Haryana

Kurukshetra

CC/405/2019

Mewa Devi - Complainant(s)

Versus

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

N.K.Jain

05 May 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KURUKSHETRA.

 

                                                                    Complaint No.:    405 of 2019.

                                                                   Date of institution:         09.09.2019.

                                                                   Date of decision: 05.05.2022

 

Mewa Devi w/o Shri Nirmal Singh, r/o village Kaulapur, Tehsil Thanesar, District Kurukshetra.

                                                                                                …Complainant.

                                                     Versus

 

1. Star Health and Allied Insurance Co. Ltd. No.15, Sri Balaji Complex, 1^st Floor Whites Lane, Royapettah, Chennai-600014, through its Manager.
2. Branch Manager, Star Health and Allied Insurance Co. Ltd., SCO No.94, 1^st Floor, Sector-17, Kurukshetra.

...Respondents.

 

CORAM:   NEELAM KASHYAP, PRESIDENT.    

                   NEELAM, MEMBER.

                   ISSAM SINGH SAGWAL, MEMBER.           

 

Present:       Shri N.K. Jain, Advocate for the complainant.             

                   Shri Mohit Goel, Advocate for Opposite Party No.1.

                   Opposite Party No.2 ex-parte, vide order dated 14.11.2019.

 

ORDER:

 

1.                This is a complaint under Section 12 of the Consumer Protection Act, 1986 (for short “Act”).

2.                It is alleged in the complaint that the complainant along with her husband taken a policy from the OPs under the head “Accident and Health Insurance Services” vide policy No.P/211123/01/2018/003363 valid from 31.03.2018 to 30.03.2019 after paying premium of Rs.18340/- and renewed the same w.e.f. 31.03.2019 to 30.03.2020 after paying premium amount of Rs.21600. The complainant was suddenly taken to Indus International Hospital, Dera Bassi due to sudden health problem and remained admitted there from 22.06.2018 to 28.06.2018 and Mitral Valve replacement, Tricaspid Annuloplasty was done and incurred total expenditure of Rs.2,55,000/- on her treatment. She applied for reimbursement of said amount with the OPs by submitting all the papers of the treatment, but the OPs of making the said payment to her, illegally repudiated her claim vide letter dated 27.09.2018. There was no knowledge of any disease prior to taking the policy in question. She came to know about the disease only when she came for treatment in the Indus Hospital, Dera Bassi. Repudiation of her genuine claim by the Ops, is an act of ospitaHos

deficiency in service on the part of OPs, causing her mental agony, harassment and financial loss, constraining her to file the present complaint against the OPs, before this Commission.

3.                On receipt of complaint, its notices were ordered to be issued to both the OPs. The OPs appeared and filed their written statement stating therein that the insured availed Family Health Optima Insurance Plan vide Policy No.P/211123/01/2018/003363 valid from 31.03.2018 to 30.03.2019. The complainant was suffering from LONG STANDING VALVLULAR HEART DISEASE (RHD), which was present prior to inception of this policy. The insured Mrs. Mewa Devi was hospitalized at UNDUS INTERNATIONAL HOSPITAL – JANETPUR on 22.6.2018 for treatment of RHD- SEVERE MS, MOD MR and submitted claim records towards medical reimbursement of medical expenses for Rs.2,59,769/-. On scrutiny of the claim records, it was found:

• As per Discharge summary, it was found that complainant was suffering from KNOWN CASE OF Rheumatic Heart Disease (RHD).
• As per Echo Report dated 05.06.2018, it showed severe MS and MR-high PA Pressure.

4.                From the above findings, it was noted that the insured patient was hospitalized in the 3^rd month of the policy as known case of RHD. It showed long standing heart disease, which was prior to the inception of policy. As per waiting periods 3 (iii) of terms and conditions of the policy, the company was not liable to make any payment in respect of expenses for treatment of the pre-existing disease/conditions, until 48 months of continuous coverage has elapsed, since inception of policy with the company on 31.03.2018. The complainant submitted a representation to reconsider the claim and same was reviewed and replied vide letter dated 19.01.2019 and same rejected. There is no deficiency in service on the part of OPs while repudiating claim of the complainant and prayed for dismissal the present complaint against them with heavy costs.  

5.                The complainant, in support of his complaint tendered affidavit Ex.AW1/A along with documents Ex.A-1 to A-8 and closed her evidence.

6.                On the other hand, the OPs, in support of their case, tendered affidavit Ex.RW1/A along with documents Ex.R-1 to Ex.R-13 and closed their evidence.

7.                We have heard the learned counsel for the parties and gone through the case file as well carefully.

8.                Learned counsel for the complainant argued that complainant along with her husband taken a policy from the OPs valid from 31.03.2018 to 30.03.2019 after paying premium of Rs.18340/- and renewed the same w.e.f. 31.03.2019 to 30.03.2020 after paying premium amount of Rs.21600. He further argued that the complainant was suddenly taken to Indus International Hospital, Dera Bassi due to sudden health problem and remained admitted there from 22.06.2018 to 28.06.2018 and Mitral Valve replacement, Tricaspid Annuloplasty was done. The complainant incurred total expenditure of Rs.2,55,000/- on her treatment and applied for reimbursement of said amount with the OPs by submitting all the papers of the treatment, but the OPs of making the said payment to her, illegally repudiated her claim vide letter dated 27.09.2018. There was no knowledge of any disease prior to taking the policy in question. The complainant came to know about the disease only when she came for treatment in the Indus Hospital, Dera Bassi. He further argued that repudiation of genuine claim of complainant by the Ops, is an act of ospitaHos

deficiency in service on the part of OPs.    

9.                 Learned counsel for OPs argued that the insured availed Family Health Optima Insurance Plan vide Policy from the OPs. He further argued that the insured Mewa Devi was hospitalized at UNDUS INTERNATIONAL HOSPITAL – JANETPUR on 22.6.2018 for treatment of RHD- SEVERE MS, MOD MR and submitted claim records towards medical reimbursement of medical expenses for Rs.2,59,769/-. As per Discharge summary, it was found that complainant was suffering from KNOWN CASE OF Rheumatic Heart Disease (RHD). As per Echo Report dated 05.06.2018, it showed severe MS and MR-high PA Pressure. As per waiting periods 3 (iii) of terms and conditions of the policy, the company was not liable to make any payment in respect of expenses for treatment of the pre-existing disease/conditions, until 48 months of continuous coverage has elapsed, since inception of policy with the company on 31.03.2018. The complainant submitted a representation to reconsider the claim and same was reviewed and replied vide letter dated 19.01.2019 and same rejected. There is no deficiency in service on the part of OPs while repudiating claim of the complainant. 

10.              There is no dispute that the complainant purchased a Family Health Optima Insurance Plan from the OPs, for a sum assured of Rs.4,00,000/-, , valid from 31.03.2018 to 30.03.2019, vide insurance policy Ex.A-1 and renewed the same w.e.f. 31.03.2019 to 30.03.2020, vide insurance policy A-2. There is also no dispute that the complainant got admitted in Indus International Hospital, Dera Bassi from 22.06.2018 to 28.06.2018. As per complainant, she incurred the expenditure of Rs.2,55,000/- on her treatment in said hospital and submitted the claim with the OPs, but the OPs repudiated her claim, vide repudiation letter dated 27.09.2018 Ex.R11 as well as rejected her request to review the same. Extract part of repudiation letter Ex.R-11 reads as under:-

                    “It is observed from the medical records, the insured patient is a known case of Rheumatic Heart Disease (RHD). ECHO report dated 05.06.2018 shows severe MS and MR-high PA Pressure. Based on these findings our medical team is of the opinion that insured patient has long standing valvular heart disease prior to date of commencement of first year policy. As per Waiting periods 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/conditions, until 48 months of continuous coverage has elapsed, since inception of the policy with the Company on 31.03.2018”.

 

11.              Since the OPs repudiated the claim of the complainant, therefore, burden to justify the repudiation, was upon the OPs. To corroborate this fact, the OPs produced copy of “Discharge Summary” of complainant as Ex.R-5 and extract part of said Summary “FINAL IMPRESSION” reads as under:-

          FINAL IMPRESSION:

          RHD-SEVERE MS

          MODERATE MR

          NORMAL LV SYSTOLIC FUNCTION

          MILD TR WITH MILD PH

12.              The OPs further produced letter dated 04.09.2019, written by one Dr. Arunkumar Krishnasamy, MBBS, MS (GS), MCh (CTS), DNB (CTS), Consultant Cardiovascular and Thoracic Surgeon, Chennai, as Ex.R-10, on the case file and extract part of said letter reads as under:-

                   “Patient known case of Rheumatic heat disease. ECHO record dated 05/06/2018 suggestive of rheumatic heart disease with severe mitral stenosis and moderate MR, mild TR and dilated LA (thickened mitral valve). Patient underwent Mitral valve replacement, tricuspid annuloplasty done on 23/06/2018. The nature of Rheumatic Heart Disease in terms of thickened MS, mild PAH; dilated LA denotes chronic Rheumatic mitral valvular disease”.                               

13.               From these documents Ex.R-5 and Ex.R-10, it is found that the OPs mainly stressed that the complainant was known case of Rheumatic Heart Disease (RHD) and severe MS and MR-high PA Pressure prior to taking the policy in question. But it is pertinent to mention here that the OPs had not produced any medical record of the complainant, on the case file, to prove that she (complainant) was suffering from the illness, referred above and taking treatment for the same, prior to taking the policy in question and that fact was in the knowledge of complainant and that she intentionally concealed the same at the time of taking the policy in question. Even also the OPs insurance company did not produce any medical record to prove that which medication and for how long the complainant was taking medicines for those diseases. It was also not proved on record as to who had disclosed that complainant was suffering from the said diseases. Furthermore, affidavit of the treating doctor, who had recorded the patient history, at the time of preparing Discharge Summary Ex.R-5, has not been produced on the record. It is commonly known that now-a-days a heart disease can occur immediately to anyone. The opposite parties have failed to prove through cogent and convincing evidence that complainant was already suffering from a pre existing disease. In this regard we are also fortified with the observations of the Hon’ble National Commission in the case titled National Insurance Company Ltd. Vs. Raj Narain, decided on 15.01.2008 (National Commission), in which, it has been held that “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 mala fide manner to repudiate all the claims. No claim is payable under the medi-claim 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^th August, 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.

14.              From the record, it is born out that the complainant was more than 50 years at the time of taking the policy in question, therefore, as per IRDAI guidelines, it was incumbent upon the OPs, prior to accepting the premium and issuing the policy, got medically examined the complainant. As it has been held by the Hon’ble State Commission, U.T., Chandigarh, in the case of Manish Goyal Vs. Max Bupa Health Insurance Co. Ltd. and others, 2018 (2) CLT, 205 that “If the opposite parties themselves, failed to adhere the instructions issued by Insurance Regulatory & Development Authority of India (IRDAI), by putting the insured to through medical examination, being her age more than 45 years, and were interested in collecting premium from the complainant, as such, now at this stage, they cannot evade their liability”.

15.              So, from the above facts and circumstances of the case, we are of the considered view that the OPs are not justified in repudiating the claim of the complainant, on the ground mentioned above, which amounts to deficiency in services on their part. Hence, the OPs are liable to reimburse the amount, which the complainant had incurred on her treatment.

16.              Now the question which arises for consideration is what should be the quantum of indemnification? In the complaint, complainant contended that she spent Rs.2,55,000/- on her treatment, and in this regard, she produced bills A-4 to A-7 on the case file, whereas, on the other hand, the OPs produced document Ex.R-13, on the case file and in that document, after deducting Rs.45436/- from Rs.2,59,679/-, Rs.2,14,243/- was shown as treatment expenses of the complainant, but it is pertinent to mention here that the OPs failed to produce any surveyor report to corroborate the document Ex.R1-13. Moreover, the OPs also produced bills of Rs.2,55,000/-, spent by the complainant, on the case file as Ex.R9. So, from bills Ex.A4 to Ex.A7/Ex.R9, it is evident that the complainant incurred expenses of Rs.2,55,000/-, on her treatment, and since as per Insurance Policy documents Ex.A-1 and Ex.A2, the sum assured in the policy was Rs.4,00,000/-, therefore, the OPs are liable to reimburse the amount of Rs.2,55,000/- to the complainant. They are also liable to compensate the complainant for the mental agony and physical harassment suffered by her, alongwith litigations expenses.

17.              In view of our above discussion, we accept the present complaint against the OPs and direct the OPs severally and jointly to pay the claim amount of Rs.2,55,000/-, to the complainant. The OPs are further directed to pay Rs.10,000/- to the complainant, as compensation for mental agony and physical harassment, caused to the complainant, due to an act of deficiency in service, on the part of the OPs along with Rs.5,000/-, as litigation expenses. The OPs are further directed to make the compliance of this order within a period of 45 days from the date of preparation of certified copy of this order, failing which, the award amount of Rs.2,55,000/- shall carry on interest @6% simple per annum, from the date of this order, till its actual realization and the complainant shall be at liberty to initiate proceedings under Section 25/27 of the Act, against the OPs. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the record-room, after due compliance.

Announced in open Commission:

Dated:05.05.2022.    

 

                                                                                        (Neelam Kashyap)               

(Neelam)                    (Issam Singh Sagwal)                   President,

Member.                    (Member).                                     DCDRC, Kurukshetra.           

 

Typed by: Sham Kalra, Stenographer.