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 insurance policy from Opposite Party under ‘Family Health Optima Insurance Plan’ vide policy no.211222/01/2018/000873 dated 12.10.2017 for the period from 12.10.2017 to 11.10.2018. The complainant regularly renewed the policy after payment of premium and lastly the same was renewed for the period 23.10.2022 to 22.10.2023. Unfortunately, wife of the complainant namely Kusam Arora (covered under the policy) fell ill in the first week of 2023 and got admitted in the Fortis Hospital, Mohali on 19.02.2023 and was diagnosed as ‘Morbid Obesity/Meta Balic Syndrome’ and got her ‘Laparoscopic Sleves Gastrectomy’ surgery done on 20.02.2023 and discharged on 23.02.2023. Alleged that the complainant spent Rs.3,50,000/- on the treatment of his wife. After discharge from the hospital, the complainant immediately lodged the claim for reimbursement of medical charges, but the Opposite Party vide letter dated 23.05.2023 repudiated the claim of the complainant. Due to non-payment of aforesaid genuine claim, the complainant has suffered mental tension and harassment. Hence, this complaint. Vide instant complaint, the complainant has sought the following reliefs:-
a) Opposite Party may be directed to pay Rs.3,50,000/- as reimbursement of medical expenses of Kusam Aora.
b) To pay an amount of Rs.1,00,000/- as compensation for mental tension and harassment alongwith interest @ 12% p.a. from the date of repudiation.
c) To pay an amount of Rs.40,000/- 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 pre mature complaint has been filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Party as per the policy terms and conditions. As per Condition No.2, the Opposite Party Insurance Company is not liable to make payment under the policy in respect of expenses incurred at the hospital for Metabolic Syndrome as the insured/claimant has failed to submit all the required documents and details called for by the answering Opposite Party. Averred further that the present complaint pertains to insurance claim under ‘Family Health Optima Insurance Plan’ bearing no.P/211222/01/2023/007543 valid from 23.10.2022 to 22.10.2023 covering complainant and his spouse Kusam Arora 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 to the insured at the time of the contract. 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 for the treatment of ‘Metabolic Syndrome’ at Fortis Hospital, Mohali on dated 15.02.2023, which was denied on the ground that ‘Estimate has not been revised’. Thereafter the insured has filed the claim for reimbursement and on scrutiny of claim documents, certain documents are found necessary to be submitted for the process of claim, hence Opposite Party advised the insured vide letters dated 08.04.2023, 23.04.2023 and 08.05.2023 to following details:-
1. To submit complete set of indoor case papers with Operation theater notes and Preanesthesia records.
2. First and all consultation papers towards Obesity, Diabetes Mellitus and Hypertension.
The required documents have not been provided despite queried vide written letters. In the absence of the above documents/details, Opposite Party is not able to process the claim, but as per Condition no.2 of the above policy, the insured person has to submit all the required documents and details called for by the Opposite Party. Hence, the claim was repudiated vide letter dated 23.05.2023. 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 complaint being pre-mature and false is not maintainable; 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. 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.
4. On the other hand, Opposite Party has tendered into evidence affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1/A alongwith copies of documents Ex.OP/1 to Ex.OP/13.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. It is proved on record that complainant availed ‘Family Health Optima Insurance Plan’ bearing no.P/211222/01/2023/007543 valid from 23.10.2022 to 22.10.2023 covering himself and his spouse Kusam Arora. It is also proved on record that during the policy coverage wife of the complainant (duly covered under the policy) suffered ‘Morbid Obesity/Metabolic Syndrome’ and ‘Laparoscopis Sleeve Gastrectomy’ surgery was done on 20.02.2023. It is also proved on record that at the time of admission, the complainant has requested the Opposite Party for cashless treatment, which was denied by the Opposite Party vide letter dated 15.02.2023 on the ground that ‘Estimate has not been revised’. After discharge from the hospital, the complainant lodged the claim with Opposite Party. Thereafter, vide letters dated 08.04.2023, 23.04.2023 and 08.05.2023, the Opposite Party demanded certain documents from the complainant i.e. complete set of indoor case papers with Operation theater notes and Preanesthesia records and first and all consultation papers towards Obesity, Diabetes Mellitus and Hypertension’, which were not supplied by the complainant. Thereafter, the claim was repudiated by the Opposite Party vide letter dated 23.05.2023 for want for aforesaid documents.
7. Now we have to decide that whether repudiation of the claim for want of aforesaid documents is genuine or not?
8. We have perused the discharge summary of Fortis Hospital, Mohali, the perusal of the same reveals that under the heading Past History/Comorbidities, it is mentioned as k/c/o Hypertension, Diabetes Mellitus (Recently diagnosed). So, it is apparent from the discharge summary that insured has recently been diagnosed for Diabetes Mellitus, so in these circumstances, the demand of first and all consultation papers towards Diabetes Mellitus is not genuine. Moreover, Diabetes Mellitus and Hypertension are common life style diseases and repudiation of claim on the basis of these diseases is not justified. Reliance in this regard is placed on RP No. 4461 of 2012, Neelam Chopra Vs. Life Insurance Corporation of India & Ors., decided on 08.10.2018, (NC), wherein it has been held by the Hon’ble National Commission that:
"11. From the above, it is clear that the insurance claim cannot be denied on the ground of these life style diseases that are so common. However, it does not give any right to the person insured to suppress information in respect of such diseases. The person insured may suffer consequences in terms of the reduced claims.
14. Moreover, the non-disclosure of information in respect of this life style disease of diabetes, will not totally disentitle the complainant for indemnification of the claim in the light of the judgment of Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., (supra)."
9. Besides discharge summary there is no other document been referred or placed on record by the Opposite Party establishing that wife of the complainant was suffering from said ailment. Nowhere, it is made evident that who supply the said information as has been recorded in the past history column of the discharge summary. Further in regards to the demand of ‘Complete Set of indoor case papers with Operation Theater notes and Preanesthesia records’ by the Opposite Party vide letters dated 08.04.2023, 23.04.2023 and 08.05.2023 seems absurd, when it is clearly been mentioned in the discharge summary (Ex.C5) duly issued by Fortis Hospital, Mohali mentioning each and every details with regard to the treatment given to wife of complainant/insured during the treatment. In our concerted view, the demand of Opposite Party for submission of documents i.e. Complete Set of indoor case papers with Operation Theater notes and Preanesthesia records appears to be baseless and in-genuine. It has been observed that Opposite Party has failed on its part to enquire qua the treatment being availed by the wife of the complainant from the hospital concerned and arbitrarily it repudiated the claim for want of documents. Moreover, there is no record revealing that the complainant ever taken any treatment for the said ailment. The deficiency in service rendered towards complainant is writ large and the present complaint deserves to be allowed.
10. Vide instant complaint, the complainant claimed the amount of Rs.3,50,000/- incurred by him for the treatment of his wife. However during the course of arguments, ld. counsel for the complainant admitted that the complainant has been given Discretionary Discount of Rs.51,162/-. Hence, the complainant is entitled for the rest of the amount, which comes to Rs.2,98,838/-.
11. In view of the discussion above, we partly allow the instant complaint and direct Opposite Party to make the payment of Rs.2,98,838/- (Rupees Two Lakh Ninety Eight Thousand Eight Hundred Thirty Eight only) to the complainant. Further Opposite Party is directed to pay compository cost of Rs.30,000/- (Rupees Thirty 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 Party within 30 days from the date of receipt of copy of this order, failing which, the Opposite Party is further burdened with additional amount of Rs.10000/- (Rupees Ten Thousand only) to be paid to the complainant in addition to the awarded amount. 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
