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 alongwith her husband has been taking Star Health Insurance Policy from Opposite Parties since, 2020 and the same has been renewed time to time and lastly a policy bearing no.P/211222/01/2023/012378 for the period 20.02.2023 to 19.02.2024 for the sum assured of Rs.3 lakh alongwith bonus was issued by Opposite Parties. Unfortunately, the complainant suffered knee pain and visited the Aastha Hospital and Test tube baby centre at Moga. The concerned doctor prescribed some medicines, but after taking these medicines, there was no improvement in the pain, so the complainant went to Orison Superspeciality, Hospital, Ludhiana on dated 16.05.2023, where concerned doctor after checkup, advised Surgery for knees. After that complainant intimated the Opposite parties for cashless treatment of above said knee surgery, but the Opposite Parties vide letter dated 27.05.2023 rejected the authorization for cashless treatment of the complainant. Alleged that she also consulted Goyal Hospital, Moga for the above said Knee pain on 10.06.2023 and the concerned doctor also advised the complainant for Knee replacement Surgery. Thereafter, the complainant again intimated the opposite parties for cashless treatment, but the opposite party again refused the cashless treatment of the Complainant, vide letter dated 12.06.2023. Alleged that the agent of the Opposite parties asked the complainant that they have to submit the physical documents regarding the treatment and Opposite parties will pay the same after the treatment done. After that the complainant got her knee surgery from the said hospital and got admitted in the hospital for the period 12.06.23 to 17.06.2023. Thereafter complainant also approached to the opposite parties and submitted her claim for medical reimbursement. However, vide letter dated 12.07.2023, the Opposite Parties repudiated the claim of the complainant on the ground of pre-existing disease. The complainant also issued legal notice dated 07.02.2023 to Opposite Parties, but with no affect. Due to such 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/reimbursement medical claim of Rs.2,24,679/- with interest @ 12% p.a. from the date of filing of the complaint till realization.
b) To pay an amount of Rs.50,000/- as compensation for mental tension and harassment.
c) To pay an amount of Rs.5500/- as cost of the complaint.
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 has been filed without any cause of action, as the claim of the complainant was denied by the answering Opposite Party on the ground of Pre-existing disease & Non-Disclosure of material facts. It has been established from the medical/treatment records as filed by the insured and as received from the treating hospital that the insured patient had been suffering from the disease "OSTEOARTHRITIS KNEE" and the same was never disclosed at the time of procurement of policy thus, the claim was found not payable. The insured/complainant by not disclosing the Pre existing disease before procuring the policy has violated the policy document/contract and also the core principle of insurance i.e. the Principle of Good Faith and had obtained the policy through concealment of material facts. Averred that the present complaint pertains to insurance claim under Family Health Optima Insurance Policy-2021 bearing No. P/211222/01/2023/012378 valid from 20.02.2023 to 19.02.2024 covering the Complainant self, Nitin Garg, Abhimanyu Garg and Mauli dependant children for a sum of Rs 300000/-. 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. Moreover the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same were served to the complainant along with policy schedule. 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 and submitted the documents for hospitalization on 12.06.2023 in Goyal Hospital, Moga towards the treatment of OA KNEE. .It is observed from the hospital records that the insured patient has the above disease which is a longstanding ailment. Opposite Parties do not able to ascertain the duration of the disease based on the documents/details submitted. It requires further evaluation. Subsequently insured has submitted the same in reimbursement. On scrutiny of the claim documents as provided by the insured, it was found and observed from the submitted investigation report that shows chronic longstanding disease. Based in the available records medical team of the opposite parties was of the opinion that the insured patient had above disease prior to inception of medical insurance policy. Hence it was a pre-existing disease. The admission and treatment of the insured patient was for the above pre existing disease. As per Exclusion - Pre-existing disease - Code Excl-01 of the policy issued and supplied, the Company is liable to make payment for any pre-existing disease only after the expiry of 48 months from 10.07.2023. Hence, the claim was rejected and the same was informed to the insured vide letter dated 12.07.2023. The complainant has got not cause of action and locus-standi to file the present complaint; the instant complaint is neither maintainable in law nor on facts; this Commission has got no jurisdiction to try and decide the present complaint; no deficient services have been rendered by the answering Opposite Parties. 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 her case, the complainant has placed on record her affidavit Ex.C1 alongwith copies of documents Ex.C2 to Ex.C27.
4. On the other hand, Opposite Parties has tendered into evidence affidavit of Sh.Sumit Kumar, Senior Manager, Star Health & Allied Insurance Co. Ltd. Ex.OP1,2/A, Power of Attorney as Ex.OP1,2/B alongwith copies of documents Ex.OP1,2/1 to Ex.OP1/11.
5. We have heard the ld. counsel for both the parties and also gone through the record.
6. It is an admitted fact that complainant has been taking Star Health Insurance Policy from Opposite Parties since, 2020. In continuation to the earlier policy, the complainant purchased the policy for the period 20.02.2023 to 19.02.2024. It is also not disputed the during the above policy coverage, the complainant visited Aastha Hospital as well Orison Superspeciality Hospital with regard to the treatment of her knee pain and when complainant got no relief for the said problem, she approached Goyal Hospital Moga, where on the advise of the concerned doctor, she got admitted in the said hospital for the period 12.06.2023 to 17.06.2023 and got her Knee replacement Surgery done. After discharge from the hospital, the complainant lodged the claim with Opposite Parties, but vide letter dated 12.07.2023, the Opposite Parties repudiated the claim of the complainant on the ground of pre-existing disease. The said repudiation has been challenged by this complaint.
7. On the other hand, ld. counsel for the Opposite Parties contended that the claim of the complainant was denied by the answering Opposite Party on the ground of Pre-existing disease & Non-Disclosure of material facts. It has been established from the medical/treatment records as received from the treating hospital that the insured patient had been suffering from the disease "OSTEOARTHRITIS KNEE" and the same was never disclosed at the time of procurement of policy thus, the claim was found not payable and hence repudiated vide letter dated 12.07.2023.
8. The perusal of repudiation letter dated 12.07.2023 (Ex.) reveals that Opposite Parties repudiated the claim of the complainant on the following grounds:-
“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of OA Knee.
It is observed that the findings of investigation confirm chronic, longstanding disease. Based on the findings 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. Hence it was a pre-existing disease. The admission and treatment of the insured patient was for the above pre existing disease.
As per Exclusion - Pre-existing disease - Code Excl-01 of the policy issued and supplied, the Company is liable to make payment for any pre-existing disease only after the expiry of 48 months from 10.07.2023.
9. After due consideration of the admitted and proved facts on record, we have also considered the rival contentions of ld. Counsels for both the parties and have gone through the record. We have also perused the discharge summary of Goyal Hospital, Moga. In the said discharge summary nowhere it is mentioned that the complainant has any history of Osteoarthritis Knee prior to admission in the hospital and in the said discharge summary reason of admission is mentioned as Knee Pain Both Side, the contents of discharge summary are reproduced as under:-
Reason for Admission: Knee pain both side
Significant Findings: Abnormal Mobility
Treatment Given and Course of Hospitalization:
Patient present to Goyal Hospital with Knee Pain Both Side X-ray was done and it showed Osteoarthritis Bilateral Knee and attendants patient was admitted and was operated for the same. Now, patient is being discharged with stable vitals and in a satisfactory condition.
10. We are of the concerted view that the said discharge summary of the treating hospital is sufficient enough to prove that complainant has no prior history of Osteoarthritis Knee as there is nothing mentioned that complainant has prior history of OA Knee. Moreover, prescription slips of Aastha Hospital and Orison Super Speciality Hospital is evident of the fact that the complainant approached the said hospitals with the problem of knee pain and in the said prescription slips there is no where mentioned that the patient has any history of Osteoarthritis Knee. Further perusal of the record reveals that the complainant has been obtaining the policy from the Opposite Party since the year, 2020 without any break, meaning thereby that the policy in question is in its 4th year of continuation, so it cannot be said that complainant is suffering from pre-existing disease. 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 judgments 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. Moreover, in case of diabetes of late, this Commission has been taking a view that diabetes is a life style disease and is so common in India that the whole insurance claim cannot be rejected on this ground."
11. Further perusal of the policy document (Ex.C3) placed on record by the complainant reveals that in the said document, the complainant has mentioned her date of birth as 23.03.1973 and in the said document date of inception of first policy is mentioned as: 20th February, 2020, meaning thereby that at the time availing the first policy, the age of the complainant was more than 45 years, so it was the bounden duty of the Opposite Parties-Insurance Company to get the life assured medically examined before issuing the policy in her name who was above the 45 years of age. As per the I.R.D.A.I Rules and Instructions with regard to thorough medical examination if the insured is more than 45 years which is reproduced as under:-
“As per instructions issued by the Insurance Regulatory and Development Authority of India (IRDAI), it was bounded duty of the insurer to put insured to thorough medical examination in case Mediclaim insured was more than 45 years and if insurance company failed to do so then insurance company has no right to decline the insurance claim on account of non disclosure of the facts of pre existing disease when the policy was taken. The above observations is supported by law cited in SBI General Insurance Company Limited Vs. Balwinder Singh Jolly” 2016(4) CLT 372 of the Hon’ble State Commission, Chandigarh.”
However, the Opposite Parties-Insurance Company has not placed on record any evidence that before issuing the policy they ever got medically examined the insured. From the discussion above, we are of the concerted view that Opposite Parties illegally and wrongly repudiated the genuine claim of the complainant.
12. Now come to the quantum of amount to be awarded to the complainant. Vide instant complaint, the complainant claimed the amount of Rs.2,24,679/- being the amount of medical expenses spent at Goyal Hospital, Moga. However, vide Bill Assessment Sheet Ex.OP1,2/11, the Opposite Party assessed the final admissible amount to the tune of Rs.2,19,448/-. There is no dispute raised qua such assessment. Hence we allow the same.
13. From the above discussion, we partly allow the complaint of the complainant and direct the Opposite Parties to pay an amount of Rs.2,19,448/- (Rupees Two Lakh Nineteen Thousand Four Hundred Forty Eight only) alongwith interest @ 9% p.a. from the date of claim till its actual realization 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 the complainant. The pending application(s), if any also stands disposed of. The compliance of this order be made by the Opposite Parties within 45 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
