Complainant Dharamveer Singh through the present complaint filed under Section 12 of the Consumer Protection Act, 1986 (for short, ‘the Act’) has sought issuance of necessary directions to the titled opposite parties to pay Rs.7,50,000/- alongwith interest to him which he has spent on his treatment alongwith mental harassment of Rs.5,00,000/- and litigation expenses of Rs.4,00,000/- alongwith interest @ 12% PA from the date of treatment till  realization of the claim and any other relief which deems appropriate, in the interest of justice.  

2.       The case of the complainant in brief is that he purchased a family health optima Insurance Plan in the year 2013 bearing policy no.P/21/212/01/2014/000223 for which he paid a sum of Rs.8778/- as premium to the opposite parties for the sum insured of Rs.3,00,000/- which was valid for one year from 30.10.2013 to 30.10.2014 renewal on yearly basis. In the year 2014 the policy was again renewed by the opposite parties after receiving the premium of Rs.6,775/- alongwith service tax of Rs.837/- total comes to Rs.7612/- and issued policy no.P/21/212/01/2015 to him which was valid from 30.10.2014 to 30.10.2015 and the limit of coverage was Rs.3,75,000/- which included bonus of Rs.75,000/- and basic floater been assured of Rs.3,00,000/-. He has further pleaded that on 30.10.2015 the family health optima insurance plan was again renewed for a period of one year from 30.10.2015 to 29.10.2016 vide policy no.P/21/212/01/2016/000571 which included the limit of coverage of Rs.3,00,000/- and recharge benefit of Rs.75,000/- total amounting to Rs.3,75,000/-. He has next pleaded that in the year 2015 he suffered headache with decreased in vision in both the eyes for which he consulted KD Hospital, Amritsar where thorough investigation including MRI Scan were done by the consultant doctor on 19.6.2015. The opposite parties were informed immediately regarding his admission and the treatment he was undergoing in the hospital on the panel of star health insurance. The TPA of opposite parties visited the hospital and took into possession all the original bills and issued claim no.CLI/2016/211212/0076306. Due to non availability of facilities at KD Hospital he was referred to Max Health Care Super Specialty Hospital, New Delhi where he remained admitted from 29.8.2015 to 8.9.2015 and was operated for right temporoparietal craniotomy and tumor decompression. The opposite parties were informed immediately regarding the admission and treatment undergone by him. The total amount spent on the operation Max Health Care Super Specialty Hospital, New Delhi is Rs.2,88,054/-. The TPA of the opposite parties visited hospital and took into possession all his original bills amounting to Rs.3,75,000 + 3,75,000 total Rs.7,50,000/- but till date the opposite parties have withheld his genuine claim and have not reimbursed the amount spent on the treatment which was supposed to be cashless as per the policy of family Health Optima Insurance Plan. Thus there is deficiency in service on the part of the opposite parties. Hence this complaint.

3.       Upon notice, the opposite parties insurers appeared and filed its written reply through the counsel taking the preliminary objections  that the complaint is not maintainable; the complainant took family Health Optima-New Covering GURPAL SINGH- SELF, RUPINDER KAUR – SPOUSE, NAVDEEP KAUR & DHARMVEER SINGH-DEPENDANT CHILDREN for the sum insured of Rs.3,00,000/- vide policy on 30.10.2013 for a period from 30.10.2013 to 29.10.2014 under policy no.P/211212/01/2014/000223 issued by B.O. Pathankot. The policy of the insured renewed on 30.10.2014 for a period from 30.10.2014 to 29.10.2015 under policy no.P/211212/01/2015/000369 issued by B.O. Pathankot. The policy of the insured renewed on 30.10.2015 for a period from 30.10.2015 to 29.10.2016 under policy no.P/211212/01/2016/000571 issued by B.O. Pathankot subject to terms, conditions, exclusions and definitions. On merits, it was admitted that at the time of issuance of policy family Health Optima-New Covering GURPAL SINGH- SELF, RUPINDER KAUR – SPOUSE, NAVDEEP KAUR & DHARMVEER SINGH-DEPENDANT CHILDREN for the sum insured of Rs.3,00,000/- vide policy on 30.10.2013 for a period from 30.10.2013 to 29.10.2014 under policy no.P/211212/01/2014/000223 issued by B.O. Pathankot. The policy of the insured renewed on 30.10.2014 for a period from 30.10.2014 to 29.10.2015 under policy no.P/211212/01/2015/000369 issued by B.O. Pathankot. The policy of the insured renewed on 30.10.2015 for a period from 30.10.2015 to 29.10.2016 under policy no.P/211212/01/2016/000571 issued by B.O. Pathankot. The prospectus of the terms and conditions of POLICY FAMILY HEALTH OPTIMA-NEW was served to the complainant and the terms and conditions of the above mentioned policy were explained to insured complainant by the opposite party. It was submitted that in second year of the policy the complainant lodged claim no.76306 before opposite party. As per abovesaid claim the insured was admitted in K.D.Hospital, Amritsar on 19.06.2015 for the treatment of GLIOMA. On receipt of the pre authorization request from the treating hospital, the opposite party has called for the following documents i.e. Exact duration of the symptoms with all past treatment details since symptomatic, details of the risk factors associated in this case with all previous treatment details, first diagnostic paper for the diagnosis of tumor, initial admission sheet, clear line of management. All past treatment details with discharge summaries, but the same not submitted by the complainant and the treating hospital to the opposite parties. Again the complainant filed claim no.145179 before opposite party. As per abovesaid claim the complainant was admitted in K.D.Hospital, Amritsar on 26.08.2015 for the treatment of seizure disorder. On receipt of the pre authorization request from the treating hospital, it is observed that the insured is known case of Glioblastoma. But in order to process the claim the opposite parties called for the following documents from complainant vide letter dated 28.08.2015 but the complainant and the treating hospital failed to submit the documents i.e. Exact duration of the symptoms with all past treatment details since symptomatic, First diagnostic/First consultation paper for the diagnosis of tumor, Initial admission sheet, Clear readable previous discharge summary. Again the complainant filed claim no.148503 before opposite party. As per abovesaid claim the complainant was admitted in Max Super Specialty Hospital-Shalimar Bagh on 29.08.2015 for the treatment of brain tumor. On receipt of the pre authorization request form the treating hospital, it is observed that patient is under treatment since June 2014. Then the opposite party have called for the following documents in order to process the claim vide letter dated 1.9.2015. The complainant and the treating hospital failed to submit all past treatment record since symptomatic, past investigation report, all scan report since June 2014 & subsequently done. But the same was not submitted by the complainant and treating hospital. However the opposite parties have sent the claim form to the insured for reimbursement of medical expenses. The opposite party have perused the claim records relating to the above insured-patient seeing reimbursement of hospitalization expenses for treatment of right temporal SOL. All other averments made in the complaint has been vehemently denied and lastly prayed that the complaint may be dismissed with costs.

4.         Complainant tendered into evidence his own affidavit Ex.C1 and of Sh.Gurpal Singh Ex.C2, alongwith other documents Ex.C3 to Ex.C61 and closed the evidence. 

5.       Ld.counsel for the opposite parties tendered into evidence affidavit of Sh.Rajnish Kohli, Assistant Vice President, Claims Ex.OP-1 alongwith other documents Ex.OP2 to Ex.OP-15 and closed the evidence.

6.        We find that the OP insurers have  repudiated (vide Ex.OP14) the complainant’s insurance claim Ex.C15 # 0148503 (out of the 3 nos. of total ‘claims’) for the reason that the insured patient (as per the discharge summary of KD Hospital for admission on 19.06.2015) had a history of ‘glioblastoma’ for the past ‘2’ years prior to ‘inception’ of the medical insurance policy i.e., on 30.10.2013; and the same was not disclosed in the related proposal form amounting to misrepresentation/non-disclosure of material facts. The OP insurers have based their above repudiation decision solely on the ‘discharge-card’ summary Ex.C16/OP9 duly mentioning the patient’s DOA (date of admission) as: 19.06.2015 & date of LAMA (left against medical advice) as: 23.06.2015; however, inadvertently mentioning therein 2 nos of MRI Brain Reports one of 26.08.2014 & other of 19.06.2014 whereas the correct dates are: 26.08.2015 & 19.06.2015 (Ex.17 & Ex.OP20). Further, there has been no documentary evidence available and/or produced on the records of the present proceedings proving the presence/knowledge/symptoms of the ‘ailment’ (prior to the date of proposal i.e., 30.10.2013) for the medical treatment of which the present 3 nos of claims stood preferred.

7.       Thus, the alleged misrepresentation/concealment/non-disclosure of material facts etc do not stand proved. In such like repudiations the o. n. p. (onus of proof) always lay heavily upon the insurers but here they have miserably failed to legally discharge the same successfully. We are strengthened in our above proposition by virtue of the valuable comments as made out by the honorable Punjab State Commission in the FA # 537 of 2008 titled: LIC of India vs. Priya Sharma & ors., as: “…. in this case, there is no evidence on record to prove that the deceased life assured was suffering from any pre-existing disease at the time of purchasing the policy. …. There is no evidence to prove that the deceased was ever admitted or took any treatment from any hospital or the doctor regarding the alleged pre-existing disease. …”.  The honorable National Consumer Commission has further elaborated the legal proposition in RP # 218 of 2008 titled United India Insurance Co. Ltd., vs. Anumolu Rama Krishan as: “7… Even if Respondent was suffering from these diseases which admittedly do not occur overnight, it is both possible and plausible that he was unaware of it since these can be ‘silent diseases’ and a person suffering from them may not even be aware until the condition aggravates and overt symptoms appear….”.   Even, the OP insurer’s refusal to ‘pre-authorizations’ requests by the treating hospitals are not justified and the subsequent demands of ‘non-descript’ and ‘non-exist’ imaginary documents are all the more un-sustainable. We also find that the other two claims put forth by the complainant have been kept illogically deferred awaiting ‘settlement’ for collateral but arbitrary reasons. Even, the expert professional opinion pertaining to pre-existing disease cannot be taken as an evidence of its ‘non-disclosure/ suppression’ by the insured since he may not be ‘himself’ aware of  the disease present in its latent hibernating state.

8.       In the light of the all above, we are of the considered opinion that the OP insurers have blatantly bruised the consumer rights of the present complainant by employing ‘unfair trade practice’ amounting to ‘deficiency in service’ (on their part) and that lines them up for an adverse statutory award under the applicable Consumer Protection Act’ 1986.

9.       We, therefore, dispose off the present complaint and thus ORDER the OP insurers to settle all 3 nos of ‘insurance claims’ as per the governing ‘terms’ of the applicable Health Insurance Policy but strictly in accordance with the IRDA guidelines on ‘settlement of claims’ to the present complainant besides to pay him Rs.10,000/- as cost and compensation within 30 days of receipt of the copy of the present orders.

10.     Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record.

                                                                         (Naveen Puri)

                                                                                President.                                                                                                             

ANNOUNCED:                                                    (Jagdeep Kaur)

June 07, 2016                                                               Member.

*MK*