BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 103 of 2021
Date of Institution : 03.05.2021
Date of Decision : 24.05.2023
Kuldeep Singh, aged 48 years, son of Shri Dara Singh, resident of village Bhiwan, Tehsil and District Sirsa.
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Ltd., Branch Office: Ground Floor, Opp. Shakti Motors, Near IDBI Bank, Sirsa, Tehsil and District Sirsa, through its Branch Manager.
2. Star Health and Allied Insurance Company Ltd., Regd. Office: 1, New Tank Street, Valluyer Kottam High Road, Nungambakkam, Chennai- 600 034, through its authorized signatory.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
Present: Sh. Vishnu Bhagwan, Advocate for the complainant.
Sh. Ravinder Goyal, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint 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 complainant had purchased health insurance policy from ops for sum insured amount of Rs. five lacs for himself and his wife Smt. Birpal Kaur for the period 21.08.2019 to 20.08.2020 vide policy No. P/211121/01/2019/ 001838, renewal endorsement No. P/211121/01/2020/002536. The complainant has been obtaining the said health policy from ops since 17.08.2017. It is further averred that on 28.11.2019, wife of complainant Smt. Birpal Kaur developed pain in her right knee and was taken to Nagpal Super Specialty Hospital, Bathinda where she was hospitalized and remained admitted there as indoor patient. She was discharged from hospital on 2.12.2019 and a sum of Rs.1,70,854/- was incurred by him in her treatment and after discharge, a sum of Rs.7264/- has been incurred on follow up treatment. The wife of complainant is still under treatment and more amount will be required for her treatment. It is further averred that claim lodged by complaint has been repudiated on the ground of pre existing disease to his wife which is wrong and illegal because before issuance of policy, she was got medically checked up by the ops through their empanelled doctor and after fully satisfying them with her medical condition, policy was issued. That the ops by their such act and conduct have been indulged in unfair trade practice and have committed gross deficiency in service towards the complainant and have caused unnecessary harassment. Hence, this complaint.
3. On notice, ops appeared and filed written version raising certain preliminary objections. It is submitted that on scrutiny of the cashless claim documents received to the company, the Medical Team observed that “Further evaluation required to ascertain the exact onset”. Hence cashless was rejected for diagnosed disease which was conveyed to the insured vide letter dated 28.11.2019. Further from the X-ray report dated 27.11.2019 submitted during cashless processing showed severe grade IV Osteoarthritic changes with significant ostophytes formation with obliteration of joint spaces. Based on these findings, the medical team of the company was of the opinion that the insured patient has chronic, longstanding disease existing prior to inception of the first medical insurance policy. Hence, the above diagnosis was a pre existing disease and admission and treatment was for pre existing disease. It is further submitted that as per waiting period 3(iii) of the policy issued to the complainant, the company is not liable to make any payment in respect of expenses for treatment of the pre existing disease/ condition until 48 months of continuous coverage has elapsed prior to date of commencement of first year policy on 17.08.2017. Therefore, on the above ground, the claim was repudiated by ops vide letter dated 1.1.2020 in a legal and lawful manner as per terms and conditions of the policy. Remaining contents of complaint are also denied and prayer for dismissal of complaint made.
4. The complainant in evidence has tendered his affidavit Ex. CW1/A and copies of documents Ex. C1 to Ex.C24 and also affidavit of Smt. Birpal Kaur as Ex.C25.
5. On the other hand, ops have tendered affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex.R1 and copies of documents Ex.R2 to Ex.R15.
6. We have heard learned counsel for the parties and have gone through the case file carefully.
7. There is no dispute of the fact that complainant has been obtaining health policy in question from the opposite parties since 17.08.2017. The policy in question was purchased by complainant for the first time from the ops for the period 17.08.2017 to 16.08.2018 against the premium amount of Rs.15,706/- whereby he alongwith his wife Smt. Birpal Kaur was insured for the sum insured amount of Rs.5,00,000/- as is evident from page no.2 of Ex.C1. Then the said policy was got renewed by the complainant from the ops for the period 21.08.2018 to 20.08.2019 after paying requisite premium amount of Rs.15,706/- whereby he alongwith his wife were insured for the amount of Rs.6,25,000/- i.e. basic floater sum insured amount of Rs.5,00,000/- and bonus of Rs.1,25,000/- as is evident from page no.2 of Ex.C2. Subsequently also the complainant got renewed the policy in question from the ops for the period 21.08.2019 to 20.08.2020 after paying premium amount of Rs.15,706/- and complainant and his wife were insured for the amount of Rs.,6,75,000/- i.e. basic floater sum insured amount of Rs.5,00,000/- with bonus of Rs.1,75,000/- as is evident from page no.2 of the Ex.C3. Then policy was also got renewed by the complainant for himself and his wife for the period 27.08.2020 to 26.08.2021 after payment of premium amount of Rs.15,706/- and limit of coverage was given as Rs.7,25,000/- i.e. basic floater sum insured amount of Rs.5,00,000/- and bonus of Rs.2,25,000/- as is evident from second page of Ex.C5. It is proved on record from the above said documents placed on file by complainant as well as also placed on file by ops themselves that the policy in question was continuously got renewed.
8. The complainant has sought reimbursement of medical expenses of Rs.1,70,854/- and Rs.7264/- incurred on the treatment of his wife Smt. Birpal Kaur insured from the ops as she was surgically operated at Nagpal Super Specialty Hospital, Bathinda due to pain in her right knee. According to the complainant, on 28.11.2019 his wife Birpal Kaur developed pain in her right knee and was taken to above said hospital and remained admitted there as indoor patient from 28.11.2019 to 2.12.2019 and was operated upon. However, the claim submitted by the complainant has been repudiated by the ops vide letter dated 01.01.2020 Ex.C24 on the ground that there was pre existing disease to the wife of complainant. The ops also rejected cashless request of the complainant. The ops have rejected the claim of the complainant vide repudiation letter dated 01.01.2020 mentioning there that “X-ray report dated 27.11.2019 submitting during cashless processing shows severe grade IV osteoarthritis changes with significant ostophytes formation with obliteration of joint spaces. Based on these findings, our medical team is of the opinion that the insured patient has chronic, longstanding disease, existing prior to inception of the first medical insurance policy. Hence, the above diagnosis is a pre existing disease. The present admission and treatment of the insured patient is for pre existing disease. As per Waiting Period. 3 (iii) of the policy issued to you, the Company is not liable to make any payment in respect of expenses for treatment of the pre existing disease/ condition, until 48 months of continuous coverage has elapsed, prior to date of commencement of first year policy on 17.08.2017.” However, the ops have wrongly and illegally repudiated the claim of the complainant in a very arbitrary manner. The ops in order to justify the repudiation of the claim of complainant has relied upon a photostat copy of document i.e. opinion of Dr. B. Pasupathy, Professor of Orthopedics Madras Medical College as Ex.R14 in which it is mentioned that the said disease is not possible to exist in two months period and this degenerative condition must exist for few years period. The ops have repudiated the claim of complainant on their own assumptions and presumptions only. It may be correct that the disease suffered by wife of complainant may not exist in two months period as mentioned by the doctor of the ops but it cannot be said at all that same is a pre existing disease prior to the purchase of policy in question which was purchased on 17.08.2017. The ops have failed to prove on record through any cogent and convincing evidence that disease of right knee of the wife of complainant was prior to the purchase of the policy in question i.e. 17.08.2017 i.e. a pre existing disease. The wife of complainant took treatment for the said disease only from 28.11.2019 and was operated upon for the said disease only thereafter and same cannot at all be said that it was a pre existing disease. Moreover, before issuance of the policies in question to the complainant and his wife, Smt. Birpal Kaur insured was got medically checked up/ examined by the ops through their empanelled doctor and the ops after fully satisfying about her medical condition issued the policy in question from 17.08.2017 and now they cannot take the plea of pre existing disease to Smt. Birpak Kaur. Therefore, ops have wrongly and illegally repudiated the genuine claim of the complainant. The complainant has been purchasing health insurance policy from the ops for a such long period i.e. since 17.08.2017 and has been spending huge amounts on the premiums for purchasing health insurance policy and at the time of taking premium amounts, the ops have not raised any such objection but when it was their turn to make reimbursement of the medical expenses incurred by complainant for the treatment of insured Birpal Kaur wife of complainant taken in the month of November, 2019 i.e. during the subsistence of the policy in question, the ops have repudiated the genuine claim of complainant on such a false, frivolous and lame excuse which clearly shows unethical attitude of the ops. The complainant is entitled to reimbursement of the amounts of Rs.1,70,854/- and Rs.7264/- spent by him on the treatment of his wife Smt. Birpal Kaur insured from ops for her treatment vide receipts/ bills Ex. Ex.C11 to Ex.C20. The authority 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 also judgment of Hon’ble State Commission Chandigarh 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.
9. In view of our above discussion, we allow the present complaint and direct the opposite parties to reimburse the total amount of Rs.1,78,118/- 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 receive the said amount of Rs.1,78,118/- alongwith interest @6% per annum from the date of this order till actual payment. We also direct the ops to further pay a sum of Rs.10,000/- as compensation for harassment to the complainant and also to pay a sum of Rs.5000/- as 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: 24.05.2023. District Consumer Disputes
Redressal Commission, Sirsa.
JK
