BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 164 of 2022
Date of Institution : 14.03.2022
Date of Decision : 09.04.2024
Dinesh Kumar Ganeriwala, aged 62 years son of Shri Prem Parkash, resident of House No. 202-2023, Rukmani Villa, Ram Colony, Sirsa, Tehsil and District Sirsa (Haryana).
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Ltd., Branch Office: Near R.C. Hotel, Hisar (Parshuram Chowk) Road, Sirsa, Tehsil and District Sirsa through its Branch Manager.
2. Star Health and Allied Insurance Company Ltd., No. 15, Sri Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai- 600 014, through its authorized signatory.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
Present: Sh. JBL Garg, Advocate for the complainant.
Sh. Ravinder Monga, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that complainant purchased a family health optima insurance plan from the ops vide policy No. P/21121/01/2020/006302 for the period 31.12.2019 to 30.12.2020 and got insured himself and his wife Smt. Partibha for sum assured amount of Rs.5,00,000/-. The complainant paid a sum of Rs.24,142/- as premium for the said policy and thereafter, said policy was further got renewed for the subsequent period i.e. 31.12.2020 to 30.12.2021 and he was issued policy No. P/211121/01/2021/011722 and he paid a sum of Rs.20,695/- as premium for renewal of the policy and they were covered for the sum assured of Rs.6,25,000/-. That on 09.04.2021, the complainant developed heart ailment and he was got admitted in C.K. Birla, Hospital, Jaipur where he remained admitted from 09.04.2021 to 20.04.2021 and incurred a sum of Rs.3,48,385/- for his treatment. It is further averred that thereafter complainant lodged his claim with the ops and supplied all the required documents and information as required by the ops for settlement of his claim. But however, very strangely vide their letter dated 02.09.2021, the ops have repudiated the claim of complainant on the ground that “It is observed from the medical records that the insured patient has cardiac ailment, which is prior to inception of medical insurance policy. Hence, it is a pre existing disease. The present admission and treatment of the insured patient is for the pre existing disease”. That complainant was shocked to know the repudiation of his claim due to above imaginary reason developed by the ops because before issuance of the above policy, the ops had got medically examined the complainant and got assessed his entire health parameters and after fully satisfying with the same, the ops had issued the policy and as such the ground of pre existing disease of complainant is quite imaginary, afterthought and appears to be manipulated one just for the repudiation of the claim of complainant. It is further averred that complainant is legally entitled to get the amount incurred on his treatment i.e. Rs.3,48,385/- from ops alongwith interest and the ops by their such act and conduct have indulged themselves in unfair trade practice and have committed gross deficiency in service and harassment to the complainant. That thereafter also the complainant approached the ops and requested them to admit his claim and also got served legal notice to the ops on 21.01.2022 but to no effect. Hence, this complaint.
3. On notice, ops appeared and filed written version raising certain preliminary objections. It is submitted that complainant availed family health optima insurance policy commencing from 31.12.2020 to 30.12.2021 covering the risk of Rs.five lacs. The insured Dinesh Kumar before purchasing the policy comfortably understood the terms and conditions of the policy which were explained to him at the time of proposing and the same was served to the complainant alongwith policy schedule. Further more, it is clearly mentioned in the policy schedule “The insurance under this policy is subject to conditions, clauses, warranty, exclusion clause etc”. The complainant after accepting the policy and being fully aware of such terms and conditions purchased the policy in question. It is further averred that complainant lodged the claim before the company and submitted the documents for reimbursement towards the treatment of Mitral Valve Regurgiaition. After carefully analyzing the documents, it is observed from the hospital record that the insured patient has the above disease which is long standing ailment, we are not able to ascertain the duration of disease based on the documents, it requires further evaluation. The cashless claim was denied vide letter dated 08.04.2021. Subsequently the insured submitted the claim for reimbursement for treatment of Mitral Valve Regurgiaition. On scrutiny of the claim documents, it is observed from the medical record that the insured patient has cardiac ailment which is prior to the inception of the medical claim policy, hence it is a pre existing disease. The present admission and treatment of the insured patient is for pre existing disease. It is further submitted that as per the exclusion clause Pre-existing disease –Code Excel01 of policy issued to the insured, expenses related to the treatment of pre existing disease and its direct complications shall be excluded until the expiry of 48 months. Therefore, they were unable to settle the claim under the policy and hence claim was repudiated vide order dated 02.09.2021. It is further submitted that as per the new IRDA guidelines, if the non disclosed disease is other than the disease from the list of permanent exclusion, then the insurer can incorporate additional waiting period nor exceeding four years for the same undisclosed disease or condition from the date the disease was found i.e.08.04.2021 and it is now incorporated in policy as pre existing disease. So the claim of the complainant has been rightly repudiated as per the terms and conditions of the insurance policy. The complainant himself is guilty of concealing the pre existing disease at the time of accepting the proposal form. It is further submitted that insurance policy is governed by limits of liability as per its clauses and in case it is found that company is liable to pay the claim in terms of the contract of insurance, than the maximum quantum of liability under the terms of the policy shall be of Rs.2,76,301/-. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
4. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C35.
5. On the other hand, ops have tendered affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex. RW1/A and documents Ex.R1 to Ex.R13.
6. We have heard learned counsel for the parties and have gone through the case file.
7. From the Family Health Optima Insurance Plan Ex.C1, it is evident that complainant purchased the health insurance policy from the ops for the period 31.12.2019 to 30.12.2020 for the sum insured amount of Rs.5,00,000/- for himself and for his wife Smt. Partibha. The said policy was got renewed by him from ops for the period of 30.12.2020 to 30.12.2021 and during this period they were insured for the sum assured amount of Rs.6,25,000/- as is evident from Ex.C3. It is also proved on record that during the said period of policy, the complainant took treatment from C.K. Birla, Hospital Jaipur from 09.04.2021 to 20.04.2021 as on 09.04.2021 he developed heart ailment and from discharge summary Ex.C9 of said hospital, it is evident that he was diagnosed with Severe Mitral Regurgitation and procedure of mitral valve replacement and coronary artery bypass grafting was done. According to the complainant he has spent amount of Rs.3,48,385/- on his above said treatment of heart ailment and has also placed on file various bills/ receipts in this regard as Ex.C15 to Ex.C31. However, the cashless request as well as claim of the complainant has been denied by the ops on the ground that insured patient has the above disease which is a longstanding ailment. The ops vide their letter dated 02.09.2021 have repudiated the claim of complainant on the ground that it is observed from the medical records that the insured patient has cardiac ailment, which is prior to inception of medical insurance policy and hence it is a pre existing disease and present admission and treatment of the insured patient is for pre exisiting disease. However, we are of the considered view that ops have wrongly, illegally and arbitrarily denied the genuine claim of the complainant on just lame excuses of long standing/ pre existing disease because from the discharge summary Ex.C9, it is duly proved on record that the complainant underwent CAG on 10.04.2021 which revealed Coronary Artery Disease, Single Vessel Disease. The ops have failed to prove on record through any cogent and convincing evidence that prior to 09.04.2021 the complainant was suffering from said heart disease or that he was taking any treatment for the said heart disease prior to 09.04.2021 and therefore, it cannot be said that said heart disease was longstanding/ pre existing disease to the complainant and as such ops have wrongly and illegally repudiated the claim of complainant and as such repudiation of claim of complainant is hereby set aside. The ops vide bill assessment sheet Ex.R13 assessed the claim amount of Rs.2,76,301/- after necessary deduction and thereby approved the said amount of Rs.2,76,301/- but however, ops have not paid this amount also in time to the complainant and as such complainant is entitled to the amount of Rs.2,76,301/- alongwith interest.
8. In view of our above discussion, we allow the present complaint and direct the opposite parties to make payment of claim amount of Rs.2,76,301/- to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 14.03.2022 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops to further pay a sum of Rs.10,000/- as compensation for harassment and Rs.5000/- as litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member President,
Dated: 09.04.2024. District Consumer Disputes
Redressal Commission, Sirsa.
