Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 578.
Instituted on : 04.10.2017.
Decided on : 15.12.2021.
Mahender Kumar s/o sh. Vinod Jain R/o H.No.522/12, Ward No.7, Pithwara Mohalla, Rohtak.
..………..Complainant.
Vs.
- Star Health and Allied Insurance Co. Ltd., through its Branch Manager having its office at Ashoka Plaza, 3rd Floor, Delhi Road, Rohtak -124001.
- Star Health & Allied Insurance Company Limited, through its regional head having its office at No.1, new tank Street, Valluvar Kottam High road, NUNGAMBAKKAM, Chennai PIN-600034.
- Director, Holi Heart Hospital Near Circuit House Delhi Bye Pass, Rohtak.
……….Opposite parties.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR.TRIPTI PANNU, MEMBER.
Present: Sh.Sanjay Sharma, Advocate for the complainant.
Sh. Gulshan chawla, Advocate for opposite party no.1 & 2.
Sh.Sanjeev Batra, Advocate for opposite party No.3.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case are that complainant alongwith his wife had taken family Health optima Insurance plan from respondent no.1 & 2 on 18.03.2017 and the policy bearing no.P/211118/01/2017/004829 for the period 18.03.2017 to 17.03.2018 for Rs.500000/- was issued. At the time of insurance all the necessary formalities including medical examination and other inquiries were conducted by respondent no.1 & 2 and the facts regarding declaration of no pre-existing disease were depicted in the policy. In the month of April 2017 the complainant felt pain in his chest and went for the treatment at Holy Hospital and he was told that he will be operated and two stunts will be inserted by the doctors at the time of operation. The staff of opposite party No.3 asked the complainant to deposit Rs.174000/- in advance on account of treatment expenses. Complainant showed his Health card issued by the opposite parties no.1 & 2. Opposite party no.3 admitted the complainant and the required treatment was given. On 27.04.2017 respondent no.3 asked the complainant to deposit a sum of Rs.140000/- with them as they have received a mail from the respondent no.1 & 2 that the claim of the complainant will be passed after further inquiry. On the assurance of opposite party No.1 & 2 to get the refund of alleged amount, the family members of the complainant deposited the alleged amount. After discharge from the hospital, complainant sent so many emails to the respondent no.1 & 2 to pass the genuine claim of the complainant but the opposite parties vide their letter dated 15.07.2017 has repudiated the claim of the complainant on the ground that : “It is observed that the CAG report dated 27.04.2017 shows severe multiple coronary artery disease which confirms the insurance patient has chronic, longstanding disease prior to inception of Medical Insurance Policy”. Hence it is a pre existing disease and as per exclusion clause no.1 of the policy, company is not liable to make any payment. The act of opposite parties is illegal and amounts to deficiency in service. Hence this complaint and it is prayed that opposite parties may kindly be directed to pay the amount of Rs.375000/- spent by the complainant on treatment, medicines, transportations and harassment etc. alongwith interest and litigation expenses of Rs.11000/- to the complainant.
2. On notice opposite parties appeared and opposite party No.1 & 2 filed their written reply submitting therein that complainant opted for Family Health Optima Insurance Plan and answering opposite party relying upon the contents of the proposal form to be true, issued the policy bearing No.P/211118/01/2017/004829 for the period 18.03.2017 to 17.03.2018 covering complainant and his spouse Babita Jain for the sum insured for Rs.500000/-. The authorization request for cashless treatment of ACS was received in the office of answering respondent on 27.04.2017 regarding the admission of insured with Holy Heart Hospital Rohtak and the same was denied vide letter dated 27.04.2017 itself as ECG shows no acute changes and further cardiac enzymes not elevated. CAG shows DVD which revealed long standing disease. As the complainant has longstanding and chronic coronary artery disease. Hence it is a pre existing disease. The present admission and treatment of the insured patient is for the pre existing disease. As per Exclusion no.1 of the policy, the company is not liable to pay 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 i.e. from 18.03.2017. Hence the claim was repudiated and the same was communicated to the insured vide letter dated 15.05.2017. The complainant had submitted the claim form with a request for reimbursement of an amount of Rs.143410/- and it is denied that complainant is entitled for Rs.175000/- or Rs.375000/- alongwith interest and litigation charges. All the other contents of the complaint were stated to be wrong and denied and opposite parties prayed for dismissal of complaint with costs.
3. Opposite party no.3 in its reply has submitted that the answering opposite party has no concern with issuance of the policy. Para no.3 to 12 of the complaint were stated to be matter of record. It is denied that complainant provided his health card to the staff of respondent no.3. Answering opposite party has no concern with the insurance policy and payment of claim. All the other contents of the complaint were stated to be wrong and denied and opposite parties prayed for dismissal of complaint with costs.
3. Both the parties led evidence in support of their case.
4. Ld. Counsel for the complainant in his evidence has tendered affidavits Ex.CW1/A, documents Ex.C1 to Ex.C5 and has closed his evidence on dated 17.09.2018. On the other hand, ld. Counsel for the opposite party No.1 & 2 has tendered affidavit Ex.RW1/A, documents Ex.R1 to Ex.R10 and has closed his evidence on 22.01.2019. Ld. Counsel for opposite party No.3 has tendered affidavit Ex.RW3/A and closed his evidence on dated 07.01.2019.
5. We have heard ld. counsel for the parties and have gone through the material aspects of the case carefully.
6. In the present case claim of complainant has been repudiated by the opposite party vide its letter Ex.C5 on the ground that: “It is observed that the CAG report dated 27.04.2017 shows severe multiple coronary artery disease which confirms the insured patient has chronic, longstanding disease prior to inception of the medical insurance policy. Hence it is a pre existing disease. The present admission and treatment of the insured patient is for the pre existing disease. As per Exclusion No.1 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 elapses, since inception of the policy i.e. from 18.03.2017”. Ld. Counsel for the respondent has placed reliance upon the opinion of Dr. Arun Kumar Krishnaswamy dated 14.07.2017 placed on record as Ex.R10, as per this report it is submitted that: “Considering the angiogram reports with ECG and echo findings, the presentation and reports not clearly suggestive of any acute coronary syndrome. Coronary artery disease likely to be long standing one”. We have also perused discharge summary placed on record by the respondent as Ex.R5. As per this document, the history and physical examination of the complainant is as under:- “47 years old male, non smoker, non alcoholic, complaining of on & off retrosternal chest pain radiating towards left arm, a/w sweating & ghabrahat N/H/O HTN,T2DM”. We have also perused Ex.R9 claim form duly signed by Dr. Om Parkash Chawla GAMS, Physician & Surgeon, Circular road, Rohtak. On the second page in column no.20, it is submitted that: “No previous history of CAD as per patient”.
7. After perusal of documents placed on record we came into the conclusion that complainant was not suffering from any Coronary Artery Disease since long and he has no knowledge regarding the disease at the time of purchase of the policy. Moreover as per declaration of patient placed on record by the respondent at page no.4/6 of Ex.R3 it has been questioned from the complainant that : “Have you ever suffered or suffering from any of the following disease: Heart disease-if yes, since when and the answer to this question has been given as ‘No”. Meaning thereby the complainant was not suffering from any heart disease at the time of taking the policy or if he was having any disease, the same was not in his knowledge. Hence there is no misrepresentation of fact on the part of complainant and the repudiation of claim on this ground is illegal and amounts to deficiency in service. A person purchases the health policy for his future benefits assuming that in case he/she will suffer any of the heath issues in future, in that case, there would be no burden on him or his family members and the insurance policy would provide him security cover and the insurance company will bear all the expenses spent by him on his treatment and for this purpose he pays a continuous premium for the same. But on the other hand, insurance companies repudiate the genuine claims of the insured persons on technical grounds, which is against the natural justice. As such opposite parties are liable to pay the claim amount to the complainant. As per the complainant, he has demanded Rs.175000/- on account of treatment, medicines etc, but to prove the same complainant has not placed on record any document. On the other hand, opposite party No.1 & 2 in its reply has submitted that the complainant had submitted the claim form with a request for reimbursement of an amount of Rs.143410/-. As such he is entitled for the said amount.
8. In view of the facts and circumstances of the case we hereby allow the complaint and direct the opposite party No.1 & 2 to pay the amount of Rs.143410/-(Rupees one lac forty three thousand four hundred and ten only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 04.10.2017 till its actual realization and shall also pay an amount of Rs.4000/-(Rupees four thousand only) as compensation on account of deficiency in service and Rs.4000/-(Rupees four thousand only) as litigation expenses to the complainant maximum within one month from the date of decision.
9. 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:
15.12.2021.
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Nagender Singh Kadian, President
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Tripti Pannu, Member.
