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 the complainant has an account in Punjab National Bank, branch Dhudike, District Moga since long. The bank officials of the said bank introduced an insurance policy “Star Group Health Insurance Policy-Gold” for Bank customers. On the allurement of officials of the bank, the complainant availed policy bearing no.P/211222/01/2023/0076 for the period 28.10.2022 to 27.10.2023 from the Opposite Parties. Under the said policy family members of complainant were also insured. In the week of February, 2023 the complainant gone to Rae Bareli (U.P) for his routine work and on 03.03.2023, the complainant suffered from CVA-Left Basal Ganglia ICH/HTN/Right Hemiparesis and he was admitted in Simhas Hospital, 551 Civil Lines, Rae Bareli uptil 11.03.2023 for his treatment. Then he was admitted in Arora Neuro Centre, Ludhiana for the period 12.03.2023 to 15.03.2023. Alleged that the complainant spent Rs.1,20,000/- on his treatment. Alleged that the complainant filed the claim with the Opposite Parties, vide claim intimation no.CIG/2023/211222/1642447. The complainant also deposited all the required documents for settlement of claim. However, on 11.05.2023 the Opposite Parties refused the claim of the complainant. Alleged that the claim of the complainant has wrongly been rejected by the Opposite Parties without considering the actual position of the complainant. Alleged further that besides the amount of Rs.120,000/-, the complainant spent Rs.30,000/-. The complainant also issued registered AD notice to the Opposite Parties on 03.10.2023, 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 Rs.1,20,000/- in favour of the complainant and Rs.30,000/- as misc. expenses spent by the complainant alongwith interest @ 2 % per month on the above mentioned amount till realization.

b)      To pay an amount of Rs.2,50,000/- as compensation harassment and for deficiency in service.  

c)       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 not maintainable, as the claim of the complainant was denied by the Opposite Parties as per terms and conditions. Averred that the present complaint pertains to insurance claim under “Star Group Health Insurance Policy-Gold” for Bank Customer bearing no.P/211222/01/2023/007863 valid from 28.10.2022 to 27.10.2023 covering the complainant self and his spouse Priyanka Yadav and dependent Child Sehajpreet Yadav for a sum of Rs.3,00,000/- for the first time. 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 complainant had accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. Averred further that the insured has requested for cashless claim and submitted the documents for hospitalization on 03.03.2023 in Simhans Hospital towards the treatment of CVA with Haemorraghic Stroke and the same was rejected, as further evaluation was required to ascertain the admissibility of the claim. Thus, the insured was advised to approach seeking reimbursement of expenses relating to the said admission/claim. Accordingly, the insured had submitted the same in reimbursement and on scrutiny of claim documents, it was observed from the submitted documents that the insured patient had intracranial bleed which was a direct effect of long standing hypertension. Hence the above diagnosis was of a pre-existing disease and the said admission and treatment of insured patient was for the pre-existing disease. Hence, the claim was rejected and the same was informed to the insured vide letter dated 11.05.2023.

          Thereafter, the complainant requested for cashless claim for the hospitalization dated 12.03.2023 in Arora Neuro Centre Pvt. Ltd., Ludhiana towards the treatment of CVA, as further evaluation was required to ascertain the admissibility of the claim. Thus, the insured was advised to approach seeking reimbursement of expenses relating to the said admission. Accordingly, the insured had submitted the same in reimbursement and on scrutiny of claim documents, it was observed from the submitted documents that the insured patient had intracranial bleed which is a direct effect of long standing hypertension. Based on the available records, medical team of the Opposite Parties was of the opinion that the insured patient has the above chronic longstanding disease prior to inception of medical insurance policy. Hence the above diagnosis is pre-existing disease and the said admission and treatment of insured patient was for the pre-existing disease. Hence, the claim was rejected and the same was informed to the insured vide letter dated 11.05.2023. Averred further that as per Exclusion No.1-Pre-existing disease- Code Excl-01 of the policy issued to insured, the company is liable to make payment of any pre-existing disease only after the expiry of 36 months of continuous coverage after the date of inception of the first policy with insurer.

The instant complaint is neither maintainable in law nor on facts; no deficient service has been rendered by the answering Opposite Parties as alleged by the complainant. 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 his case, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C56.

4.       On the other hand, Opposite Parties has placed on record affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. as Ex.OP1,2/A alongwith copies of documents Ex.OP1,2/1 to Ex.OP1, 2/19.

5.         We have heard the ld. counsel for both the parties and also gone through the record.

6.       The complainant availed policy bearing no.P/211222/01/2023/0076 for the period 28.10.2022 to 27.10.2023 from the Opposite Parties covering self, his wife and one dependent child is not disputed. It is also not disputed that in the month of February, 2023 the complainant gone to Rae Bareli (U.P), where he suffered some health problem and got admitted in Simhas Hospital, Bareli for the period 03.03.2023 to 11.03.2023, where he was diagnosed with ‘intracranial bleed’. Thereafter, he again got admitted in Arora Neuro Centre, Ludhiana with complaints of “Sudden onset of weakness of right side F/B, Aphasia, unable to bear weight over right side of body and was diagnosed with “CVA- Left Basal Ganglia ICH/HTN/Right Hemiparesis” and remained admitted in the hospital for the period 12.03.2023 to 15.03.2023. It is proved on record that during the first hospitalization, the complainant requested the Opposite Parties for cashless treatment, but the request of the complainant was denied and when the complainant lodged the claim with the Opposite Parties alongwith all the documents, the Opposite Parties repudiated the claim of the complainant on ground of pre-existing disease. It is also proved on record that during the second hospitalization, the complainant also requested the Opposite Parties for cashless treatment and the request of the complainant was denied and when the complainant lodged the claim alongwith documents, the Opposite Parties again repudiated the claim of the complainant on ground of pre existing disease.

7.       The perusal of the record reveals that Opposite Parties repudiated both the claims of the complainant, vide letter dated 11.05.2023 on the same ground. As the contents of both the repudiation letters are same, so we reproduced the contents of only one letter, which are as under:-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of CVA (cerebrovascular accident) with hemorrhagic stroke.

It is observed from the submitted documents that the insured patient has intracranial bleed is a direct effect of long standing hypertension. Based on the available record, our medical team is of the opinion that the insured patient has the above chronic longstanding disease prior to inception of medical insurance policy. Hence the above diagnosis is pre-existing disease. The present admission and treatment of the insured patient is for the pre existing disease.

As per Exclusion No.1-Pre-existing disease- Code Excl-01 of the policy issued to you, the company is liable to make payment for any pre-existing disease only after the expiry of 36 months of continuous coverage after the date of inception of the first policy with insurer.

We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim.”  

8.       We are of the concerted view that the repudiation of both the claims of the complainant on aforesaid ground is not genuine, as there is no document on record which clearly shows that the complainant was suffering from CVA (cerebrovascular accident) with hemorrhagic stroke or the complainant was suffering from the same prior to inception of insurance policy or was suffering from hypertension as alleged by the Opposite Parties. Even the discharge summaries of Simhans Hospital as well as Arora Neuro Centre (Ex.C5 & Ex.C51) nowhere reveals that complainant has any history of the ailment he suffered. Further discharge summary of Arora Neuro Centre (Ex.C51) reveals that complainant got admitted in the hospital with complaints of “Sudden onset of weakness of right side F/B, Aphasia, unable to bear weight over right side of body and was diagnosed with “CVA- Left Basal Ganglia ICH/HTN/Right Hemiparesis” and was treated for the same. So, it is apparent from the discharge summary (Ex.C51) that insured has no past history of the alleged disease and has recently been diagnosed for the same, so in these circumstances, the repudiation of the claim by the Opposite Parties is not genuine. Further no medical expert opinion or report has been made part of the record that how the Opposite Parties reached the conclusion that complainant’s claim fall under the pre-existing clause or any complication of any pre existing disease and further no expert opinion has been placed on record showing that ‘intracranial bleed’ is a effect of long standing hypertension as alleged by the Opposite Parties. In these circumstances, the repudiation of the claims of the complainant by the Opposite Parties is held as unjustified and illegal.

11.     From the above discussion, we allow the complaint of the complainant in part and direct the Opposite Parties to pay the claim for medical expenses incurred by complainant for his hospitalization at Simhans Hospital, Rae Bareli as well as Arora Neuro Centre, Ludhiana (including pre and post hospitalization charges), subject to submission of photocopies of medical bills by the complainant. Opposite Parties are also directed to pay compository costs of Rs.15,000/-(Rupees Fifteen Thousand only) as compensation and litigation expenses to the complainant. The compliance of this order be made by the Opposite Parties next within 30 days from the date of receipt of copies of medical bills submitted by the complainant, failing which, the Opposite Parties are further burdened with additional cost of Rs.20,000/-(Rupees Twenty Thousand only) to be paid to the complainants for non compliance of the order. 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