The complainant Raman Watts (here-in-after referred to as complainant) has filed this complaint U/s 12 of Consumer Protection Act, 1986 (Now C.P. Act, 2019, here-in after referred to as 'Act') before this Forum (Now Commission) against Star Health & Allied Insurance Co. Ltd., (here-in-after referred to as opposite party).
Briefly stated the case of the complainant is that the opposite party approached the complainant in year 2018 through Varinder Sharma Agent for the renewal of medical Insurance Policy which was already existing with The New India Assurance Co. Ltd. for the last about 8 years. The complainant paid Rs.24,142/- as one year premium and the opposite party renewed the previous policy which was already existing with The New India Assurance Co. Ltd. under Family Health Optima Insurance Plan vide Policy No. P/211217/01/2019/000667 w.e.f. 08.08.2018 to 07.08.2019 and the opposite party took the Original Policy No. 36060134172800000094 from the complainant issued by The New Insurance Co. Ltd. as per the opposite party terms of renewal. Opposite party insured the complainant Raman Watts and his wife Vandana Watts for the amount of Rs.5,00,000/- each.
The complainant alleged that the opposite party assured the complainant that this is the cashless insurance and in case of any problem total treatment in any hospital in India is free and total medical bills upto Rs.5,00,000/- will be paid directly to the hospital. The complainant suffered problem of breathlessness in the month of Oct., 2018 and the complainant duly consulted the doctors of DMC Hospital, Ludhiana who prescribed him 15 days medicine.
It is alleged that the complainant visited with DMC Hospital, Ludhiana for follow up on 05.11.2018 and the doctors diagnosed hypertension and chronic stable angina and recommend the complainant for Coronary Angiography (Triple Vessel Disease) and thereafter the complainant again visited with DMC Hospital, Ludhiana for By Pass surgery on 08.11.2018 and surgery was done on 09.11.2018 and he discharge on 16.11.2018. The family of the complainant also lodged the cashless claim with the opposite party through DMC under their system by E-Mail, but the opposite party on the wrong facts and with concocted objections denied the cashless treatment of the complainant. Having no alternative, the family of the complainant arranged such huge amount from the relatives on loan and paid the bills of Rs. 2,57,089/- (Rs.13,929/- + Rs. 2,43,160/-) for treatment and Medicine charges etc. to DMC Ludhiana. Thereafter the complainant submitted all the original bills with original treatment files to the opposite party on 22.11.2018 with the claim form for reimbursement of the same as per directions given by the opposite party at the time of denial of cashless treatment. The opposite party firstly not approved cashless treatment and thereafter they are not ready to reimburse the expenses incurred by complainant.
The complainant further alleged that he received one letter dated 18.12.2018 from the office of the opposite party vide which they illegally rejected the claim of the complainant without any genuine reason on the ground of pre-existing Disease/Condition.
It is further alleged that the opposite party denied the claim on one prescription of Dr. Ripu Daman KaIra. The complainant already disclosed that 3 years ago some temporary Hypertension tablets were prescribed by the said doctor but later on, the same doctor stopped the medicine.
The complainant alleged that the opposite party till date never issued any such complete policy which includes such exclusion clause to the complainant even the opposite party did not supply the same with this No Claim Letter dated 18.12.2018. The complainant is not suffering from any diseases and he never undergone any hospitalization for heart deceases in the past history, as such there is no question of concealment of pre-existing disease.
It is further alleged that the claim of Rs.2,57,089/- (Rs.13,929/- + Rs.2,43,160/-) is still pending with the opposite party. Due to non-payment of Rs.2,57,089/- (Rs.13,929/- + Rs.2,43,160/-), complainant is suffering mental agony and pain, for which he claims compensation to the tune of Rs.1,00,000/-.
On this backdrop of facts, the complainant has prayed for directions to the opposite party to pay Rs.2,57,089/- with interest @ 18% per month alongwith compensation to the tune of Rs. 1,00,000/- and litigation expenses to the tune of Rs.50,000/-.
Upon notice the opposite party put in appearance through counsel and contested the complaint by filing written reply. In written reply, the opposite party raised legal objections that intricate questions of law and facts are involved in the present complaint which require voluminous documents and evidence for determination which is not possible in the summary procedure under the 'Act'. That the complainant has concealed material facts and documents from this Commission as well as the opposite party.
It has been pleaded that the complainant has concealed the fact that the insured availed Family Health Optima Insurance Plan covering Mr. Raman Watts - Self and Mrs. Vandana Watts - Spouse, for the sum insured of Rs. 5,00,000/- vide Policy No. P/211217/01/2019/000667 for the period from 08/08/2018 to 07/08/2019. The above mentioned policy was ported from The New India Assurance for the period 08/08/2016 to 07/08/2018. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant along with the Policy Schedule. Moreover it is clearly stated in the policy schedule that the insurance under this policy is subject to conditions, clauses, warranties and exclusions etc.,
Further legal objections are that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The Complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the Proposal Form.
It has been pleaded that the insured has intimated the claim in the 3rd year of the inception of the policy. The insured submitted claim for Rs. 2,53,878/-. The insured was admitted in Dayanand Medical College and Hospital on 08-11-2018 towards the treatment of HTN, CHRONIC STABLE ANGINA, TVD. The insured submitted Pre-authorization request for availing cashless treatment of above mentioned disease. On scrutiny of pre-authorization document, it was observed that the patient is symptomatic for 3 years and records pertaining to the same are not provided. Thus, the pre authorization was denied and the same was informed to the insured vide letter dated 09/11/2018. Subsequently, the insured submitted claim for reimbursement of the medical expenses. On scrutiny of the claim documents, it was observed that insured patient is suffering from breathlessness on exertion since 3 years, hence patient is symptomatic of the above disease angina/coronary artery disease prior to policy.
As per waiting Period: 3 (iii) of the above policy, 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 elapsed, since inception of the policy i.e., from 08/08/2018. Thus, the claim was repudiated and the same was informed to the insured vide letter dated 18/12/2018. At the time of porting of policy, the complainant submitted previous policy schedule, in which it is mentioned that the inception of first policy is 2016 and in the portability form, the insured has mentioned only 2 years policy. Thus, the insured was admitted for PED in the 3rd year of the policy, hence the claim was repudiated and the same was informed to the insured vide letter dated 18/12/2018.
Further legal objections are that the complainant is not consumer of the opposite party; the complainant has no locus standi or cause of action to file the complaint and that the complaint is not maintainable in the present form.
On merits, the opposite party has admitted that the rejection of the claim was on the ground of pre-existing disease/condition, there being no continuous coverage for 48 months. It is denied that complainant took insurance from New India Assurance Company Limited from the last about 8 years rather the complainant first time took insurance of the above said company first time for the year 2016-17 with commence date of 08.08.2016 as per records supplied by the complainant and that the period of 48 months clause of the insurance was already lapsed when the Insurance was renewed by the opposite party. After controverting all other averments of the complainant, the opposite party prayed for dismissal of complaint.
In support of his complaint, the complainant has tendered into evidence his affidavit dated 26-2-2019 (Ex. C-1) and the documents (Ex. C-2 to Ex. C-17).
In order to rebut the evidence of complainant, opposite party tendered into evidence affidavit dated 19-4-2019 of Rajiv Jain (Ex. OP-1/1) and the documents (Ex. OP-1/2 to Ex. OP-1/12).
We have heard learned counsel for the parties and gone through the record.
The admitted facts of the parties is that complainant Raman Watts and his wife Vandana Watts are insured for the sum insured of Rs. 5,00,000/- each vide Insurance Policy No. P/211217/01/2019/000667 for the period from 08-08-2018 to 07-08-2019 (Ex. C-2). The said policy was ported from policy of New India Assurance Company.
The submission of learned counsel for the complainant is that complainant was insured for Rs. 5,00,000/-. He suffered some health problem during the covered period but the opposite party neither given approval for cashless treatment nor reimbursed medical expenses incurred by him on his treatment rather repudiated the claim on illegal ground of pre-existing disease. The complainant was never hospitalized or was suffering from any health problem prior to treatment in question.
The learned counsel for the opposite party argued that insured was admitted in DMC & Hospital, Ludhiana on 8-11-2018 for the treatment of HTN, Chronic Stable Angina, TVD. The complainant was suffering from breathlessness on exertion since 3 years which confirms the insured patient is symptomatic of the disease angina/coronary artery disease prior to issuance of policy. Since it was a pre-existing disease, claim of the complainant rightly repudiated.
We have considered the rival contentions and gone through the record carefully.
In the case in hand, the opposite party has repudiated the claim of the complainant vide letter dated 18-12-2014 (Ex. C-14). The relevant portion of this letter reads as under :-
“It is observed from the pre auth request form duly completed and signed by the doctor and with the seal of the above hospital that the insured patient is suffering from breathlessness on exertion since 3 years which confirms the insured patient is symptomatic of the above disease angia/coronary artery disease prior to our policy. Hence, it is a pre-existing disease. The present admission and treatment of the insured patient is for pre-existing disease
As per Waiting Period 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/condition untill 48 months of continous coverage has elapsed, prior to date of commencement of first year policy on 8-8-2018.”
A perusal of pre-authorization for cashless treatment Ex. OP-1/4 reveals that under the column of 'Moderate/Past History of any chronic illness” it has been mentioned Heart Disease – 5-11-2018 ; Hypertension 2-3 years. The opposite party has also relied upon one prescription of Kalra Hospital (Ex. OP-1/9) in this regard.
Hon'ble National Commission in Revision Petition No. 2939 of 2011 decided on 15-11-2017 case titled Vipin Grover & anothers Vs. New India Assurance Co. observed :-
“If Insurance companies co-relate each and every disease with pre-existing condition, under such circumstances, insured i.e. helpless consumers will never succeed to get his genuine claim from Insurance Company.”
Similarly Hon'ble State Commission, Punjab in the case :-
(i) CC No. 100 of 2017 decided on 24-4-2018 case Rajesh Singla Vs. Max Bupa Health Insurance Co., observed :-
“Hypertension is not a disease, which is required to be referred in proposal form.”
(ii) First Appeal No. 673 of 2015 decided on 12-5-2017 case titled Life Insurance Corporation of India & Anr Vs. Sarabjit Kaur also observed :-
“Hypertension is not serious disease. It is part of ordinary strain, stress of life.”
In the case of Virpal Nagar Vs. HDFC Standard life Insurance Co. Ltd., II (2019) CPJ 59 (Del.), Hon'ble Delhi State Commission after noticing the observations of Hon'ble National Commission and Hon'ble Supreme Court in various judgements, concluded that :-
“Unless and until a person is hospitalised or undergoes operation for a particular disease in near proximity of obtaining insurance policy or any disease for which he has never been hospitalised or undergone operation is not a pre-existing disease.”
It was also observed :-
“Malaise of hypertension, diabetes, occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is full of tension at the place of work, in or out of the house and are controllable on day-to-day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalised or operated upon for treatment of these disease or any other disease.”
Perusal of file reveals that complainant also brought on file insurance policies (Ex.C-3 to Ex.C-6) issued by previous insurance company i.e. New India Assurance Company from which complainant ported to opposite party. Perusal of policy Ex.C-6 reveals that period of Insurance this policy is from 08-08-2014 to 07-08-2015. In this policy (Ex.C-6) number of previous policy is also mentioned as 36060434120100000033 meaning there by, there was an another policy prior to this policy. Further perusal of policy Ex.C-2 reveals that in this policy number of previous policy i.e. Ex.C-3 is mentioned and same is the case with further previous policies. So exclusion clause of waiting period of 48 months is not applicable to the case of complainant as complainant is availing insurance policy from the year 2013. There is nothing on record to prove that in near proximity of obtaining insurance policy i.e. year 2013, complainant was hospitalised or took any treatment for breathlessness on exertion or for angina/coronary artery disease.
Therefore, keeping in view the above observation also, the conclusion is that the repudiation on the ground of pre-existing diseases of HTN (Hypertension) is not sustainable and repudiation of claim amounts to deficiency in service on the part of the opposite party. As such, the complainant is entitled to the reimbursement of medical expenses incurred by him on his treatment alongwith interest from the date of repudiation. He is also entitled to compensation for harassment and mental agony caused to him on account of non-payment of claim.
In the result, this complaint is partly allowed with Rs.10,000/- as cost and compensation. The opposite party is directed to pay claim amount as per bills submitted by complainant with interest @ 8% p.a. w.e.f the date of repudiation i.e. 18-12-2018 till payment.
The compliance of this order be made by the opposite party within 45 days from the date of receipt of copy of this order.
The complaint could not be decided within the statutory period due to heavy pendency of cases.
Copy of order be sent to the parties concerned free of cost and file be consigned to the record room.
Announced :
24-08-2022
(Kanwar Sandeep Singh)
President
(Paramjeet Kaur)
Member
