Sharma, Regional Manager/Senior Manager, Star Health and Allied Insurance Company Limited, 2^nd floor, SCF 137, Sector-13, Urban Estate, near ICICI Bank, Karnal.

 

…..Opposite Parties.

 

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 Vinod Gupta, counsel for the complainant.

                    Shri Gaurav Gupta, counsel for the OPs.

                   

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant is account holder in Punjab National Bank, Sector-12 Branch, Urban Estate, Karnal and used to visit there, as well as in Branch of Punjab National Bank in Sector-13, Urban Estate, Karnal. Complainant is a practicing Advocate, who has been practicing in civil, criminal and consumer cases and is an panel Advocate of many banks including Punjab National Bank and due to this reason, complainant has to visit the various branches of Punjab National Bank for going through the documents of the banks, pertaining to bank cases. OP no.3, who is a working person, for and on behalf of OPs no.1 and 2, came to know about the medi-claim policies of the complainant, in Oriental Insurance Company Ltd. from 2012 onwards, approached the complainant and requested to port the policy from Oriental Insurance Company to OPs and assured the complainant to provide cashless policy, by waiving the waiting period for the new customers of medi-claim policies of OPs no.1 and 2. OP no.3 showed the green pastures to the complainant regarding the benefits of purchasing the health policy from OPs no.1 and 2 by porting the same from Oriental Insurance Company. On the allurement of OP no.3, OPs no.1 and 2 issued Master Policy No.P/900000/01/2022/000039, certificate policy no.P/211114/01/ 2022/014448, commencing from 09.02.2022 to 08.02.2023. Complainant further renewed the said policy commencing from 09.02.2023 to 08.02.2024. On 03.06.2023, complainant suffered a chest pain, excessive sweating and uneasiness (Ghabrahat) in the morning and was taken to Aashirwad Advanced Heart, Lung and Critical Care Centre, Karnal, where Doctor present in the hospital gave emergent treatment and admitted the complainant in the hospital. The complainant was advised ECG, ECHO, various blood tests and doctor concerned diagnosed the case of Coronary Artery disease and advised for Angioplasty. The intimation in this regard was sent to OPs but OPs reject the case of cashless medi-claim on false and frivolous ground.  Complainant spent an amount of Rs.1,60,000/- on his treatment. After discharge from the hospital, complainant lodged the claim with the OPs and submitted all the required documents for reimbursement of the said amount but OPs did not pay the said amount and repudiated the claim of complainant, vide letter dated 14.07.2023 on the false and frivolous ground. Due to this act and conduct of OPs, complainant has suffered mental pain, agony and harassment as well as financial loss. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence complainant filed the present complaint seeking direction to the OPs to pay Rs.50,000/- for denial of cashless benefit against the policy in question, to pay Rs.1,00,000/- on account of repudiation of the claim, to pay Rs.2,00,000/- on account of medical expenses incurred by him on his treatment, to pay Rs.1,00,000/- as damages for mental pain, agony and harassment and Rs.33000/- as litigation expenses.

2.             On notice, OPs appeared and filed its written version raising preliminary objection with regard to maintainability; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the insured Virender Adalkha availed the Star Group Health Insurance Policy-Gold (for Bank Customers) covering Virender Adalkha (self), Neeru Adlakha (spouse) for the sum insured Rs.10,00,000/-, vide policy No.P/211114/01/2023/ 015540 for the period from 09.02.2023 to 08.02.2024. The insured has requested for cashless and submitted claim documents for the treatment of CAD, at Aashirwad Advanced Heart Lung and Critical Care Centre, Karnal on 03.06.2023. Cashless was denied because, as per submitted documents the Chronicity of the ailment cannot be ascertained at cashless level. So complainant was requested submit for reimbursement with all supporting documents. Thereafter, complainant has submitted the same in reimbursement. On scrutiny of claim documents, the following documents are necessary to process the claim, hence OPs requested the complainant, vide letter dated 28.06.2023 to furnish the following documents:-

.       Consultation papers, prescriptions and investigation reports for the submitted bills.

.       Kindly submit exact onset of cardiac symptoms and any past history of cardiac intervention/treatment done and documents, if any.

.       Submit first consultation papers/Cardiac markers/serial ECG/ECHO reports.

        Further, the insured has submitted the query reply documents. On scrutiny of claim documents, OPs had requested complainant to furnish the exact duration, first consultation paper and treatment taken details for heart disease. Despite requests, complainant has not provided mandatory required documents and details, in order to process the claim of the complainant, as per terms and conditions of the policy. In the absence of above documents/details, OPs’ company is not able to further process complainant’s claim. As per condition no.13 of the above policy, the insured person has to submit all the required documents and details called for by OP. Hence, being not maintainable, as per terms and conditions of the policy, the claim was repudiated vide letter dated 14.07.2023. It is further pleaded that present complaint is premature as till date complainant has not furnished/submitted requisite mandatory documents, in order to process the claim of the complainant as per terms and conditions of the policy. There is no deficiency in service and unfair trade practice on the part of the OPs. 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.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of claim form-A Ex.C1, claim form B Ex.C2, copy of previous policy report Ex.C3, copy of star health insurance policy Annexure-2 Ex.C4, copy of insurance policies of 2022-2023 and 2023-2024 Ex.C5 and Ex.C6, copy of denial of pre-authorization request Ex.C7, copy of status of intimation Ex.C8 and Ex.C9, copy of documents and treatment report Ex.C10, copy of application dated 03.07.2023 by complainant to OP regarding request for coverage-spontaneous heart attack Ex.C11, copy of repudiation letter dated 14.07.2023 Ex.C12, copy of medical bills Ex.C13 and Ex.C14, copy of clinical presentations and ECG reports Ex.C15 to Ex.C18, Ex.C20 to Ex.C23, copy of medical bill Ex.C19, copy of Drug Allergic test report Ex.C24, copy of consent for heart treatment Ex.C25, copy of admission and discharge check list Ex.C26, copy of Plan of care Ex.C27, copy of informed consent for cardiac procedures Ex.C28, copy of initial assessment sheet Ex.C29, copy of progress notes Ex.C30, copy of Nurse Medication Chart Ex.C31, copy of Nurse Daily Report Ex.C32, copy of Fluid Balance Vital Signs and Drug Chart Ex.C33, copy of investigation Flow chart Ex.C34, copy of to Prevent Phelebitis by IV cannula Ex.C35 and closed the evidence by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Sumit Kumar Sharma, Senior Manager Ex.RW1/A, copy of proposal form Ex.R1, copy of policy schedule Ex.R2, copy of terms and conditions of the insurance policy Ex.R3, copy of portability form Ex.R4, copy of request for cashless hospitalization Ex.R5, copy of query letter dated 03.06.2023 Ex.R6, copy of denial letter dated 04.06.2023 Ex.R7, copy of claim form Ex.R8, copy of discharge summary of Aashirwad Hospital Ex.R8, copy of final bill Ex.R9, copy of requirement of additional documents Ex.R10, copy of repudiation letter dated 14.07.2023 Ex.R11 and closed the evidence on 10.07.2024 by suffering separate statement.

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

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant purchased a Health Insurance Policy from the OPs under the portability scheme. Prior to purchase policy from OPs, the complainant was having health policy from the year 2012 to 2022 from Oriental Insurance Company Ltd. and thereafter ported the said policy to the OPs company. The sum insured under the policy is Rs.10,00,000/-. During the subsistence of the insurance policy, complainant had taken the treatment from Aashirwad Advanced Heart, Lung and Critical Care Centre, Karnal. The pre-authorization claim of complainant was denied by the OPs. Complainant paid Rs.1,60,000/- to said hospital from his own pocket and requested the OPs for reimbursement of said amount, but OPs did not pay the said amount and repudiated the claim the of complainant on the false and frivolous ground. He further argued that complainant has not taken any treatment prior to said treatment and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that OPs issued a health insurance policy for the sum insured of Rs.10,00,000/- for covering complainant (self) and his spouse. Complainant did not provide the mandatory required documents and details, in order to process the claim, as per terms and conditions of the policy. Thus, the claim of the complainant was rightly repudiated by the OPs and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, complainant availed Health Insurance Policy from the OPs under portability scheme. It is also admitted that medical policy is without any break since 2012. It is also admitted that during the subsistence of the insurance policy the complainant has taken treatment from Aashirwad Advanced Heart, Lung and Critical Care Centre, Karnal and spent an amount of Rs.1,60,000/-

11.           The claim of the complainant has been repudiated by the OPs, vide letters Ex.C12/Ex.R11 dated 14.07.2023 on the ground, which are reproduced as under:-

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

In order to process the claim, we had requested you to furnish the exact duration, first consultation paper and treatment taken details for heart disease. We note that you have not furnished the required documents and details. In the absence of the above documents/details, we are not able to further process your claim.

As per condition no.13 of the above policy, the insured person has to submit all the required documents and details called for by us.

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 OPs on the above-mentioned ground. When the complainant has specifically stated that he has not taken any treatment prior to the present treatment, then question for submitting the alleged demanding documents does not arise at all. Further, there is nothing on file to prove that complainant was having any disease prior to inception of the insurance policy from Oriental Insurance Company or prior to portability of the policy.

13.           Complainant was having health policy from the year 2012 to 2022 from the Oriental Insurance Company and thereafter got ported the policy with the OPs company. The said fact has been admitted by the OPs. The portability defined by the IRDA vide its circular Reference No. IRDA/HLT/MISC/CIR/209/ 09/2011) is as under:-

Portability:  Portability means the right accorded to an individual health insurance policyholder (including family cover) to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policyholder chooses to switch from one insurer to another insurer or from one plan to another plan of the same insurer, provided the previous policy has been maintained without any break.                 

14.           There is no break in the medical insurance policy issued by the Oriental Insurance Company, prior to portal of the same in the OPs company. The OPs have ported the insurance policy and issued the fresh policy Ex.C5 dated 09.02.2022. In the said policy OPs have itself covered the pre-existing disease and waived off the waiting period. Furthermore, there is nothing on the file that complainant has taken treatment prior to purchase of the policy from the OPs. In this regard, we fortified with the observation of Hon’ble National Commission in case titled as Mrs. Rubi Chandra Dutta Versus M/s United India Insurance Co. Ltd., (2011) 3 scale 654, decided on 16.12.2016 wherein it is held that “It was 2 years before switching over the policy with the OPs. Therefore, once portability scheme was accepted by OPs then they had no right to decline the claim upto the amount of sum assured of previous insurance policy in case it was within the terms and conditions of the policy. The policy with New India Assurance Company was continuing since 2001 and counsel for OPs was unable to pin point how the claim to the extent of Rs.1,30,000/- allowed by the District Forum was not payable under the policy. Clause 1 of the policy speaks that under portability right accorded to an individual health insurance policy holder to transfer the credit gained by the insured for pre-existing conditions and time bound exclusions if the policy holder chooses to switch from the one insurer to another insurer or from one plan to another plan. Under that scheme whatever has been gained by the insured under the policy insured by the previous insured will be gained by the insured under the portability scheme. Therefore, we do not agree with the plea raised by the OPs. Even otherwise, the policy was continuing one since 2001.

15.             Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, 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”.

16.           Keeping in view that the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, the act of the OPs while repudiating the claim of the complainant amounts to deficiency in services, which is otherwise proved genuine one.

17.           The complainant has spent an amount of Rs.1,60,000/-  on his treatment and in this regard he submits the medical bills to the OPs and the said facts neither denied nor rebutted by the OPs.  Hence, the complainant is entitled for the amount of Rs.1,60,000/- alongwith interest, compensation for mental pain, agony harassment and litigation expenses etc.

18.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.1,60,000/- (Rs. one lakh sixty thousand only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 14.07.2023 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. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Dated: 12.09.2024   

                                                       

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

(Neeru Agarwal)         (Sarvjeet Kaur)

                   Member                          Member