Haryana

Kurukshetra

173/2018

Manoj Kumar - Complainant(s)

Versus

Star Health - Opp.Party(s)

R.K.Taneja

26 Sep 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, KURUKSHETRA.

 

Complaint Case No.173 of 2018.

Date of instt: 10.08.2018. 

                                                                      Date of Decision: 26.09.2019.

 

Manoj Kumar aged 53 years s/o Shri Ram Parkash, r/o House No.218/5, Bhagwan Nagar Colony, Pipli, Tehsil Thanesar, District Kurukshetra.

 

                                                                        ……..Complainant.

                                        Versus

 

1. Star Health and Allied Insurance Company Limited, 1^st Floor Himalaya House, 23, Kasturba Gandhi Marg, New Delhi-110001, through its Managing Director.
2. Star Health and Allied Insurance Company Limited, SCO 94, 1^st Floor, Backside of Hotel Silver-Sand Sector-17, Kurukshetra through its Branch Manager.

                        .……Opposite parties.

 

Complaint under Section 12 of the Consumer Protection Act.

 

Before       Smt. Neelam Kashyap, President.

                   Ms. Neelam, Member.

                   Shri Sunil Mohan Trikha, Member.

 

Present:     Shri R.K. Taneja, Advocate for the complainant.

Shri Gaurav Gupta, Advocate for the opposite parties.

 

ORDER

 

                   This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Manoj Kumar against Star Health and Allied Insurance Company Limited, the opposite parties.

2.            Brief facts of the present complaint are that the complainant has purchased a cashless Medi-Claim Policy No.P/211120/01/2016/ 004112 with Family Floater for a sum of Rs.5,00,000/- alongwith recharge benefit of Rs.1,50,000/- on 22.3.2016 valid upto 21.3.2017 from the OPs through their agent Suresh Kumar and paid the requisite premium for that policy. According to aforesaid policy, the OPs had also issued the customer I.D. numbers to him, his wife namely Smt. Suman and his daughter-Shaily as 51365921-2, 51365921-3 respectively with the assurance to give their best services if complainant-insured will require regarding any diseases/ailment during the period of insurance and opposite parties will pay the whole treatment expenses of insured if needed. It is further alleged that in the month of Septmber-2016, the complainant fell ill and got his treatment as indoor patient from Forties Hospital, Sector-62, Phase-VIII, Mohali w.e.f. 1.9.2016 to 9.9.2016 vide UHID No.00642650 and debridement of his right foot was done on 02.09.2016. He was also diagnosed by the doctors of said hospital and it was come to light that he is suffering from diabetes mellitus and HIV Antibody Test was also confirmed to be positive with three different methodologies as per Naco guidelines on 3.9.2016.  Again he fell-ill and admitted in Department of Cardiac Surgery on 26.9.2016, wherein, right foot debridement was done on 27.6.2019. He remained admit as indoor patient upto 29.9.2016 at that time.  It is further alleged that he again admitted in Forties Hospital, Mohali for his further treatment on 15.11.2016 and remained upto 16.11.2016. In the discharge summary dated 16.11.2016 it has also been mentioned that he is suffering from diabetes mellitus type II and H/O HIV positive under the head past history. It is further alleged that the whole treatment expenses were paid by the opposite parties. It is further alleged that the Policy No.P/211120/01/2016/004112 was valid upto 21.3.2017 and thereafter, he got renewed the said policy with opposite parties vide insurance policy No.P/211123/01/2017/000961 under Family Health Optima Insurance Plan, through their agent Suresh Kumar valid up to 22.3.2017 to 21.3.2018 and paid a sum of Rs.13,858/- as total premium. It is further alleged that after the expiry of the period of aforesaid policy, he again got renewed the said policy vide policy No.P/21123/01/2018/002916 from OPs valid from 22.3.2018 to 21.3.2019 and paid Rs.21,654/- as premium.  According to this policy, Rs.5,00,000/- was insured as basic Flouter sum Rs.50,000/- as Bonus and Rs.1,50,000/- as recharge benefit.  In this way, he and his family was insured for a sum of Rs.7,00,000/- by the opposite parties. On 18.4.2018 he suffered from heart-disease and admitted in B.S. Heart Care Hospital at Mohan Nagar, Kurukshetra, where, Temporary Pacemaker was inserted in his body, but due to the critical condition, doctors advised the family members to take him somewhere else in better hospital for further treatment and charged Rs.28,000/- vide invoice No.232 dated 18.4.2018. Thereafter he was got admitted in Forties Hospital, Mohali on 18.04.2018, where he was treated as indoor patient w.e.f.18.4.218 to 25.4.2018 as detailed in the discharged summary dated 25.4.2018. The opposite parties were duly informed regarding his admission in the Forties Hospital, Mohali through their agent Suresh Kumar as well as by the hospital authorities under cashless treatment, upon which, OPs advised him to get his treatment firstly and then opposite parties will pay the whole treatment expenses to the said Hospital as per the terms and conditions of the aforesaid Insurance policy.  During the period of treatment, the OPs were repeatedly requested to approve the claim, but vide letter dated 24.4.2018, they flatly refused to admit the claim by alleging that he has not disclosed the material facts to them though nothing has been concealed by him as alleged.  However, due to the said illegal act of the opposite parties, he paid Rs.4,64,079/- to the Forties Hospital, Mohali vide Bill No.1002/18/1/CS/0001080 dated 25.4.2018 from his own pocket. By not paying the claim amount, the OPs are deficient in providing the services. Hence, this complaint.

3.             Upon notice, the Opposite Parties appeared and filed written statement raising certain preliminary objections regarding maintainability; limitation; jurisdiction; complaint is bad for mis-joinder & non-joinder of necessary parties and cause of action. It is further stated that the insured availed Family Health Optima Insurance Policy covering Mr. Vinod Kumar, Suman Spouse, Shelly dependent child for a sum of Rs.5,00,000/- vide policies No.P/211120/01/2016/004112-22.03.2016 to 21.03.2017; P/211123/01/2017/000961-22.03.2017 to 21.03.2018 and P/21123/01/2018/002916 – 22.03.2018 to 21.03.2019. The claim was reported in the 3^rd year of the policy. The insured Manoj Kumar was admitted in the Fortis Hospital, Mohali on 18.04.2018 for the treatment of ACS and raised pre authorization request for cashless treatment. On perusal of claim documents, it is observed that “As per Pre Auth Form, the insured was admitted with the complaints of Unstable Angina, provisionally diagnosed as ACS. As per ICP, the insured was under the HIV on Ayurveda for the past 4 years and also with DM (on medicine since 18 years). The said finding confirm that the insured has failed to disclose that he has HIV on Ayurveda for past 4 years and also with DM (on meds since 18 years) in the proposal form, which amounts to non disclosure of material facts. The OPs had earlier settled the claims based on the available documents:-

• CLI/2017/211120/0182511- The insured was admitted at B.S. Heart Care and Multispecialty Hospital for the treatment of Right Foot Cellulites and settled. No mention of HIV. Thus, the claim was approved for Rs.58,434/-.
• CLI/2017/211120/0191315- The insured was admitted at Fortis Hospital, Mohali for the treatment of R leg Cellulites. Thus, the claim was approved for Rs.2,65,422/-.
• CLI/2017/211120/0232732- The insured was admitted at Fortis Hospital, Mohali for the treatment of Diabetic Foot. The claim was approved for Rs.89,086/-.
• CLI/2017/211120/0304426- The insured was admitted at Fortis Hospital, Mohali for the treatment of R Diabetic Foot. The claim was approved for Rs.30,625/-.

                At the time of settlement of earlier documents, the insured submitted a declaration letter given by treating doctor stating that the HIV was detected in September 2016, which is after policy inception, hence the claim was settled, whereas, now the patient is admitted for complete heart block, in ICP, it was mentioned as HIV since 4 years and DM since 18 year which was not disclosed at the time of policy. Hence, the cashless authorization was rejected on 24.04.2018 and same was communicated to the treating hospital and the insured. On merits, the rest of the contents of the complaint are denied and prayed for dismissal of the complaint.  

4.             The complainant has tendered affidavit Ex.CW1/A alongwith documents Ex.C1 to Ex.C17 and closed his evidence. On the other hand, the opposite parties have tendered affidavit Ex.RW1/A documents Ex. R1 to Ex.R17 and closed the evidence.

5.             We have heard learned counsel for the parties and have perused the case file carefully.

6.            The learned counsel for the complainant has argued that the complainant purchased a cashless Medi-Claim Policy on 22.3.2016 from the OPs through their agent Suresh Kumar, valid till 21.3.2017 and thereafter, renewed the same twice i.e. from 22.03.2017 to 21.03.2018 and lastly from 22.03.2018 to 21.03.2019. He further argued that in the month of Septmber-2016, the complainant fell ill and got his treatment as indoor patient from Forties Hospital w.e.f. 01.09.2016 to 09.09.2016 and debridement of his right foot was done on 02.09.2016. The complainant was also diagnosed by the doctors of said hospital and it came to light that he is suffering from diabetes mellitus, and HIV Antibody Test was also confirmed to be positive with three different methodologies as per Naco guidelines on 03.09.2016. Again he fell-ill and admitted in Department of Cardiac Surgery on 26.09.2016, wherein, right foot debridement was done on 27.06.2019 and remained admit upto 29.09.2016 at that time. He further argued that the complainant again admitted in Forties Hospital, Mohali for his further treatment on 15.11.2016 and remained upto 16.11.2016. In the discharge summary dated 16.11.2016, it has also been mentioned that he is suffering from diabetes mellitus type II and H/O HIV positive under the head past history. It is further alleged that the whole treatment expenses were paid by the opposite parties. On 18.04.2018, the complainant suffered from heart-disease and admitted in B.S. Heart Care Hospital, Mohan Nagar, Kurukshetra, where, Temporary Pacemaker was inserted in his body, but due to the critical condition, he was referred to other hospital and charged Rs.28,000/-. Thereafter he was got admitted in Forties Hospital, Mohali on 18.04.2018, where he was treated as indoor patient w.e.f. 18.04.218 to 25.04.2018 vide Discharge Summary dated 25.04.2018. During the period of treatment, he repeatedly requested the OPs to approve the claim, but vide letter dated 24.04.2018, they flatly refused to admit the claim. However, due to the said illegal act of the opposite parties, he paid Rs.4,64,079/- to the Forties Hospital, Mohali from his own pocket. By not paying the claim amount, the OPs are deficient in services. In support of his contention, the learned counsel for the complainant has placed reliance on the cases, titled as Life Insurance Corporation of India Vs. Smt. Veena Puri, 2006 (2) CPC, 465 (HP); Meneti Rawat Vs. Life Insurance Corporation of India and others, 2008 (1) CPC, 548 (DC) and New India Assurance Co. Ltd. Vs. Raj Kumar Chuchra, 2008 (1) CPC, 602 (NC).

7.             Contrary to it, the learned counsel for the OPs has argued that the insured availed Family Health Optima Insurance Policy. The insured Manoj Kumar was admitted in the Fortis Hospital, Mohali on 18.04.2018 for the treatment of ACS and raised pre authorization request for cashless treatment. On perusal of claim documents, it is observed that the insured was admitted with the complaints of Unstable Angina, provisionally diagnosed as ACS. As per ICP, the insured was under the HIV on Ayurveda for the past 4 years and also with DM (on medicine since 18 years) and the insured failed to disclose the said fact in the proposal form, which amounts to non disclosure of material facts. The OPs had settled all the earlier claims of the complainant. There is no deficiency on the part of the OPs. In support of his contention, the learned counsel for the OPs has placed reliance on the cases, titled as Satwant Kaur Sandhu Vs. The New India Ins. Co. Ltd., Civil Appeal No.2776 of 2002, d.o.d. 10.07.2009 (SC); TATA AIG Life Ins. Co. Ltd. Vs. Orissa State Co-Operative Bank and Anr., Revision Petition No.1695 of 2012, d.o.d. 20.09.2012 (NCDRC, New Delhi); Surinder Kaur Vs. National Ins. Co. Ltd., Misc. Application No.129 of 2016, d.o.d. 04.05.2016 (NCDRC, New Delhi); C.N. Mohan Raj Vs. New India Ins. Co. Ltd., Revision Petition No.2314 of 2012, d.o.d. 08.10.2012 (NCDRC, New Delhi); M/s Suraj Mal Ram Niwas Oil Mills Pvt. Ltd., Vs. United India Ins. Co. Ltd., Civil Appeal No.1375 of 2003, dod 08.10.2010 (SC) and Aman Kapoor Vs. National Ins. Co. Ltd.,. Revision Petition No.429 of 2017, dod 17.04.0217 (NC).

8.             Admittedly, the complainant had purchased the policy in question from the OPs initially on 22.03.2016 and got renewed it twice and lastly upto 21.03.2019 vide policy documents Ex.R-2 to Ex.R-4. There is also no dispute that earlier the complainant was admitted in B.S. Heart Care Hospital and Fortis Hospital time to time and the OPs settled the claim amount. From the perusal of repudiation letter dated 24.04.2018 (Ex.C-11), it is evident that the OPs rejected the Pre-Authorization Request for Cashless Treatment of the complainant on the ground that the insured patient has been diagnosed with HIV positive, diagnosed 4 years ago and DM since 18 years. On perusal of copy of proposal Form (Ex.R-1), it is revealed that the complainant & his family had given answers in negative to all the questions and to the question, ‘Are you in good health and free from physical and mental disease or infirmity, if not, give details’, he had given answer ‘yes’. To support his contention, the complainant produced Test report as Ex.C-6 and Discharge Summary as Ex.C-9 and from the perusal these documents, it is evident that the complainant is a patient of Diabetes Mellitus Type II. H/O HIV Positive. It is pertinent to mention here that the OPs had already paid the claim of this admission to the complainant and this fact had been admitted by the OPs himself in their reply as well as in their affidavit that they had paid all the earlier claims to the complainant. Now the OPs had rejected the claim of the complainant on the ground that the insured patient has been diagnosed with HIV positive, diagnosed 4 years ago and DM since 18 years. Since the OPs had earlier paid the claims of the complainant for the treatment of that disease in the year 2016, then how they can reject his claim in the year 2018 for the same disease. On the one hand, the OPs had approved the claim of the complainant for the said disease in the year 2016, on the other hand, they are rejecting his claim for the same disease in the year 2018, therefore, the stand taken by the OPs for rejection of the claim of the complainant, is self contradictory in itself. Furthermore, the OPs has contended that the insured was under the HIV on Ayurveda for the past 4 years and also with DM (on medicine since 18 years) and to support their contention, the OPs produced Admission Card of the complainant as Ex.R-10. It may be stated here that except this Admission Card, the insurance company has not produced any medical record of the complainant to prove that the complainant was taking treatment for the diseases, referred to above, prior to taking the policy in question. It was not proved on record as to who had disclosed that complainant was suffering from the said diseases. Further, affidavit of the treating doctor, who had recorded the patient history, at the time of admission, has not been produced on record. The entire defence revolves around the said admission card, which is not supported by cogent document. In the case of Rajinder Singh Vs. The New India Assurance Co. Ltd. & Ors., 2018(3) CLT-187, the Hon’ble State Commission Haryana, has held that the treating doctor mentioned that the complainant was suffering from diabetes and hypertension for the last about three years without mentioning his source of knowledge in this regard and has not mentioned as to whether the patient had himself told him that he was suffering from the abovementioned ailments- Repudiation of the claim was not justified. Further, in the case of LIC of India Vs. Joginder Kaur, 2005, CPJ-78, the Hon’ble State Commission Haryana has held that the unproved case history recorded by some person on the date of admission of the patient, would not be cogent and convincing evidence to repudiate the case, unless it was coupled with medical record for the treatment prior to the submission of the proposal form. The case law produced by the complainant are fully applicable to the facts of instant case, whereas, on the other hand, the case laws produced by the OPs are not applicable to the present case and are distinguished being rested on different footings. Keeping in view the ratio of the law laid down by the superior Fora in the aforesaid cases and the facts and circumstances of the present case, we are of the considered opinion that the OPs has committed mistake in rejecting the claim of the complainant. Hence, the OPs are liable to reimburse the amount which the complainant had incurred on his treatment.

9.             Now the question which arises for consideration is what should be the quantum of indemnification? The complainant had produced bills of Rs.28,000/- of B.S. Heart Care, Kurukshetra as Ex.C-4; Rs.18,000/- Ambulance Charges as Ex.C15; Rs.2200/- of Vikas Diagnostic & Clinical Laboratories, Kurukshetra as Ex.C16 and of Rs.4,64,079/- of Fortis Hospital, Mohali as Ex.C14, total amounting Rs.5,12,279/- (28,000+18,000 + 2200 + 4,64,079). Therefore, the OPs are liable to reimburse the said amount of Rs.5,12,279/- alongwith interest to the complainant. They are also liable to compensate the complainant for the mental agony and physical harassment suffered by him, alongwith litigations expenses.

10.            In view of the aforesaid discussion, we hereby allow the present complaint against the OPs and direct them in the following manner:-

1. To pay the amount of Rs.5,12,279/- to the complainant.
2. To pay Rs.5,000/- as compensation for mental agony and         physical harassment suffered by the complainant.
3. To pay Rs.5,000/- as litigation expenses.

 

                The OPs are further directed to comply with the aforesaid directions jointly and severally within the period of 45 days from the date of communication of this order, failing which, the awarded amount shall carry interest @ 9% per annum from the date of order till actual payment and the complainant will be at liberty to initiate proceedings under Section 25/27 of the Act against the OPs. Certified copy of this order be supplied to the parties concerned, forthwith, free of cost as permissible under Rules. File be indexed and consigned to the record-room, after due compliance.

Announced in open Forum:

Dt.:26.09.2019.  

                                                                        (Neelam Kashyap)

                                                                        President.

 

 

(Sunil Mohan Trikha),           (Neelam)       

Member                             Member.