Order by:
Smt.Priti Malhotra, President
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that complainant purchased/obtained the policy from Opposite Parties in the year 2022, which is in continuation till now. Alleged that on 22.01.2023, the complainant suffered pain in chest and went to Sukhmani Hospital & Heart Care Centre, Faridkot, where the doctor conducted various blood tests of the complainant. On the same day, the complainant went to Guru Nanak Cardiac Care, Faridkot for his treatment. On 25.01.2023, the complainant again went to Dr.Gagandeep Singh, who advised the complainant to higher centre of CAG. On the reference of Dr.Gagandeep Singh, complainant visited Dr.Parminder Singh Sandhu, who gave advise to the complainant for ECG, Echo and other blood tests. Accordingly, the complainant got the said tests conducted and doctor gave some medicines to complainant. On 20.05.2023, the complainant again suffered chest pain, then he visited Delhi Heart Institute & Multispeciality Hospital, Moga and on the same day Dr.Saurab Bansal obtained various blood tests and other tests i.e. Coronary Angiogram of the complainant and complainant remained admitted in the said hospital. On 27.05.2023, the complainant again suffered Heart Problem and got admitted in Fortis Hospital, Ludhiana, where bypass surgery of the complainant was done and he got discharged from the hospital on 03.06.2023 and the said hospital received Rs.3,10,674/- from the complainant. After discharge of the complainant from the hospital, entire bills and hospital record of the hospitals were submitted with Opposite Parties, but on 17.10.2023, complainant received a notice from the Opposite Parties, vide which they required the additional documents. Then the complainant went to Fortis Hospital, Ludhiana for getting the required documents demanded by Opposite Parties, then Dr.Nikhil Bansal gave a letter on the letter head to the complainant and the complainant deposited the same with Opposite Parties. However, the Opposite Parties repudiated the claim of the complainant on 04.03.2024. Alleged that the complainant spent an amount of Rs.4,07,379/- for the treatment, lab charges, ultra sound charges and medicines etc. The Opposite Parties were asked many times to pay the said amount, but to no effect. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to pay an amount of Rs.4,07,379/- regarding the policy bearing no.P/211222/01/2023/006300.
b) To pay a sum of Rs.1,00,000/- as compensation on account of mental tension, and harassment.
c) To pay Rs.50,000/- as litigation expenses.
d) And any other relief which this Commission may deem fit and proper be granted to the complainant in the interest of justice and equity.
2. Opposite Parties appeared through counsel and contested the complaint by filing written reply taking preliminary objections therein inter alia that the present complaint is filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Parties as per policy terms and conditions. Averred that the present complaint pertains to insurance claim under ‘Family Health Optima Insurance Plan’ bearing No.P/211222/01/2023/006300 valid from 21.09.2022 to 20.09.2023 covering the complainant self, his spouse Sarabjit Kaur for a sum of Rs 10,00,000/-. However it is submitted that the aforesaid insurance policy was issued to the insured by the answering Opposite Party subject to the terms and conditions of the insurance policy. The said terms and conditions were handed over and supplied to the insured at the time of the contract. Averred further that the insured availed the said policy through online proposal form and in the online proposal form the insured verify the fact by confirming the OTP sent on his mobile number and hence the insured himself authenticated the details by entering the OTP at 21.09.2022 received by SMS. Averred further that the insured has preferred the clam in 1st year of the policy. The first claim of the complainant was registered vide claim no.CIR/2024/211222/0229603 and the insured had requested for cashless only and submitted the documents for hospitalization on 20.05.2023 in Delhi Heart Institute Multispeciality Hospital, Moga towards the treatment of CAD. Moreover, as per the record submitted, consultation paper dated 20.05.2023 of Dr Sourav Kansal shows history of CAD on Ayurvedic medicine. But Ayurvedic consultation papers not provided. It was observed from the hospital records that the insured patient has the above disease which is a longstanding ailment. Thus Opposite Parties were not able to ascertain the duration of the disease based on the documents/details submitted by insured. And it required further evaluation. Hence, the claim was rejected and the same was informed to the insured vide letter dated 21.05.2023. Even after reminders, the complainant has not furnished the above sought documents. Therefore the replying Opposite Parties were forced to reject the claim for non-submission of documents in the absence of which the claim could not be processed. Further insured had not utilized the cashless facility and has not approached for reimbursement.
Thereafter, the complainant lodged 2nd claim, which was registered vide claim no.CIR/2024/211222/0258263. The insured had requested for cashless and hospitalization on 27.05.2023 in Fortis Hospital towards the treatment of CAD DVD, but the cashless request was denied as Opposite Parties were not able to ascertain the duration of the disease based on the documents/details submitted by insured thus it required further evaluation. Subsequently insured had submitted the claim for reimbursement. On scrutiny of claim documents, it was observed that CAG Angiography shows DVD (Double vessel disease), which reveals that this is a longstanding ailment but exact duration not provided.
As per the report of the verification officer of the Opposite Parties, it was observed that as per patient, he had ghabrahat since last 1 week and Went to Moga hospital, where they did angiography and tried to put up stent but it was unsuccessful. Instead of got reduced. POBA to Lad done on 20.05.2023. Then he came to Fortis for further management. Dvd came out in angiography Patient takes aspirin 3-4 times in winters on and off as per advise of his lab friends for thick blood since 4-5 yrs. he consumes opium 1-2 times in 1-2 months for thick blood. He takes 100ml of alcohol till 4-5month. The findings of ECG and CAG report confirm chronic, longstanding heart disease. Based on these findings and available medical records, our medical team was of the opinion that the insured patient has the above disease prior to inception of the medical insurance policy. At the time of inception of policy which is from 21.09.2022 to 20.09.2023, insured have not disclosed the above mentioned medical history/health details of the insured- person in the proposal form which amounts to misrepresentation/non-disclosure of material facts. As per Condition No.1, of the policy issued to insured, if there is any misrepresentation/non disclosure of material facts whether by the insured person or any other person acting on his behalf, the Company is not liable to make any payment in respect of any claim. Hence, the claim was rejected and the same was informed to the insured vide letter dated 04.03.2024.
Averred further that it will be relevant to place on record that the insured has a duty to disclose all material facts in proposal while buying an insurance policy. The complainant availed policy through online and has deliberately answered "None" to the query raised in the online proposal form regarding Health history of insured patient, which is reproduced as under:
"Health History:-
Do you have any health problems (if any) in the below field.
NONE"
Have you or any member of your family proposed to be insured, suffered or are suffering from any disease/ailment/adverse medical condition of any kind especially Heart/Stroke/Cancer/Renal disorder/Alzheimer's disease/Parkinsons's disease - "No".
It is further averred that from the above findings, it is clearly evident that the insured failed to disclose the same in the proposal form, which amounts to non disclosure of material facts thus violated the Cardinal Principle of the Insurance and made the Contract of Insurance voidable and unenforceable. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. In order to prove the case, complainant has placed on record his affidavit as Ex.C1 alongwith copies of documents Ex.C2 to Ex.C33.
4. On the other hand, Opposite Parties have placed on record affidavit of Sh.Sumit Kumar Sharma, Authorized Signatory, Star Health & Allied Insurance Co. Ltd. as Ex.OP1,2/A and copies of documents Ex.OP1,2/1 to Ex.OP1,2/22.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. It is admitted and proved on record that the complainant availed health insurance policy namely ‘Family Health Optima Insurance Plan’ bearing no.P/211222/01/2023/006300 for the period 21.09.2022 to 20.09.2023 for self, his wife for a sum insured of Rs.5,00,000/-. It is also proved on record that during the policy coverage, complainant suffered chest pain and for the treatment of same, he visited various hospitals and got conducted different tests, but he did not get any relief. Thereafter, the complainant got admitted in Delhi Heart Institute and Multispeciality Hospital, Moga, where he was diagnosed as ‘CAD/AWMI, CAG Double Vessel Disease, POBA to LAD EF45%’ and he remained admitted in the said hospital for the period 20.05.2023 to 21.05.2023. During the hospitalization, the complainant requested the Opposite Parties for cashless treatment, but the cashless request of the complainant was rejected, vide letter dated 21.05.2023. Thereafter the complainant lodged claim for medical reimbursement. Then the Opposite Parties issued different letters on different dates requiring certain documents from the complainant and thereafter vide letter dated 13.07.2023, the Opposite Parties rejected the claim of the complainant for want of documents.
It is not disputed that the complainant again suffered with the same problem and again got admitted in Fortis Hospital, Ludhiana on 27.05.2023 and after treatment got discharged from the hospital on 03.06.2023. During the hospitalization, the complainant requested the Opposite Parties for cashless treatment, but the request of the complainant was rejected vide letter dated 29.05.2023 and thereafter claim of the complainant was also denied/not admitted by the Opposite Parties vide letter dated 04.03.2024.
7. The perusal of the record further reveals that the first claim lodged by the complainant for the reimbursement of the medical expenses incurred by him at Delhi Heart Institute and Multispeciality Hospital was rejected by the Opposite Parties for want of following documents:-
a) Discharge summary
b) Investigation reports with X-ray films, Scan report etc.
c) Main Hospital bills, Payment receipts with break-up
d) Prescriptions, Medical bills, Investigation bills, Receipts etc.
e) Earlier treatments records, if any.
However, the demand of aforesaid documents by Opposite Party is not genuine, as all the available documents have been placed on record by the complainant and there is no reason for the complainant for not submitting the said documents with Opposite Parties. Moreover, if the complainant allegedly failed to supply the said documents to Opposite Parties, the Opposite Parties were at liberty to enquire from the hospital concerned to elucidate the genuineness of the claim raised.
8. The second claim of the complainant regarding the expenditure incurred by the complainant at Fortis Hospital, Ludhiana was also denied/not admitted by the Opposite Parties, vide letter dated 04.03.2024. The contents of said letter are reproduced as under:-
“After a comprehensive assessment by our medical team, we’ve observed that we’re unable to admit the claim because of the below-mentioned reason(s):
Policy Exclusion Clause No./Condition(s), if any: NA
Detailed Remarks:
It is observed that the findings of ECG and CAG report confirm chronic, longstanding heart disease. Based on this finding and available medical records, our medical team is of the opinion that the insured patient has the above disease prior to inception of medical insurance policy.
At the time of inception of policy which is from 21.09.2022 to 20.09.2023, you have not disclosed the above mentioned medical history /health details of the insured-person in the proposal form which amounts to misrepresentation/non-disclosure of material facts.
As per Condition No.1 of the policy issued to you, if there is misrepresentation/non disclosure of material facts whether by the insured person or any other person acting on his behalf, the Company is not liable to make any payment in respect of any claim.
In our considered opinion, the denial/non admission of the claim of the complainant on the aforesaid ground is also not genuine, as there is no document on record revealing that the complainant is suffering from the disease in question prior to the inception of the policy in question or the same is longstanding disease. Moreover in the latest Discharge Summary of the hospital concerned i.e. Fortis Hospital, Ludhiana (Ex.C29) nowhere it is mentioned that the disease suffered by the complainant is longstanding disease. Furthermore, the certificate duly issued by the doctor concerned (Ex.C32) i.e. Dr.Nikhil Bansal of Fortis Hospital, Ludhiana is evident of the fact that the complainant was suffering from the disease in question since, 2023 and has no prior history of the same, whereas the policy in question has been obtained in the year, 2022. The contents of aforementioned certificate are reproduced as under:-
“Patient Gurcharan Singh, 60/M presented in cardiology with history of attempted PCI (1 week) back at Delhi Heart Institute, Moga on 20.05.2023. Patient has a history of Coronory artery disease since, 2023. There is no history of similar complaints in past. He was diagnosed as Double Vessel Disease or Angiography done on 27.05.2023. He was operated by CAB4x2 on 30.05.2023 and discharged on 03.06.2023.”
The contents of the Certificate mentioned above are sufficient enough to hold that the denial of the claim of the complainant on the ground of alleged pre-existing disease is wrong and not genuine. Also the rejection of the 1st claim on the ground of non submission of documents is wrong and illegal. From the discussion above, we are of the concerted view that Opposite Party illegally and wrongly repudiated the genuine claims of the complainant.
9. Vide instant complaint, the complainant has claimed the amount of Rs.4,07,379/-, which is duly proved on record vide Ex.C6, Ex.C12, Ex.C18, Ex.C22, Ex.C23 and Ex.C30 (which includes pre and post hospitalization charges). Hence we allow the said amount.
10. In view of the discussion above, the instant complaint is allowed in part and Opposite Parties are directed to make the payment of Rs.4,07,379/- (Rupees Four Lakh Seven Thousand Three Hundred Seventy Nine only) (which includes pre and post hospitalization charges) to the complainant. Opposite Parties are also directed to pay compository costs of Rs.10,000/-(Rupees Ten Thousand only) as compensation and litigation expenses to complainant. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Parties within 30 days from the date of receipt of copy of this order, failing which, the Opposite Parties are liable to pay interest @ 9% per annum on the awarded amount from the date of filing of this complaint till its realization. Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room.
Announced on Open Commission
