BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 180 of 2018
Date of Institution : 05.06.2018
Date of Decision : 11.06.2019
Mukesh Kumar @ Mukesh Verma aged...years resident of H.No.35, Gali No.1, MITC Colony, Sirsa District Sirsa.
……Complainant.
Versus.
- Star Health & Allied Insurance Company Ltd. Branch Office: Ground Floor, Opp. Shakti Motors, Near IDBI Bank, Sirsa, Tehsil & District Sirsa, through its Branch Manager.
- Star Health and Allied Insurance Company Limited Regd. Office: 1, New Tank Street, Valluyer Kottam High Road, Numgambakkam, Chennai-600034, through its authorized signatory.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA………………. ……PRESIDENT.
SH. ISSAM SINGH SAGWAL ………MEMBER.
MRS. SUKHDEEP KAUR……………..MEMBER.
Present: Sh. JBL Garg, Advocate for the complainant.
Sh. M.K. Saini, Advocate for opposite parties.
ORDER
The case of the complainant, in brief, is that the complainant purchased a Family Health Optima Insurance Plan for himself, his wife Lalita Rani and son Harshdeep Verma son, vide policy No.P/211121/01/2018/002273 for the period w.e.f. 24.11.2017 to 23.11.2018 with basic floater sum assured of Rs.5 lakhs and paid premium of Rs.17,635/-. The complainant had purchased such policy for the period 07.01.2016 to 06.01.2017 due to some financial crises with the complainant, he could not continue with this policy and thus the same lapsed. The policy was revived for the period 24.11.2017 to 23.11.2018 by payment of above amount of premium. That on 29.12.2017 the complainant suffered sudden chest pain and he got himself medically checked up from doctor Karan Singh, who referred him to Poonia Hospital, Sirsa. A CAG test was got conducted upon the complainant and then Dr.Mandeep Garg diagnosed that there is a heart problem to the complainant. On 30.12.2017, the complainant was taken to Medanta, The Medicity Hospital, Gurgaon where he was got admitted as an indoor patient and he was operated upon on 04.01.2018 and spent Rs.3,95,000/- on his treatment, transportation charges, cost of medicines etc. The complainant lodged claim with Ops and also deposited all the requisite documents besides completing all the formalities but the Ops have repudiated the claim vide letter dated 26.02.2018 on the ground that the complainant has longstanding heart disease prior to date of commencement of first year policy and the insured patient diagnosed during the first 30 days from the date of commencement of the policy and as per waiting period 3 (III) of the 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 with the company on 24.11.2017. The policy was elapsed on 07.01.2016 which was revived on 24.11.2017 and the complainant was diagnosed on 29.12.2017 about heart ailment. The complainant requested the Ops to make the amount incurred by him on his treatment and also got served legal notice upon the Ops but to no avail. The act and conduct of the Ops clearly amounts to deficiency in service on their part. Hence, this complaint.
2. On notice, opposite parties appeared and filed their joint written statement in which it has been submitted that the claim for amount Rs.3,96,868/- was reported in the 36th day of the policy as the cashless treatment was denied vide letter dated 01.01.2018 on the ground that CAP report shows longstanding multi vessel coronary artery disease and also patient consulted another hospital and documents pertaining to it not provided. As per waiting period 3 (III) of the policy, the company I not liable to make any payment in respect of expenses for treatment of the pore-existing disease/condition, until 48 months of continuous coverage has elapsed, since inception of the policy with the company on 24.11.2017. The claim as rightly repudiated on the ground of pre-existing disease. The complainant has not come to this Forum with clean hands. It has been further submitted that the complainant has no cause of action and locus standi to file the present complaint because the insured patient had longstanding heart disease prior to the date of commencement of first year policy. There is no deficiency in service on the part of the Ops. Other contentions have been controverted and prayer for dismissal of the complaint has been made.
3. Thereafter, both the parties have led their respective evidence.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. Learned counsel for the complainant has contended that the complainant has proved on record that he has purchased a Family Health Optima Insurance Plan from the Ops for the period 24.11.2017 to 23.11.2018 and got insured himself, his wife Smt.Lalita Rani and son Harshdeep Verma for the basic floater sum insured of Rs.5 lakh and paid a sum of Rs.17,635/- as insurance premium. On 29.12.2017, the complainant suffered chest pain and he was medically checked upon from doctor Karan Singh and he referred him to Poonia Hospital, Sirsa. Then a CAG test was got conducted upon the complainant and then Dr.Mandeep Garg diagnosed that there is a heart problem to the complainant. On 30.12.2017, the complainant was taken to Medanta, The Medicity Hospital, Gurgaon where he was got admitted as indoor patient and was he was operated upon i.e. CABG on 04.01.2018 and he incurred Rs.3,95,000/- on his operation, including fee of doctors, transportation charges, cost of medicines etc. Due intimation was given to the insurance company and claim was lodged, but however, the Ops have repudiated the claim arbitrarily and illegally, which amounts to deficiency in service and unfair trade practice on their part. Learned counsel for the complainant has relied upon the judgments reported as M/s Royal Sundaram Alliance Insurance Co.Lted. and others Vs. Melanie Das 2018 (2) CLT page 459 (NC), Dr. Varsha Trivedi Vs. New India Assurance Company Limited and others 2019 (1) CLT 57 (NC), Kiranjit Kaur and others Vs. HDFC Standard Life Insurance Company Limited 2018 (3) CLT, 51 (NC), Bharti Axa Life Insurance Company Limited and others 2018 (3) CLT 208 (SCDRC, Chandigarh), LIC of India Vs. Reena Nanda 2019 (1) CLT 380 (NC), Rajinder Singh Vs. The New India Assurance Co.Lted. and others 2018 (3) CLT page 187 (SCDRC Haryana), Birla Sun Life Insurance Company Limited and others Vs. Gudela Siva 2019 (1) CLT 89 (NC).
6. On the other hand, learned counsel for the Ops has contended that at the time of taking the policy by the complainant, the terms and conditions were explained to him and the was also served to the complainant. The insurance under this policy is subject to conditions, clauses, warranties, exclusion etc. the claim reported in the 36 day of the policy and claim amount was Rs.3,96,868/-. The CAG report dated 29.12.2017 shows ecstatic, chronic multi vessel long standing severe disease with involving branches. The above findings confirmed that the insured patient was longstanding heart disease prior to date of commencement of first year policy within short span of 1 month and 7 days. Hence, it is a pre-existing disease. As per waiting period 3 (III) of the 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 with the company on 24.11.2017 and the claim as rightly repudiated on the ground of pre-existing disease.
7. We have considered the rival contentions of the parties and gone through the record as well as the judgments relied upon by learned counsel for the complainant very carefully.
8. The perusal of the case file reveals that, the complainant in order to prove his case has furnished his affidavit Ex.C1/A wherein he has reiterated all the averments made in his complaint. The complainant has also placed on record documents such as policy schedule Ex.C1, Ex.C2, repudiation letters Ex.C3, Ex.C4, registered letter Ex.C5, medical treatment and tests Ex.C6 to Ex.C8, legal notice Ex.C9, postal receipts Ex.C10, Ex.C11, bills of medicines and hospital Ex.C12 to Ex.C23 whereas the opposite parties have furnished affidavit of Sh. Rajiv Jain, Chief Manager as Ex.RW1/A in which he has reiterated the averments of the written statement. The OPs have also furnished copies of documents such as request for cashless hospitalization Ex.R1, FVR (Pan India) Revised Ex.R2, query on preauthorization Ex.R3, claim form Ex.R4, discharge slip Ex.R5, repudiation letter Ex.R6, common proposal form Ex.R7, policy schedule Ex.R8, terms and conditions Ex.R9.
6. There is no dispute qua the fact that the complainant had purchased health policy for himself, his wife and children from the Ops on payment of premium and further there is no dispute qua the fact that the complainant suffered chest pain and he was admitted in Poonia Hospital and the doctor had referred him to Medanta Hospital, Gurgaon, where surgery was conducted upon him and he made the payment of his treatment from his own pocket. Further, there is no dispute that the claim was lodged with the Ops, but however, the same was repudiated and prior to that query of pre-authorization was put by which it is written that our medical penal has processed the authorization request and other documents. The panel requires the following documents Treatment and investigation records from 28.12.2017, Cag report, Echo and Cardiac Enzymes Report and any past history of cardiac ailment. If so then kindly provide the reports related to the same. Thereafter, the pre-authorization was cashless was declined by letter dated 01.02.2018 on the ground that the patient diagnosed angina and CAG report shows longstanding multi vessel coronary artery disease and also patient consulted another hospital documents pertaining to it not provided further evaluation is required to ascertain onset of present ailment. Hence, claim denied. The Ops have placed on record the discharge summary of Poonia Hospital Ex.R5, which finds mention the history of present illness as patient is apparently well before that he is having chest pain with restlessness x 1 day for which he was investigated and today came here for further evaluation. Again history of past illness N/H/O CAD, DMT2, COPD Allergy, family history, Nothing significant. Thereafter, the Ops have placed on record, the discharge summary of Medanta Hospital, which finds mentioned that the patient was admitted for stabilization and evaluation for which investigations were done. After appropriate evaluation, relevant investigation and pre anesthesia, neurology, respiratory clearance patient underwent CABG on 04.01.2018. Patient gradually weaned off from ventilator and extubated. Patient was shifted to Post OP Ward where patient was further stabilized and treated. Pacing wire were cut. Wound healthy and healing. Now patient is being discharged in stable condition with following advice; Significant medication given Antibiotics, Anti Platelet, Beta Blockers, Antacids, Nebulizations, Inotropes.
7. Perusal of the record reveals that the Ops have relied upon the opinion of TPA/Medical penal, who thoroughly investigated the bills and documents of the complainant qua getting of treatment, but however, the Ops have not placed on record the name of members of that penal, who conducted the whole investigation qua the alleged pre-existing disease of the complainant and find their opinion, as such, on the basis of which they declined the claim of the complainant, nor the Ops have placed on record the affidavit of those person of the medical penal qua their findings given in the present case, nor the Ops have placed on record any other document from which it could be presumed that the complainant was already suffering from pre-existing disease of heart. So, it appears from the evidence of the Ops, that they have arbitrarily and wrongly repudiated the claim of the complainant. Moreover, we find force from the judgments relied upon by learned counsel for the complainant.
8. In view of the above discussion, we hereby allow the present complaint with a direction to the Ops to settle and pay the claim of the complainant as per terms and conditions of the policy within 45 days of the receipt of the copy of this order. In case the orders are not complied within the stipulated period then the claimed amount would carry interest @ 7 % per annum from the date of lodging of complaint till its realization. The Ops are further directed to pay Rs.5,000/- as compensation on account of harassment and Rs.2,000/- as litigation expenses to the complainant. A copy of this order be sent to both the parties free of costs. File be consigned to the record room.
Pronounced in open Forum. President,
Dated: 11.06.2019. District Consumer Disputes
Redressal Forum, Sirsa.
Member Member
DCDRF, Sirsa DCDRF, Sirsa
