Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 386.
Instituted on : 20.08.2018.
Decided on : 19.10.2020.
Kulbhushan Madaan age 48 years, s/o Sh. R.D.Madaan R/o H.No.481-18, Green Road, Rohtak.
………..Complainant.
Vs.
- Star Health and Allied Insurance Co. Ltd. Ashoka Plaza, 3rd Floor, Delhi Road, Rohtak through its General Manager.
- Star Health and Allied Insurance Co. Ltd. No.15, Sri Balaji Complex, 1st floor, Whites Lane, Royapettah, Chennai-600014 through its General Manager.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. RENU CHAUDHARY, MEMBER.
MS.TRIPTI PANNU, MEMBER.
Present: Sh. R.K.Sehrawat, Advocate for complainant.
Sh. Gulshan Chawla, Advocate for opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that the complainant availed Star health and Allied Insurance policy for himself and his family members from the opposite party No.1 at Rohtak under Star comprehensive -2015 and family package plan/Hospitalization benefit policy vide policy No. P/211118/01/2018/003121 vide proposal dated 13.10.2014. The said health insurance policy covered the risk and diseases of the insurer i.e. Mrs. Richa Madaan w/o Sh. Kul Bhushan Madaan. In the month of May 2018 Smt.Richa become ill and felt left upper Ureteric Caluculus operation in Max Super Speciality Hospital, Shalimar Bagh, New Delhi on dated 14.05.2018. In the month of June, 2018 the co-insurer Smt. Richa Madaan become ill and she felt Left Residual Renal Calculus operation in Max Super Speciality Hospital on dated 14.05.2018. The complainant had paid approximately Rs.250000/- regarding the operations out of his own pocket. The complainant duly intimated the opposite party no.1 regarding the above mentioned operations, after getting discharge from the Hospital and furnished all the requisite documents for needful action and passing of claim upto the satisfaction of the opposite parties and requested the opposite parties to pass the claim under the policy. The opposite party no.1 forwarded all the documents and claim to opposite party no.2 as his TPA and some correspondence was also took place between the complainant and opposite party no.2 but of no use. Lastly the opposite parties repudiated the claim of the complainant vide their letters dated 29.06.2018 & 05.07.2018 on the pretext that it was a case of pre-existing disease and thus the claim was not payable. Whereas at the time of purchase of the policy, co-insurer Smt. Richa Madaan was physically fit and was not suffering from any disease. The repudiation letters issued by the opposite parties are illegal and against the principal of natural justice. There is also deficiency in service on the part of opposite parties. Hence this complaint and it is prayed that opposite parties may kindly be directed to make the payment of alleged amount of Rs.250000/- alongwith interest compensation and litigation expenses to the complainants as explained in relief clause.
2. After registration of complaint, notice was issued to the opposite parties. Opposite parties in their reply has submitted that the claim intimation was received in the office of the answering opposite party with request for cashless authorization for treatment of the patient Richa with Max Super specialty Hospital, New Delhi on 14.05.2018. The authorization for cashless treatment for the authorized patient was given to the Hospital with initial sanctioned limit of Rs.30000/- During the correspondence Max Super Specialty Hospital , New Delhi and as per the internal verification of documents which duly signed by the insured, it came to the knowledge that patient had Renal Calculi and had undergone surgery for the same 10 years back at Jaipur, which was not disclosed in the proposal form during the policy inception. Hence the cashless authorization given was withdrawn and rejected and the same was communicated to the insured. That subsequently the insured submitted a claim for re-imbursement of medical expenses alongwith the claim form for re-imbursement of medical expenses to an amount of Rs.152940/- , but the claim of the complainant was rightly declined vide letter dated 28.06.2018, duly served upon by the complainant and admitted by the complainant, on the ground that the patient is known-case of renal Calculi and had undergone surgery for the same 10 years back at Jaipur, which is prior to medical insurance policy. Hence the disease was pre-existing and the company is not liable. As per the contract of insurance, the medical Hospital, Health of person proposed for insurance are to be disclosed in the proposal form at the time of inception of the policy. Since insured had not disclosed about the pre-existing disease in the proposal form and at the time of inception of policy. Hence the claim of the complainant was not payable. Another claim intimation was received in the office of the answering opposite party, regarding treatment of insured with Max super Specialty Hospital, New Delhi for the period 07.06.2018 to 09.06.2018 and have alleged to be spent an amount of Rs.69470/-.This time the claim of the complainant was again repudiated vide letter dated 05.07.2018 on the basis of repudiation of previous claim no.0071342 as the insured patient was known case of renal calculi and had undergone surgery for the same 10 years back at Jaipur. Hence the claim was rightly rejected by the opposite parties and there is no deficiency in service on the part of opposite parties. As such, dismissal of complaint has been sought.
3. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.CW-2 to Ex.CW-5 and has closed his evidence on dated 25.03.2019. On the other hand, Ld. counsel for the opposite party No.1 & 2 has tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R22 and closed his evidence on dated 29.07.2019.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. After going through the file and hearing the parties it is observed that in the present case, the claim of the complainant has been repudiated by the opposite parties vide letter Ex.R17 on the ground that : “From the documents and information available with us that the insured patient is a known case of renal calculi and has undergone surgery for the same 10 years back which is prior to inception of the medical insurance policy. Hence the above disease is a pre existing disease. The present admission and treatment of the insured patient is related to the pre existing disease”. But to prove the same, only a medical history sheet prepared by the opposite party itself, has been placed on record as Ex.R11, as per which in the column No.20, it is mentioned that : “H/o Rt. Kidney stone- surgery done 10 years back at Jaipur(No document)”. This document itself shows that the opposite party has no document available with it to prove the pre-existing disease of the patient Richa Madaan. We have also perused the document Ex.R11 and in this document in column no.4 Clinical Assessment Details are mentioned as under:
Specify if any investigation was done outside the Hospital: USG Abd(Om Sai), Date of onset of illness with duration: one month.
Provisional diagnose : Ureteric Caluculus left.
Previous history of similar complaint: Yes/No(No is tick marked).
Meaning thereby contradictory view has been taken by the respondent. This document is prepared by the respondent itself, hence cannot be believed. Moreover, the complainant was not suffering from any disease and in the discharge summary Ex.R12, history of patient has not been mentioned anywhere. It can be presumed that when a patient was operated by the doctor then the previous history of the patient was also mentioned. In this case previous history was not mentioned, meaning thereby the patient was not suffering from this disease or any other disease previously. Moreover, the life assured was not having any chronic disease. As per the definition of kidney stone taken from the internet: “Our kidneys remove waste and fluid from the blood to make urine. Sometimes, when we have too much of certain wastes and not enough fluid in our blood, these wastes can build up and stick together in our kidneys. These clumps of wastes are called kidney stones”. If kidney stone is small, sometimes it can be removed itself by taking plenty of fluid and if there is a big stone, then it needed a surgery. Hence the definition of kidney stone itself shows that the same is not a chronic disease and can occur in the body at any time. Moreover, opposite party has failed to place on record any document to prove that the life assured Richa Madaan was suffering from kidney stone 10 years back. Hence the repudiation of claim on this ground is illegal and amounts to deficiency in service.
6. As per documents placed on record, Smt.Richa Madaan was got operated for left upper Ureteric Caluculus in Max Super Speciality Hospital, Shalimar Bagh, New Delhi on dated 15.05.2018 and was discharged on 17.05.2018 and as per bill Ex.CW4, she had spent a sum of Rs.132580/- on her treatment and the complainant filed the claim no.CLI/2019/211118/007/0071342. In the month of June, 2018 the insured Smt. Richa Madaan again got treatment of Left Residual Renal Calculus operation on dated 07.06.2018 and had spent an amount of Rs.69470/-on account of treatment bill and filed claim no. CLI/2019/211118/0131606. Hence the complainant is entitled for the alleged claim of Rs.132580/- plus Rs.69470/- i.e. Rs.202050/-.
7. In view of the facts and circumstances of the case, we hereby allow the complaint and direct the opposite parties to pay the amount of Rs.202050/-(Rupees two lac two thousand and fifty only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 20.08.2008 till its realization and also to pay Rs.5000/-(Rupees five thousand only) on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainants within one month from the date of decision.
8. Copy of this order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
19.10.2020.
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Nagender Singh Kadian, President
………………………………..
Renu Chaudhary, Member.
…………………………………..
Tripti Pannu, Member.
