BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, SIRSA.
Consumer Complaint no. 90 of 2018
Date of Institution : 9.3.2018
Date of Decision : 13.2.2019.
Naresh Kumar aged about 28 years son of Shri Bhup Singh, resident of village Rampura Bagria, Tehsil Nathusari Chopta, District Sirsa.
……Complainant.
Versus.
- Star Health & Insurance Company Ltd. Ground Floor, Rathore Towers, Near Hotel Mehak, Dabwali Road, Sirsa, through its Branch Manager.
- M/s Star Health & Allied Insurance Co. Ltd., 1, Newtank Street, Valuvar Kottam High Road, Nungambakkam, Chennai, 600034.
...…Opposite parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. R.L.AHUJA…………………………PRESIDENT
SH. ISSAM SINGH SAGWAL …… MEMBER.
Present: Sh. M.S. Gill, Advocate for the complainant.
Sh. M.K. Saini, Advocate for opposite parties.
ORDER
The case of the complainant in brief is that complainant got insured with op company through its Branch Manager at Sirsa regarding his health for a sum of Rs.5,00,000/- on 5.7.2017 and the complainant had paid the requisite premium of Rs.5994/- with op no.1 and the company issued the policy number P-211121/01/2018/000836 valid for one year. The complainant is a young man of 28 years and is quite hale and healthy. He was got medically checked by officials of ops at the time of insurance and he was not having any disease and as per the policy of the ops, the complainant is entitled to get the medical treatment expenses up to Rs.5,00,000/-. It is further averred that on 21.8.2017, the complainant had suddenly and accidently fallen down from the stairs of his house at about 2.00/ 3.00 p.m due to loss of balance and got injury on his person. The complainant has not made any complaint to police in this respect because there was no fault of any third person and it is not MLC case and he did not take any alcohol or drug at the time of accidental fall and he did not take any doctor consultation before 22.8.2017. That thereafter the complainant started suffering pain in his left knee and contacted Dr. Vikram Jain, orthopedic surgeon of Aadhar Health Institute, Hisar on 22.8.2017 and said doctor checked him thoroughly and advised the complainant to admit himself in the said hospital with the opinion “Paitent admitted with complaint of pain in left knee jerky movement of left knee while walking present. H/o locking of joint knee while walking present. H/o fall from stairs. MRI on dated 22.8.2017 a/o ACL tear melia Menisers and fateral tear left knee. It is further averred that complainant was admitted in hospital on 29.8.2017 and operated upon on 30.8.2017 and the doctor fixed milagioseraus in his left knee and was discharged on 1.9.2017. Thereafter complainant remained under treatment as outdoor patient and the doctor of hospital asked him to deposit Rs.62,000/- and complainant deposited the said amount vide receipt No.7466 OPD No.4248 dated 29.8.2017 and at the time of discharge, the doctor also advised him to take special diet and costly medicines. It is further averred that complainant sent his request for authorization letter to the company which was repudiated/ rejected by the company’s New Delhi office on 25.8.2017. That thereafter the complainant had submitted his claim/ intimation No.CLI/2018/211121/0261712 for getting a sum of Rs.68,744/- and the matter was thoroughly investigated by surveyor of the company. The complainant also submitted all the relevant documents to the company for getting the above said medical expenses amount from the company and the application was duly signed by the above said Doctor but the company has rejected/ repudiated the claim of complainant on 25.9.2017 on the ground that complainant was suffering from this injury prior to the policy inception, so the claim is not payable and the company also remarked that this injury is not an acute/ recent injury, hence it is pre-existing injury. The company has also remarked that as per exclusion No.1 of the policy, issued to the complainant the company is not liable to make any payment in respect of expenses of treatment of the pre-existing disease/ condition until 48 months of continuous coverage has elapsed since inception of policy on 5.7.2007 (it should be 5.7.2017), hence the claim of complainant was repudiated by the company on the above said grounds. It is further averred that rejection/ repudiation of the claim of complainant is totally wrong, arbitrary, not sustainable in the eyes of law, against law and facts and is liable to be ignored. The complainant has not violated the terms and conditions of the insurance policy. The company is bound to pay the claim amount to the complainant because the injury was suffered after 30 days of commencement of policy. The complainant also sent a legal notice on 11.1.2018 but till today they have not given any reply and they have caused harassment and deficiency in service towards the complainant. Hence, this complaint.
2. On notice, opposite parties appeared and filed written statement taking certain preliminary objections regarding suppression of material facts, no cause of action, no jurisdiction and no locus standi. It is submitted that true facts of the case are that the complainant/ insured availed Mediclassic insurance policy (Individual) vide policy No.P/211121/01/2018/000836 for the period of 5.7.2017 to 4.6.2018 covering Mr. Naresh Kumar for the sum insured of Rs.5,00,000/- as per the terms and conditions of the insurance policy and it was believed that the information provided by the insured is true and correct. The claim was reported in the one month eleven days old policy. It is further submitted that complainant/ insured was admitted at Aadhar Health Institute, Hisar on 25.8.2017 for the treatment of ACL Tear and submitted pre authorization request for cashless authorization and the same was denied vide letter dated 25.8.2017 stating that MRI does not correlate with the acute injury sustained and are suggestive of a long standing disease. The insured submitted claim records for reimbursement of medical expenses. On scrutiny of the claim records, it is observed that “ MRI report dated 22.8.2017 shows ACL tear fluid in knee joint, Grade II- III irregular tear involving posterior horn of medical and lateral meniscus in peripheral zone.” The above findings confirm that the insured patient has the above injury prior to inception of medical insurance policy and is not an acute/ recent injury. Hence it is a pre-existing injury. As per Exclusion No.1 of the policy, the ops are 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. Hence, the claim was repudiated and same was communicated to the insured vide letter dated 28.9.2017. It is further submitted that the complainant has no locus standi to claim any alleged sum assured, as the insurance policy was obtained by the insured by misrepresenting the material facts in order to defraud the ops and as such the contract of insurance is void, and not tenable in the eyes of law. With these averments dismissal of complaint has been prayed for.
3. The parties then led their respective evidence by way of affidavits and documents.
4. We have heard learned counsel for the parties and have perused the case file carefully.
5. The complainant in order to prove his complaint has furnished his affidavit Ex.CW1/A wherein he has reiterated all the averments made in his complaint. He has also produced copy of his pan card Ex.CW1/B, copy of adhar card Ex.CW1/C, mediclassic insurance policy Ex.C1, copy of customer identity card Ex.C2, MRI report Ex.C3, copy of receipt of Rs.5500/- Ex.C4, copy of bill Ex.C5, copy of bill list Ex.C6, prescription slip Ex.C7 and treatment record and bills Ex.C8 to Ex.C20, cancelled cheque Ex.C21, authorization letter Ex.C22, claim form Ex.C23 and letter of denial of pre-authorization Ex.C24, copy of legal notice Ex.C25, postal receipt Ex.C26. On the other hand, ops produced affidavit of Sh. Rajiv Jain, Chief Manager Ex.RW1, copy of repudiation letter Ex.R1, copy of MRI report Ex.R2, copy of proposal form Ex.R3, copy of bill Ex.R4, copy of claim form Ex.R5, copy of claim form Ex.R6, copy of authorization letter Ex.R7, copy of denial letter Ex.R8, copy of case summary/ discharge slip Ex.R9, copy of follow up card Ex.R10 and copy of policy Ex.R11.
6. The perusal of the file reveals that it is undisputed fact between the parties that complainant had purchased health policy for a sum of Rs.5,00,000/- on 5.7.2017 vide policy No. P-211121/01/2018/000836 for a period of one year. As per averments of complainant, he fell down on 21.8.2017 suddenly and accidently from the stairs of his house due to loss of balance and got injury on his person and he took consultation of Dr. Vikran Jain, Orthopedic Surgeon of Aadhar Health Institute, Hisar on 22.8.2017. He was admitted in the said hospital on 29.8.2017 and was operated for his left knee on 30.8.2017 and was discharged on 1.9.2017 and thereafter remained under treatment as outdoor patient. The said hospital charged a sum of Rs.62,000/- from the complainant for his treatment. On 25.9.2017 the ops repudiated the claim of the complainant on the ground of pre-existing injury. The perusal of the evidence of complainant reveals that complainant has furnished his affidavit Ex. CW1/A in which he has deposed as per averments made in the complaint. He has specifically deposed qua injury which he suffered accidentally in his house. He has further deposed that he remained admitted in the hospital from 29.8.2017 to 1.9.2019 and spent Rs.68,744/- on his treatment. Due intimation was given to the ops and claim was lodged with the ops, but however, same has been repudiated by ops on 25.9.2017.
7. Though, ops have taken the plea that it was a pre-existing disease prior to inception of the policy, but however, the ops have not led any cogent and convincing evidence that complainant was having any pre-existing disease prior to the inception of the policy. The ops have furnished affidavit of Sh. Rajiv Jain, Chief Manager of the ops who has deposed on the lines of the averments made in the written statement and relied upon repudiation letter Ex.R1. The repudiation letter Ex.R1 reveals that while repudiating the claim they have reported that they have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of ACL tear. It is observed that the MRI report dated 22.8.2017 shows ACL tear fluid in knee joint, Grade II- III irregular tear involving posterior horn of medial and lateral meniscus in peripheral zone. These findings confirm that the insured patient has the above injury prior to inception of medical insurance policy and is not an acute/ recent injury. Hence it is a pre existing injury. As per Exclusion No.1 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 on 5.7.2017.
8. The perusal of evidence of ops reveals that ops have not furnished affidavit of concerned doctor who had given such opinion on the basis of MRI report that complainant was suffering from some pre-existing disease qua which he got treatment from Aadhar Health Institute, Hisar after inception of the policy. The MRI report Ex.R2 also reveals that it is no where mentioned that it is an old disease or it is pre-existing disease on the person of Naresh Kumar complainant. So it appears from the evidence of ops that ops have failed to prove on record by leading cogent and convincing evidence that complainant was suffering from any pre-existing disease prior to inception of the policy and further ops have repudiated the claim of complainant arbitrarily and illegally for which he is found entitled.
9. In view of the above, we allow the present complaint and direct the opposite parties to pay/ reimburse the amount of Rs.68,744/- to the complainant within a period of 30 days from the date of receipt of copy of this order, failing which the complainant will be entitled to interest @7% per annum from the date of order till actual realization. We also direct the ops to further pay a sum of Rs.5,000/- as compensation for harassment and Rs.2000/- as litigation expenses to the complainant. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.
Announced in open Forum. President,
Dated:13.02.2019. Member District Consumer Disputes
Redressal Forum, Sirsa.
