Haryana

Kurukshetra

187/2018

Naveen Aggarwal - Complainant(s)

Versus

Star Health - Opp.Party(s)

22 Jul 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, KURUKSHETRA.

 

Complaint Case No.187 of 2018.

Date of instt: 04.09.2018. 

                                                                       Date of Decision: 22.07.2019.

 

Naveen Aggarwal son of Sh. Sham Lal, resident of House No.1166/5-A, Shankar Colony, Pipli, Kurukshetra.

 

                                                ……..Complainant.

                        Vs.

1. Star Health and Allied Insurance Company Limited., No.15 Sri Balaji Complex, 1^st Floor, White Lane, Royapettah, Chennai- 600014.   
2. Star Health and Allied Insurance Company Limited, SCO No.94, First Floor, Sector-17, Back side of Hotel Silver Sand, Kurukshetra.
3. Star Health and Allied Insurance Company Limited, Grievance Department No.1 New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai- 600034.
4. Star Health and Allied Insurance Company Limited, Office of Insurance Ombudsman, SCO No.101, 102 & 103, 2^nd Floor, Batra Building Sector 17D, Chandigarh- 160017.

..………Opposite parties.

 

Complaint under section 12 of Consumer Protection Act.                   

 

Before       Smt. Neelam Kashyap, President.

                Ms. Neelam, Member.

                Sh. Sunil Mohan Tirkha, Member.

 

Present:     Sh. Gaurav Bansal, Advocate for complainant.

Sh. Gaurav Gupta, Advocate for opposite parties.

           

ORDER     

 

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

2.            Brief facts of the present complaint are that representative of op no.2 had approached the complainant to obtain the medi-claim policy and only upon his persuasion, the complainant purchased a medi claim insurance policy No.P/211123/01/2017/000416 and the premium of Rs.11,880/- was paid by the complainant to the ops. The policy period commenced from 29.11.2016 to 28.11.2017. Thereafter, the said policy was further renewed for the period 5.12.2017 to 4.12.2018 and the complainant had deposited an amount of Rs.15,287/- with the ops. It is further averred that before issuance of the policy, the ops got through medical check up of the complainant and after being satisfied with the medical reports, the policy was issued to the complainant. That the complainant suddenly fell ill on 30.1.2017 and the doctor diagnosed that the complainant is suffering from CAD-ACUTE IWMI. The complainant was treated from B.S. Heart Care and Multi Speciality Hospital, Kurukshetra and two stent were inserted and complainant had spent an amount of Rs.five lacs on his treatment. It is further averred that complainant approached the ops and submitted the requisite documents with the ops for claim, but the ops postponed the matter on one pretext or the other. The ops issued a letter dated 19.1.2018 to the complainant vide which the ops repudiated the claim of complainant on the grounds that complainant was patient of hyper tension for the last six months and as such the claim of complainant has been illegally repudiated by the ops and they have caused harassment and mental agony to the complainant. Hence, this complaint.

3.             On notice, opposite parties appeared and filed written statement taking certain preliminary objections. It is submitted that complainant has not come to this Forum with clean hands and he has suppressed the true and material facts, therefore, he is not entitled to any relief. It is submitted that complainant availed family health optima insurance plan covering himself, Aarti Aggarwal spouse, Shruti Aggarwal and Ankit Aggarwal children for the period from 29.11.2016 to 28.11.2017. The terms and conditions of the policy were explained to the complainant at the time of proposing for policy and the same was served to the complainant alongwith the policy schedule. Moreover, it is clearly stated in the policy schedule “The insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. attached”. It is further submitted that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. It is further submitted that complainant Mr. Navin Aggarwal was admitted in the 2^nd month in B.S. Heart Care and Multispeciality Hospital, Thanesar on 30.1.2017 and discharged on 2.2.2017 towards the treatment of CAD- Acute IWMI, CAG- SVD Primary PTCA- Stent to RCA. The answering ops have received a pre authorization request towards the treatment of CAD. On scrutiny of it, answering ops observed that ECG reveals left ventricular strain and significant Q waves in lead II points to old MI/ infarct changes and also HTN mentioned in past history is tampered. Thus, with the available documents, the exact onset of injury cannot be ascertained. Hence, the pre authorization for cashless treatment of above complainant-patient is denied and the same was informed to complainant and treating hospital on 31.1.2017. Subsequently, the complainant submitted claim for reimbursement of medical expenses of Rs.40,000/- on receipt of claim documents, it was scrutinized and observed that (a) as per the discharge summary for the period 30.1.2017 to 2.2.2017, the complainant was diagnosed with CAD- Acute IWMI, CAG SVD Primary PTCA- Stent to RCA, (b) As per the internal verification report (FVR), the complainant has HTN since six months (prior to the policy) and was on medication for the same. Based on these findings, it is noted that the complainant patient has HTN prior to the policy and CAD is the complication of pre existing hypertension. Thus, it is a pre existing disease. 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. Therefore, the claim was repudiated under Exclusion No.1 and same was communicated to the complainant vide letter dated 19.1.2018. With these averments dismissal of complaint prayed for.

4.             Learned counsel for complainant tendered affidavit Ex.CW1/A and documents Ex.C1 to Ex.C20. On the other hand, learned counsel for ops tendered affidavit Ex.RW1/A and documents Ex.R1 to Ex.R17.

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

6.             Learned counsel for complainant has contended that opposite parties have wrongly and illegally repudiated the genuine claim of the complainant and prayed for acceptance of the complaint. He has relied upon judgments in case titled as Smt. Santosh Kanwar vs. LIC RP No.2049 of 2000 decided on 9.9.2008 (NC) and Smt. Dipashri Vs. LIC, Writ Petition No.585 of 1980 decided on 21.12.1983 (Bombay HC).

7.             On the other hand, learned counsel for ops has contended that complainant was having pre-existing disease of hypertension and as per exclusion clause 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. He has further contended that complainant has obtained the policy in question from the ops by concealing material fact of his pre existing disease and therefore, the claim of the complainant has been rightly repudiated by the ops as per terms and conditions of the policy and prayed for dismissal of the complaint. He has also relied upon judgments of the Hon’ble Supreme Court in cases titled as Satwant Kaur Sandhu Vs. NIIACL, CA No.2776 of 2002 decided on 10.7.2009, P.C. Chako and another vs. Chairman, LIC of India and others, CA No. 5322 of 2007 decided on 20.11.2007, decisions of Hon’ble National Commission in cases titled as Aman Kapoor vs. NIC, RP No.429 of 2017 decided on 17.4.2017, Tata AIG Life Insurance Vs. Orissa State Co-operative Bank and anr. RP No.1695 of 2012 decided on 20.9.2012 and C.N. Mohan Raj vs. NIAC, RP No.2314 of 2012 decided on 8.10.2012.

8.             We have considered the rival contentions of the parties and have gone through the record as well as judgments relied upon by the learned counsel for the ops.

9.             It is an admitted fact between the parties that complainant purchased a medi claim insurance policy from the opposite parties for himself and his family members from 29.11.2016 which was effective from 28.11.2017 and the said policy was further renewed for the period 5/12/2-17 to 4.12.2018. According to the complainant, before issuance of the policy the ops got thorough medical check of the complainant and after being satisfied with the medical reports, the policy was issued to the complainant. The ops have not denied this fact that before issuance of the policy to the complainant, he was not got medically examined by them. According to the complainant, he was not having any pre existing disease and fell suddenly ill on 30.1.2017 and the doctor diagnosed that he is suffering from CAD-Acute IWMI. According to the complainant, he was treated from B.S. Heart Care and Multi Speciality Hospital, Kurukshetra and two stents were inserted and he spent an amount of Rs.five lacs on his treatment but the claim submitted by the complainant with the ops has been wrongly and illegally repudiated by the ops. The ops have repudiated the claim of the complainant vide letter Ex.C5 on the ground that the insured patient has hyper tension for the past six months, which is prior to inception of medical insurance policy and the present admission and treatment of the insured patient is for accelerated hyper tension and hypertensive/ ischemic heart disease both of which are due to pre existing hypertension. But the ops have not placed on file any authentic and cogent proof that complainant was already suffering from hyper tension or any heart disease prior to taking of the policy in question. The complainant has placed on file query reply of B S Heart Care Hospital asa Ex.C6 in which it is mentioned that patient was admitted in emergency with the complaint of chest pain with diagnosis CAD- acute IWMI and no past consultation available with this disease because patient felt chest pain first time on 30.1.2017. Further the medical records placed on file by the complainant i.e. discharge summary Ex.C8 and history chart Ex.C9 show that complainant was admitted in emergency with the severe chest pain on 30.1.2017. The ops have failed to prove that complainant was suffering from hypertension for the past six months, prior to inception of the policy. The ops have failed to produce any medical record or any report of the doctor in this regard and the ops have wrongly and illegally repudiated the claim of the complainant. We can also rely upon the order dt. 27.02.2015 passed by Hon’ble State Commission, Punjab in case titled as Ashwani Joshi Vs. Reliance General Insurance bearing first appeal No.1671 of 2012, wherein in para No.12 and 13 of the said order, Hon’ble State Commission, Punjab has taken the view on relying upon the view of Hon’ble Supreme Court and Hon’ble Delhi State Commission.  In para No.12 of the said order, it is mentioned that “Moreover, the Supreme Court in its judgment dt. 10.10.1995 recorded in Biman Krishan Bose Vs. United India Insurance Company, in Civil Appeal No.3438 of 1995 had stated: that if a person is suffering from hypertension, the insurance claim of the legal heirs of such a person cannot be repudiated on the ground that the life assured had suppressed this information from the insurance company.  Moreover hypertension is not a material disease which is fatal in itself”.  In para No.13 of the above-said order, it is mentioned that “Similarly, the Hon’ble Delhi State Consumer Disputes Redressal Commission, in case of Life Insurance Corporation of India Vs. Sudha Jain, 2007(2) CLT 423, had drawn the conclusions in para 9 and had stated as under. 

        “Malaise of hypertension, diabetes occasional pain, cold, headache, arthritis and the like in the body are normal wear and tear of modern day life which is fully of tension at the place of work, in and out of the house and are controllable on day to day basis by standard medication and cannot be used as concealment of pre-existing disease for repudiation of the insurance claim unless an insured in the near proximity of taking of the policy is hospitalized or operated upon for the treatment of these diseases or any other disease.” 

10.           The authorities cited by learned counsel for ops are not disputed but same are not applicable to the facts and circumstances of the present case whereas the authorities cited by learned counsel for complainant are applicable in this case.  The repudiation of the claim of complainant clearly amounts to deficiency in service on the part of ops. Though complainant has claimed that he has spent an amount of Rs.5,00,000/- on his treatment but the complainant has placed on file copies of bills and receipts Ex.C10 to Ex.C17, the total amount of which comes to Rs.2,95,377/- and in our view the complainant is entitled to the amount of medical bills and receipts subject to verification. 

11.            In view of the above, we allow the present complaint and direct the opposite parties to pay an amount of Rs.2,95,377/- to the complainant subject to verification of bills/ receipts by ops within a period of 45 days from the date of receipt of copy of this order, failing which the complainant will be entitled to interest @9% per annum from the date of order till actual payment. We also direct the ops to further pay a sum of Rs.10,000/- as compensation for harassment and 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:

Dt.:22.07.2019.  

                                                                        (Neelam Kashyap)

                                                                        President.

 

 

(Sunil Mohan Tirkha),           (Neelam)       

Member                             Member.