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 availed a medical insurance policy from Opposite Parties in the year, 2019 and since then the complainant has been renewing the said policy from the Opposite Parties. The complainant again got renewed the said policy for the period from 24.08.2022 to 23.08.2023. On 26th July, 2023, the complainant suffered from pain in abdomen and got admitted in Sidhu Hospital at Moga. Thereafter, the complainant was referred to DMC & Hospital, Ludhiana on 28.07.2023 and got discharged from the hospital on 03.08.2023. Alleged that the complainant spent Rs.1,68,532.89 NP on her treatment. The complainant applied to the Opposite Parties for cashless claim, but the Opposite Parties vide letter dated 29.07.2023 denied the same. Thereafter, the Opposite Parties again denied the request of the complainant for approval of cashless treatment vide letter dated 30.07.2023 with the reason that the current claim is a complication of previous surgery which is a disease/condition incorporated as pre-existing disease in the policy schedule at the time of the inception of the first medical insurance policy. Alleged that the DMC Hospital has issued a Certificate dated 30.07.2023 that the complainant has no previous history of Hernia and the Opposite Parties told the complainant to lodge reimbursement of the claim. After the treatment and discharge from the hospital, the complainant lodged the claim for reimbursement, but the Opposite Parties repudiated the genuine claim of the complainant vide its letter dated 06.09.2023. Due to aforesaid act and conduct of the Opposite Parties, the complainant has suffered mental tension and harassment. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Parties may be directed to pay Rs.1,68,532.89 NP on account of medical expenses incurred by the complainant alongwith interest @ 12% p.a. from the date of filing of complaint till realization.
b) To pay an amount of Rs.1,00,000/- as compensation harassment and for deficiency in service.
c) To pay an amount of Rs.11,000/- 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 Party as per insurance policy’ terms and conditions. Averred further that the present complaint pertains to insurance claim under ‘Star Health Gain Insurance Policy bearing No.P/211222/01/2023/005212 valid from 24.08.2022 to 23.08.2023 covering self for a sum of Rs 5,00,000/-. The policy is in continuation since 19.08.2019. However it is submitted that the aforesaid insurance policy was issued to the insured by the answering Opposite Party is subject to the terms and conditions of the insurance policy. Averred further that in the present claim no.CIR/2024/211222/0557916, the insured had requested for cashless and submitted the documents for hospitalization for the period 28.07.2023 to 03.08.2023 in Dayanand Medical College and Hospital towards the treatment of Ventral Hernia and cashless was rejected on the ground that the alleged claim was a complication of previous surgery which is a disease/condition has been incorporated as a pre-existing disease in the policy schedule at the time of inception of first medical insurance policy. Thereafter the insured submitted reimbursement and it was observed from the medical records that the insured patient had undergone treatment for the above disease which is a complication of pre existing condition already incorporated in the above policy at the time of inception of medical insurance policy. Averred that as per exclusion clause no.(1) Pre-existing disease- Code Excl-01 (D) of the policy issued to insured, the coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by insurer. Thus for the reasons stated above Opposite Parties were unable to settle the claim under the above policy and same was repudiated. The instant complaint is neither maintainable in law nor facts; no deficient services have been rendered by answering Opposite Parties as alleged by the complainant; the complainant has not come with clean hands and he has not disclosed the entire true facts. On merits, all other allegations made in the complaint are denied and a prayer for dismissal of the complaint is made.
3. Complainant filed replication to the written reply of Opposite Parties denying the objection raised by them in their written reply.
4. In order to prove his case, the complainant has placed on record his affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C9.
5. On the other hand, Opposite Parties has placed on record affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1,2/A alongwith copies of documents Ex.OP1,2/1 to OP1,2/10.
6. We have heard the ld. counsel for both the parties and also gone through the record.
7. It is well proved on record that the complainant is the holder of Insurance policy namely ‘Star Health Gain Insurance Policy’ for the period 24.08.2022 to 23.08.2023 for herself (Ex.C2) and the inception period of the policy in question is since, 2019. It is also proved on record that during the policy coverage, the complainant suffered from ‘Obstructed Ventral Hernia’ and got admitted in Dayanand Medical College and Hospital, Ludhiana on 28.07.2023 and after treatment got discharged on 03.08.2023 (Ex.C3). It is also proved on record that at the time of admission in the hospital, the complainant requested the Opposite Parties for cashless authorization. Thereafter the Opposite Parties issued letter dated 29.07.2023 demanding documents/details i.e. Cause for ventral hernia and Diagrammatic representation of hernia and also issued letter of the same date i.e. 29.07.2023 denying the preauthorization request for cashless treatment. It is also on record that the Opposite Parties issued another rejection letter dated 30.07.2023 vide which they rejected the authorization for cashless treatment. It is also proved on record that after discharge from the hospital, the complainant lodged the claim for the reimbursement of the medical expenses, which was also repudiated by the Opposite Parties vide letter dated 06.09.2023.
8. The perusal of the record reveals that the Opposite Parties repudiated the claim of the complainant vide letter dated 06.09.2023 on the following grounds:-
“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of Ventral Hernia.
It is observed from the submitted records that the insured patient has undergone treatment for the above disease which is a complication of pre existing condition already incorporated in the above policy at the time of inception of the medical insurance policy. Hence the present admission and treatment of the insured patient is for the complication of the pre existing condition.
As per Exclusion No.(1). Pre-existing disease- Code Excl-01(D) of the policy issued to you, the coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by insurer.
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.”
8. The reason so mentioned in the repudiation letter is highly unjustified and not sustainable. At it is well proved on record that complainant got admitted in the hospital for the treatment of ‘Ventral Hernia’ and there is no document which clearly shows that the complainant was suffering from any pre-existing disease in regard to the present ailment or as alleged by the Opposite Parties. Rather the doctor concerned of the DMC and Hospital, Ludhiana, who treated the complainant also issued well reasoned certificate (Ex.C7) to the following effect:-
“There is no previous history of Hernia. Patient has history of only 2 days of non passage of stools and Flatus. Patient was then diagnose to how obstructed hernia. Prior to 2 days ago patient was asymptomatic and there was no hernia.
From the above certificate, it is clear enough that complainant was not suffering from any pre existing disease as alleged by the Opposite Parties or the present ailment was any complication emerge out of any pre existing disease as alleged by the Opposite Parties. Even the perusal of discharge summary (Ex.C3) placed on record reveals that complainant got admitted in the hospital with complaints of “Swelling in abdomen X 5 days, Non passage of Stool and Flatus X 1 Day, Vomiting X 1 Day” and was diagnosed with “Obstructed Ventral Hernia” and was treated for the same. So, it is apparent from the discharge summary (Ex.C3) as well as Certificate so issued by doctor concerned (Ex.C7) that insured has not any history of ‘Ventral Hernia’ 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 showing that how the Opposite Parties reached the conclusion that complainant’s claim fall under the pre-existing disease or any complication of any pre existing disease. In these circumstances, the repudiation of the claim of the complainant by the Opposite Parties is held as unjustified and illegal.
9. Vide instant complaint, the complainant has claimed for the expenses incurred i.e. he claimed for an amount of Rs.1,68,532/-, which is duly proved on record vide Ex.C4. Hence we allow the same.
10. In view of the discussion above, we partly allow the instant complaint and direct Opposite Parties to make the payment of Rs.1,68,532/- (Rupees One Lakh Sixty Eight Thousand Five Hundred Thirty Two only) to the complainant. Further Opposite Parties are directed to pay compository cost of Rs.20,000/- (Rupees Twenty Thousand only) as compensation and litigation expenses to the complainant for rendering deficient services and for thrusting avoidable litigation. The pending application(s), if any also stands disposed off. 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 further burdened with additional cost of Rs.20,000/- (Rupees Twenty Thousand only) to be paid to the complainant 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
