Order by:
Aparana Kundi, Member
1. The complainant has filed the instant complaint under section 35 of the Consumer Protection Act, 2019 stating that he has purchased a policy bearing no.11240467865800 for the period from 23.10.2023 to 22.10.2024. Unfortunately, complainant feel pain in his body and complainant went to Moga Medicity Super Speciality Hospital, Moga for medical check-up and treatment, where several medical tests were conducted and then doctors of the said hospital detected that it was anxiety attack. Thereafter the complainant was admitted in Moga Medicity Superspeciality Hospital, Moga on 24.12.2023 in ICU as his condition was very critical and thereafter discharge from the hospital on 28.12.2023. Alleged that the complainant has spent more than Rs.54,307/- on medicines and treatment. The complainant sent many letters to the Opposite Parties for the approval of claim, but to no effect. However, the complainant was very astonished to know that his claim was rejected by the Opposite Parties on 20.04.2024. Complainant also sent a letter dated 02.04.2024 to Opposite Parties, through his counsel, 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.54,307/- with regard to the policy no.11240467865800.
b) To pay a sum of Rs.1,00,000/- as compensation on account of mental tension, harassment and for deficient services.
c) To pay Rs.20,000/- 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 Party 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 answering Opposite Party as per policy terms and conditions. Averred that the present complaint pertains to insurance claim under ‘Young Star Insurance Policy’ bearing No.11240467865800 valid from 23.10.2023 to 22.10.2024 covering the complainant self for a sum of Rs.5,00,000/-. 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 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 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 23rd October, 2023 received by SMS. This forms part of the validation process. Averred further that the insured preferred the following claim in 1st Year of the policy. The insured had requested for cashless and submitted the documents for hospitalization for the period from 24.12.2023 to 28.12.2023 in Moga Medicity Superspeciality Hospital towards treatment of Seizure. The Opposite Parties rejected the cashless request of the complainant on the ground that they were not able to ascertain the duration of the disease based on the documents/details submitted by the insured. It required further evaluation thus the insured was advised to approach Opposite Parties with complete documents for reimbursement. Subsequently, the insured had submitted claim for reimbursement. On scrutiny of claim documents, it was observed that the findings of investigation report confirms chronic, longstanding disease. Based on the available records, medical team of the Opposite Parties was of the opinion that the insured patient was for pre-existing disease. It was observed by the medical team of the Opposite Parties that lab reports of Micro diagnostic lab shows that it was done on dated 26.08.2023 referred by Dr.Sandeep Garg. Also Lab reports of Apollo diagnostic lab dated 30.08.2023 shows ICU 06. But previous consultation papers not provided and ICU 06 hospitalization, discharge summary not provided. The policy was incepted on 23.10.2023, these reports are prior to the inception of first policy. As per Exclusion No.1-Pre-existing disease- Code Excl-01 of the policy issued to insured, the company is liable to make payment for any pre-existing disease only after the expiry of 12 month from 30.03.2024. Hence, the claim was rejected and the same was informed to the insured vide letter dated 20.04.2024. Averred further that the instant complaint is neither maintainable in law nor on facts; no deficient services have been rendered by the answering Opposite Party as alleged by the complainant; the claim in question was duly entertain, inquired into and after due application of mind the alleged claim has been repudiated; the complainant has not come with clean hands. 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.CW1/A alongwith copies of documents Ex.C1 to Ex.C14.
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 alongwith copies of documents Ex.OP1,2/1 to Ex.OP1,2/12.
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 ‘Young Star Insurance Policy’ bearing no.11240467865800 for the period 23.10.2023 to 22.10.2024 for self. It is also proved on record that during the policy coverage, complainant suffered ‘Anxiety Neurosis and Seizure Disorder’ and got admitted in Moga Medicity Superspeciality Hospital, Moga on 24.12.2023 and got discharged from the hospital on 27.12.2023. It is also proved on record that the complainant requested the Opposite Parties for cashless treatment, but request of the complainant was denied by the Opposite Parties, vide letter dated 26.12.2023. Thereafter, the complainant lodged the claim for the reimbursement of medical expenses and treatment, but the claim of the complainant was also not admitted by the Opposite Parties and denied, vide letter dated 20.04.2024 (Ex.OP1,2/11). The contents of which 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 investigation report confirms chronic, longstanding disease. Based on the available records, our medical team is of the opinion that the insured patient has the above disease prior to inception of the first medical insurance policy. Hence it is a 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 of any pre-existing disease only after the expiry of 12 months from 30.03.2024.
We wish to bring to your kind attention that the above Pre-Existing Disease/s is/are found while processing the claim of the above insured patient.
As per the new IRDA guidelines, if the non-disclosed disease is other than the disease from the list of permanent exclusion, then the insurer can incorporate additional waiting period of not exceeding 1 year for the said undisclosed disease or condition from the date the disease was found out (i.e.30.03.2024) and it is now incorporated in your policy as per existing disease/condition by passing endorsement.
8. However, the non admission of the claim of the complainant by the Opposite Parties on the aforesaid ground is not genuine, as the Opposite Parties have not placed on record any document showing that the complainant was suffering from the disease in question prior to the inception of the policy. However, it is important to mention here that in written reply, the plea taken by the Opposite Parties is that complainant is suffering with the disease in question before the inception of the policy, as he undergone many tests on 26.08.2023 and 30.08.2023 form Apollo Diagnostic and Micro Diagnostic Lab which is placed on record by the Opposite Parties as Ex.OP1,2/10 and on the basis of these test reports medical team of the Opposite Parties comes to the conclusion that the complainant is suffering from disease in question before the inception of the policy, but the Opposite Parties have not placed on record the opinion/report of the their medical team, which states so. Moreover, the Opposite Parties failed to prove that how these reports show that complainant is suffering from the disease in question. They did not point out anything in the reports which clearly states as alleged. Moreover perusal of the discharge summary (Ex.OP1,2/8) reveals that complainant was discharged from the hospital concerned on 27.12.2023 against the medical advise, but in discharge summary in the clinical history, nowhere it is mentioned that complainant was suffering from Anxiety and seizure disorder, prior to the admission in the hospital on 24.12.2023. In the absence of any cogent and convincing evidence, it cannot be said the complainant was suffering from Anxiety prior to the inception of the policy. Further the onus to prove that the complainant was suffering from a pre-existing disease as per settled law is on the Opposite Parties, but the Opposite Parties have not produced any documentary evidence/expert medical opinion in support of its case. For this observations we are well guided by the judgment of Hon’ble National Consumer Disputes Redressal Commission in case titled Reliance Life Insurance Co. Ltd & Anr. v. Tarun Kumar Sudhir Halder in Revision Petition No. 2097 of 2019 has also held so:-
"The Insurance Company has not filed any evidence to show that the DLA was taking treatment for the disease prior to filling up of the proposal form. Even if there was disease inside the body, but the life insured did not know about the disease and was not taking any treatment for the same, the insurance claim cannot be denied on mere presumption that the life assured might be suffering from pre-existing disease. Thus, on merits, I am convinced on the (FA-383/2016) PAGE 8 OF 10 basis of the entries in the Medical Attendant Certificate that the disease was complained for the first time by the DLA on 22.06.2011, which is much after the date of the proposal form. The onus to prove the pre-existing disease lies on the Insurance Company and no supporting documents have been filed by the Insurance Company in support of their assertion."
9. In view of the above discussion, we are of the opinion that if the policy is admitted, hospitalization of the complainant is admitted and tests conducted are admitted, then non admission of the claim of the complainant by Opposite Parties on the ground that complainant was suffering from the disease in question prior to the inception of the policy in question without any cogent evidence is not good.
10. Vide instant complaint, the complainant has claimed the amount of Rs.54,307/-. The bills pertaining to medicine, bed charges, room charges, admission charges, misc charges, tests, X-ray, MRI and procedure charges have been placed on record by the complainant from Ex.C2 to Ex.C6 and Ex.C9 (Final bill). Whereas, the amount filled in the claim form by complainant, which is placed on record by Opposite Parties as Ex.OP1,2/7 clearly shows that the total amount claimed by the complainant is Rs.54,007/-. Hence we allow the same.
11. Sequel to the above discussion, the instant complaint is allowed in part and Opposite Parties are directed to make the payment of Rs.54,007/- (Rupees Fifty Four Thousand Seven only) to the complainant. Opposite Parties are also directed to pay Rs.2500/-(Rupees Two Thousand Five Hundred only) as 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 further burdened with additional amount of Rs.2,000/- (Rupees Two 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
