Chandigarh

StateCommission

CC/112/2020

Sukhdeep Singh Bhinder - Complainant(s)

Versus

Star Health and Allied Insurance Company - Opp.Party(s)

Jasdeep Singh Walia & Dilraj Singh Bhinder Adv.

16 Aug 2021

ORDER

 STATE CONSUMER DISPUTES REDRESSAL COMMISSION,

U.T., CHANDIGARH

1. Sukhdeep Singh Bhinder S/o Pritpal Singh Bhinder R/o House No. 2376, Sector 65, SAS Nagar, Mohali
2. Parminder Kaur W/o Sukhdeep Singh Bhinder R/o House No. 2376, Sector 65, SAS Nagar, Mohali.

……Complainants

V e r s u s

1. Star Health and Allied Insurance Company, No.15, Sri Balaji Complex, 1st Floor, Whites lane, Royapettah, Chennai, through its Managing Director.
2. Star Health and Allied Insurance Company, SCO 5A, 2^nd Floor Madhya Marg, Sector 7-C, Chandigarh, through its Branch Manager.
3. Star Health and Allied Insurance Company, SCO 236, Sector 20, Main Road Vegetable Market, Panchkula, Haryana, through its Branch Manager.
4. The Grievances Redressal Officer, Corporate Grievance Department, Star Health and Allied Insurance Co. Ltd., No.1, New Tank Street, Valluvar Kottam High Street Road, Chennai, 60034.
5. Fortis Healthcare Limited, Fortis Hospital, Sector 62, Phase 8, SAS Nagar Mohali, through its Managing Director

…..Opposite parties

BEFORE:    JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT.

                   MRS. PADMA PANDEY, MEMBER.

                   MR.RAJESH K. ARYA, MEMBER.

Present through video conferencing:-

                   Sh.Dilraj Singh Bhinder, Advocate for the complainants.

                             Sh.Neeraj Khanna, Advocate proxy for Sh.Ravinder Arora,     Advocate for opposite parties no.1 to 3.

                   Sh.Munish Kapila, Advocate for opposite party no.5.

                   Opposite party no.4 exparte vide order dated 09.07.2021

JUSTICE RAJ SHEKHAR ATTRI, PRESIDENT

                   The facts necessary for disposal of this case are that on 30.11.2018, the complainants, who are husband and wife, respectively, purchased  health insurance policy named ‘Star Family Delite’, Annexure C-2 from opposite parties no.1 to 3. It has been stated that at the time of filling the proposal form, it was duly disclosed by complainant no.1 that he has been suffering from high blood pressure since 2011. The policy in question was valid for the period from 30.11.2018 to 29.11.2019, with coverage of health insurance upto Rs.10 lacs. It is the case of complainant no.1 that on 12/13 January 2019, he suffered breathlessness and as such was taken to Pulse Advanced Heart and Critical Care Centre, Bathinda. It is evident from the discharge summary dated 13.01.2019, Annexure C-3 issued by the said hospital that complainant no.1 was brought on 13.01.2019, with the complaint of breathlessness, where he was admitted and first aid treatment was given to him. Thereafter, he was discharged on the same day. On 14.01.2019, he was taken to Fortis Hospital, Mohali, where he was admitted and his coronary angiography was done. It has been stated that since complainant no.1 has got insurance from opposite parties no.1 to 3, as such, his case was processed by opposite party no. 5 for preauthorization of cashless treatment.

2.           To the utter shock of the complainants, pre-authorization for cashless treatment of complainant no.1 was rejected by opposite parties no.1 to 4 on the ground that, in the report of coronary angiography done at Fortis Hospital on 14.12.2018, it was found that he was having pre-existing disease i.e. triple vessel disease, which fell within 30 days waiting period from commencement of the policy in question. It has been stated that complainant no.1 never visited any hospital before 14.01.2019 for coronary angiography. Later on, it was found that there was a mistake on the part of opposite party no. 5 while preparing the said angiography report of complainant no.1. When this fact was brought to the notice of opposite party no.5, an email was sent by it to opposite parties no.1 to 4 clarifying that coronary angiography of complainant no.1 was done on 14.01.2019 and not on 14.12.2018. However, despite the fact that clarification in that regard was given to opposite parties no.1 to 4, pre-authorization of cashless treatment was again denied by opposite parties no.1 to 4 on the ground that since the disease was chronic in nature, as such, it is required to ascertain admissibility of the claim. Complainant no.1 was given permission to apply for reimbursement of claim amount after treatment. Coronary artery bypass graft Surgery of the heart of complainant no.1 was conducted by Dr.Karun Behal, MBBS, MD, DM (Cardiology), Senior Consultant, Cardiology at opposite party no.5-Hospital, for which, he paid an amount of Rs.4,84,499/- from his pocket. It has been pleaded that thereafter despite the fact that the entire formalities were completed by complainant no.1, yet, opposite parties no.1 to 4 repudiated his claim on 14.06.2019, Annexure C-15, on the ground that CAG report dated 14.12.2018 showed that he was suffering from ‘triple vessel disease’ which was a longstanding cardiac disease; that he  failed to disclose about the same, at the time of obtaining the policy in question; and that the said disease also fell during the first 30 days waiting period from the date of commencement of the policy in question. The pleas taken by the complainants in this regard in para nos.5 to 19 of their complaint are reproduced hereunder:-

‘…..5.  That in emergency condition on 14.01.2019 the complainant no. 1 was shifted from Pulse Hospital Bathinda to Fortis Hospital, Mohali (Opposite Party No.5) transporting by ambulance. On reaching Fortis Hospital, Mohali (Opposite Party No.5) the Complainant No. 1 was admitted and was advised to get done Coronary Angiography.

6.        That as the Complainant No. 1 was insured by the Star Health and Allied Insurance Company so it was brought to the notice of Fortis Management that the Complainant No.1 is having Star health cashless insurance policy and thus the Fortis Management initiated the process of cash less treatment at their end and intimated the claim to the Star Health and Allied Insurance Company (Opposite Party No.1).

7.        That to the utter surprise of the Complainants on 16.01.2019 the Pre-authorization for cashless treatment was rejected by the Star Health Allied and Insurance. Company (Opposite Party No. 1) on the ground that "As per submitted documents, patient underwent angiography in Fortis Hospital on 14.12.2018 showing triple vessel disease, diagnosis fall within 30 days waiting period and prior consultation paper before 14.12.2018 has not been given".

8.        That it is pertinent to mention here that the Complainant No. 1 never visited any hospital prior to intervening night of 12/13.01.2019 and also no angiography was got done before 14.01.2019, rather the date was wrongly mentioned as 14.12.2018 instead of 14.01.2019 in the Coronary Angiography Report of the Complainant No. 1 by the Fortis Hospital staff. Copies of the same Coronary Angiography Reports dated 14.12.2018 and 14.01.2019 are annexed as Annexure C-4 and C-5 respectively. Copy of the pre authorization for cashless treatment rejection dated 16.01.2019 is annexed as Annexure C-6.

9.        That on when the issue of rejection due to error of Fortis Hospital (Opposite Party No.5) was raised with the Fortis Hospital then one justification mail was sent by Fortis Hospital to Star Health and Allied Insurance Company along with certification from Dr. Karun Behal who conducted the Coronary Angiography of the Complainant No. 1 clarifying that the angiography was done on 14.01.2019 and not on 14.12.2018. Copy of the Justification mail along with certification from Dr. Karun Behal dated 16.01.2019 to Star Health and Allied Insurance Company is annexed as Annexure C-7 (Colly).

10.      That again on 17.01.2019 the Pre-Authorization Request for cashless treatment of the Complainant No. 1 was denied by the Star Health and Allied Insurance. Company saying that the disease is of chronic nature and further evaluation is required to ascertain the admissibility of the claim, however the Complainant No.1 was given the permission to apply for re-imbursement after the treatment by applying for the same along with all the requisite documents. Copy of the denial dated 17.01.2019 is annexed as Annexure C-8.

11.      That as the cashless claim was denied by Star and Allied Insurance Company so the Complainants at the time of discharge on 24.01.2019  had to pay the total bill amount of Rs.4,84,499.00/ themselves. Copy of the detailed bill dated 24.01.2019 is annexed as Annexure C-9. It is worth mentioning here that the Complainants arranged such a huge amount with much embarrassment from their relative on interest @18% per month as life of the Complainant No. 1 was in danger due to major heart surgery.

12.      That as it was open for the Complainant to apply for re-imbursement so the Complainants approached the office of the Star Allied and Health Insurance Limited (Opposite Party No. 1) situated at sector 34, Chandigarh (now shifted to sector 7-A, Chandigarh) and applied for re-imbursement by filling the claim form and also handing over all the original documents. Copy of the acknowledgement E-mail dated 22.02.2019 is annexed as Annexure C-10.

13.      That as the Star Health and Allied Insurance Company was not in mood to reimburse the amount paid by Complainants so it dilly dally and on 02.03.2019 Star Health and Allied Insurance Company approached the Complainant No.2 and asked for additional documents so as to enable them to process the claim further. The documents so claimed by the Star Haelth and Allied Insurance were:

a. A letter from the treating doctor stating the duration of CAD

b. Complete medical record of ECG, Echo, TMT CAG reports done prior to this admission.

c. CD for the submitted CAG Reports

d. Serial ECG Reports, Echo and cardiac markers taken on 12.01.2018

e. Complete set of indoor papers taken for both the admission.

f. Complete medical records taken for vocal cord nodule since diagnosed

g. Cash paid receipts in original towards the final bill along with seal and sign.

Copy of the letter dated 02.03.2019 demanding the documents are annexed as Annexure C-11.

14.      That after great difficulty and running from pillar to post when the Complainant received the indoor documents from Fortis Hospital (Opposite Party No. 5) and the same were submitted to the Star Health and Allied Insurance Company having their office at sector 34, Chandigarh and acknowledgment E-mail regarding the same was received on 09.04.2019. Copy of the acknowledgment E-mail along with the documents which were submitted is annexed as Annexure C-12.

15.      That again on 30.04.2019 another request for additional documents was sent by the Star Allied and Health Insurance Company wherein they demanded

a. Post Operative Echo Reports

b. Complete medical record taken in PGI 2016 with complete investigation reports.

Copy of the letter dated 30.04.2019 is annexed as Annexure C-13. It is pertinent to mention here that the Star Health and Allied Insurance Company was harassing the Complainants unnecessarily by demanding documents again and again which were already submitted to them earlier, just to avoid the payments of genuine claim. On one side Heart Specialist advised Complainant No. 1 to take complete rest on the other hand Complainants under the burden of 18% interest were running here and there to collect documents documented by Star Health and Allied Insurance Company time and again.

16.      That again on 27.05.2019 again the Complainant No.2 went to the office of Star Health and Allied Insurance Company situated at Sector 34 (now shifted to sector 7, Chandigarh) and handed over the documents once again along with a letter saying that documents have already been supplied to you on the hope that now their claim will be settled by Star Health and Allied Insurance Company and they will clear their debts.

           Copy of the documents so supplied again to Star Allied and Health Insurance Company are annexed as Annexure C-14.

17.      That even after supplying all the requisite documents and fulfilling all the formalities, to the utter surprise of the Complainants, the insurance claim was ultimately repudiated on 14.06.2019 by giving the reason that the CAG Report dated 14.12.2018, which does not exists, showing triple vessel disease is during the first 30 days from the date of commencement of the policy. The clarification from the hospital regarding the date of angiography is not acceptable.

18.      That it is pertinent to mention here that the Complainant No. 1 had never undergone Angiography before 14.01.2019 and it due to the mistake and error of the Fortis Hospital (Opposite Party No.5) that the Complainants are suffering. So much so by giving this reason that clarification by Hospital is not acceptable the Star Health and Allied Insurance is harassing the Complainants even without any iota of their fault. This is pure deficiency of service on the part of the Star Health and Allied Insurance Company.

19.      That furthermore it is also mentioned in letter dated 14.06.2019 that pre existing condition has not been disclosed before hand to the insurance company but to the contrary same (blood pressure) has been mentioned in the proposal form (Annexure C-1) which was duly filled before taking the said insurance policy and no objection or rejection of proposal form was done by insurance company….’

3.           Hence, this complaint has been filed by the complainants, seeking directions to the opposite parties to reimburse the amount paid by complainant no.1 towards his treatment aforesaid alongwith compensation totaling to Rs.36,22,808/- alongwith interest @18% p.a. from 16.01.2019 till realization.
4.           None put in appearance on behalf of opposite party no.4, as a result whereof it was proceeded against exparte vide order dated 09.07.2021.
5.           The claim of the complainants has been contested by opposite parties no.1 to 3 and 5, on numerous grounds.
6.           Opposite parties no.1 to 3, in their joint written reply admitted the factual matrix of the case with regard to obtaining of insurance policy in question by the complainants on making payment of premium and treatment taken by complainant no.1 in the Fortis Hospital, referred to above. However, it has been stated that this complaint involves complicated questions of law and facts, as such, it be relegated to the civil court; that this Commission did not vest with pecuniary jurisdiction to entertain this complaint; that the policy in question was taken on 30.11.2018 and complainant no.1 took treatment of ‘triple vessel disease’ which was detected on 14.12.2018  i.e. within 30 days waiting period from the date of commencement of the policy in question; that at the time of obtaining the policy in question, complainant no.1 failed to disclose that he was suffering from heart problem; that he has only mentioned in the proposal form that he was suffering from high blood pressure since 2011 and was under medication; that the claim of  complainant no.1 was rejected on the basis of documents provided by opposite party no.5; and that since complainant no.1 was suffering from pre-existing disease, his claim was rightly repudiated by the insurance company. Prayer has been made to dismiss the complaint.
7.           Opposite party no.5 in its written reply admitted the factual matrix of the case to the effect that complainant no.1 was admitted in the Fortis Hospital on 14.01.2019 with the complaint of chest pain; that coronary angiography was conducted upon him on the said date; and that bypass surgery of his heart was also performed by Dr.Karun Behal, MBBS, MD, DM (Cardiology), Senior Consultant, Cardiology at opposite party no.5-Hospital. However, it has been stated that before performing the heart surgery of complainant no.1, the hospital authorities forwarded the angiography report to opposite parties no.1 to 4, wherein, by virtue of typographical error, the date was mentioned thereon as 14.12.2018 instead of 14.01.2019. However, the moment, the said fact came to the notice of opposite party no.5, it immediately rectified the same and forwarded the corrected angiography report after mentioning the date thereon as 14.01.2019. However, when still the preauthorization cashless treatment for complainant no.1 was denied, opposite party no.5 sent email to opposite parties no.1 to 4 stating therein that it is ready to get investigated the matter with regard to typographical error of mentioning the date on the said report, as 14.12.2018 instead of  14.01.2019 but to no avail. It has been stated that after successfully undergoing bypass procedure, complainant no.1 was discharged from the hospital on 24.01.2019, after making payment of Rs.4,84,499/-. It has been pleaded that there is nothing on record to prove that opposite party no.5 was responsible in any manner, with regard to rejection of claim of complainant no.1. Rather, his claim has been rejected on the ground that he was suffering from pre-existing disease. Territorial jurisdiction of this Commission has been disputed by opposite party no.5. Prayer has been made to dismiss the complaint against opposite party no.5.  
8.           The contesting parties have been afforded adequate opportunities to adduce evidence in support of their respective contentions. They have adduced evidence by way of affidavit and also produced numerous documents. Opposite parties no.1 to 3 and 5 also filed their written arguments.
9.           We have heard the contesting parties and have gone through record of the case, including the written arguments filed by opposite parties no.1 to 3 and 5, very carefully.
10.           Following questions arises for consideration in this complaint:-
    1. Whether this Commission is vested with pecuniary and territorial jurisdiction to entertain this complaint?
    2. Whether opposite parties no.1 to 4 are able to prove on record that complainant no.1 was suffering from any preexisting disease before obtaining the policy in question?
    3. Whether the claim of complainant no.1 was rightly repudiated by opposite parties no.1 to 4 or not?
    4. Whether there was any deficiency in providing service to the complainants, on the part of the opposite parties?
    5. Whether complainant no.1 is entitled for reimbursement of the amount paid by him towards the treatment undergone by him or not?
11.           First coming to the objection taken by opposite parties no.1 to 3 to the effect that this Commission did not vest with pecuniary jurisdiction to entertain this complaint, it may be stated here that if the amount spent by complainant no.1 to the tune of Rs.4,84,499/- on his treatment and also the compensation claimed by him in his complaint are clubbed together, the same exceeds Rs.20 lacs and fell below Rs.1 crore. Thus, this Commission has pecuniary Jurisdiction to entertain and decide this complaint, as per CPA 1986, under which this complaint has been filed. Objection taken by the opposite parties no.1 to 3 in this regard stands rejected.
12.           Now we will deal with the objection regarding territorial jurisdiction of this Commission, it may be stated here that it is settled law that even an infinitesimal fraction of a cause of action will be part of the cause of action and confer jurisdiction on the Court/Tribunal/Fora within the territorial limits of which that occurs. In the present case, perusal of letter dated 27.05.2019, Annexure C-14 reveals that the same was sent by complainant no.1 to Chandigarh office of opposite parties no.1 to 4 i.e. at Sector 34, Chandigarh. Not only as above, even email dated 22.07.2019, Annexure C-17 was sent by opposite party no.4 from its office located at SCO Nos.101 to 103, Sector 17-D, Chandigarh, wherein it was informed to complainant no.1 that the company is expressing its inability to consider his claim. Thus, from the documents, referred to above, it is clearly proved that the company was actually and voluntarily residing and carrying on its business, from the said Chandigarh Offices and personally works for gain thereat. As such, objection taken with regard to territorial jurisdiction of this Commission stands rejected. 
13.           Factual matrix of the case i.e. purchase of the policy in question on 30.11.2018 by the complainants; declaration by complainant no.1 at the time of filling the proposal form to the effect that he has been suffering from high blood pressure since 2011; coronary angiography conducted of his heart and bypass surgery performed upon him by the doctors of opposite party no.5-Hospital are not in dispute. However, it is coming out from the record that the claim of complainant no.1 was repudiated by opposite parties no.1 to 4, vide letter dated 14.06.2019, Annexure C-15, relevant part of which is reproduced as under:-

‘…..We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of coronary artery disease (CAD) with TVD, LVEF 26% with mild mitral regurgitation.

It is observed CAG report dated 14.12.2018 shows triple vessel disease. Based on these findings our medical team is of the opinion that insured patient has longstanding cardiac disease i.e. heart disease prior to date of commencement of first year policy and hence it is pre existing disease. The present admission and treatment of the insured patient is for pre existing heart disease. Moreover, the insured patient underwent angiography at Fortis Hospital dated 14/12/2018 showing triple vessel disease which is during the first 30 days from the date of commencement of the policy. The clarification from the hospital regarding the date of angiography is not acceptable.

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, since inception of the policy with the Company on 30/11/2018

We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim

It is brought to your attention that as per the Contract of Insurance, the medical history/health details of the person(s) proposed for insurance are to be disclosed in the proposal form at the time of inception of the policy. Since you have not disclosed the above mentioned pre-existing disease / condition in the proposal form at the time date of commencement of first year policy, it is now incorporated in your policy as pre existing disease/condition by passing endorsement.

The above decisions are taken as per the terms and conditions of the policy and based on the claim details documents submitted…..’

14.           From the bare perusal of contents of repudiation letter extracted above, it is evident that the claim of  complainant no.1 was repudiated on following grounds:-

1. that complainant no.1 underwent angiography at Fortis Hospital on 14.12.2018 showing ‘triple vessel disease’ which date falls within the waiting period of 30 days of commencement of the policy in question;

2.  that clarification of opposite party no.5-Hospital regarding the date of angiography as 14.01.2019 instead of what was earlier mentioned by it as 14.11.2018 in the medical record pertaining to complainant no.1 is not acceptable.

3. that complainant no.1 was suffering from pre-existing heart disease, prior to commencement of the policy in question whereas on the other hand, as per clause 3 (iii) of the policy any claim of pre-existing disease was not payable until 48 months of continuous coverage has elapsed from inception of the said policy dated 30/11/2018, which date comes to 29.11.2021.

hey   failed   to   understand,   as   to   how,   the   patient/

insured/complainant, who was admitted in a serious condition, referred to

above and was struggling between life and death, could be held responsible

for mismatch of the medical reports and records maintained by the treating

doctor   and   hospital.  It   is   significant   to   mention   here   that   the   treating

doctor/opposite  party   no.5  is   the  prime   person  who   has  to   oversee  this

process   and   is   primarily   responsible   for   history,   physical   examination,

treatment   plans,   operative   records,   consent   forms,   medications   used,

referral papers, discharge records, and medical certificates of the patient.

There should be proper recording of nursing care, laboratory data, reports of

diagnostic evaluations, pharmacy records, and billing processes.  However,

in the present case, it appears that opposite parties no.4 and 5 have failed

to perform their duties.

hey   failed   to   understand,   as   to   how,   the   patient/

insured/complainant, who was admitted in a serious condition, referred to

above and was struggling between life and death, could be held responsible

for mismatch of the medical reports and records maintained by the treating

doctor   and   hospital.  It   is   significant   to   mention   here   that   the   treating

doctor/opposite  party   no.5  is   the  prime   person  who   has  to   oversee  this

process   and   is   primarily   responsible   for   history,   physical   examination,

treatment   plans,   operative   records,   consent   forms,   medications   used,

referral papers, discharge records, and medical certificates of the patient.

There should be proper recording of nursing care, laboratory data, reports of

diagnostic evaluations, pharmacy records, and billing processes.  However,

in the present case, it appears that opposite parties no.4 and 5 have failed

to perform their duties.

They   failed   to   understand,   as   to   how,   the   patient/

insured/complainant, who was admitted in a serious condition, referred to

above and was struggling between life and death, could be held responsible

for mismatch of the medical reports and records maintained by the treating

doctor   and   hospital.  It   is   significant   to   mention   here   that   the   treating

doctor/opposite  party   no.5  is   the  prime   person  who   has  to   oversee  this

process   and   is   primarily   responsible   for   history,   physical   examination,

treatment   plans,   operative   records,   consent   forms,   medications   used,

referral papers, discharge records, and medical certificates of the patient.

There should be proper recording of nursing care, laboratory data, reports of

diagnostic evaluations, pharmacy records, and billing processes.  However,

in the present case, it appears that opposite parties no.4 and 5 have failed

to perform their duties.

They   failed   to   understand,   as   to   how,   the   patient/

insured/complainant, who was admitted in a serious condition, referred to

above and was struggling between life and death, could be held responsible

for mismatch of the medical reports and records maintained by the treating

doctor   and   hospital.  It   is   significant   to   mention   here   that   the   treating

doctor/opposite  party   no.5  is   the  prime   person  who   has  to   oversee  this

process   and   is   primarily   responsible   for   history,   physical   examination,

treatment   plans,   operative   records,   consent   forms,   medications   used,

referral papers, discharge records, and medical certificates of the patient.

There should be proper recording of nursing care, laboratory data, reports of

diagnostic evaluations, pharmacy records, and billing processes.  However,

in the present case, it appears that opposite parties no.4 and 5 have failed

to perform their duties.

15.           For adjudicating the above issues, we will first like to find out, as to on which date, complainant no.1 underwent coronary angiography at the Fortis Hospital. It may be stated here that it is the definite case of  complainant no.1 that since he suffered breathlessness, on 13.01.2019, as such, on the very same day, he was for the first time taken to Pulse Advanced Heart and Critical Care Centre, Bathinda, where he was given first aid. Thereafter, on 14.01.2019, he was shifted to the opposite party no.5-Hospital where he was admitted and coronary angiography was performed upon him on 14.01.2019, by Dr.Karun Behal, MD, DM (Cardiology), Senior Consultant, Cardiology.

                   We have perused the record of the paper book of this complaint, wherefrom it is coming out that, in the first instance, Dr.Karun Behal of Fortis Hospital, issued coronary angiography report Annexure C-4 in respect of complainant no.1 showing the date thereon as 14.12.2018, which was infact a typographical mistake, as a result whereof, when the same was submitted to opposite parties no.1 to 4 for pre-authorization cashless, the same had been rejected on the ground that it falls within the first 30 days waiting period of commencement of the policy in question. However, when the matter was taken up by the complainants with opposite party no.5-Hospital, the said typographical mistake was rectified by Dr.Karun Behal and corrected coronary angiography report dated 14.01.2019, Annexure C-5 was provided to opposite parties no.1 to 4. Even letter (at page 73 of the paper book) was also sent by opposite party no.5 to opposite party no.1 to 4 in that regard and it was also mentioned therein that the insurance company can send its investigator to investigate the matter, if required. Apart from it, Dr.Karun Behal also provided a certificate dated 16.01.2019 (at page 74 of the paper book) stating therein that coronary angiography of complainant no.1 was done only on 14.01.2019. However, it is further coming out from the record that despite the fact that the Doctor concerned, had clearly brought to the notice of opposite parties no.1 to 4 through the documents, referred to above, with regard to the typographical error of mentioning wrong date aforesaid on coronary angiography report of complainant no.1, yet, they miserably failed to accept the same and were enthusiastic on repudiating his claim.

16.           It is very significant to mention here that complainant no.1 was the patient of opposite party no.5, who had undergone bypass surgery there. He was having no control on the medical records/reports/tests being conducted upon him, during the period he was struggling with life. It was the doctors concerned and the medical staff who are duty bound to oversee this process and are primarily responsible for history, physical examination, treatment plans, operative records, consent forms, medications used, referral papers, discharge records, and medical certificates of the patient. There should be proper recording of nursing care, laboratory data, reports of diagnostic evaluations, pharmacy records, and billing processes.  Thus, in the present case, if the doctor or the medical staff of opposite party no.5-Hospital, in the first instance, provided a report with the wrong date, though it was rectified later on, in the manner, referred to above, we fail to understand, as to how, the patient/insured/complainant no.1, who was admitted in a serious condition and was struggling between life and death, could be held responsible for the same.  It is therefore held that once opposite party no.5 has clearly admitted its mistake of mentioning wrong date on the coronary angiography report of complainant no.1 as 14.12.2018 instead of actual date as 14.01.2019 and the same had been conveyed by it, to opposite parties, no.1 to 4 through various documents, referred to above, then there was no reason with the insurance company to deny preauthorization for cashless treatment to complainant no.1. Thus, this Commission is not hesitant to hold that coronary angiography was conducted upon complainant no.1 by Dr.Karun Behal on 14.01.2019 and not on 14.12.2018. By rejecting the preauthorization for cashless treatment to complainant no.1 on the ground that he underwent coronary angiography at Fortis Hospital on 14.12.2018 showing ‘triple vessel disease’ which date falls within the first 30 days waiting period of commencement of the policy in question, opposite parties no.1 to 4 were deficient in providing service to him.
17.           The next question that falls for consideration is, as to whether, complainant no.1 was suffering from any pre-existing heart disease, prior to commencement of the policy in question or not?. It may be stated here that opposite parties no.1 to 4 have failed to produce on record even an iota of evidence to  convince this Commission that complainant no.1 was suffering from any pre-existing heart disease, prior to commencement of the policy in question or before 14.01.2019, when coronary angiography was performed upon him. Not even a single document has been placed on record to prove that complainant no.1 got treatment of any disease relating to his heart, from any other hospital before obtaining of the policy in question. None of  the reports placed on record, issued by the Pulse Advanced Heart and Critical Care Centre, Bathinda, or by opposite party No.5 reveal that  complainant no.1 took any treatment for his heart before 13.01.2019 or before obtaining the policy in question, from any of the hospital. Even in the written reply filed by opposite party no.5 it has no where been mentioned by it that complainant no.1 had taken any treatment of his heart from any other hospital before 13/14.01.2019. Furthermore, there is nothing on record to prove that the insured was aware of his heart ailment. It is also not imaginable that though he was aware of his heart ailment but he waited for the treatment thereof, till he obtained the insurance cover and took the risk of his death. Normally, the burden of proving the facts lies on the party who is leveling the allegations. A plea taken in the written statement/reply cannot be countenanced without documentary evidence. Thus, though, in the coronary angiography report of complainant no.1 it has been written ‘triple vessel disease’ but that fact is not sufficient for this Commission to draw an adverse inference that he was in his knowledge that he was suffering from pre-existing disease.
18.           It is significant to mention here that complainant no.1 is a senior citizen aged 63 years, when he took treatment and at the time of obtaining the policy in question, he was honest enough to bring to the notice of opposite parties no.1 to 4 that he was suffering from high blood pressure, which fact has not been disputed by opposite parties no.1 to 3.  Thus, when he was detected to be suffering from ‘triple vessel disease’ for the first time on 14.01.2019 and also there is nothing on record that he was in the knowledge of the said fact or was taking any treatment for the same, as such, it cannot be held that there was any concealment on his part. Opposite parties no.1 to 4 cannot deny the claim of complainant no.1, on mere presumption that he might be suffering from a pre-existing disease. Not even an iota of evidence in the shape of any report of the doctor has been placed on record by opposite parties no.1 to 3 to prove their case. A similar controversy came for adjudication before the Hon’ble National Commission in Praveen Damani v. Oriental Insurance Co. Ltd. , IV (2006) CPJ 189 (NC), wherein also when coronary angiography was conducted upon the insured, he was detected as ‘Triple Vessel Disease’.  His claim was rejected by the insurance company holding that it was a pre-existing disease, as such, he was excluded from the insurance cover stating that he deliberately suppressed this fact. The Hon’ble National Commission allowed the revision petition filed by the insured by holding that there is nothing on record to prove that the insured was aware of the heart ailment and that if in reality, had he been aware, he would not have waited for its treatment till he obtains the insurance cover, and take the risk of death. Relevant part of the said order reads as under:-

“…..In our view, the Insurance Company has erroneously relied on the certificate of Dr. Aggarwal because it was based on medical texts and not based on the reports as the case papers were not given to him for reasons best known to them. He gave the final opinion only in the year 2003 after the Insurance Company sent the case papers of the Complainant. The report Dr. Aggarwal gave on 10.1.2003 also assumes that the Complainant must have had treatment elsewhere is not proved by him or by the Insurance Company. We cannot rely on such assumptions and presumptions of experts. He has not seen nor examined the insured and hence he cannot say that the insured was having knowledge of heart disease. The other expert Dr. Farishta also did not conclusively opined as to how long the Complainant suffered the disease, as ECG and TMT reports were not given to him. We have to rely on the documentary evidence produced by the Complainant which is not disproved by the Insurance Company.

Hence, in our view, the Insurance Company has erroneously repudiated the claim by relying upon the so-called certificates of Dr. Aggarwal and Dr. A. Farishta to whom they have paid fees. None of the aforesaid certificates by Doctors would establish that the insured was aware of the heart ailment. If, in reality, had he been aware, he would not have waited for its treatment till he obtains the insurance cover, and take the risk of death.

The District Forum also relied on Clause 4.1 of the policy which states that it is not material whether the insured had knowledge of the disease or not, and even existence of symptoms of the disease prior to effective date of insurance enables the Insurance Company to disown the liability.

If this interpretation is upheld, the Insurance Company is not liable to pay any claim, whatsoever, because every person suffers from symptoms of any disease without the knowledge of the same. This policy is not a policy at all, as it is just a contract entered only for the purpose of accepting the premium without the bonafide intention of giving any benefit to the insured under the garb of pre-existing disease. Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the Insurance Company relies on their Clause 4.1 of the policy in a malafide manner to repudiate all the claims. No claim is payable under the mediclaim policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him which he is genuinely unaware of them. Hindsight everyone relies much later that he should have known from some symptom. If this is so every person should do medical studies and further not take any insurance policy. Even on the facts on record, there is no material to show that the Petitioner had any symptoms like chest pain etc. prior to 11.8.2000.

Since there were no symptoms, the question of linking up the symptoms with a disease does not arise. In any case, it is the contention of the Complainant that he was thoroughly checked up by the Doctors who were nominated by the Insurance Company and at that time he was found hale and hearty. In such set of circumstances, it would be difficult to arrive at the conclusion that the insured had suppressed the pre-existing disease.

 In view of the above discussion and from the records available before us, in our opinion, the Complainant has proved that he was unaware of the disease at the time of taking the policy and hence the Complaint is allowed.

In the result, we set aside the orders of the State Commission and the District Forum. The Insurance Company is directed to pay Rs.1,38,691/- with interest @ 9% p.a. from 1.7.2002 till the date of payment alongwith Rs.10,000/- as costs to the Complainant within four weeks from the receipt of this order…..”

19.           Thus, in the present case also, even if complainant no.1 was, for the first time, deducted by opposite party no.5-Hospital on 14.01.2019, that he was suffering from ‘triple vessel disease’ but  since there is nothing on record that he was in the knowledge of the same or was taking any treatment for the same, as such, his claim was illegally and arbitrarily denied by opposite parties no.1 to 4.  

                   Even otherwise, as stated above, when the policy in question was sold to complainant no.1, he was aged 63 years. It is commonly seen that if a person is at the age of 60 years or older, and having , it can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications, etc. depending upon varied factors. That implies that there is probability of such ailments. Thus, if, at the time of accepting the proposal form, the insured clearly brought to the notice of opposite parties no.1 to 4 that he is suffering from high blood pressure but even then they preferred not to get him medically examined to washout the possibility of any heart disease or any other disease relating to the heart or otherwise, the insured/ complainant no.1 would assume and perhaps, reasonably that later unforeseen ailments would be covered. Opposite parties no.1 to 4 could have got conducted complete medical check of complainant no.1 at the time of selling the policy in question but they did not prefer to do so. As such, when opposite parties no.1 to 4 themselves preferred not to get medical checkup of the complainants (senior citizens), especially, when it had been brought to their notice that complainant no.1 is suffering from high blood pressure since 2011, as such, now they cannot deny his claim, on the ground that he was suffering from pre-existing disease, especially, when nothing has been placed on record to prove that he was in the knowledge that he is suffering from the said disease. Thus, we are of the considered view that by repudiating the genuine claim of complainant no.1 on the ground that he was suffering from pre-existing heart disease, prior to commencement of the policy in question, opposite parties no.1 to 4 also indulged into unfair trade practice, which has caused him lot of mental agony and harassment. 

20.           Regardless of what we hear on national television advertising, an insurance company is neither on the insured side nor the insured is in good hands. That is because an insurance company is a for-profit business. An insurance company does not exist to pay the insured, as much money as possible. Their business model is to pay the insured nothing at all or as little money as legally possible. Thus, in our considered view, in the present case, opposite parties no.1 to 3 have failed to make out their case, of any pre-existing disease suffered by complainant no.1 or concealment of facts with regard to the same by him, at the time of obtaining the policy in question. The refusal by opposite parties no.1 to 4, to process and reimburse the claim of complainant no.1 is arbitrary and perverse.  Complainant no.1 is therefore held entitled to get the entire amount spent by him from his own pocket, for taking treatment at opposite  party no.5-Hospital.
21.           Now coming to the liability of opposite party no.5, it may be stated here that it has been clearly stated by opposite parties no.1 to 3 that the claim of complainant no.1 was rejected by them solely on the basis of documents provided by opposite party no.5, wherein it was stated that coronary angiography was performed him on 14.12.2018 instead of correct date as 14.01.2019. Though, later on, opposite party no.5 issued clarification in that regard to the insurance company/opposite  parties no.1 to 4, but it cannot be disputed that the root cause of rejection of claim of  complainant no.1 was the  result of negligent and careless act of opposite party no.5. In the present case, improper record keeping has resulted in declining claim of complainant no.1 by opposite parties no.1 to 4. Medical records include a variety of documentation of patient's history, clinical findings, diagnostic test results, preoperative care, operation notes, post operative care, and daily notes of a patient's progress and medications. An undated/incorrect date(s) on the medical records/reports can land the insured in a trouble, as has also been seen in the present case. There are also many records that are indirectly related to patient management such as accounts records, service records of the staff, and administrative records, which are also useful as evidences for litigation purposes. The doctor is the prime person who has to oversee this process and is primarily responsible for the same. In the present case, the staff/doctor(s) of opposite party no.5 failed to work with due diligence, as a result whereof, complainant no.1 was made to suffer and his genuine claim has been rejected and still he is struggling for getting his money back. He was deprived of the cashless treatment for which he was legally entitled to and on the other hand, had to pay the same from his own pocket, which has certainly caused him mental agony, harassment and financial loss. Under these circumstances, to deprecate the callous attitude adopted by opposite party no.5 and also with a view that no other person like the complainant no.1 should suffer in future, we impose penalty of Rs.50,000/-  upon the said hospital-opposite party no.5, to be paid to complainant no.1, which will meet the ends of justice. 
22.           As far as plea taken by opposite parties no.1 to 3 to the effect that complicated questions of law and facts are involved in this case and that the same needs to be relegated to the civil court, it may be stated here that it is a simple case, wherein, the opposite parties no.1 to 4 were deficient in providing service, negligent and  also adopted unfair trade practice by rejecting the genuine claim of  complainant no.1, on vague grounds. As stated above, neither, it has been proved that complainant no.1 was suffering from any pre-existing disease nor it has been proved that he took any treatment from any hospital prior to 13/14.01.2019. At the same time, despite the fact that the treating Doctor of opposite party no.5-Hospital conveyed opposite parties no.1 to 4, in writing, that there was typographical error in mentioning the date on his coronary angiography report as 14.12.2018 instead of 14.01.2019, yet, they did not accept the same without assigning any reasons. At the same time, opposite party no.5 also adopted callous attitude in issuing the coronary angiography report of complainant no.1 with incorrect date, which resulted into rejection of his claim. Thus, all these inactions on the part of the opposite parties amount to deficiency in rendering service, negligence and adoption of unfair trade practice, for which the complainants were well within their right to file this consumer complaint. As such, no complicated questions of law and facts are involved in this case and, therefore, plea taken by opposite parties no.1 to 3 in this regard stands rejected.
23.           For the reasons recorded above, this complaint is partly accepted with costs as under:-
    1. Opposite parties no.1 to 4 shall reimburse the entire amount to complainant no.1, spent by him on his treatment at opposite party no.5-Hospital alongwith interest @9% p.a. from the date of filing of this consumer complaint, within a period of 15 days from the date of receipt of certified copy of this order, failing which the same shall carry penal interest @12% p.a. from the date of default till realization.
    2. Opposite parties no.1 to 4 shall pay compensation to the tune of Rs.2 lacs for deficiency in providing service and adopting unfair trade practice, in rejecting the genuine claim of complainant no.1, on vague grounds despite the fact that clarification in that regard was given to them by opposite party no.5, thereby causing him mental agony, harassment and financial loss.
    3. Opposite party no.5 shall pay compensation to the tune of Rs.50,000/- to complainant no.1, for its callous approach and negligence in maintaining record/report aforesaid,  which resulted into rejection of his claim by opposite parties no.1 to 4, within a period of 30 days from the date of receipt of certified copy of this order, failing which the same shall carry interest @9% p.a. from the date of default till realization. 
    4. Opposite parties no.1 to 5, jointly and severally, shall pay cost of litigation to the tune of Rs.35,000/- to complainant no.1 within a period of 30 days from the date of receipt of certified copy of this order, failing which the same shall carry interest @9% p.a. from the date of default till realization. 

24.           Certified copies of this order be sent to the parties, free of charge.
25.           The file be consigned to Record Room, after completion.

Pronounced

16.08.2021

Sd/-

[JUSTICE RAJ SHEKHAR ATTRI]

PRESIDENT

Sd/-

 (PADMA PANDEY)

          MEMBER

Sd/-

(RAJESH K. ARYA)

 MEMBER

 Rg.