Delhi

East Delhi

CC/550/2016

JAGPAL SINGH - Complainant(s)

Versus

STAR HEALTH - Opp.Party(s)

09 Apr 2019

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

C.C. NO.  550/16

 

Shri Jagpal Singh

S/o Shri Shyam Lal

R/o B-551, Gokalpuri

Delhi – 110 094                                                                            …….Complainant

Vs.

 

M/s. Star Health & Allied Insurance Co. Ltd.

Through its Branch Manager

Branch Off: 209-210, Lakshmi Deep Building

Distt. Centre, Lakshmi Nagar, Delhi – 110 092

Head Off.: KRM Centre, 6^th Floor, No. 2

Harrington Road, Chetpet

Chennai – 600 031                                                                               ….Opponent

 

Date of Institution: 25.10.2016

Judgment Reserved on: 09.04.2019

Judgment Passed on: 15.04.2019

CORUM:

Sh. Sukhdev Singh (President)

Dr. P.N. Tiwari  (Member)

Ms. Harpreet Kaur Charya (Member)

 

Order By : Sh. Sukhdev Singh (President)

 

 

JUDGEMENT

          This complaint has been filed by Shri Jagpal Singh against M/s. Star Health & Allied Insurance Co. Ltd. (OP) under Section 12 of the Consumer Protection Act, 1986 with allegations of unfair trade practice and deficiency in service. 

2.         The facts in brief are that the complainant purchased a Family Health Otima Insurance Plan bearing no.  P/161111/01/2016/007338 including his wife and minor daughter for a sum of Rs. 4,00,000/-.

            It was stated that on 30.05.2016, motorcycle of the complainant  slipped due to which he fell on the road and had severe multiple injuries.  The complainant approached Jag Pravesh Chand Hospital where the concerned doctor prepared MLC, provided treatment and advised MRI. 

            On 31.05.2016, the complainant got done MRI from Nishkam Imaging Solutions Pvt. Ltd., Yamuna Vihar and went to Khandelwal Hospital & Urology Centre, Krishna Nagar for medical check-up where he was again advised MRI.  At that time, he did not get the report of MRI.

It was also stated that on 03.06.2016, the complainant again went to Khandelwal Hospital with MRI report and was advised for operation.  The complainant sent an email to M/s. Star Health & Allied Insurance Co. Ltd. (OP) from Khandelwal Hospital for revival, but M/s. Star Health & Allied Insurance Co. Ltd. (OP) flatly refused for approval of cashless policy saying that his injuries were very old and said “Apni jeb se paisa dekar apna operation kara le”, due to which the complainant has suffered great mental tension, pain and agony.  He visited the office of M/s. Star Health & Allied Insurance Co. Ltd. (OP) several times, but all in vain. 

The complainant sent legal notice on 30.09.2016 which was neither replied nor complied.  Hence, the complainant has prayed for directions to OP to pay compensation of Rs. 5,00,000/- on account of mental torture, pain and agony and Rs. 20,000/- towards cost of litigation.       

3.         In the WS, filed on behalf of M/s. Star Health & Allied Insurance Co. Ltd. (OP), they have taken various pleas.  They have stated that it was observed from the MRI report of the complainant that there was no evidence of fresh injury.   Thus, the admission and treatment of the complainant was for pre-existing disease which was prior to the inception of the policy.  Hence, the complainant lost his entitlement as per condition no. 8 of the policy according to which:

“The company is not liable to make any payment under the policy in respect of any claim if information furnished at the time of proposal is found to be incorrect or false or such claim is in any manner fraudulent means or device, misrepresentation whether by the insured person or by any other person acting on his behalf”.

It was, therefore, the request of the complainant for authorization of cashless treatment was denied and the same was communicated to the insured vide letter dated 10.06.2016.Other facts have also been denied.

4. The complainant has filed rejoinder to the WS of OP, wherein he has controverted the pleas taken in the WS and reasserted his pleas. 

5.         In support of its complaint, the complainant have examined himself on affidavit.  He has narrated the facts which have been stated in the complaint. 

            In defence, M/s. Star Health & Allied Insurance Co. Ltd. (OP) have examined Shri N. Gopalan, Chief Manager of OP, who have deposed on oath.  He has narrated the facts which have been stated in the WS. 

6.         We have heard Ld. Counsel for the parties and have perused the material paced on record.  It has been argued on behalf of M/s. Star Health & Allied Insurance Co. Ltd. (OP) that complainant was having pre existing disease.  In support of his arguments, counsel for OP have made reference to its letter of dated 12.06.2016 where it has been stated that “Doc stands as per MRI. No evidence of fresh injury, Requested to patient come in reimbursement”.

            On the other hand, Ld. Counsel for complainant have argued that there was no old injury and by merely not writing on the document that there was no fresh injury, repudiation of the claim of the complainant on the ground of pre existing disease was not warranted.

            If the letter of M/s. Star Health & Allied Insurance Co. Ltd. (OP) of dated 12.06.2016 is perused, it is noticed that claim of the complainant was rejected which was of pre authorization for cashless treatment.  He was requested for reimbursement.  However, counsel for complainant have argued that since his claim was rejected for cashless treatment, the complainant being a poor person could not take the treatment.  He has only claimed in the complaint compensation on account of denial of his cashless which have prevented him from taking the treatment.

            The first and foremost point which requires consideration has been as to whether from the documents, it can be gathered the complaint was having pre existing disease.  The only point which has been taken on behalf of       M/s. Star Health & Allied Insurance Co. Ltd. (OP) has been that the documents on record particularly MRI do not show that it was a fresh injury.  For this, MRI report of dated 01.06.2016 is to be looked into.  If findings on the report are seen, it has been stated that “MR imaging of right knee joint reveals complete tear at femoral attachment of anterior cruciate ligament fibers.  Linear hyperintensity reaching up to the articular surface is seen in posterior horn of medial meniscus – suggestive of tear”.  No doubt, this report does not say as to whether injury was a fresh one, it also does not say that it was an old one.  This MRI report have to be correlated with the prescription of Khandelwal Hospital as well as Jag Pravesh Chand Hospital.  In the prescription of Jag Pravesh Chand Hospital, it has been stated as “History of fall from bike on slippery surface by his own sustained injury over (R) knee followed by  pain/swelling in (R) knee“.  Similarly, in the Khandelwal Hospital, it has been stated as “Suspected Ligament Injury”. 

            When the complainant have fall from bike, as stated in the first prescription of Jag Pravesh Chand Hospital and Khandelwal Hospital have diagnosed as “Suspected Ligament Injury” which have been corroborated by the report of MRI, non mention of fresh or old injury in the MRI report, it cannot be said that the injury was an old one.  Even otherwise also, when the prescription of both the hospitals have stated the injury which the complainant had and his MRI have been got done immediately, it cannot be said that the injury was an old one.  If the injury would have been an old one, certainly, it would have come in the MRI report.  When there is no mention of this, it cannot be said that complainant was having an old injury which comes within the head of pre existing disease.

            Coming to the second point with regard to the complainant having not taken the treatment as his pre authorization claim was denied, the question arises as to whether the complainant have to be compensated for denial of his pre authorization claim.  No doubt, the complainant have been asked to submit the claim with the insurance company, but the fact remains that his final claim would have been rejected by the insurance company on this very ground itself.

            In the complaint, the complainant have not claimed any amount which he has spent on his treatment, but he has only prayed for compensation.  No doubt, the complainant would have approached M/s. Star Health & Allied Insurance Co. Ltd. (OP) and have filed his claim, but the fact that he has not sent any amount on his treatment, it has prevented him from filing the claim for reimbursement.  When he has not filed the claim for reimbursement with the insurance company and have claimed compensation, the denial of his pre authorization on the ground of pre existing disease amounts to deficiency in service on the part of M/s. Star Health & Allied Insurance Co. Ltd. (OP).  When there has been deficiency on the part of M/s. Star Health & Allied Insurance Co. Ltd. (OP), certainly, the complainant have to be compensated for the same.

            In view of the facts and circumstances of the case, we order compensation for an amount of Rs. 30,000/- which includes the cost of litigation.  The awarded amount be paid within a period of 45 days from the date of receipt of order.

Copy of the order be supplied to the parties as per rules.

            File be consigned to Record Room.

 

 

(HARPREET KAUR CHARYA)                                                 (SUKHDEV SINGH)

              Member                                                                                   President