BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 40 of 2022
Date of Institution : 17.01.2022
Date of Decision : 23.04.2024
Harish Chander (aged about 54 years) son of Sh. Hemraj, Shop No. 177, Mandi Kalanwali, District Sirsa.
……Complainant.
Versus.
1. Star Health and Allied Insurance Company Ltd., Sri Bala Ji Complex, 15, Whites Road Lane Roy Apettah, Chennai- 600014 through its Senior Manager/ Incharge.
2. Star Health and Allied Insurance Company Ltd., Ground Floor, Rathore Tower, Near Hotel Mehak, Dabwali Road, Sirsa through its Branch Manager/ Senior Manager.
…….Opposite Parties.
Complaint under Section 35 of the Consumer Protection Act, 2019.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
SMT. SUKHDEEP KAUR……………MEMBER.
Present: Sh. R.S. Varch, 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 newly launched policy known as Corona Kavach Policy bearing No. P/211121/01/2021/003634 from the ops for the period 30.07.2020 to 11.05.2021 after making payment of premium as per schedule of the company. The said policy as further renewed for the period 12.05.2021 to 20.02.2022. That before purchasing the said policy, the complainant made it clear to the agent that he is suffering from cardio problem and taking treatment for the same and the agent told him that if complainant suffers from Corona infection and receives the treatment of Corona only then the company shall make payment of entire treatment and he also assured him that this policy is known as cashless and immediate relief giving policy. That authorized representative of ops clearly explained that it is the only policy which covers the risk with specification “lump sum benefit = 100% of the sum insured shall be payable on positive diagnosis of COVID, requiring hospitalization for a minimum continuous period of 72 hours. The positive diagnosis of COVID shall be from a Govt. authorized Diagnostic Centre” and assured him to make entire agreed payment of Rs. five lacs without any question. It is further averred that complainant felt some medical problem and got admitted on 16.05.2021 in Alchemist Ojas Hospital, Panchkula. The treating doctor advised investigation from the authorized laboratory and after giving sample to the concerned lab, report of RT- PCR received on 16.05.2021 and found Antigen positive. The doctors started treatment as per guidelines issued by the Govt. of India. The complainant remained admitted in the hospital till 24.05.2021 and remained under regular follow up with the concerned doctors. That complainant felt so many problems during the period of treatment and later on approximately for a period of one month and thereafter regularly felt body-ache and weakness as well as post COVID effects. It is further averred that complainant upon taking admission in the hospital immediately informed to the officer of ops for cashless treatment and he assured to get treatment but after few days the said officer informed that there are some technical hitch with the company so the complainant has to make the payment of entire treatment and medicine charges. That complainant and his other family members were also admitted in the same hospital being Corona positive and op’s company had made payment to other family members being insured, although complainant has lost his mother. That complainant after recovery contacted with the ops and their authorized representatives for the purpose of reimbursement of treatment amount i.e. Rs.90,000/- as hospital charges and Rs.35,000/- as medicine charges. The op no.2 and his authorized representative collected all the documents required under the policy and sent the same to the higher authorities for reimbursement but thereafter ops sent impugned letter dated 16.05.2021 with the observation that “As per the documents received by us, it is observed that the insured patient has been suffering from the disease/ condition for the past 30 years which is prior to inception of the first policy. Hence, it is pre existing disease. But the insured has failed to disclose this in the proposal form at the time of inception of first policy. This amounts to concealment of material facts. The claim is not admissible under the policy issued to the insured.” It is further averred that complainant has claimed amount for the treatment of Corona positive only and not for other ailment like heart disease. The policy was issued by the ops for a specific purpose and disease known as Corona Kawach policy and ops had also got verified from the concerned hospital that complainant has not taken treatment for any other disease except Corona but despite knowing all the factual position, the ops have wrongly and illegally repudiated the claim of complainant and have caused deficiency in service and unnecessary harassment to the complainant. Hence, this complaint.
3. On notice, ops appeared and filed reply raising certain preliminary objections. It is submitted that terms and conditions of the policy were explained to the complainant at the time of proposing policy and same was served to the complainant alongwith policy schedule. The policy is contractual in nature and claims arising therein are subject to the terms and conditions forming part of the policy and complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed proposal form. It is further submitted that insured Harish Chander was admitted in Ojas Super Specialty Hospital, Panchkula on 16.05.2021 for treatment of Covid-19. That insured raised a pre authorization request for the cashless authorization for alleged hospitalization for the treatment of COVID. On scrutiny of the claim documents, it is observed that :-
A. As per the Doctor’s Progress Notes, the insured is a known case of HTN, Bypass Surgery since 1990 and the SPO2 is 95% on room air (which is within the normal limit).
4. It is further submitted that above findings shows that the insured has pre existing heart disease and underwent bypass surgery or the same. However, the insured has not disclosed the same in the proposal, thus the claim was initially repudiated based on the fact of non disclosure of material facts. It is further submitted that insured patient has been suffering from IHD – POST CABG which is prior to inception of the first policy, but the insured has failed to disclose this pre-existing disease in the proposal form at the time of inception of the first policy and this amounts to concealment of material facts. Hence the policy issued is void-ab-initio. That as per condition 9.8, if any claim made by the insured person is in any respect fraudulent, or if any false statement, or declaration is made or used in support thereof or if any fraudulent means or devices are used the insured person or anyone acting on his/ her behalf to obtain any benefit under this policy, all benefits under this policy shall be forfeited. Further as per condition No. 9.1 of the policy regarding disclosure of information the policy shall be void and all premium paid thereon shall be forfeited to the company in the event of misrepresentation, mis-description or non disclosure of any material fact by the policy holder. Hence, the claim was repudiated and the same was communicated to the insured vide letter dated 31.12.2020. It is further submitted that cashless approval is given by the ops insurance company only on a preliminary evaluation of documents submitted by treating hospital/ insured and it is subject to review upon the receipt of further details/ documents from the insured patient or at any time. If amount of treatment is exceeding to cashless approval or cashless approval is denied then insured can submit his final claim for the reimbursement of the medical expenses incurred by him with the ops insurance company with all required documents. The insurance company settles the claim according to terms and conditions of policy. It is further submitted that as per CT report dated 14.05.2021, the severity score is 7 out of 25 (which is very high suspicion or typical for COVID), however, the insured has not submitted RTPCR report, discharge summary and medicine bills till date to prove the diagnosis and expenses incurred towards the same. If the insured submits claim for reimbursement with the documents, the claim can be processed as per terms and conditions of the policy. On merits it is submitted that complainant has availed Corona Kavach Policy which is a health insurance policy and covers the treatment expenses and not the lumpsum benefit. That Corona Rakshak Policy is the lumpsum benefit policy and the insured has not availed that policy. It is further submitted that complainant has submitted only the pre authorization documents alone. The letter dated 16.05.2021 issued by company after carefully observing the documents submitted by complainant. The observation/ order passed by the company was in a speaking manner, well within the knowledge of complainant. It is denied that complainant has spent Rs.90,000/- for hospitalization and Rs.35,000/- for medicine. As per pre authorization form, the approximate treatment expenses is Rs.90,000/-, however, there is no bills to prove the same. All other contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
5. The complainant in evidence has tendered his affidavit Ex. CW1/A and documents Ex.C1 to Ex.C28.
6. On the other hand, ops have tendered affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex.R1 and documents Ex.R1 to Ex.R5.
7. We have heard learned counsel for the parties and have gone through the case file.
8. Admittedly the complainant had purchased health insurance policy namely Corona Kavach Policy from the ops for the period 30.07.2020 to 11.05.2021 for the sum insured amount of Rs.5,00,000/- as is evident from policy schedule Ex.C2. The said policy was got renewed by complainant from the ops for the period 12.05.2021 to 20.02.2022 for the sum insured amount of Rs.5,00,000/- as is evident from Annexure R2. During the period of policy, on 16.05.2021 the complainant was diagnosed as Covid-19 positive as is evident from report Ex.C24 and he was admitted in Alchemist Ojas Hospital, Panchkula and remained admitted there from 16.05.2021 to 24.05.2021 but the ops declined the cashless request. The claim submitted by complainant has also been repudiated by the ops vide letter dated 16.05.2021 on the ground of non disclosure of pre existing disease of IHD – POST CABG i.e. cardio problem but however, we are of the considered view that ops have wrongly and illegally repudiated the claim of complainant. The policy purchased by complainant was a specific Corona Kavach policy launched by ops after pandemic disease of Covid-19 and the complainant is claiming reimbursement for treatment of Corona disease and as such the repudiation of the claim of complainant is baseless and arbitrary because complainant specifically disclosed to the agent of the ops at the time of purchasing the policy in question that he is suffering from Cardio problem. Moreover, it is not proved by ops through cogent and convincing evidence that any terms and conditions of the policy were supplied to the complainant. Further more, repudiation of the claim of complainant on the ground that he is suffering from pre existing disease of IHD – POST CABG since long is not justified because complainant purchased specific policy launched by ops i.e. CORONA Kavach which has no concern with any other disease. Further more, ops have also failed to prove on record through any cogent and convincing evidence that any specific questions were asked to the complainant about his any pre existing disease and he concealed any material information regarding his health. As such repudiation of the claim of complainant is hereby set aside. The complainant is entitled to reimbursement of Rs.1,25,000/- as spent by him on his treatment for Corona disease and in this regard complainant has also placed on file various bills/ receipts.
9. In view of our above discussion, we allow the present complaint and direct the opposite parties to make reimbursement of claim amount of Rs.1,25,000/- to the complainant within a period of 45 days from the date of receipt of copy of this order, failing which complainant will be entitled to receive the said amount of Rs.1,25,000/- from ops alongwith interest at the rate of @6% per annum from the date of this order till actual payment. 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,
Dt. 23.04.2024. District Consumer Disputes
Redressal Commission, Sirsa.
