Punjab

Ludhiana

CC/20/86

Aman Kumar - Complainant(s)

Versus

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

J.S.Sibal Adv.

06 Sep 2021

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:86 dated 06.03.2020.                                                

Date of decision: 06.09.2021. 

 

Aman Kumar son of Sh. Dev Raj, R/o. H. No.830, St. No.5/3, Harcharan Nagar, Near Samrala Chowk, Ludhiana.                                                                                                                                                          ..…Complainant

                             Versus

1. Star Health and Allied Insurance Co. Ltd., Registered and Corporate office: 1, New Tank Street, Valluvar Kottam High Road, Nugambakkam, Chennai-600034 through its CEO/M.D./Director/authorized signatory/Manager.
2. Star Health & Allied Insurance Co. Ltd., Branch Office-Ludhiana-II, SCO-17,18,19, 2^nd Floor, Jhandu Tower, Miller Ganj, G.T. Road, Ludhiana, through its CEO/M.D/Director/authorized signatory/Manager.                                                                                                                                                …..Opposite parties 

 

Complaint under Section 12 of the Consumer Protection Act, 1986.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainants            :         Sh.  J.S. Sibal, Advocate.

For OPs                         :         Sh. Rajeev Abhi, Advocate.

 

ORDER

PER K.K. KAREER, PRESIDENT

1.                Simply put, the case of the complainant is that he purchased a cashless accident and health insurance policy bearing No.P/211218/01/2019/009445 dated 01.03.2018, which was valid up to 28.02.2019. The policy was got renewed up to 29.02.2020. The wife and children of the complainant were also covered in the policy. On 14.10.2019, the complainant fell down in his office and felt sever pain in his right elbow. The complainant was admitted in Mohandai Oswal Hospital, Ludhiana for the treatment of the injury. The complainant also applied for cashless claim as per norms of the policy, which was not allowed. The complainant was diagnosed as Distal Humerus as ICA Extension, which means there was a break in the lower end of the upper arm bone, one of three bones that come together to form the elbow joint. It is also known as Distal Humerus Fracture. During the course of treatment, the plating was done by the doctors on 15.10.2019. The complainant remained under treatment at Mohandai Oswal Hospital till 19.10.2019. The claim lodged by the complainant was rejected by the OPs on the ground that at the time of inception of the policy he did not disclose the pre-existing disease i.e. ITP (Immune Thrombocytopenic Purpura). However, the said disease has no co-relation with the fall of the complainant. As a result, the complainant was constrained to pay the amount of Rs.2,45,420/-  to the hospital. Dr. Parveen Gupta, MS (Ortho) MCH (Ortho), specialist in Joint Replacement and Trauma of Mohandai Hospital, Ludhiana apprised the complainant of the fact that ITP has no co-relation with the fall of the complainant and in this regard, the said doctor also issued a certificate dated 23.01.2020. In this manner, the genuine claim of the complainant has been repudiated on the false and frivolous grounds which amounts to deficiency of service and unfair trade practice on the part of the OPs. The complainant got served a legal notice dated 14.02.2020 through Sh. J.S. Sibal, Advocate, but despite that the claim was not disbursed. In the end, it has been requested that the OPs be directed to pay the claim amount of Rs.2,45,420/- along with interest @12% per annum and compensation of Rs.2,00,00/-.

2.                The complaint has been resisted by the OPs. In the written statement, it has been pleaded that the complaint is not maintainable. According to the OPs, on receipt of the claim, it was registered and processed. No regular claim for reimbursement of the medical expenses after discharge of the complainant Aman Kumar from the hospital has been lodged till date. The complainant had obtained family health optima insurance policy covering the complainant, his wife Ritu and children namely Tanishika and Aryan Kumar for a sum of Rs.3,00,000/-. The policy was taken on 01.03.2018 and was renewed on 01.03.2019 up to 29.02.2020. The terms and conditions of the policy were issued to the complainant at the time of proposing the policy. The claim was reported in the second year of the policy towards the treatment of dislocation of RT elbow at Mohandai Oswal Hospital. The complainant was admitted on 14.10.2019. A request for pre-authorization of cashless treatment of Rs.90,500/- was received and as per the submitted cashless documents, an amount of Rs.20,000/- was initially approved on 14.10.2020. Later on, the complainant approached for enhancement of pre-authorization and based on the submitted documents, the pre-authorization was withdrawn and authorization for cashless treatment was rejected vide letter dated 19.10.2019 on the ground that the insured had been suffering from ITP since 2016. The insured had ITP prior to the policy and therefore, it was a pre-existing disease, which was not disclosed in the proposal form. It has further been pleaded that even though the current ailment is not is not related to ITP, it is the duty of the insured to disclose the material facts in the proposal form at the time of inception of the policy and hence the cashless claim was rejected. Thereafter, the complainant has not submitted any bills for reimbursement so far. The complainant was well aware of his past medical history, but he did not disclose the same in the proposal form which amounts to violation of cardinal principle of insurance, making the contract of insurance void and unenforceable. The rest of the averments made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

3.                In evidence, the complainant submitted his affidavit as Ex. CA along with documents Ex. C1 to Ex. C39 and closed the evidence.

4.                On the other hand, the OPs submitted affidavit Ex. RA of Sh. Rajiv Jain, Chief Manager of OPs along with documents Ex. R1 to Ex. R11 and closed the evidence.

5.                We have heard the learned counsel for the parties and have also gone through records.

6.                During the course of arguments, the counsel for the complainant has contended that the claim has been declined on false and frivolous grounds. The complainant remained under treatment at Mohandai Oswal Hospital, Ludhiana from 14.10.2019 to 19.10.2019. He was operated upon 15.10.2019 whereby plating was done. The complainant was diagnosed to be suffering from Distal Humerus which is not a pre-existing disease. Therefore, the repudiation of the claim is not justified at all.

7.                On the other hand, the counsel for the OPs has argued that no claim has been lodged by the complainant nor any bills have been submitted. Therefore, the complaint is pre-mature. The counsel for the OPs has also contended that the claim for cashless treatment was repudiated on the ground that the complainant was suffering from ITP since 2016, but this fact was not disclosed in the proposal form Ex. R1. The counsel for the complainant has further referred to Field Visit Report wherein the complainant is referred to be a known case of Thrombocytopenia since 2016 with HTN. The counsel for the OPs has further referred to letter Ex. R8 whereby the approval for pre-authorization previously given was rejected on the ground that the insured patient had been suffering from ITP since 2016, which is prior to the inception of the policy and this fact was not disclosed by the insured in the proposal form at the time of inception of the policy. In these circumstances, according to the counsel for the OPs, the request for pre-authorization of the claim has been rightly rejected. In support of his arguments, the counsel for the relied upon Life Insurance Corporation of India Vs Piari Devi and others in II(2008) CPJ 156 decided by Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh whereby it has been held that if major disease is not disclosed while filling proposal form, it amounts to fraudulent suppression of material facts and in the given circumstances, the repudiation was justified. The counsel for the OPs has further relied upon case title Satwant Kaur Sandhu Vs New India Assurance Company Ltd. IV(2009) CPJ 8 (SC) passed by Hon’ble Supreme Court of India whereby it has been held that if the policy holder is suffering from chronic diabetes and renal failure, which was not disclosed and the contract of insurance being a contract of uberrimae fidei, the repudiation of the claim was justified on account of suppression of material facts. The counsel for the OPs also relied upon case title Branch Manager, Bajaj Allianz Life Insurance Company Ltd. and others Vas Dalbir Kaur in 2020(4) Civil Court Cases 142 (SC) whereby it has been held by Hon’ble Supreme Court of India that if the pre-existing ailment was in the knowledge of the insured and it was not disclosed in the proposal form, it is a valid ground for rejection of the claim. The counsel for the OPs has further relied upon Life Insurance Corporation of India Vs Manish Gupta in III(2019) CPJ 31 (SC) whereby it has been held by Hon’ble Supreme Court of India that if documentary material indicates that there was a clear failure to disclose that the complainant had suffered from rheumatic heart disease since childhood, this was a valid ground for repudiation. The counsel for the OPs has further relied upon LIC of India Vs Jyothi Sudhir in I(2017) CPJ 256 (NC) whereby it has been held by Hon’ble National Consumer Disputes Redressal Commission, New Delhi that had the assured disclosed that he was suffering from hypertension and diabetes mellitus, the corporation would have ask for special medical reports. Therefore, the repudiation is justified on the ground that false and inaccurate statement was given by the insured. The counsel for the OPs has further placed reliance on case title as Life Insurance Corporation of India Vs Neelam Sharma in IV(2014) CPJ 658 (NC) of Hon’ble National Consumer Disputes Redressal Commission, New Delhi whereby it has been held that if the answers given by insured in proposal form were untrue to his knowledge, there was a clear suppression of material facts and under the circumstances, the repudiation was justified. The counsel for the OPs has further relied upon Life Insurance Corporation of India Vs Rajesh Kumar in IV(2020) CPJ 229 (NC) passed by Hon’ble National Consumer Disputes Redressal Commission, New Delhi on this point.

8.                We have weighed the contentions raised by the counsel for the parties and have also gone through the record very carefully.

9.                In this case, though the main claim has not been lodged, but the pre-authorization of the claim has been rejected on the ground that the insured has been suffering from ITP since 2016 which is prior to the policy and this fact was not disclosed in the proposal form at the time of inception of the policy and therefore, there is concealment of a pre-existing disease. In the discharge summary Ex. C19 of Mohandai Oswal Hospital, Ludhiana, the complaint is said to have been diagnosed for closed Fracture Distal Humerus Right with TN Articular Extension. As per information available on the internet, Distal Humerus Fractures are traumatic injuries to the elbow that comprise of supracondylar fractures, single column fractures, column fractures or coronal shear fractures. In this regard, the counsel for the complainant has referred to a certificate Ex. C36 issued by Dr. Parveen Gupta, MS (Ortho) MCH (Ortho) of Mohandai Oswal Hospital, Ludhiana wherein it is mentioned that the complainant Aman Kumar  was admitted on 14.10.2019 with history of fall at office and pain in right elbow for which X-ray was done and diagnosed as Distal Humerus with ICA extension following which plating was done. It is further mentioned in certificate Ex. C36 that Immune Thrombocytopenic Purpura (ITP) has not correlation with the fall. From the Ex. C36, it is evident that the complainant was diagnosed as Distal Humerus which was attributed to fall in the office resulting in bone injury on the right elbow. In the field report Ex. R6 relied upon by the OPs, it has been claimed that the complainant has been a known case of Immune Thrombocytopenic Purpura (ITP) since 2016 with HTN. Similarly in the letter Ex. R8 also, the pre authorization approval has been rejected by the OPs on the ground that the pre-existing disease i.e. ITP since 2016 was not disclosed. Therefore, the approval for pre authorization could not be granted. Thus, it is evident from the record that the claim has been sought to be rejected on the ground of non-disclosure of the fact that the complainant was suffering from ITP since 2016. As stated in Ex. C36, ITP has no correlation with the fall injury suffered by the complainant. Considering the fact that ITP has no correlation with distal humerus with which the complainant was diagnosed at the time of having been hospitalized, in our considered view, the repudiation of the pre authorization claim cannot be said to be justified. Though it has been argued by the counsel for the OPs that no claim has been lodged and the complaint is pre-mature, but this argument does not appear to be tenable considering the fact that had the main claim been lodged, the same would have been rejected in similar manner in which the advance claim was repudiated. In the light of what has been discussed above in the foregoing paras of the judgment, the case law relied upon by the OPs cannot be applicable to the facts and circumstances of the present case.

10.              As a result of above discussion, the complaint is allowed with an order that the complainant shall submit the claim within one month which shall be allowed and disbursed by the OPs strictly in accordance with the terms and conditions of the policy within a period of 40 days from the receipt of the claim. The OPs shall further pay composite compensation of Rs.7,000/- (Rupees Seven Thousand only) to the complainant. Payment of compensation shall be made within a period of 30 days from the date of the receipt of the copy of this order. Copies of order be supplied to parties free of costs as per rules. File be indexed and consigned to record room.         

11.              Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:06.09.2021.

Gobind Ram.