BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 106 of 2020
Date of Institution : 20.02.2020
Date of Decision : 12.05.2023
Kiran aged about 47 years widow of Shri Satish Kumar, resident of Street No.2, Bhagat Singh Nagar, 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. JBL Garg, Advocate for the complainant.
Sh. Mukesh Saini, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 (after amendment under Section 35 of the Consumer Protection Act, 2019) against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that on 03.03.2017 husband of complainant namely Satish Kumar purchased Family Health Optima Insurance Plan/ insurance policy from the ops for himself, his son Anil Sharma as well as for the complainant. A sum of Rs.13,858/- as premium was also paid to the ops for one year and thereafter again it was renewed by her husband on 03.04.2018 for one year i.e. up to 02.04.2019 and paid premium amount of Rs.17,635/- to the ops. It is further averred that proposal form for said policy was filled up by the agent of the ops. That all of sudden, Satish Kumar husband of complainant was attacked with Pneumonia and viral fever on 7.7.2018 and was admitted in Poonia Hospital, Sirsa on 7.7.2018 and was discharged on 9.7.2018 and after then he was referred to Fortis Hospital, Mohali, where he was admitted on 10.7.2018 and was discharged on 25.7.2018. Again he was admitted in Medanta Hospital, Gurgaon on 27.08.2018 and was discharged on 6.9.2018 and after then he was admitted in Mann Multi Specialty Hospital, Rohtak on 20.10.2018 and unfortunately he died on 24.10.2018. It is further averred that on the above said ailment, the complainant has spent about Rs. Thirty Five lacs on his entire treatment in the above said hospitals.
3. It is further averred that thereafter complainant requested the ops to reimburse the medical bills and also submitted all the requisite documents to the ops but the ops have repudiated the claim of complainant on 16.02.2019 on the ground that complainant has not submitted all required documents, which is wrong and illegal. That at the time of purchasing of above said health policy in the year 2017, the ops got conducted medical examination of her husband and found that he was not suffering from any disease or vices and he has not concealed anything from the ops. He was hale and hearty at the time of purchase of policy but now ops are harassing and humiliating the complainant and are not ready to pay the above said medical bills to the complainant. That in this manner, the ops have refused to admit the claim of complainant and the act and conduct of the ops comes under the ambit of deficiency in service as well as unfair trade practice due to which complainant is suffering recurring financial losses and harassment. Hence, this complaint seeking amount of Rs.5,00,000/- alongwith interest besides compensation for harassment and litigation expenses from ops.
4. On notice, ops appeared and filed written statement raising certain preliminary objections. It is denied that agent has filled the proposal form. It is submitted that the true facts of the case are that insured availed the Family Health Optima Insurance Plan covering Satish Kumar himself, Kiran Devi spouse and Anil Sharma dependent child for the sum insured of Rs.5,00,000/-. The terms and conditions of the policy were explained to the insured at the time of proposing policy and same was served to him alongwith the Policy Schedule. It is further submitted that policy is contractual in nature and claims arising therein are subject to the terms and conditions. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. That insured preferred claims in the second year of the policy and requested a cashless of the medical expenses towards the treatment of RPGN – PAUCI IMMUNE CRESENTRIC GLOMERULONEPHRITIS, ANEMIA, HYOERTENSION at Fortis Hospital, Mohali on 10.07.2018 to 25.07.2018. It is further submitted that on the scrutiny of the cashless documents, it is noted that the “Patient has history of similar episodes two years ago, Poonia Hospital records not available. History of cought on and off for 1.5 years. Exact onset of illness cannot be ascertained in cashless. Based upon the information/ clarification provided the answering ops are not in a position to decide upon the admissibility of the claim”. Hence, the cashless authorization was denied calling the insured for reimbursement of medical expenses and the same was communicated to the treating hospital as well as to the insured vide letter dated 14.7.2018.
5. It is further submitted that subsequently, the insured submitted claim documents for reimbursement. On scrutiny of claim documents, it is observed that from the indoor case records of above hospital, the insured patient had similar episode two years back and cough since 1.5 years. Hence answering ops requested the insured to furnish past treatment records for the past two years but the complainant has not furnished the required documents. In the absence of the above documents/ details, answering ops are not able to process the claim of complainant. It is further submitted that as per condition No.3 of the above policy, the insured person has to submit all the required documents and details called for by the answering ops. Hence, the reimbursement claim was rejected and conveyed to the insured vide letter dated 16.2.2019. It is further submitted that subsequently the insured has sent answering ops a representation in response to answering ops letter dated 16.02.2019 seeking reconsideration of claim. That answering ops’ medical team has perused the insured representation and has noted the contents. The team which re-examined the claim records has observed that as per the indoor case records of the aforesaid treatment, the patient has a history of similar episode two years back and has complaints of cough for the past 1.5 years, but the consultations and treatment records relating to the same are not submitted by the insured inspite of answering ops query which amounts to non submission of required documents. The answering ops are therefore, unable to consider the representation favorably and informed the complainant that repudiation of claim is in order and repudiation of claim was again conveyed to the insured vide letter dated 16.3.2019. It is further submitted that insurance is act of good faith and done on the information of the insured supplied by the insured in his proposal form, to be actual and correct. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
6. The complainant in evidence has tendered her affidavit Ex. CW1/A and copies of documents Ex.C1 to Ex.C94.
7. On the other hand, ops have tendered affidavit of Sh. Rajiv Jain, Chief Manager as Ex.R1 and copies of documents as Ex.R2 to Ex.R14.
8. We have heard learned counsel for the parties and have perused the case file carefully.
9. It is an admitted fact between the parties that Sh. Satish Kumar husband of complainant purchased the health insurance policy from ops for the period 03.03.2017 to 02.03.2018 vide which Satish Kumar himself, complainant Kiran Devi being spouse and their son Anil Sharma were insured for the sum insured amount of Rs.5,00,000/- and in case of renewal of the said policy, they were also entitled to recharge benefit of Rs.1,50,000/-. It is also proved on record that above said health insurance policy was got renewed by the husband of the complainant for the period 03.04.2018 to 02.04.2019 for the coverage amount of Rs.6,25,000/- against the premium amount of Rs.17,635/- which is evident from policy schedule Ex.C1. The husband of the complainant during the period of said policy fell ill as he suffered from Pneumonia and viral fever and was admitted in above said hospitals from 7.07.2018 to 9.7.2018, 10.07.2018 to 25.7.2018, 27.8.2018 to 6.9.2018 and from 20.10.2018 to 24.10.2018 and ultimately died on 24.10.2018. The complainant has alleged that an amount of Rs. thirty five lacs was spent on the treatment of her husband in the above said hospitals and has claimed amount of Rs.5,00,000/- from the ops towards reimbursement of the medical bills. The complainant has also placed on file medical record, test reports as well as bills and receipts of the amounts incurred in the above said hospitals as Ex.C9 to Ex.C92 and has also placed on file death certificate of her husband Satish Kumar as Ex.C8.
10. The claim submitted by the complainant as well as cashless authorization request has been rejected by the ops on the ground insured patient had similar disease two years back and cough since 1.5 years back and they requested the insured to furnish past treatment records for the past two years but complainant has not furnished the required document. But however, it may be possible that complainant may not be in position of any earlier treatment record of her husband. Further more before issuance of the policies in question to the insured persons, they all including Satish Kumar insured were subjected to the medical examination by the ops and now the ops cannot reject the claim of the complainant on the ground of pre existing disease or suppression about any disease from the ops or on the ground of non submission of previous treatment record. It appears that ops in order to deny genuine claim of complainant has wrongly and illegally repudiated the claim of the complainant because demanding of the previous treatment record of disease like cough is immaterial and it cannot be said that without record of such disease, the claim cannot be settled and paid. Moreover, it may be possible that Satish Kumar insured suffered cough 1.5 years back and same would have been disclosed to the doctor but it cannot be said at all that Satish Kumar insured took treatment of cough problem because it is very common and known fact that cough is a very simple and common disease which is cured at its own within a short period and taking treatment for the same is not necessary. The ops have not placed on record any material document from which it could be ascertained that Satish Kumar insured now deceased met with similar episode two years back and that Satish Kumar insured knowingly and intentionally did not disclose the episode of disease which he suffered two years back. Moreover, the ops have also failed to prove on record that who supplied the information of similar episode of two years back. So, it is proved on record that ops have wrongly and illegally repudiated the claim of the complainant. The authorities of the Hon’ble National Commission in cases titled as M/s Royal Sundaram Alliance Insurance Co. Ltd. and others vs. Melanie Das, 2018 (2) CLT 459 and LIC of India versus Reena Nanda, RP No.1782 of 2018 decided on 20.7.2018 and also judgments of Hon’ble State Commissions, Panchkula and Chandigarh in cases titled as Rajinder Singh vs. New India Assurance Co. Ltd. and others, FA No.588 of 2017 decided on 23.5.2018 and in case titled as Manish Goyal Versus Max Bupa Health Insurance Co. Ltd. and others Complaint Case No.234 of 2017 decided on 22.3.2018 cited by learned counsel for complainant are fully applicable to the facts and circumstances of the present case. Though it is proved on record that complainant spent amount more than the sum insured amounts on the treatment of her husband Satish Kumar insured and they have coverage of the amount of Rs.6,25,000/- from the ops but the complainant has restricted her claim to the amount of Rs.5,00,000/- as she has claimed only amount of Rs.5,00,000/- from ops. The complainant is entitled to the reimbursement of said amount of Rs.5,00,000/- from ops spent by her on the treatment of her husband Satish Kumar insured, now deceased and therefore repudiation of the claim of the complainant which is wrong, illegal and arbitrary is hereby set aside.
11. In view of our above, we allow the present complaint and direct the opposite parties to pay a sum of Rs.5,00,000/- to the complainant within a period of 45 days from the date of receipt of copy of this order, failing which complainant will be entitled to the above said amount of Rs.5,00,000/- alongwith interest @6% per annum from the date of this order till actual realization from the ops. We also direct the ops to further pay a sum of Rs.20,000/- as compensation to the complainant for harassment and also to pay a sum of Rs.5000/- as ltigiation 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: 12.05.2023. District Consumer Disputes
Redressal Commission, Sirsa.
JK
