BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No.83-14

Date of Institution:11-02-2014

Date of Decision:16-03-2015

Smt.Gurinder Kaur wife of S.Surjit Singh, resident of C/O Kukreja Medicos Goal Hatti Chowk  Bazar Ram Bagh, Amritsar and old address: 27 Kashmir Avenue (W) Amritsar and at present 744 R.B.Estate Loharke Road, Amritsar.

Complainant

Versus

1. Star Health and Allied Insurance Company Limited, KRM Centre, VIth Floor No.2, Harrington Road, Chetpet, Chennai-600031 through its M.D/ Director/ Administrative etc.
2.  Star  Health and Allied Insurance Company Limited, Regd.& Corporate Office_I, New Tank Street, Valluvar Kottam High Road, Nungam Bakkam, Chennai 600034 through its  Director/ Administrator/ Incharge etc.
3. Star Health and Allied Insurance Company Limited, Branch Office SCO 25, Ist Floor, Ranjit Avenue, District Shopping Centre, Amritsar-143001 through its Manager.

Opposite Parties

Complaint under section 12 and 13 of the Consumer Protection Act.

Present: For the Complainant: Sh.R.S.Aulakh, Advocate

              For the Opposite Parties: Sh.S.S.Salaria, Advocate

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member     

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Smt.Gurinder Kaur under the provisions of the Consumer Protection Act alleging therein that in June, 2006 she obtained medical claim insurance policy from ICICI Lombard General Insurance Company and thereafter, she continued her policy till June, 2013. The complainant never committed any default and continued her policy with ICICI Lombard General Insurance Company. The complainant and her husband approached the ICICI Lombard General Insurance Company for further renewal/ continued the policy of complainant, the ICICI Lombard General Insurance Company refused to extend the policy of the complainant on the pretend that the age of husband of the complainant is more than 70 years that is why the policy of the complainant can not be continued. On refusing by ICICI Lombard General Insurance Company, the complainant contacted the Opposite Parties  who on seeing the previous record and conduct of the complainant immediately ready to port the policy under the Portability scheme and issued a policy to  the complainant bearing No.P/211111/01/2014/000664 under the Plan i.e. Senior Citizens Red Carpet Insurance Policy and at the time of issuing the policy by the Opposite Parties, the complainant was assured that as the Opposite Parties have port the insurance policy of the complainant and the complainant will be  given complete benefit under this  policy from the year 2006 although the complainant has previously taken the policies from ICICI Lombard General Insurance Company. At the time of issuing the policy in question by the Opposite Parties, they also mentioned previous policy number issued by ICICI Lombard General Insurance Company and received premium of Rs.9500/- and sum assured is Rs.2 lacs. The Opposite Parties also handed over the list of hospitals from which the complainant can avail the facilities of treatment/ hospitalization in the need of any emergency.  Unfortunately, on 10.6.2013 the complainant felt mild pain in the right eye and also felt  that he was feeling little uneasy in looking/ seeing the things. She was brought to KD Hospital, Majitha Road, Amritsar to get  routine check up and after examining the complainant, the doctor suggested the complainant to get conducted MRI and as per the advice of the doctor, MRI of the complainant was got  conducted from Advance Diagnostic Centre on 11.6.2013. Thereafter, the complainant was brought to Apex Hospital, Batala Road, Amritsar where Dr.Somil Kansal checked the complainant and further advised for more tests  on dated 14.6.2013 and also on 15.6.2013 which were got conducted as per the advice of the doctor. After going through the complete reports of various tests of the complainant, the doctor referred the complainant on 22.6.2013 to All India Institute of Medical Science, New Delhi and Medanta Medicity for better opinion as she was doubted/ found that the complainant was suffering with “Invasive Pituitary Adenoma”. On review of the slides and blocks by the doctor of Medanta Medicity, they confirmed  and reported as in the report i.e. Impression: supraseller mass-pituitary adenoma (Gonadotropin secreting) and they charged Rs.11000/- for the review of the slides Plus Rs.600/- for consultation charges from the complainant on 2.7.2013. On receiving the reports, Dr.Somil Kansal  of Apex Hospital, Batala Road, Amritsar referred the complainant to All India Institute of Medical Science, New Delhi where the complainant was diagnosed by Dr.Manmohan Singh of Neuro Surgery Department in 1.7.2013 in OPD where the complainant was brought by her  relatives. After checking the complainant, Dr.Manmohan Singh advised for admission in the hospital, but due to non availability of room on that day, she was admitted in All India Institute of Medical Science, New Delhi on 27.7.2013 for operation upon the complainant where on 2.8.2013, first operation of the said illness was operated upon and thereafter, she was discharged on 7.8.2013. Before discharging the complainant, Dr.Manmohan  Singh on 5.8.2013 advised for  second stage surgery after three weeks. The complainant was again admitted in the hospital on 14.9.2013 and she was operated upon for her second stage surgery on 18.9.2013 and she was discharged after second stage surgery from hospital on 19.9.2013. In all, the complainant spent an amount of Rs.1,83,499/- on her treatment. The complainant filed the claim with the Opposite Parties and also completed all the formalities, but the Opposite Parties closed the claim file of the complainant on 23.12.2013. Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite parties to release the medical claim of Rs.1,83,499/- alongwith interest @ 12% per annum.   Compensation and litigation expenses were also demanded.
2. On notice, opposite parties appeared and filed written version in which it was submitted that the complainant has obtained the Senior Citizens Red Carpet Insurance Policy bearing No.P/211111/01/2014/000664 effective from 11.6.2013 to 10.6.2014. During the currency of  said insurance, the complainant submitted claim form  for reimbursement of hospitalization expenses for treatment of INVASIV PITUITARY MACROADENOMA. On receipt of the claim intimation regarding the medical treatment and hospitalization and subsequently papers regarding medical treatment from complainant/ insured, the same were investigated and claim was duly processed and it was found and observed by he medical team of the Opposite Party from investigation reports and hospital records including discharge summary, the insured/ complainant has profound visual loss of 6/60 (right) and 6/36 (left) with bilateral temporal field defects. The insured/ complainant has these symptoms from two months prior to the date of admission, which is prior to inception of policy. At the time of inception of the first insurance policy from the Opposite Party from 11.6.2013 to 10.6.2014, the complainant had not disclosed the above mentioned medical history/ health details of the insured/ complainant in the proposal form  which amounts to mis-representation and non disclosure of material facts and as per condition No.7, the claim is not payable by the Opposite Party and in this regard, the intimation was given to the complainant vide letter dated 26.11.2013. However, complainant again requested for reinvestigation of her claim and again the claim was reconsidered and it was further observed that  the complainant had  earlier taken medical insurance policies from 2008-2009 to 2012-2013 from ICICI Lombard General Insurance Company and subsequently taken the policy in question from the Opposite Parties.  While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence her affidavit Ex.CW1/A alongwith documents Ex.C1 to Ex.C75 and closed the evidence on behalf of the complainant.
4. Opposite Parties tendered into evidence affidavit of Sh.Rajnish Kohli, Assistant Vice President Claims Ex.OP1,2,3/1 alongwith documents Ex.OP1,2,3/2 to Ex.OP1,2,3/19 and closed the evidence on behalf of the Opposite Party.
5. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant got medi claim insurance policy from ICICI Lombard General Insurance Company  in June, 2006 and thereafter, she continued her policy till June, 2013 Ex.C2 to Ex.C7. Thereafter, the complainant approached the Opposite Parties  who after going through the previous record and conduct of the complainant became ready to port the policy under the Portability scheme and issued a policy to  the complainant bearing No.P/211111/01/2014/000664 under the Plan i.e. Senior Citizens Red Carpet Insurance Policy for the period from 11.6.2013 to 10.6.2014 Ex.C8. The complainant felt mild pain in the right eye on 10.6.2013. She was taken to KD Hospital, Majitha Road, Amritsar and on the  request of the doctor, the complainant got conducted MRI from Advance Diagnostic Centre on 11.6.2013. Thereafter, the complainant was taken to Apex Hospital, Batala Road, Amritsar where Dr.Somil Kansal checked the complainant and further advised for more tests  which were got conducted as per the advice of the doctor. After going through the complete reports of various tests of the complainant, the doctor referred the complainant to All India Institute of Medical Science, New Delhi and Medanta Medicity on 22.6.2013 for better opinion as she was suffering with “Invasive Pituitary Adenoma”. Then, the complainant approached Medanta Medicity, who also confirmed  the report as the  impression was given  supraseller mass-pituitary adenoma (Gonadotropin secreting). On receiving the reports, Dr.Somil Kansal  of Apex Hospital, Batala Road, Amritsar referred the complainant to All India Institute of Medical Science, New Delhi where the complainant was diagnosed by Dr.Manmohan Singh of Neuro Surgery Department in 1.7.2013 in OPD  and advised the complainant for  admission, but due to non availability of room, she was admitted in All India Institute of Medical Science, New Delhi on 27.7.2013 where on 2.8.2013, first operation of the complainant was conducted and  she was discharged on 7.8.2013 and advised the complainant for second  stage surgery after three weeks. Resultantly,  the complainant was again admitted in All India Institute of Medical Science, New Delhi on 14.9.2013 where the  second stage surgery was conducted on 18.9.2013 and the complainant was discharged after second stage surgery from hospital on 19.9.2013. In all, the complainant spent an amount of Rs.1,83,499/- on her treatment. The claim was lodged with the Opposite Parties alongwith all relevant documents, but the Opposite Parties  failed to settle the claim of the complainant, rather repudiated the claim of the complainant vide letter dated 26.11.2013 Ex.OP14 on the ground that as per the hospital record, the insured/ complainant has profound visual loss of 6/60 (right) and 6/36 (left) with bilateral temporal field defects. The insured/ complainant had these symptoms for two months prior to the date of inception of policy and the complainant has not disclosed the above mentioned medical history/ health details of the insured/ complainant to the Opposite Parties. Ld.counsel for the complainant submitted that the complainant has been regularly taking the policies from ICICI Lombard General Insurance Company and under the portability scheme, she has taken the policy in continuity of the policy from the Opposite Parties. So, the Opposite Parties could not rebut the claim of the complainant on this ground that she had this problem 2 months prior to taking of the policy by the complainant from the Opposite Parties Ex.C8. The Opposite Parties  have repudiated the claim of the complainant on illegal and false ground which amounts to deficiency in service on the part of the Opposite Parties.
7.  Whereas the case of the opposite parties No.1 to 3 jointly, is that the complainant has obtained policy in question from the Opposite Parties  for the period from 11.6.2013 to 10.6.2014. On receipt of the claim intimation from the complainant, the same was got investigated and it was found and observed from the hospital record of the complainant that the  insured/ complainant had profound visual loss of 6/60 (right) and 6/36 (left) with bilateral temporal field defects. The insured/ complainant had these symptoms for two months prior to the date of admission, which is prior to inception of policy. The complainant had not disclosed the above mentioned medical history/ health details of the insured/ complainant in the proposal form  which amounts to mis-representation and non disclosure of material facts and as per condition No.7, the claim is not payable by the Opposite Party and in this regard, the intimation was given to the complainant vide letter dated 26.11.2013 Ex.OP1,2,3/14. However, complainant again requested for reinvestigation of her claim. Resultantly, the claim case of the complainant was reconsidered and it was found that  the complainant was admitted with the complaints of progressive diminution of vision since two months i.e. from 27.5.2013 which is prior to the inception of the policy and the complainant got the policy from the Opposite Parties by misrepresentation and the concealment of the facts. Ld.counsel for the Opposite Parties  submitted that the Opposite Parties were justified in repudiating the claim of the complainant vide letter dated 26.11.2013 Ex.OP1,2,3/14.  
8. From the entire above discussion, we have come to the conclusion that the complainant obtained the medi claim policy from ICICI Lombard General Insurance Company i.e. policy Ex.C1 for the period 8.6.2008 to 7.6.2007 and thereafter, she continued her policy upto the year 2012-2013  i.e. last policy from ICICI Lombard General Insurance Company for the period from 11.6.2012 to 10.6.2013 Ex.C7 and thereafter, the complainant obtained medi claim policy from the Opposite Parties bearing No.P/211111/01/2014/000664 under the Plan i.e. Senior Citizens Red Carpet Insurance Policy for the period from 11.6.2013 to 10.6.2014 Ex.C8. The complainant felt mild pain in the right eye on 10.6.2013 and she was taken to KD Hospital, Majitha Road, Amritsar and on the  request of the doctor, the complainant got conducted MRI from Advance Diagnostic Centre on 11.6.2013 Ex.C14  and the doctor prescribed the medicines to the complainant for the first time on 11.6.2013 on the basis of MRI. Thereafter, the complainant was taken to Apex Hospital, Batala Road, Amritsar where Dr.Somil Kansal checked the complainant on 14.6.2013 and 15.6.2013. After going through the complete reports of various tests of the complainant, the doctor referred the complainant on 22.6.2013 to All India Institute of Medical Science, New Delhi and Medanta Medicity. The complainant was got checked by Medanta Medicity who confirmed that the complainant is suffering  with “Invasive Pituitary Adenoma” and thereafter, she was referred to All India Institute of Medical Sciences, New Delhi where Dr.Manmohan Singh of Neuro Surgery Department medically checked up the complainant on 1.7.2013 in OPD  and advised her for  admission, but due to non availability of room, the complainant was admitted in All India Institute of Medical Science, New Delhi on 27.7.2013 where she was firstly operated  on 2.8.2013 and  was discharged on 7.8.2013 with the advice of second stage surgery after three weeks. Then, the complainant was again admitted in All India Institute of Medical Science, New Delhi on 14.9.2013 where the  second stage surgery was conducted on 18.9.2013 and the complainant was discharged from hospital on 19.9.2013 as is evident from the record of the All India Institute of Medical Science, New Delhi i.e. discharge summary Ex.C32 and Ex.C35. The complainant spent a sum of Rs.1,83,499/- on her medical treatment as is evident from the bills produced by the complainant Ex.C9 to Ex.C30, Ex.C33 to Ex.C44 and Ex.C47 to Ex.C74. The claim was lodged with the Opposite Parties, but the Opposite Parties repudiated the claim of the complainant vide letter Ex.OP1,2,3/14 on the ground that  the complainant obtained the policy from the Opposite Parties  for the period from 11.6.2013 to 10.6.2014, whereas the medical history of the complainant recorded by the All India Institute of Medical Science, New Delhi shows that the complainant has profound visual loss of 6/60 (right) and 6/36 (left) with bilateral temporal faked defects. The insured patient had these symptoms for 2 months prior to the date of admission, which is prior to inception of policy.
9. It is the admitted case of the Opposite Parties  that they issued the policy in question to the complainant for the period from 11.6.2013 to 10.6.2014 under portability scheme which proves that the complainant has been in continuation of the policy from June, 2006 onwards without any break and the Opposite Parties  have issued the present policy Ex.C8 to the complainant for the period 11.6.2013 to 10.6.2014 under portability scheme that they have accepted the continuity of the policy since June, 2006. As such, the Opposite Parties  can not repudiate the claim of the complainant on the ground that the complainant had these problems two months prior to her admission i.e. prior to the inception of the policy of the Opposite Parties for the period 11.6.2013 to 10.6.2014. Apart from this, the Opposite Parties  have relied only on the history of the complainant recorded in the hospital record without any cogent evidence i.e. without examining  any doctor who ever medically treated the complainant for the aforesaid disease prior to the inception of the policy nor the Opposite Parties  could produce any medical record  that the complainant was suffering from the aforesaid  disease and was medically treated  or that she had knowledge of this disease prior to taking of the policy from the Opposite Parties. So, we are of the opinion, that the Opposite Parties  have wrongly and illegally repudiated the claim of the complainant.
10. Resultantly, we allow the complaint with costs and the Opposite Parties  are directed to pay the amount spent by the complainant on her treatment i.e. Rs.1,83,499/- alongwith interest @ 9% per annum from the date of filing the complaint till the payment is made to the complainant. The Opposite Parties  are also directed to pay Rs.2000/- to the complainant as costs of litigation.   Copies of the order be furnished to the parties free of costs. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 16.03.2015.                                                (Bhupinder Singh)            

                                                                                 President

hrg                                      (Kulwant Kaur Bajwa)    (Anoop Sharma)

              Member                               Member