Sh. Sanjay Kumar, President

1. In brief facts of the present case are that complainant no.2 i.e Mr. Ravin Balggana availed health insurance policy from the Bajaj Allianz from 17.03.2010 to 16.03.2011 and the complainant no.1 herein was one of the beneficiary/insured person in that insurance policy. It is stated that in March 2011 the health  insurance policy with Bajaj Allianz was taken over by the OP  company and since then without any break/default the complainants had been availing services from the OP company. OP  company vide Policy No. P/161211/01/2013/004451 and the complainant no.1 herein was one  of the beneficiary/insured person.
2. It is stated that the insurance policy was valid from 15.03.2013 to 14.03.2014. It is further stated that in and about September 2013 the complainant no.1 herein started experiencing chest pains and on 03.10.2013 was admitted in Medanta Hospital, Gurgaon. It is further stated that the complainant no.1 was diagnosed with RHD-LLA Clot and was shifted to the Emergency ward of Medanta Hospital. It is stated that the complainant no.1 under went Coronary Angiography on 11.10.2013. It is stated that on 12.03.2014, she under went MV Repair and LAA Clot  removal. It is further stated that the complainant no.1 incurred an expense of almost 3.75 lacs during the period of hospitalization and in addition an amount of Rs.25,000/- (approximate figure) was spent by the  complainant towards medication, medical tests, doctor’s fees etc. It is stated that as per the insurance policy, the OP has insured the complainant for an amount of  Rs.3,75,000/- (basic floater  sum insured + bonus).
3. It is stated that after discharge from the above stated hospital, the complainants vide claim no. CLI/2014/161211/126987 lodged a claim of Rs.3,75,000/- (Rupees three lakhs only) with the OP company. It is further stated that to utmost surprise of the complainants herein, the OP company, vide its letter dated 16.01.2014 rejected the claim of the complainants on false and frivolous grounds. It is stated that the complainants herein vide letter dated 01.02.2014, called upon the OP to settle the claim within 15 days. It is further stated that a frivolous reply dated 04.02.2014 was sent by the OP, whereby they refused to entertain the claim of the complainant. It is further stated that the complainant no.1 sent a legal notice dated 02.05.2014 to the OP at the above mentioned address, which was duly served upon the OP. Even after receipt of the legal notice dated 02.05.2014, the OP failed to settle the claim of the complainants.
4. It is stated that OP have not failed to provide ample and bonafide services to the complainants herein but even failed to act on the requests and reminders of the complainants, leading to mental harassment and agony to the complainants and is indulged in unfair practice  and provided deficient services as a reason thereof the complainants had to go through severe emotional, physical and financial harassment.
5. The complainant is seeking direction to OP to pay the amount of Rs.3,75,000/- (Rupees three lakh seventy five thousand only) alongwith interest at the rate of 24% per annum, to pay a sum  of Rs.1,00,000/- towards mental agony and harassment caused to complainant alongwith litigation expenses of Rs.55,000/- and any other order which deems fit and proper.
6. OP filed WS and taken preliminary objections that the complaint filed by complainant is false, frivolous, vague, and baseless and misconceived because there was/is no deficiency in service on the part of OP. It is stated that the Branch office, Pitampura, of the OP issued the Family Health Optima Insurance Policy covering Mr. Ravin Blaggana Self, Mrs, Naina Blaggana- Spouse, Arush Blaggana- Dependent Child for the sum insured of Rs.3,00,000/- vide policy no. P/161211/01/2011/002368 from 17.03.2011 to 16.03.2012, P/161211/01/2012/003934 from 15.03.2012 to 14.03.2013, P/161211/1/2013/004451 from 15.03.2013 to 14.03.2014. The copy of the policy is filed on record. It is further stated that the insured/complainant was admitted in Medanta The Medicity, Gurgaon on 03.10.2013 for the treatment of Chronic Rheumatic Heart Disease (RHD) with Severe Mitral Stenosis. On receipt of the pre authorization request form the treating hospital, it is observed that the present ailment of insured was symptomatic prior to the inception of policy, therefore, cashless was denied and the same was communicated to the treating hospital and the insured vide letter dated 03.10.2013. It is stated that OP sent the claim form to the insured to approach for reimbursement.
7. It is stated that the OP have perused the claim records relating to the above insured seeking reimbursement of hospitalization expenses for treatment of Rheumatic Heart Disease (RHD) with Severe Mitral Stenosis, Atrial Fibrillation. It is further stated that on scrutiny of the claim records, it is observed that  as per the discharge summary of the treating hospital and ECHO with Doppler reports, the insured patient had severe MS (Mitral valve area = 1.1cm) + TR+ severe pul.HTN+ Atrial fibrillation with fast ventricular rate with LA clot also with clinical symptoms of D.O.E grade, which indicates the present ailment is longstanding existing prior to the inception of the policy. Copy of discharge summary is filed on record and as per Exclusion No.1 of the policy. It is stated that OP company is not liable to make any payment in respect of expenses for treatment of pre existing disease, until 48 months of continuous coverage has elapsed, since inception of the first policy with the company. Copy of terms and conditions are filed on record.
8. It is stated that the claim was repudiated and the same was communicated to the insured vide letter dated 04.02.2014.Copy of repudiation letter filed on record and also copy of expert opinion is filed on record. It is further stated that complainant has not come with clean hands and has suppressed the material facts from this Hon’ble Forum, therefore, the complainant is not entitled to any relief from this Hon’ble Forum. It is stated that no cause of action ever arose in favor of the complainant and against the OP for filing the present complaint, therefore, the complaint is liable to be rejected/dismissed with heavy cost.
9. It is stated that the complaint involves intricate question of law and fact, plethora of records to be introduced and number of witnesses to be examined to decide the allegations in just and fair manner, therefore, this Hon’ble Forum is not an appropriate Forum to adjudicate upon the subject matter. It is further stated that the complainant has in fact indulged himself in speculative litigation and adventurism taking undue advantage of the fact that no court fee is payable under the Consumer Protection Act, which is an abuse of benevolent provisions  of law. It is further stated that the registered and corporate office of the answering OP is situated in Chennai, therefore, this Hon’ble Court has no jurisdiction to try and entertain and decide the present complaint.
10. On merit all the allegations made in the complaint are denied by  OP and reiterated the contents of preliminary  objections. The OP referred the judgment of Max New York Life Insurance Company Ltd. Vs. Mr. Amaresh Reddy Revision Petition No.610 of 2012 decided on 05.02.2014 and  P.C Chacko and Anr. Vs Chairman Life Insurance Corporation of India and Ors. (2008) 1 SCC 321, Revision Petition no.4678 of 2009, Satish Kumar Vs Branch Manager Vs. Life Insurance Corporation of India. It is stated that present complaint is liable to be dismissed.
11. Complainant filed replication to the WS of OP and denied all the allegations made in the WS and reiterated the contents of the complaint. It is stated that OP took no medical opinion and the claim was rejected on false and frivolous grounds. It is stated that complainant is entitled to all the reliefs.
12. Complainant 1 and 2 filed evidence by way of his affidavit and reiterated contents of complaint.
13. OP filed evidence by way of affidavit of Sh. Rajnish Kohli Assistant Vice  President and reiterated  contents of WS. OP relied on copy of policy Ex. OPW1/1, copy of proposal form Ex.OPW1/2, copy of  discharge summary Ex.OPW1/3, copy of terms and conditions Ex.OPW1/4 and copy of export opinion Ex.OPW1/5.
14. Written arguments filed by complainant as well as by OP.
15. We have heard Sh. Mohit Garg counsel for complainant and Sh. Prashant Kumar proxy for Sh. S.K Sharma counsel for OP.
16. It is admitted case of the parties that complainant got issued Family Health Optima Insurance Policy covering complainant and dependent children or assured sum of Rs.3,00,000/- since 17.03.2011 and got renewal till 14.03.2014. It is further admitted case of the parties that complainant was admitted in Medanta, The Medicity Gurgaon on 03.10.2013 for the treatment of Chronic Rheumatic Heart Disease (RHD) with Severe Mitral Stenosis. The cashless facility was denied. It is admitted case of the parties that as per discharge summary the complainant was discharged on 18.10.2013. It is further admitted case of the parties that complainant lodged claim of Rs.3,75,000/- with supporting documents. It is further admitted case of the parties that the claim was repudiated vide letter dated 16.01.2014.
17. As per OP the ground of repudiation of the claim is as under

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of RHD, MS-severe, atrial fibrillation.

  It is observed from the discharge summary of the above hospital and ECHO with Doppler reports, the insured patient has severe MS (Mitral valve area=1.1cm) + TR + severe pul.HTN + Atrial fibrillation with fast ventricular rate with LA clot also with clinical symptoms of D.O.E grade 4. All these facts confirm chronic long standing rheumatic Mitral valve disease existing prior to inception of medical insurance policy.

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, until 48 months of continuous coverage has elapsed, since inception of the first policy with the company.

 We therefore regret out inability to admit your claim under the above policy and we hereby repudiate your claim.

 It is brought to your attention that as per Condition No.7 of the above policy, you  have to disclose the medical history/health details of the person(s) proposed for insurance in the proposal form at the time of inception of the policy. Since you have not disclosed the above mentioned preexisting disease in the proposal form at the time of inception of the policy, it is now  incorporated in your policy as per existing disease/condition by passing endorsement.

18. The complainant challenged the repudiation letter that during the insurance policy valid from 15.03.2013 to 14.03.2014 in about September 2013 complainant experienced chest pain and on 03.10.2013 admitted in Medanta Hospital and diagnosed with RHD-LLA Clot and shifted to emergency ward. The complainant underwent Coronary Angiography on 11.10.2013 and underwent MV Repair and LLA Clot Removal on 12.03.2014 (It seems that there is typographical error because as pe medical record documents complainant undergone treatment in the month of March 2013). We have gone through the discharge summary. In the medical history it is mentioned that Ms. Naina Blaggna (30 years aged Female) presented with complaints of dyspnoea on exertion since 19.9.2013 associated with palpitation on & off, for which she was evaluated for the same, Echo done revealed RHD severe MS with LLA clot. Now she was admitted here in Emergency for further evaluation & management.
19. The OP also filed a letter of Dr. M.M Rathina Sabapathy who has given his medical opinion to OP Insurance Co. He has observed that “as per discharge summary insured patient records, investigation ECHO with Doppler report and Pathophysiological features of valve lesions leads to formation of blood clot in left atrium & clinical features show this heart valvular disease.

In addition raised Pulmonary Hypertension with Tricuspid Regurgitation also additional features for the evidence of chronicity of this Heart disease”.

20. The discharge  summary and the opinion of Dr. M.M Rathina Sabapathy clearly established that the complainant suffered from the heart disease for the first time in September 2013 and got admitted on 03.10.2013 for treatment at Medanta Hospital Gurgaon. The OP Insurance Co. has not filed proposal form or any other medical document on record which shows that the disease was pre existing and complainant did not disclosed at the time of renewal of insurance policy. As per record complainant established that for the first time she suffered or diagnosed with the heart disease as per medical record in September 2013. It is further established that the complainant did not conceal or misrepresent with regard to heart ailment at the time of renewal of policy for the year 15.03.2013 to 14.03.2014. The OP failed to corroborate the fact that the ailment of complainant is long standing existing prior to inception of the policy. In our considered view on the basis of above observation and discussion the repudiation letter dated 16.01.2014 is unjustified and not in accordance with terms and conditions of the policy. The complainant established her claim, therefore, we hold OP guilty of deficiency of services.
21. On the basis of above observation and discussion we direct OP to:-

1. To pay to complainant Rs.3,75,000/- alongwith 6% interest p.a.
2. To pay to complainant Rs.50,000/- compensation.
3. To  pay to complainant Rs.10,000/- litigation expenses.

22. In case OP failed to pay Rs.3,75,000/- and compensation of Rs.50,000/- within one month from the date of receipt of present order then liable to pay interest @  9% p.a on Rs.3,75,000/- and on compensation amount Rs.50.000/- till realization. File be consigned to record room.
23. Copy of the order be given to the parties free of cost as per order dated 04.04.2022 of Hon’ble State Commission after receiving an application from the parties in the registry. The orders be uploaded on www.confonet.nic.in.

Announced in open Commission on  04.04.2024.

    SANJAY KUMAR                 NIPUR CHANDNA                       RAJESH

       PRESIDENT                             MEMBER                                MEMBER