Before the District Consumer Disputes Redressal Forum, Rohtak.
Complaint No. : 325.
Instituted on : 01.06.2017.
Decided on : 27.11.2019.
Ramesh Kumar son of Sh. Chudiya Mal, age 45 years, Resident of H.No. 287/1, Ward No. 17, Nehru Street, Arya Nagar, Rohtak and also at House No. 1457/2, Ward no. 5, Jain Sons India, Railway Road, Rohtak.
………..Complainant.
Vs.
1. Star Health and Allied Insurance Company Ltd., Branch Office at Narain Complex, IInd Floor, near Chhotu Ram Chowk, Rohtak through its Branch Manager.
2. Star Health and Allied Insurance Company Ltd. Branch Office at SCO No. 242, 1st Floor, Sector 12, Opposite Mini Secretariat, Karnal through its Branch Manager.
3. Star Health and Allied Insurance Company Ltd. Regd. Office at KRM Centre, VI Floor, No. 2, Harington Road, Chetpet, Chennai-600031 through its authorized person/Managing Director.
……….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. Kunal Juneja, Advocate for complainant.
Sh. Gulshan Chawla, Advocate for opposite parties.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. The present complaint has been filed by the complainant with the averments that the complainant got himself insured vide policy No.P/211114/01/2017/002651 from 03.09.2016 to 02.09.2017 through the agent of the opposite parties and paid premium of Rs. 11,800/- for two adults and two children’s and he was given Health Member ID No. 5792982-1, 5792982-2, 5792982-3 and 5792982-4 in the name of his family members. It is alleged that in the month of October 2016 the daughter of complainant had pain in ear and as such she initially taken treatment from Sh.Anil.K.Monga, E.N.T Surgeon, Sir Ganga Ram Hospital, Delhi and some procedure was done and treatment was advised. Thereafter on 28.10.2016, the daughter of the complainant had a viral fever and she took treatment from Dr. Sunder Lal Garg, Gupta Clinic and she remained patient of Dr. Hari Om Manchanda and Dr. Siwach and was diagnosed as a patient of Haemoptysis, SOB & Fever and remained hospitalized from 10.11.2016 to 15.11.2016. That on 18.11.2016, the complainant’s daughter had pain in stomach and as such she approached Medanta(The Medicity), Gurgaon vide registration No. MM00978364 and was diagnosed as a patient of ANCA associated vasculitis and after diagnose some test & procedure or surgery was done and she remained hospitalized there from 18.11.2016 to 03.12.2016. The complainant incurred expenses of Rs. 6,30,004.98/- which were paid to the Medanta(The Medicity) vide various bills dated 03.12.2016. It is further alleged that after discharge, the complainant approached the respondents for reimbursement of the aforementioned expenses incurred on treatment alongwith bills of Rs.6,30,004.98/- vide claim No. CLI/2017/211114/0309919 and submitted all the requisite documents. But the claim of the complainant was repudiated by the opposite parties vide letter dated 12.03.2017 on false and illegal grounds. That the act of opposite parties is illegal and there is deficiency in service on the part of opposite parties. As such, it is prayed that opposite parties may kindly be directed to pay the claim amount of Rs.6,30,004.98/- alongwith interest @ 18% per annum from the date of its accrual till realization and also to pay Rs. 3,00,000/- as compensation and litigation expenses 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 of the complainant was repudiated by the opposite party for reason of suppression of material facts and mis-representation by the DLA in the proposal form. That the claim was reported in the second month of the commencement of the policy, wherein insured was admitted in Siwach Hosptial on 10.11.2016 for the treatment of LRTI and submitted Pre Authorization Request form for cashless treatment vide claim no.CLI/2017/211114/0298328. On perusal of the documents submitted by the treating hospital, it is observed that: As per Pre Auth Form, the insured was admitted with the complaints of cough, Hematemesis and the Provisional Diagnosis was LRTI. , The progress sheet dated 10.11.2016 states that the insured was admitted with the complaints of cough, fever, general weakness, bleeding from nose, hemoptysis and shortness of breath and mild exertion. Hence some documents were sought but the treating hospital has not submitted the documents. Hence the cashless authorization was denied on the ground of insufficient documents and the same was communicated to the treating hospital and the insured vide letter dated 11.11.2016. That the patient was also admitted in Siwach hospital and Medanta hospitals and based on the findings given by the hospitals, it was observed that the insured patient has vasculitis due to colonic disease which is prior to inception of the medical insurance policy and it is a pre existing disease. The present admission of the insured patient is for the non disclosed pre existing colonic disease and ANCA associated vacuities. That at the time of inception of the policy, the insured have not disclosed the above mentioned medical history/health details of the insured person in the proposal form which amounts to misrepresentation/non-disclosure of material facts. Hence the claim was rightly repudiated and was communicated to the insured vide letter dated 12.03.2017. That there is no deficiency in service on the part of opposite parties and dismissal of complaint has been sought.
3. Learned counsel for the complainant in his evidence tendered affidavit Ex.CW1/A, documents Ex.P1 to Ex.P9 and has closed his evidence on dated 10.12.2018. On the other hand, ld. Counsel for the opposite parties has tendered affidavit Ex.RW1/A, document Ex.R1 to Ex.R17 and has closed his evidence on dated 18.02.2019.
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 firstly the patient was brought in Sunder Lal Garg, Gupta Clinic, near Railway station, Rohtak on dated 28.10.2016 and thereafter she was treated by Sh. Hari Om Manchanda and Dr. Siwach at Siwach Hospital, Rohtak. She was remained admitted in Siwach Hospital, Rohtak from 10.11.2016 to 15.11.2016. On dated 18.11.2016, the patient namely Kajal has suffered stomach pain and she approached in Medanta(The Medicity) Hospital, Gurgaon on dated 18.11.2016. She was remained admitted in Medanta hosptial from 18.11.2016 to 03.12.2016. As per the respondent, the claim of the complainant was repudiated on the ground that as per discharge summary of the hospital, “The insured patient has ischemic colitis, lung nodules, saddle nose and left paracentral stroke with history of epistaxis and haemoptysis for the past 1 month, as per the indoor case records of the above hospital, the insured patient has history of malena for the past 6 months. Based on these findings, the medical team opined that the inured patient has vasculitis due to colonic disease prior to inception of the medical insurance policy and it is a pre-existing disease. The present admission of the insured patient is for the non disclosed pre existing colonic disease and NCA associated vasculitis”. This fact has been mentioned in repudiation letter Ex.R17. Meaning thereby the claim of the complainant was repudiated on the ground of non disclosure of pre-existing chronic disease by the complainant in his proposal form.
6. The main stress of the respondent is that in Ex.R16 on page no.8, on dated 21.11.2016 prescription slip cross consultation form of Medanta Hospital, it has been mentioned that the patient has the history of Malena on/off 6 months. After believing this document the claim of the complainant has been repudiated by the respondent insurance company. On the other hand, the complainant has placed on record several other documents like prescription slip issued by Siwach Hospital dated 10.11.2016 as Ex.P9. After perusal of these documents, we came to the conclusion that it has not been mentioned anywhere that patient suffers with a history of Melena for the past six month. In fact as per Dr. Siwach, the patient was having a history of fever for 15-20 days, bleeding from nose 15/20 days. She was also suffering from cough and having shortness of breath. Moreover, the Medanta Hospital also issued review dated 28.11.2016, which is placed on record as Ex.P7 regarding the treatment of patient on the request of Gastro Department and they had issued a detailed consultation report in which it has been specifically mentioned that : “Seen previously for GI bleed case of systemic vasculitis. Later diagnosed to have bowel perforation. Now suspected Exploratory laprotomy, subtotal colectomy. Loop jejunostomy with distal mucous fistula. Patient initially gave history of altered stools, darker in colour, however can’t be confirmed to be malena. On examination PR- there was no evidence of Malena/Hematochezia. UGI Endoscopy(22.11.2016) did not show any active bleed. Sigmoidoscopy(22.11.2016) also did not show any active bleed either”. Hence from the alleged report it is proved that the patient was not suffering from Melena or other ailments which was not covered under the policy. Hence opposite parties failed to prove the fact that the complainant was suffering from the pre-existing disease which was not covered under the policy.
7. In view of the facts and circumstances of the case it is observed that opposite parties are liable to pay the sum insured under the policy i.e. Rs.500000/-(Rupees five lacs only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 01.06.2017 till its realization and shall also to pay a sum of Rs.5000/-(Rupees five thousand only) as compensation as well as litigation expenses to the complainant within one month from the date of decision.
8. Copy of this of and the order be supplied to both the parties free of costs. File be consigned to the record room after due compliance.
Announced in open court:
27.11.2019.
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Nagender Singh Kadian, President
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Renu Chaudhary, Member.
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Tripti Pannu, Member.
