Haryana

Kurukshetra

CC/333/2020

Krishan Gopal S/o Chunni Lal - Complainant(s)

Versus

Star Health And Allied Insurance company - Opp.Party(s)

Anand Garg

05 Aug 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISISON, KURUKSHETRA

                           Complaint No. 333 of 2020

                                   Date of institution: 21.09.2020

                                 Date of decision: 05.08.2024

 

Krishan Gopal son of Chunni Lal, resident of House No. 1623/5, Jyoti Nagar, Thanesar, District Kurukshetra.

                                                                …Complainant.

Versus

 

1. Star Health and Allied Insurance Company Limited, Sri Balaji Complex, 15, Whites Road Chennai-600014 through its authorized signatory.
2. The Branch Manager, Star Health and Allied Insurance Company Limited, SCF 137, Second Floor above ICICI Bank, Sector-13, Karnal-132001.

 

…Opposite parties.

 

•  

Neelam, Member.

Ramesh Kumar, Member.

 

•  

Shri Mohit Goel, Advocate for OPs.

 

• :     

1.             This is a complaint under Section 35 of the Consumer Protection Act, 2019.               

2.             Briefly stated, it is the case of the complainant that complainant retired as Senior Officer from National Institute of Technology, Kurukshetra on 31.03.2018. The complainant remained insured under group health policy for the period 02.12.2015 to 08.06.2018 obtained by the institute for its employees and students from United Insurance Company. The last policy period w.e.f from 09.06.2017 to 08.06.2018 bears policy No. 1126002817P104057628. The complainant was again engaged by the NIT Kurukshetra vide offer letter dated 03.07.2018 as consultant for library of the institute for a period of twelve months. It is pertinent to mention here that before re-appointment, the complainant was thoroughly medically examined by the medical officer NIT Kurukshetra on dated 04.07.2018 and the complainant was found physically and mentally fit to perform duties and responsibilities. After that the officials/agent of OPs approached the complainant to obtain the medi-claim policy of star health and upon their persuasion, the complainant purchased a medi-claim insurance policy for a sum of Rs. 5 lakhs for himself and his wife, namely family health optima insurance plan vide policy No. P/211114/01/2019/004705 for the period w.e.f. 29.08.2018 to 28.08.2019 and the premium of Rs.29695/- including taxes was paid by the complainant to the OPs. The above said policy was further renewed vide renewal endorsement No. P/211114/01/2020/004705 for the period 29.08.2019 to 28.08.2020 for a sum insured Rs. 625000/- i.e. Rs. 500000/- basic sum insured plus Rs. 125000/- as bonus and thereafter the policy was again renewed vide renewal endorsement No. P/211130/01/2021/001235 for the period of w.e.f. 29.08.2020 to 28.08.2021 for a total coverage of Rs. 675000 ie. Rs. 500000 as basic sum insured plus Rs. 17500 as bonus.  It is further averred that on 01.05.2019, th3e complaianant suddenly fa ced problem in passing urine and took treatment form Vishal Hospital, Kurukshetra and the doctor advice for ultra sound and accordingly ultra sound was got done from Akash Imaging Center, Kurukshetra.  The complainant contacted Dr. Ajay Aggarwal, Aggarwal Nursing Home, Salarpur Road, Kurukshetra and the said doctor referred the complainant to Alchemist hospital, Panchkula, where on the very next day, complainant approached the said hospital  as OPD patient regarding the same problem and discussed the doctor that sometimes he observes pain in his legs or feels fatigue. The doctors advised the complainant for MRI and Pet Scan. On the advice of the doctors, the complainant was done the MRI and PET scan on 04.07.2019 and 06.07.2019.  On 09.07.2019, the complainant was admitted in Alchemist Hospital for x-ray spine and the complainant was discharged on same day, but the complainant observed no relief. On 12.07.2019, he visited the Paras Hospital, Gurugram and where he was admitted and doctors observed bunches in spin veins on the basis of MRI and was discharged on 13.07.2019 with the advice of angiography. On the same day, the complainant was admitted to Artemis Hospital, Gurugram with the problem of difficulty in Maturation followed by lower limb weakness and therefore, uneventful and the complainant was again discharged by the hospital on 15.07.2019.  Thereafter, on the complainant was again admitted to Paras Hospital, Gurugram on 15.07.2019 itself and had undergone spinal surgery on 16.07.2019 and was discharged on 23.07.2019. From December 2019, the complainant again observed the problem of walking and therefore, the complainant again got admitted on 29.04.2020 in Paras Hospital, Gurugram for spinal angiography and embolization and was later discharge on 03.05.2020 and since then the complainant was getting treatment from Paras Hospital, Gurugram.  The complainant also applied for the cashless treatment but the same was rejected by the OP’s vide letter dated 01.05.2020.   The complainant had paid a sum of Rs.19,344/- in Alchemist Hopsital, Panchkula vide bill dated 09.07.2019 and had also paid a sum of Rs.12,000/- on account of MRI charges vide receipts dated 04.07.2019 and a sum of Rs.15,099/- on account of PET scan and registration charges vide receipt dt. 06.07.2019.  the complainant also paid a sum of Rs. 12,245/- in Paras Hospital, Gurugram vide receipt dt. 13.07.2019.  The complainant further paid a sum of Rs. 89,204/- in Artemis hospital, Gurugram vide bill dt. 15.07.2019.  The complainant further paid a sum of Rs.4,23,448/- to Paras Hospital, Gurugram vide bill dt. 23.07.2019 and had also paid a sum of Rs.5,84,272/- to Paras Hospital, Gurugram vide bill dt. 03.05.2020.  OPs had rejected the genuine claim of the complainant on the ground of pre-existing disease which is totally wrong and illegal. The OPs have wrongly relied and mis-interpreted the medical record dated 04.07.2019 issued by Alchemist Hospital Panchkula which was only an observation of the doctor whereas in the discharge summary dated 09.07.2019 it is categorically mentioned that the complainant was having a complained of difficulty in passing urine. The complainant had applied for the cashless treatment in Paras Hospital Gurugram  twice and same was declined by the Ops both the time.  The OPs never wanted to pay the lawful and genuine claim and cause and lastly repudiated the claim of complainant on flimsy grounds. The above act and conduct of the OPs, amounts to deficiency in services, due to which, complainant has suffered mental agony, physical harassment and financial loss, constraining him, to file the present complaint, against the OPs, before this Commission.

3.             On notice, OPs appeared and filed their written version raising preliminary objections with regard to maintainability; cause of action; locus standi; jurisdiction and concealment of true and material facts. On merits, it is pleaded that the OP insurance company issued Star Comprehensive insurance policy vide policy No. P/211114/01/2019/004273 for the period 29.08.2018 to 28.09.2019 and policy No. P/211114/01/2020/004705 for the period 29.08.2019 to 28.09.2020 covering risk of Krishan Gopal self and Meena spouse and basic floater sum assured was Rs. 500000/-. The insured patient Krishan Gopal was hospitalized at Paras Hospital, Gurugram from 15.07.2019 to 23.07.2019 for treatment of D8 Spinal AV FISTULA. The insured requested for cashless authorization based upon the submitted cashless documents on 16.07.2019.  It was observed from the hospital records that the complainant has above disease which is a longstanding ailment, Hence, cashless- authorization was denied calling the documents for reimbursements of medical reimbursement and same was communicated treating hospital as well as to the complainant vide letter dated 20.07.2019.  Subsequently, the insured submitted the claim documents for reimbursement of Rs.4,23,448/-.    

4.             The insured patient Krishan Gopal was hospitalized at Paras Hospital from 29.04.2020 to 03.05.2020 for treatment of D8 Spinal AV Fistula.  The insured requested for cashless authorization based upon the submitted cashless documents on 29.04.2020. That the pre authorization was repudiated    on the ground of pre-existing disease not covered till continuous coverage of 48 months.  Subsequently, the insured submitted claim documents for reimbursement for Rs.5,84,272/-.                                 

5.             The learned counsel for complainant has tendered into evidence affidavit of complainant Ex. CW1/A and documents EX. C1 to Ex. C47 and closed the evidence on 06.04.2022 by suffering separate statement.

6.             The learned counsel for the OPs No. 1 & 2 has tendered into evidence affidavits Ex. RW1/A & Ex. RW2/A and documents EX. R1 to Ex. R21 and closed the evidence on 03.03.2023 by suffering separate statement.

7.            We have heard the learned counsel for the parties at length and have gone through the record available on the file carefully.

8.             Shri Anand Garg, counsel for the complainant has argued that complainant retired as Senior Officer from National Institute of Technology, Kurukshetra on 31.03.2018. The complainant remained insured under group health policy for the period 02.12.2015 to 08.06.2018 obtained by the institute for its employees and students from United Insurance Company. The last policy period w.e.f from 09.06.2017 to 08.06.2018 bears policy No. 1126002817P104057628. The complainant was again engaged by the NIT Kurukshetra vide offer letter dated 03.07.2018 as consultant for library of the institute for a period of twelve months. It is pertinent to mention here that before re-appointment, the complainant was thoroughly medically examined by the medical officer NIT Kurukshetra on dated 04.07.2018 and the complainant was found physically and mentally fit to perform duties and responsibilities. After that the officials/agent of OPs approached the complainant to obtain the medi-claim policy of star health and upon their persuasion, the complainant purchased a medi-claim insurance policy for a sum of Rs. 5 lacs for himself and his wife, namely family health optima insurance plan vide policy No. P/211114/01/2019/004705 for the period w.e.f. 29.08.2018 to 28.08.2019 and the premium of Rs.29695/- including taxes was paid by the complainant to the OPs. The above said policy was further renewed vide renewal endorsement No. P/211114/01/2020/004705 for the period 29.08.2019 to 28.08.2020 for a sum insured Rs. 625000/- i.e. Rs. 500000/- basic sum insured plus Rs. 125000/- as bonus and thereafter the policy was again renewed vide renewal endorsement No. P/211130/01/2021/001235 for the period of w.e.f. 29.08.2020 to 28.08.2021 for a total coverage of Rs. 675000 i.e. Rs.500000/- as basic sum insured plus Rs.17500/- as bonus.  It is further argued that on 01.05.2019, the complainant suddenly faced problem in passing urine and took treatment form Vishal Hospital, Kurukshetra and the doctor advice for ultra sound and accordingly ultra sound was got done from Akash Imaging Center, Kurukshetra.  The complainant contacted Dr. Ajay Aggarwal, Aggarwal Nursing Home, Salarpur Road, Kurukshetra and the said doctor referred the complainant to Alchemist hospital, Panchkula, where on the very next day, complainant approached the said hospital  as OPD patient regarding the same problem and discussed the doctor that sometimes he observes pain in his legs or feels fatigue. The doctors advised the complainant for MRI and Pet Scan. On the advice of the doctors, the complainant was done the MRI and PET scan on 04.07.2019 and 06.07.2019.  On 09.07.2019, the complainant was admitted in Alchemist Hospital for x-ray spine and the complainant was discharged on same day, but the complainant observed no relief. On 12.07.2019, complainant Krishan Gopal visited the Paras Hospital, Gurugram and where he was admitted and doctors observed bunches in spin veins on the basis of MRI and was discharged on 13.07.2019 with the advice of angiography. On the same day, the complainant was admitted to Artemis Hospital, Gurugram with the problem of difficulty in Micturition followed by lower limb weakness and therefore, uneventful and the complainant was again discharged by the hospital on 15.07.2019.  Thereafter, on the complainant was again admitted to Paras Hospital, Gurugram on 15.07.2019 itself and had undergone spinal surgery on 16.07.2019 and was discharged on 23.07.2019. From December 2019, the complainant again observed the problem of walking and therefore, the complainant again got admitted on 29.04.2020 in Paras Hospital, Gurugram for spinal angiography and embolization and was later discharge on 03.05.2020 and since then the complainant was getting treatment from Paras Hospital, Gurugram.  The complainant also applied for the cashless treatment but the same was rejected by the OP’s vide letter dated 01.05.2020.   The complainant had paid a sum of Rs.19,344/- in Alchemist Hospital, Panchkula vide bill dated 09.07.2019 and had also paid a sum of Rs.12,000/- on account of MRI charges vide receipts dated 04.07.2019 and a sum of Rs.15,099/- on account of PET scan and registration charges vide receipt dt. 06.07.2019.  the complainant also paid a sum of Rs. 12,245/- in Paras Hospital, Gurugram vide receipt dt. 13.07.2019.  The complainant further paid a sum of Rs. 89,204/- in Artemis hospital, Gurugram vide bill dt. 15.07.2019.  The complainant further paid a sum of Rs.4,23,448/- to Paras Hospital, Gurugram vide bill dt. 23.07.2019 and had also paid a sum of Rs.5,84,272/- to Paras Hospital, Gurugram vide bill dt. 03.05.2020.  OPs had rejected the genuine claim of the complainant on the ground of pre-existing disease which is totally wrong and illegal.            

9.             Counsel for the OP has argued that complainant was having the pre-existing disease of  FRISTULA which was not disclosed by him in his Insurance form and therefore, they had rejected the claim on the ground of pre-existing disease. 

10.           Rebutting this plea of pre-existing disease, counsel for the complainant has argued that the disease was diagnosed at the medical test conducted at different hospitals at Kurukshetra, Alchemist Hospital at Panchkula and thereafter Paras Hospital at Gurugram.

11.          For this reliance is placed on the authority laid down in case tilted “Manish Goyal Vs. Max Bupa Health Insurance Company Limited” in CC No. 234 of 2017 decided on 22.03.2018 in which it has been held that on ground that insured had not disclosed the pre-existing disease and doctor recorded the past history of illness. It was held that OP failed to produce on record any documents to show that insured was still suffering from the epilspsy or tuberculosis at the time of taking the policy and she had intentionally concealed the said material fact.   

12.          From December, 2019, onwards the complainant again observed the problem of difficulty in walking and therefore, the complainant again got of difficulty in walking and therefore, the complainant again got admitted on 29.04.2020 in Paras hospital, Gurugram for spinal angiography and embolization and was later discharged on 03.05.2020 and since then the complainant is getting treatment from Paras Hospital, Gurugram. As per Ex. C-47, discharge summary  prepared by Paras Hospital, Gurugram, there is diagnosis D8 Spinal AV Fistula detected in the body.  Vide Ex. C-4, the cover note of Star Health Insurance company in which limit of coverage mentioned to be Rs.5,00,000/- and the recharge benefit is mentioned to be Rs.1,50,000/-. 

13.          As per Ex. C-6, limit of coverage is to be mentioned 6,25,000/- and recharge benefit is mentioned to be 1,50,000/-.   The total amount of Rs.6,50,000/- vide Ex. C-4 and Rs.7,75,000/- vide Ex. C-6 . 

14.           As a sequel to our foregoing discussion, We award Rs.571340+584272= Rs.11,55,612/- along with 9% penal interest to the complainant, which shall be paid by the OPs from the date of filing this complaint till its realization within 45 days from today. The complaint is accepted with costs, which is assessed Rs. 11,000/-.

15.           In default of compliance of this order, proceedings shall be initiated under Section 72 of Consumer Protection Act, 2019, as non-compliance of court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which sha-ll not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both. A copy of this order be sent to the parties free of cost. File be consigned to the record room after due compliance.     

Announced in open 05.08.2024

                                                       (Dr. Neelima Shangla)            

                                                               President,

                                                               DCDRC, Kurukshetra.

 

(Neelam)                (Ramesh Kumar)

Member                   Member