BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 43 of 2020
Date of Institution : 22.01.2020
Date of Decision : 29.08.2024
Dr. Vinod Gupta, aged about 66 years son of Shiv Shaker Gupta, resident of Kothi No. 20, Sector 20, HUDA 1st Lane, HUDA Part-I, Sirsa, Tehsil and District Sirsa (Haryana).
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Limited, Opposite Maruti Car Show Room, Dabwali Road, Sirsa through its Incharge/ Manager.
2. M/s Star Health and Allied Insurance Company Limited, No.15, SRI Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai- 600014 through its Managing Director.
…….Opposite Parties.
Complaint under Section 12 of the Consumer Protection Act, 1986.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
Present: Sh. Deepak Monga, Advocate for the complainant.
Sh. M.K. Saini, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that complainant obtained Family Health Optima Insurance Plan from ops vide insurance policy bearing No. P/211121/01/ 2019/ 005412 for the period 14.02.2019 to 13.02.2020 for sum assured amount of Rs.5,00,000/- by paying insurance premium amount of Rs.25,165/- to the ops and at that time complainant was hale and hearty and ops got completed all requisite formalities for issuance of above said policy to the complainant. That in the month of March, 2019 the complainant fell down and sustained serious injuries on his person and remained under treatment of local neurosurgeon. The MRI done showed clear annular tear in disc and was put on conservative treatment. It is further averred that unfortunately thereafter in the month of July, 2019 he again slipped down in washroom at night. MRI was done which showed right paracentral disc extrusion at L5 S1 level causing compression over thecal sac, right lateral recess narrowing and neural foramen encroachment with compression of Rt existing and traversing nerve roots leading to severe excruciating pain. He was referred to Max Health Care hospital, Mohali for his treatment on 02.08.2019 and remained admitted there up to 08.08.2019 and during this period so many other tests were conducted and he was operated upon. That for said ailment and treatment, complainant has incurred a sum of Rs.2,87,295/- and submitted his claim to the ops alongwith bills and other requisite documents for reimbursement but the ops have repudiated his claim vide order dated 05.10.2019 on the ground that it is an old injury and this treatment is not applicable in the first year of the insurance which is wrong and illegal because before the aforesaid incident, the complainant previously did not have any spine problem but they mentioned that L4 Grade 1 Luysthesis with no fracture which can occur due to fall. Even the ops have wrongly mentioned that MRI confirm non traumatic condition and in this regard in the report of Radiologist there is no mention that it is non traumatic and actually Radiologist is never in a position to comment and he can report the findings only. It is further averred that in literature it is mentioned that in accidental fall victim can often suffer neck or back injuries. Vertebra can be displaced (14 Listhesis clearly mentioned in the MRI report) which can cause a spinal disc to bulge out between the vertebrae or rupture (annular tear clearly mentioned in first MRI report and disc bulge also mentioned in same). The waiting period clause does not apply to the accident (3 ii d) and even the fall in bathroom is also an accident and in all the injuries facture is not essential. The ops have wrongly mentioned that MRI confirm non traumatic condition and in this way the order dated 05.10.2019 passed by ops is liable to be set aside. It is further averred that after slipping in bathroom, MRI clearly mentioned annular tear in disc, which is a usual finding after trauma and after second fall on 30.07.2019 trauma caused Herniation of disc in paracentral space causing compression of nerve root (clearly reported in MRI) resulting in severe pain compelling emergency admission and surgery and before the event of fall in March, 2019 the complainant had no neck problem. The complainant is an active and healthy person, family physician by profession having no other ailments like diabetes or hypertension and in fact and in reality the complainant had to go for spine surgery after fall (trauma) and ops contradicts this truth and in this manner, the complainant was not having any old injury or trauma as alleged by ops. It is further averred that in this manner, the ops have wrongly and illegally rejected the genuine claim of complainant without any rhyme or reason and with the reasons to usurp the amount of claim. The complainant approached the ops and requested to admit his claim and to pay above said amount with interest and also got served legal notice upon ops on 14.11.2019 but all in vain and as such ops have caused deficiency in service, unfair trade practice and unnecessary harassment to the complainant. Hence, this complaint.
3. On notice, ops appeared and filed written statement raising certain preliminary objections. It is submitted that insured availed health insurance plan covering himself, Mrs. Neena Gupta spouse for the sum insured amount of Rs.5,00,000/- for the period 14.02.2019 to 13.02.2020. This policy was issued as per terms and conditions of insurance policy believing that the information provided by the insurer in his proposal form are true and correct. The policy is contractual in nature and claims arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being full aware of such terms and conditions and executed the proposal form. It is further submitted that claim is reported in the 6th month of the policy. As per the submitted documents insured patient was admitted on 02.08.2019. The insured requested a pre authorization request to avail cashless facility towards the treatment of PIVD at Max Super Specialty Hospital, Mohali on 02.08.2019. It is observed from the hospital records that the insured patient has the above disease which is a longstanding ailment. The answering ops are not able to ascertain the duration of the disease based on the documents/ details submitted by complainant and it requires further evaluation. Hence, the pre authorization request was denied and advised the insured to approach for reimbursement. It is further submitted that subsequently the insured requested reimbursement of the medical expenses towards the treatment of L5/S1 RIGHTPARACENTRALDISC CAUSING EXITINGAND, TRANSVERSING NERVE IMPINGMENTCOINCIDESWITH SEVERE L5 RADICULARPAIN, L4 GRADE 1 IYSTHESISWITH NO FRACTURE OROBIOUS INSTABLITY, L4/5 FACETJOINTS ARTHRITIS. The insured was hospitalized at Max Super Specialty Hospital for a hospitalization period from 02.08.2019 to 08.08.2019. On perusal of the medical record, it is observed that the findings of MRI confirm non traumatic condition and the insured patient has undergone treatment for the above disease during first year of the policy. As per waiting period 3(ii) of policy, the company is not liable to make any payment in respect of any expenses incurred by the insured person for treatment of the above mentioned disease during the first two years of continuous operation of the insurance cover. As per waiting period of 24 consecutive months of continuous coverage from the inception of this policy will apply to all types of treatment for Degenerative disc and Vertebral diseases including replacement of bones and joints and Degenerative diseases of the Musculo-skeletal system. Hence, the claim was repudiated and same was informed to the insured vide letter dated 05.10.2019. It is further submitted that in case it is found that ops are liable to pay the claim in terms of the contract of insurance, then the maximum quantum of liability under the terms of the policy shall be Rs.2,57,508/- Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
4. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C15.
5. On the other hand, ops have tendered affidavit of Sh. Rajiv Jain, Chief Manager as Ex. RW1/A and documents Ex.R1 to Ex.R10.
6. We have heard learned counsel for the parties and have gone through the case file.
7. From the policy schedule Ex.C8, it is evident that complainant purchased health insurance policy from ops for the sum insured amount of Rs.5,00,000/- for the period 14.02.2019 to 13.02.2020 for himself and for his wife Smt. Neena Gupta. It is also proved on record that during the period of policy in question, the complainant took treatment from Delhi Spine and Neuro Hospital, Sirsa as he fell down while taking bath as is evident from prescription slip dated 14.03.2019 Ex.C4 and thereafter as he again slipped down in washroom in the month of July, 2019 he remained admitted in Max Super Specialty Hospital, Mohali from 02.08.2019 to 08.08.2019 where his surgery was done on 06.08.2019 as is evident from discharge summary Ex.C2. However, pre authorization request for cashless treatment of complainant as well as claim of the complainant has been denied by ops but the ops have failed to prove on record through any cogent and convincing evidence that it was a longstanding disease to the complainant. There is no medical opinion of any expert in this regard on file. Further the observation of the ops that MRI confirm non traumatic condition is also not supported by any other expert medical opinion or affidavit of any expert doctor. So, it appears that observation of ops are just based on their own opinion, surmises and conjectures and as such repudiation of the genuine claim of complainant is wrong and illegal. Since the complainant suffered problem in his spine and disc due to sudden fall/ slipping i.e. accident, therefore, clause of waiting period of 24 consecutive months will not apply to the case of the complainant because it is not proved on record that complainant was having Intervertebral Disc problem since long due to any other reason other than accident which has waiting period of 24 months as per policy. So, the repudiation of the claim of complainant by ops is hereby set aside. The complainant has claimed that he has spent an amount of Rs.2,87,295/- on his above said treatment and has placed on file bill/ receipt of the amount of Rs.2,72,242/- of the above Max Super Specialty Hospital, Mohali as Ex.C11 and vide assessment sheet Ex.R10, the ops have also assessed admissible amount as Rs.2,57,508/-, so it can easily be said that complainant has spent such huge amount on his treatment and ops have also admitted the said fact and have assessed the admissible amount as Rs.2,57,508/-. So, the complainant is entitled to an amount of Rs.2,57,508/- from ops as assessed by them vide assessment sheet Ex.R10 and non payment of the same clearly amounts to deficiency in service on the part of ops due to which complainant has suffered unnecessary harassment.
8. In view of our above discussion, we allow this complaint and direct the ops to make reimbursement of the claim amount of Rs.2,57,508/- to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 22.01.2020 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops to further pay a sum of Rs.10,000/- as composite compensation for harassment and litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member President,
Dated: 29.08.2024. District Consumer Disputes
Redressal Commission, Sirsa.
