Punjab

Ludhiana

CC/19/256

Manmohan Singh - Complainant(s)

Versus

Star Health Allied Ins.Co.Ltd. - Opp.Party(s)

Sunil Srivastav Adv.

03 Mar 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No:256 dated 23.05.2019.                                                        Date of decision:03.03.2023.

Manmohan Singh son of Late S. Ram Singh, resident of House No.1177/5, Ward No.38, Baba Than Singh Nagar, Ludhiana (now deceased) through his following LRs:-

1. Amarjit Kaur (widow)
2. Kawaljit Singh (son)
3. Simran Jot Singh (son)

All residents of House No.1177/5, Ward No.38, Baba Than Singh Nagar, Ludhiana

4. Manpreet Kaur (daughter) wife of Manpreet Singh, resident of Hose No.30/2, Alam Nagar, SBI Bank, Dugri Road, Ludhiana.                                                                                                 ..…Complainant

                                                Versus

1. Star Health and Allier Insurance Company Ltd., 4^th Floor, 3369, Sandhu Tower-II, Gurdev Nagar, Ludhiana through its Branch Manager/authorized signatory.
2. Star Health and Allied Insurance Company Ltd., Red. And Corporate Office: 1, New Ank Street V Alluvar Kottam High Road, Nungamb Akkam, Chennai-600034 through its Managing Director/Chairman/Authorized Signatory.

…..Opposite parties 

Complaint Under Section 12 of the Consumer Protection Act.

QUORUM:

SH. SANJEEV BATRA, PRESIDENT

SH. JASWINDER SINGH, MEMBER

MS. MONIKA BHAGAT, MEMBER

 

COUNSEL FOR THE PARTIES:

For complainant            :         Sh. Sunil Srivastav, Advocate.

For OPs                         :         Sh. Rajeev Abhi, Advocate.

 

ORDER

PER SANJEEV BATRA, PRESIDENT

1.                Shorn of unnecessary details, the facts of the case are that the complainant, as per allurement of the respondents has taken medical insurance policy No.P/211200/01/2019/000511 dated 05.05.2018 valid up to 04.05.2019 midnight against premium of Rs.17,310/- and he has been regularly purchasing medical policy since 2017. The policy covers any treatment of the complainant and his family members up to Rs.4,00,000/- being cashless policy without paying any charges to any hospital.

                   The complainant submitted that in the month of September, 2018, unfortunately his wife Smt. Amarjit Kaur suffered some health problem and was admitted in CMC hospital, Ludhiana on 28.09.2018 where doctors diagnosed and found that the wife of the complainant is suffering from EROSIVE PAN GASTRITIS-STATUS POST EXPIORATORY LAPOROTOMY. Doctors of CMC Hospital also gave certificate that the said disease has no connection with any previous ailments if any. Wife of the complainant remained in DMC  Hospital, Ludhiana for 5 days for her proper treatment and spent Rs.46,575/- on medical expenses including medicines. The complainant presented the insurance policy number and ID to CMC Hospital to deduct the ill from the insurance company being a cashless insurance policy. The hospital authorities intimated the opposite parties for claiming medical expenses but they refused to give any medical claim upon which the hospital authorities asked the complainant to deposit medical expenses and the complainant deposited the said amount and his wife was discharged from the hospital on 03.10.2018. After her discharge, the wife of the complainant also taken treatment from various doctors and Rs.2,50,000/- were incurred by him on her treatment. The complainant and the hospital authorities provided full detail of health problem and medical bills to the opposite parties but they refused to clear the medical claim of the complainant without any reason for which the complainant time and again approached the opposite parties with request to sanction the claim but they postponed the matter on one pretext or the other. Later on, the opposite parties flatly refused to pay anything to the complainant. The complainant further submitted that due to non-settlement of the claim, he has suffered mental torture, pain and agony and same amounts to deficiency in service and unfair trade practice on the part of the opposite parties for which he is entitled for compensation to the tune of Rs.2,00,000/-. The complainant further submitted that the rejection of the claim is illegal and without giving any opportunity of being heard to the complainant. The complainant got served legal notice dated 15.03.2019 through his counsel Sh. G.S. Panesar, Advocate calling upon the opposite parties to pay the claim of the complainant along with compensation but no reply was given to the said notice. Hence this complaint whereby a prayer has been made to direct the opposite parties to pay the claim amount of Rs.2,50,000/- along with compensation of Rs.2,00,000/- and litigation expenses of Rs.33,000/-.

2.                Upon notice, the opposite parties appeared and filed joint written statement by taking preliminary objections that the complaint is barred under section 26 of the Consumer Protection Act, the complaint is not maintainable, there is no deficiency in service on their part, the complainant is stopped by his own act and conduct from filing the present complaint and has concealed the material acts.  The opposite parties alleged that immediately on receipt of the claim, it was duly registered, entertained and processed. The complainant had obtained Family Health Optima Insurance policy No.P/211/200/01/2019/000511 covering Sh. Manmohan Singh complainant and Mrs. Amarjit Kaur spouse for a sum insured of Rs.4,00,000/- valid from 05.05.2018 to 04.05.2019. The opposite parties further alleged that the policy is issued on the principles of uberrimae fides and utmost good faith is a cardinal principle of insurance which means that all the parties to an insurance contract must deal in good faith, making a full declaration of all material fats in the insurance proposal. Material facts are those that would influence underwriters as to whether he should or should not accept the risk and if a party fails to adhere to the principles of utmost good faith, the outcome of the claim may be affected. The insurance policy is issued on the basis of proposal form and is a contractual in nature and he claims arising therein are subject to 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 and in the policy schedule it is clearly stated “the insurance under this policy is subject to conditions, clauses, warranties, exclusions etc.” The opposite parties alleged that as per one of the conditions No.3 of the policy that “the insured person shall obtain and furnish the company with all original bills, receipts and other documents upon which a claim is based and shall also give the company such additional information and assistance as the company may require in dealing with the claim........” The complainant preferred claim in 4^th month of the policy towards hospitalization dated 28.02.2018 at CMC Hospital, Ludhiana for the treatment of Erosive Pan Gastritis and raised pre-authorization request for cashless treatment approximately Rs.35,000/- to Rs.40,000/-. After receipt of cashless pre-authorization request, query on pre-authorization was raised by the opposite parties vide their letter dated 29.09.2018 calling upon the hospital to provide the information/documents reproduced as under:-

• Admission case sheet, exact duration with all previous consultations, cause of abdomen pain
• All supporting documents and investigations done for hospitalization
• Any previous H/O hospitalization
• Detailed line of management

After scrutinizing the documents of cashless pre-authorization of the complainant received from CMC Hospital, Ludhiana on behalf of patient Amarjit Kaur and the same was denied vide letter dated 03.10.2018 stating that the patient has the history of exploratory laparotomy in 2004 which is a pre-existing and also high risk which was not disclosed by the insured in the proposal form during policy inception. The copy of denial letter dated 03.10.2018 was sent to CMC Hospital, Ludhiana and the complainant. Subsequently, the complainant lodged the claim for reimbursement of medical expenses incurred for a sum of Rs.59,210/- and on scrutiny of the claim documents by the officials of the respondents it was observed that

• The discharge summary dated 21.12.2004 submitted in response to our query raised cashless states that the insured has acute intestinal obstruction - small bowel, osteoarthritis and operated and underwent exploratory laparotomy.
• As per discharge summary dated 28.09.2018, the insured was admitted with past history of status / post exploratory laparotomy (2004), further the Antral biopsy taken from HPE.

The opposite parties further alleged that vide letter dated 11.01.2019 following with reminder dated 26.01.2019 and 10.02.2019, they called upon the complainant to submit the documents to process the claim, which are reproduced as under:-

• HPE reports
• A letter from the treating doctor stating the duration of pangastritis
• Previously done UGI endoscopy reports prior to this admission
• Complete treatment records taken for gastritis since diagnosed

The opposite parties further alleged that the complainant has failed to submit the said documents despite repeated requests and reminders as the same were required for processing the claim and in the absence of same, they were not able to further process the claim. The claim of the complainant was rejected vide letter dated 25.02.2019 on account of non-submission of documents demanded vide letters dated 11.01.2019 and 10.02.2019. However, on receipt of legal notice of complainant dated 15.03.2019, the opposite parties one again called the aforesaid documents vide letter dated 10.04.2019 but the insured neither submitted a clarification letter nor furnished the necessary documents. The claim of the complainant has been rightly rejected vide letter dated 03.10.2018 on the legal, valid grounds as per terms and conditions of the policy due to non-submission of documents.

                   On merits, the opposite parties reiterated the crux of averments made in the preliminary objections. The opposite parties alleged that no particulars of the insurance are disclosed nor the policy for the year 2017 is produced to show that it was a renewal of earlier policy which shows that the complainant has obtained the insurance policy for the first time valid from 05.05.2018 to 04.05.2019. The opposite parties alleged that as per discharge summary, the complainant was diagnosed as case of erosive pan gastritis and status post exploratory laparotomy i.e. surgery related to gastro intestinal system which is extensive surgery and has squealed. This surgery if was disclosed at the time of policy inception, then underwriting the policy or not would have been a choice. The complainant and Amarjit Kaur have not disclosed the said disease in the proposal form at the time of inception f the policy. The certificate of CMC Hospital has no connection or concern with the procedure of issuance of the policy, policy terms and conditions. The complainant never remained admitted in DMC Hospital, Ludhiana nor spent Rs.46,575/- on treatment of Amarjit Kaur. The opposite parties alleged that wife of the complainant had never taken any treatment from various doctors after her discharge nor spent Rs.2,50,000/- on her treatment. However, the opposite parties submitted that the maximum quantum of liability of the company under the terms of the policy shall be Rs.45,574/-. Rest of the averments made in the complaint have been denied being incorrect and in the end, a prayer for dismissal of the complaint has been made.

3.                During the pendency of the complaint the complainant Sh. Manmohan Singh expired and his legal heirs moved an application for impleading them as party was moved on 25.03.202,whichw as allowed vide order dated 23.11.2021.

3.                In support of his claim, the complainant tendered his affidavit Ex. CA in which he reiterated the allegations and the claim of compensation as stated in the complaint. The complainant also tendered documents Ex. C1 to Ex. C11, Ex. C18 to Ex. C27 are the copies of the bills/receipts of medicines and tests, Ex. C12 to Ex. C17 are the copies of prescription slips of Dr. Karamvir Goyal, Ludhiana, Ex. C28 is the copy of prescription slip of Saini Clinic, Ludhiana Ex. C29 is the copy of surgical pathology report, Ex. C30, Ex. C31, Ex. C37, Ex. C41 are the copies of discharge summary of CMC Hospital, Ludhiana, Ex. C32, Ex. C36, Ex. C42 are the copies of certificate dated 04.10.2018 issued by CMC Hospital, Ludhiana, Ex. C33, Ex. 38 are the copies of claim form – Part A, Ex. C34 are the copies of claim form - Part B, Ex. C35, Ex. C40 are the copies of authorization letter, Ex. C43 is the copy of advise, Ex. C44, Ex. C53, Ex. C62 are the copies of bill of CMC Hospital, Ludhiana for Rs.46,575/-, Ex. C45 to Ex. C52, Ex. C54 to Ex. C61 are the copies of bills/receipts of medicines issued by CMC Hospital, Ludhiana and closed the evidence.

4.                On the other hand, counsel for opposite parties tendered affidavit Ex. RA of Sh. Rajiv Jain, Chief Manager of the opposite parties along with documents Ex. R1 is the copy of  policy schedule  valid from 05.05.2018 to 04.05.2019, Ex. R2 is the copy of common proposal form, Ex. R3 is the policy documents, Ex. R4 is the pre-authorization request form, Ex. R5 is the copy of field visit report, Ex. R6 is the copy of query on preauthorization dated 29.09.2018, Ex. R7 is the copy of denial letter dated 03.10.2018, Ex. R8 is the copy of claim form- Part B, Ex. R9 is the copy of discharge summary of CMC Hospital, Ludhiana dated 27.12.2004, Ex. R10 is the copy of discharge summary of CMC Hospital, Ludhiana dated 03.10.2018, Ex. R11 is the copy of certificate of CMC Hospital, Ludhiana dated 03.10.2018, Ex. R12 is the copy of patient cases notes, Ex. R13 is the copy of bill of Rs.46,575/- issued by CMC Hospital, Ludhiana, Ex. R14 to Ex. R18 are the copies of letters dated 11.01.2019 and 26.01.2019, 10.03.2019, 25.02.2019, 10.04.2019 respectively written by the opposite parties to the complainant, Ex. R19 is the copy of billing assessment sheet, Ex. R20 is the copy of power of attorney in name of Sh. Rajiv Jain executed by the opposite parties and closed the evidence.

5.                We have heard the arguments of the counsel for the parties and also gone through the complaint, affidavit and annexed documents and written reply along with affidavit and documents produced on record by both the parties.

6.                Undisputably, wife of complainant namely Amarjit Kaur remained hospitalized in CMC, Ludhiana from 28.09.2018 till 03.10.2018 and she was finally diagnosed having EROSIVE PAN GASTRITIS-STATUS POST EXPIORATORY LAPOROTOMY. Her pre-authorization cashless treatment was declined. However, she submitted the reimbursement for an amount of Rs.46,575/-  with the opposite parties. It may be noted that the complainant preferred a claim in the 4^th month of the policy. During the process of the claim, the opposite parties demanded certain clarification and documents vide letter dated  11.02.2019, 26.01.2019 and 10.03.2019 Ex. R14 to Ex. R18 respectively, reproduced as under:-

• HPE reports
• A letter from the treating doctor stating the duration of pangastritis
• Previously done UGI endoscopy reports prior to this admission
• Complete treatment records taken for gastritis since diagnosed

 

Despite reminders, the desired documents were not submitted and claim was rejected on 25.02.2019 vide letter Ex. R17. The insurance companies are required to be more liberal in their approach without being too technical. This Commission is of the considered view that in the light of the guidelines issued vide IRDA circular 20.09.2011, it can be safely held that the insurance company cannot be allowed to reject the claim on technical grounds. Rather the rejection by the insurance company must be based on sound logic and valid grounds.

8.                In this regard, reference can be made to 2022(2) Apex Court Judgment 281 (SC) in case title Gurmel Singh Vs Branch Manager National Insurance Company Ltd. whereby it has been held by the Hon’ble Supreme Court of India that the insurance company has become too technical while settling the claim and has acted arbitrarily. The appellant has been asked to furnish the documents which were beyond the control of the appellant to    procure and furnish. Once, there was a valid insurance on payment of huge sum by way of premium and the Truck was stolen, the insurance company ought not to have become too technical and ought not to have refused to settle the claim on non­submission of the duplicate certified copy of certificate of registration, which the appellant could not produce due to the circumstances beyond his control. In many cases, it is found that the insurance companies are refusing the claim on flimsy grounds and/or technical grounds. While settling the claims, the insurance company should not be too technical and ask for the documents, which the insured is not in a position to produce due to circumstances beyond his control. In the given set of circumstances, it would be just and appropriate if the complainant is directed to submit the above said documents as per repudiation letter dated 25.02.2019 Ex. R17 opposite parties within 15 days from the date of receipt of copy of order and thereafter, the opposite parties shall consider and reimburse claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant. 

9.                As a result of above discussion, the complaint is partly allowed with an order that the complainant is directed to submit the documents as per repudiation letter dated 25.02.2019 Ex. R17 to the opposite parties within 15 days from the date of receipt of copy of order and thereafter, the opposite parties shall consider and reimburse the claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant.  However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.         

10.              Due to huge pendency of cases, the complaint could not be decided within statutory period.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                          Member                            Member                                       President         

 

Announced in Open Commission.

Dated:03.03.2023.

Gobind Ram.

 

 

Manmohan Singh Vs Star Health and Allied Insurance Co.    CC/19/256

Present:       Sh. Sunil Srivastav, Advocate for complainant.

                   Sh. Rajeev Abhi, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint is partly allowed with an order that the complainant is directed to submit the documents as per repudiation letter dated 25.02.2019 Ex. R17 to the opposite parties within 15 days from the date of receipt of copy of order and thereafter, the opposite parties shall consider and reimburse the claim of the complainant as per terms and conditions of the policy within 30 days from the date of receipt of documents from the complainant.  However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

 

(Monika Bhagat)          (Jaswinder Singh)                      (Sanjeev Batra)                       Member                     Member                                       President         

 

Announced in Open Commission.

Dated: 03.03.2023.

Gobind Ram.