Delhi

East Delhi

CC/993/2013

RAJ RANI - Complainant(s)

Versus

STAR HEALTH - Opp.Party(s)

17 Jan 2014

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM (EAST)

GOVT OF NCT OF DELHI

CONVIENIENT SHOPPING CENTRE, SAINI ENCLAVE: DELHI-92

 

CC. NO-993/13

In the matter of:

Sh. Raj Rani,

w/o Sh.Rajinder Kumar,

R/o House No. A-615 DDA Colony Khyala,

New Delhi-110018.            

           

Complainant

 

Vs

 

1. Star Health and Allied Insurance Company Ltd.

Claim Deptt. /Office, 2^nd  Floor,

Exchange Store Building, 13, Alipur Road,

Civil Lines, Delhi-54

 

 

2. Star Health and Allied Insurance Company Lt

Issuing Office: No. 209-210,

Lakshmi Deep Building, District Centre,

Lakshmi Nagar, Delhi-110092

 

 

3. Star Health and Allied Insurance Company Ltd.

Regd. Corporate office: 1, New Tank Street,

Valluvar Kottam High Road Nungambakkam,

•  

Through Its Managing Director/Director/A.R.

 

                                                                                                                    Opposite Parties

 

                                                                                        DATE OF ADMISSION-21/03/2013

                                                                                    DATE OF ORDER       -23/11/2015

ORDER

SH. N.A.ZAIDI, PRESIDENT

This complaint has been filed with the allegation that the complainant has purchased a “Family Health Optima insurance Policy” on 12/07/2011, which covers the risk of the health of the complainant and her spouse Sh. Rajinder Kumar, through its East Delhi branch, Laxmi Deep Building, District centre, Lasmi Nagar, Delhi-110092. The details of the premium paid have been mentioned. This also renewed year to year and lastly it on 02/07/2013. The complainant was having pain in her left hip from the last one year and when pain increase, she consulted Dr. O.N. Negi at Sir Ganga Ram Hospital on 14/08/2013. He advised her for the total Left Hip Replacement Surgery. She contacted TPA Helpdesk of Sir Ganga Ram Hospital to initiate approval process for total hip replacement surgery on 25/08/2013 as the policy covers all types of joint replacement mentioned in the policy bond. The Star Health insurance Company denied the cashless treatment on the ground of pre existing disease. Complainant had bought the medical health policy keeping in mind that in case of any mis-happening the respondent will stand by the complainant and will not let her down. She sent the scan copy ofX-Ray report & other documents for reconsideration along with Dr. Nagi’s supporting documents. The respondent requires the X-Ray images which were provided but again it was denied. The complainant felt cheated as she has paid the high amount premium under the hope that she will be taken care at the required time. Again the request was sent by her son Sh. Sonu for reconsideration of the “cashless treatment” to AVP Claims. Sh. Rajnish Kohli mail was received approving the cashless treatment after consideration of the X-Ray films and hospital was accordingly informed. Only the amount of Rs.1,50,000/- for the treatment of “OA Left Hip/Surgical Management”  was sanctioned and her surgery was performed on 03/09/2013 at Sir Ganga Ram Hospital. Discharge summary was sent to Star Health for full and final payment of the complete treatment. On 10/09/2013, complainant was shocked, by the “withdrawal of the authorization letter stating that that submitted discharge summary clearly indicates preexisting disease prior to the policy, symptoms since five years, discharge summary clearly indicates that she has under gone core decompression two years ago”.  The reconsideration letters along with supporting documents by the Doctor were sent to the respondent. The Doctor submitted that there were some numerical typo graphical errors the number of years in discharging summary. The history of pain was only for one year back. The decompression surgery was done on 05/08/2011 out of pocket of the complainant. The discharge summary shows that this disease was not the preexisting disease and it has developed after July 2011, while the policy of insurance is already bought. She made the final payment by taking the personal loan of Rs.99,000/- at high interest and made the payment of Rs.2,49,408/- through Credit Cards. The documents were submitted for reimbursement which was rejected on 05/10/2013 on the same ground of preexisting disease. The rejection is with malafide intention and contrary to the cashless approval granted after considering the documents and X-ray on the basis of same X-Ray films contrary view has been taken by the respondent. The complainant has prayed for reimbursement of Rs.3,39,408/-together with Rs.2,00,000/- for mental pain agony and cost of litigation.

            The respondent in their written statement have taken the plea that complainant was admitted at Sir Ganga Ram Hospital on 02/09/2013. On the Pre Authorization Request by the Hospital, the claim records were scrutinized. As per the discharge summary, the patient was admitted with the complaints of pain in left hip joint since 5 years and difficulty in walking since 2 years and core depression 2 years ago. Later on, the treating Hospital submitted the letter dated10/09.2013 in which it was mentioned that “the decompression surgery of LS spine was done in August, 2011 as against mentioned 2012 which is again a printing mistake” and also stating that the insured has been admitted with the complaints of pain in left hip joint since one year and difficulty in walking since one year. As the corrected documents cannot be accepted in cashless, therefore the respondent have denied the cashless authorization vide letter dated 10/09/2013. The complainant has not disclosed her medical illness in the proposal form at the time of proposing insurance with the respondent which is totally illegal and therefore the complainant is not entitled to any benefit.

The medical officer of the respondent observed “X-ray films shows complete destruction of head of femur with proximal migration of femur; degenerative acetabulum with widening of acetabulum. This is a late sequel of secondary degenerative arthritis of the hip due to avascular necrosis of hip. The duration of the disease must be more than 5 years.

            As per the expert opinion, clinically gross restriction of movement, flexion deformity of 50*, internal rotation of 0* complete destruction of femur head nad proximal migration all features are suggestive of chronic disease.

            All these symptoms takes more than 3 years to develop and complainant is symptomatic of the above disease prior to inception of medical insurance policy. The respondent is not liable to make any payment in respect of pre existing disease, until 48 months of continuous coverage. The complainant has not come with clean hands and claim is liable to be rejected. Rest all the allegations been denied.

            Both the parties have filed evidence in support of their respective case.

            We have heard and perused the record.

            This fact is not in dispute that Smt. Raj Rani in this case was not first insured with the respondent on 12/07/2015 and this also not in dispute that in September 2013 she was operated at Sir Ganga Ram Hospital for hip replacement. This is also not in dispute that conditions of the insurance provide exclusion. The complainant herself has filed along with complaint Annexure-1, terms and condition of the policy chapter 3 of the terms and condition deals with the exclusion 3(e) for type of joint replacement (other than by the accident) condition No.3 (1) deals with the pre existence disease which shows”preexisting disease as defined in the policy until 48 consecutive months of continuous coverage has lapsed since the inception of the first policy with any Indian insurer.

In the present complaint the total dispute revolves around two facts-

1. On the admission of the complainant on 25/08/2013, Dr. O.N. Negi started the process of cashless approval with the TPA which was initially denied on the basis of preexisting disease but on further representation and submission of the X-Ray reports on amount of Rs.1,50,000/- was allowed but the same was withdrawn on the basis of discharge summary indicating pre existing disease prior to the policy, symptoms, since last five years.
2. The second issue arises for our consideration is as to whether respondent can take back authorization of cashless facility and can repudiate the claim by taking shelter of exclusion clause of the policy.

The letter dated 10/09/2013 cited the preexisting disease and undergoing core decompression two years ago. The documents submitted by Sir Ganga Ram Hospital reveals there was pain in the left hip for the last five years and difficulty in walking for two years in the history of patient illness, further there is mention of two years of pain. Two certificates have been issued by Dr. Satnam Chabra and Dr. O.N.Negi, where in the treating Doctors have mentioned that she was having this hip problem for the last one year and she has been under treatment for the last one year and all the changes developed during the last one year and not three years as stated by the rejection committee of the Star Health. The counsel for the complainant submitted that on 10/09/2013 another certificate was issued by the doctor wherein he has mentioned that decompression surgery of the LS Spine was done in August 2011 as against 2012 which is the printing mistake. In this certificate, Doctor has emphasized that in fact it is one year and not five year. It has been pointed out that in the discharge summary history of the patient, it is noted that “patient was apparently alright one year back when she developed pain in left hip, mild intensity, aggravated activity, and walking long distance and relieved on taking rest on medication…..” if this be taken into consideration then the mentioning of five years pain in the left hip joint appears to be a clerical mistake. Had it not been so, there was no occasion to the Doctor to write that the patient was apparently alright one year back. In such circumstances this has to be accepted that there is printing mistake, in fact she was not suffering from the disease prior to the inception of the policy. Annexure 11 (a) the bed head ticket also confirms that it is one year and not five year. This fact is to be taken into consideration for looking to the withdrawal of the cashless sanction. The communication between hospital and TPA and on submission of the documents included X-Ray plate, the cashless sanction up to Rs.1,50,000/- was accorded. This fact was submitted before the respondent that the patient is having pain, his X-Ray and its reports were submitted and it is after satisfaction of the respondent, the sanction was accorded. There is no change post operation in the status of the disease, the operating Doctor has verified this fact that it has started within one year prior to the operation. In so far as the decompressed is concerned that has nothing to do with hip ailment and cannot be considered at this stage. In the light of Evidence on record Smt. Raj Rani was operated in September 2013. The policy of insurance started in July 2011, more than two year prior to this operation. In these circumstances this cannot accepted that this disease in the hip was existing at the time of buying of this policy. The respondent has not filed on record the deceleration forms submitted by the complainant to show that she has not disclosed the disease that she was suffering from. Had she been suffering from hip ailment, she has been mentioned it in the declaration form. There is no plea taken by the respondent that she has concealed this fact. In these circumstances the plea of the respondent cannot be accepted that it was pre-existing disease. In these circumstances, the respondent withdrawal of the cashless sanction cannot be said to be bonafide and legal and the rejection of the claim is also not supported by the material on record.

            We allow this complaint. The respondent is directed to reimburse the amount of Rs.3,39,408/- which has been paid as per Annexure-18 at the Sir Ganga Ram Hospital. Let this amount be paid to the complainant within 45 days from the date of the order. The complainant shall be paid 9% interest over this amount if it is not paid within a period specified and till it is paid. We further award the compensation of Rs.50,000/- on account of harassment, mental pain, and agony which shall also include the cost of litigation.

The copy of the order be sent to the parties as per rules.

 

POONAM MALHOTRA                                                                                          N.A.ZAIDI

          MEMBER                                                                                                        PRESIDENT