Before the District Consumer Disputes Redressal Commission, Rohtak.
Complaint No. : 37
Instituted on : 22.01.2019
Decided on : 14.11.2023
Shashank S/o Sh. Avinash Kant Sharma R/o H.No. 295, old Housing Board, Rohtak Haryana
………..Complainant.
Vs.
Star Health and Allied Insurance Company Limited, Branch Office, Ashoka Plaza, 3rd Floor, Delhi Road, Rohtak-124001 (through its Branch Manager)
……….Opposite party.
COMPLAINT U/S 12 OF CONSUMER PROTECTION ACT,1986.
BEFORE: SH.NAGENDER SINGH KADIAN, PRESIDENT.
DR. TRIPTI PANNU, MEMBER.
DR.VIJENDER SINGH, MEMBER.
Present: Sh. LalitKaushik, Advocate for the complainant.
Sh. Gulshan Chawla, Advocate for opposite party.
ORDER
NAGENDER SINGH KADIAN, PRESIDENT:
1. Brief facts of the case, as per the complainant are that he purchased a health policy No. P/211118/01/2019/001311 for a period of 12.06.2018 to 11.06.2019 from opposite party. The insurance policy covered all fatal and health risk of insured persons. On 10.10.2018, complainant was admitted in Life Care Hospital, Rohtak with the complaint of high grade fever for last 3 days. In this regard the claim was lodged with the opposite party vide complaint no. CLI/2019/211118/0382538 for preauthorization of expenses of treatment. But the opposite party sent a letter of denial of authorization request for cashless treatment and asked him to claim the amount later on for its reimbursement of expenses. Thereafter the complainant was discharged on 18.10.2018 and Rs.1,03,360/- were incurred upon his treatment. All necessary documents regarding the treatment and bills were deposited to the opposite party. On 24.11.2018, complainant received a repudiation letter with the reason that “complainant has problem of acute pancreatitis. However the admission and treatment of the insured patient is for pancreatitis not the diagnosis as stated in the discharge summary”. The repudiation of claim by the opposite party is wrong & illegal and there is deficiency in service on the part of opposite party. Hence this complaint and it is prayed that opposite party may kindly be directed to pay Rs.1,03,360/- alongwith interest @ 18% per annum from the date of discharge i.e. 18.10.2018 till its realization, Rs.11,000/- as litigation charges and to pay Rs.1,00,000/- for harassment as explained in relief clause.
2. After registration of complaint, notice was issued to the opposite party. Opposite party in its reply has submitted that complainant opted for Family Health Insurance Policy bearing No. P/211118/01/2019/001311 for basic floater sum assured of Rs.3,00,000/-which was issued on 12.06.2018, covering Shashank-Self. The complainant continued the policy upto 11.06.2019 covering the date of accident. It is further submitted that policy in question was issued only on the basis of declaration given by the complainant in the proposal form, subject to terms and conditions. The insured patient on getting hospitalized on 10.10.2018, in Dr.Jales Life Care Hospital, raised a pre-authorisation request for availing cashless facility for the treatment of PUO. (Pyrexia of unknown origin). On scrutiny of the medical records, it is observed that with available documents underlying cause for pancreatitis cannot be ascertained, final diagnosis is still not established and the patient is still under investigations and evaluation-Based upon the information/clarification provided we are not in a position to decide upon the admissibility of the claim. Hence, cashless was denied vide letter dated 11.10.2018and informed the insured to approach for reimbursement. Subsequently, the insured submitted claim for reimbursement of medical expenses of Rs.103360/- for acute pancreatitis. From the above findings, it is observed that the insured was diagnosed with acute pancreatitis and was treated for the same. Further the insured patient has undergone treatment for the pancreatitis disease which is during the first year of the policy. Hence as per waiting period 3-B-(ii) of the policy, the company shall not be liable to make any payments under the alleged policy in respect of any expenses whatsoever incurred by the insured person during the first two years of continuous operation of insurance cover any expenses on all types of treatmentsfor : “All treatments(conservative, interventional, laparoscopic and open) related to Hepato-pancreato-biliary diseases including Gall bladder and Pancreatic calculi. All types of management for Kidney and Genitourinary tract calculi”. Hence the claim was repudiated on the ground of two years exclusion and the same was communicated to the complainant vide letter dated 24.11.2018. All the other contents of the complaint were stated to be wrong and denied and opposite party prayed for dismissal of complaint with costs.
3. Ld. counsel for the complainant in his evidence has tendered affidavit Ex.CW1/A, documents Ex.C1 to Ex.C58 and closed his evidence on dated 18.03.2021. Ld. counsel for the opposite party has tendered affidavit Ex.RW1/A and documents Ex. R-1 to Ex. R-14 in his evidence and closed the same on dated 12.08.2021.
4. We have heard learned counsel for the parties and have gone through material aspects of the case very carefully.
5. In the present case the claim of the complainant has been repudiated by the opposite party vide letter dated 24.11.2018. The repudiation letter is placed on record by the complainant as Ex.C1 and by the respondent as Ex.R13. The main ground of the repudiation by the respondent is that after considering CT report dated 12.08.2018 the insurance company came into the conclusion that the complainant is suffering from acute pancreatitis and as per the policy clause 3-B-II of the policy, insurance company is not liable to make any payment in respect of any expenditure incurred by the policyholder for the treatment of pancreatitis during first two years of the continuous operation of the insurance cover. It has been further submitted in this letter that the life assured is taking alcohol so as per the exclusion clause no.6, the insurance company is not liable to make any payment in respect of expenses incurred at hospital for treatment of any disease/condition due to use of alcohol and the company repudiated the claim of the complainant.
6. We have minutely perused the documents placed on record by both the parties. As per discharge summary Ex.C43, the complainant was admitted in the Life Care Hospital on 10.10.2018 and was discharged on 18.10.2018 and diagnosed for PUO-
AC Gastritis. Meaning of which is PUO in medical term is “Pyrexia of unknown origin (PUO) or fever of unknown origin (FUO) is defined as the persistent increase in body temperature (>38.3 °C. /101.0 °F) for at least 3 weeks without a clear cause in an immunocompetent patient despite undergoing thorough clinical evaluations for two outpatient and three inpatient visits”. And the meaning of AC Gastritis is that :“Acute gastritis is a sudden inflammation or swelling in the lining of the stomach. Gastritis only directly affects the stomach, while gastroenteritis affects both the stomach and the intestines. The most common causes of acute gastritis are nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids”.
We have also minutely perused the clause of the policy 3(b)(ii), as per which company shall not be liable to make any payments under the alleged policy in respect of any expenses whatsoever incurred by the insured person during the first two years of continuous operation of insurance cover any expenses on all types of treatments or : “Desmoid tumour of anterior abdominalwall Gall bladder and Pancreatic diseases and all treatments(conservative, interventional, laparoscopic and open) related to Hepato-pancreato-biliary diseases including Gall bladder and Pancreatic calculi. All types of management for Kidney and Genitourinary tract calculi” But the same are all together different. The disease of complainant is different from the diseases as mentioned in 3-b(ii) as mentioned in written statement. The complainant was not suffering from any such disease and he was admitted in the hospital for PUO-AC Gastritis as explained above. Moreover insurance company has not placed on record any affidavit that the same is co-related to each other. No evidence of alcohol is placed on record. Initially as per Ex.C2, the complainant was admitted with history of high grade fever with chill for last 3-4 days, episodes of vomiting for 2 days, severe pain, headache, general weakness, loose stool watering in natureand treatment is also given by the doctor for the above mentioned disease. He was not treated for the treatment as mentioned in the written statement. Hence the complainant is entitled for claim amount. As per the complaint, complainant is demanding a sum of Rs.103360/- regarding treatment expenses but perusal of the bill and other documents show that as per Ex.C11 to Ex.C57 the complainant has spent an amount of Rs.86509/- on his treatments, tests, medicine and CT whole abdomen etc. On the other hand, opposite party has calculated the net payable amount to the insured as Rs.51883/-The calculation sheet is placed on record as Ex.R14. But as per our opinion the complainant is entitled for Rs.86509/-.
7. In view of the facts and circumstances of the case, we hereby allow the complaint and direct the opposite party to pay Rs.86509/-(Rupees eighty six thousand five hundred and nine only) alongwith interest @ 9% p.a. from the date of filing the present complaint i.e. 22.01.2019 till its realization and shall also pay a sum of Rs.5000/-(Rupees five thousand only) as compensation on account of deficiency in service and Rs.5000/-(Rupees five thousand only) as litigation expenses to the complainant within one month from the date of decision.
8. 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:
14.11.2023.
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Nagender Singh Kadian, President
………………………………..
TriptiPannu, Member.
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Vijender Singh, Member.
