DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/52/2023
Date of Institution: 25.04.2023
Date of Decision: 05.07.2024
Ritesh Bansal ageed about 37 years son of Arun Kumar resident of H.No. B-XI/1260A, Gobind Colony, Street No. 1, Barnala.
…Complainant
Versus
1. Star Health and Allied Insurance Company Ltd., No. 15, Sri Balaji Complex, 1st Floor, Whites Lane, Royapettah, Chennai-600014, through its Authorized Signatory.
2. Star Health and Allied Insurance Company Ltd., 2nd Floor, Above Delhi Tractor and Combines, Opposite PNB Bank, College Road, Barnala through its Branch Manager.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Sh. Anuj Mohan Adv counsel for complainant.
Sh. Rohit Jain Adv counsel for opposite parties No. 1 & 2.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Sh. Navdeep Kumar Garg: Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainant has filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Star Health and allied Insurance Company Limited & others (in short the opposite parties).
2. The facts leading to the present complaint are that the complainant purchased one Health Insurance policy named as Health Optima Insurance Plan bearing No. P/211229/01/2022/001285 from the opposite party No. 2 and said policy was valid from 16.1.2022 to 15.1.2023 in which the complainant, his wife and his two minor children are insured for Rs. 10,00,000/- for the next one year for any type of ailment and medical need to the whole members of the family. It is further alleged that the complainant had suffered some medical problem and he admitted in Deep Hospital, Ludhiana on 26.112022 and in the said hospital he was diagnosed for Immune Thrombocytopenia and discharge on 1.12.2022 and the complainant had incurred Rs. 84,900/- on the said treatment. The complainant immediately approached to the opposite parties for submission of the claim documents and after completion of all required documents the opposite parties generated claim information No. CIR/2023/211229/1138670 of the said claim of the complainant and assured that the claim will be paid very soon to the complainant by cheque or through account. The complainant approached the opposite parties many times to pay the claim amount, but the opposite parties never accede the legitimate request of the complainant. However, the opposite parties against law and facts wrongly repudiated the claim vide letter dated 3.1.2023 on the sole ground that 5 years back the complainant was suffered from Dengue and the same has not been disclosed at the time of purchasing the policy. It is submitted that due to some miscommunication a Nurse in the duty of emergency ward wrongly mentioned that the complainant was diagnosed for dengue fever 5 years back, whereas the complainant has disclosed that he had simple fever 5 years back due to whether change and this information was given to the hospital. It is further alleged that there was no serious previous history of any disease to the complainant. However, there is no such history of dengue fever of the complainant 5 years back. Moreover, the hospital at the time of issuing discharge summary has nowhere mentioned that there is a previous history of dengue fever to the complainant. The complainant also sent a legal notice dated 18.3.2023 to the opposite parties but the opposite parties have not replied the said notice. As such, there is deficiency in service on the part of opposite parties. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to release the claim amount of Rs. 84,900/- along with interest @ 18% per annum from the date of admission i.e. 26.11.2022 till realization.
- To pay Rs. 50,000/- as mental tension and harassment.
- Further, to pay Rs. 11,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties appeared and filed written version by taking preliminary objections interalia on the grounds that the complainant has no locus-standi to file the present complaint. The present complaint is not legally maintainable. The complainant has no cause of action to file the present complaint. The complainant has not come with clean hands etc.
4. On merits, it is admitted that the insured availed the Family Health Optima Insurance Plan through Branch Office Covering Ritesh Bansal-Self, Rajni- Spouse, Paarth and Paanav- dependent child for the sum insured Rs. 10,00,000/- vide policy No. P/211229/01/2022/001285 valid from 16.1.2022 to 15.2.2023. It is further submitted that it is matter of record that the complainant suffered some medical problem and was brought to Deep Hospital, Ludhiana on 26.11.2022 and was diagnosed for “IMMUNE THROMBOCYTOPENIA” and was discharged on 1.12.2022 and the complainant incurred Rs. 84,900/- on his treatment. It is admitted that the complainant approached the opposite parties for submission of claim documents and claim information No. CIR/2023/211229/1138670 was generated of the said claim of the complainant. It is admitted that the claim of the complainant has been repudiated on the grounds mentioned in the letter. It is denied that the complainant also sent a legal notice dated 18.3.2023 to the opposite parties, no such notice ever reached at the doors of the opposite parties. It is further alleged that the terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant alongwith the policy schedule. 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. It is further alleged that as per the documents received, the patient has been suffering from this disease since the age of 4 years which is prior to inception of the first policy. Hence, it is a pre-existing disease/condition. The insured has failed to disclose this in his proposal form at the time of inception of the first policy. As per the waiting period/exclusion No. Excl 01.a of the policy, the claim for treatment of the disease/condition is not admissible until the expiry of 48 months from the date of admission 26.11.2022 after 1st October 2020. Therefore, the opposite parties unable to approve the claim and the authorization already given for cashless treatment of the above diagnosed disease stands withdrawn. Hence, the opposite parties requested the insured to furnish the past treatment records of Dengue and Thrombocytopenia. But the insured has not furnished the required documents and details. In the absence of the above said documents, insurance company is not able to further process the claim. All other allegations of the complaint are denied and prayed for the dismissal of complaint.
5. Ld. Counsel for complainant on 21.11.2023 suffered the statement that I do not want to file any rejoinder against the version of opposite parties.
6. To prove the case the complainant tendered into evidence copy of policy Ex.C-1, copy of report of emergency doctor’s initial assessment sheet Ex.C-2, copy of discharge summary dated 1.12.2022 Ex.C-3, copy of bills dated 30.11.2022 and 1.12.2022 Ex.C-4 and Ex.C-5 respectively, copy of rejection letter dated 3.1.2023 Ex.C-6, copy of legal notice dated 18.3.2023 Ex.C-7, postal acknowledgement Ex.C-8 and Ex.C-9, affidavit of complainant Ex.C-10, affidavit of Sh. Surinder Mohan Gupta Advocate Ex.C-11, copy of notice for vacation and adjustment of security deposit Ex.C-12 and closed the evidence.
7. To rebut the case the opposite party tendered into evidence affidavit of Sumit Kumar Sharma Ex.O.Ps-1, copy of proposal form Ex.Ops-2 (containing 4 pages), copy of policy Ex.O.Ps-3 (containing 2 pages), copy of terms and conditions Ex.O.Ps-4 (containing 6 pages), copy of pre authorization request O.Ps-5, copy of cashless authorization letter Ex.O.Ps-6 (containing 7 pages), copy of doctors note Ex.O.Ps-7, copies of rejection of approval Ex.O.Ps-8 & Ex.O.Ps-9, copy of claim form Ex.O.Ps-10 (containing 4 pages), copy of discharge summary Ex.O.Ps-11 (containing 2 pages), copy of doctors note Ex.O.Ps-12, copy of Final Bill Ex.O.Ps-13, copy of letter dated 15.12.2022 Ex.O.Ps-14 (containing 2 pages), copy of repudiation letter Ex.O.Ps-15 (containing 3 pages), copy of bill assessment sheet Ex.O.Ps-16 (containing 3 pages) and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on the file.
9. It is admitted case of the opposite parties that the insured availed the Family Health Optima Insurance Plan through Branch Office Covering Ritesh Bansal-Self, Rajni- Spouse, Paarth and Paanav- dependent child for the sum insured Rs. 10,00,000/- vide policy No. P/211229/01/2022/001285 valid from 16.1.2022 to 15.2.2023 (as per Ex.C-1 & Ex.O.Ps-3). It is also not disputed between the parties that the complainant suffered some medical problem and was brought to Deep Hospital, Ludhiana on 26.11.2022 and was diagnosed for “IMMUNE THROMBOCYTOPENIA” and was discharged on 1.12.2022 (as per Ex.C-3 & Ex.O.Ps-11). It is also admitted case of the opposite parties that the complainant approached the opposite parties for submission of claim documents and claim information No. CIR/2023/211229/1138670 was generated of the said claim of the complainant.
10. Ld. Counsel for the complainant argued the complainant had incurred Rs. 84,900/- on the said treatment and the complainant immediately approached to the opposite parties for submission of the claim documents and after completion of all required documents the opposite parties generated claim information No. CIR/2023/211229/1138670 of the said claim of the complainant and they assured that the claim will be paid very soon to the complainant by cheque or through account. It is further argued that the complainant approached the opposite parties many times to pay the claim amount, but the opposite parties never accede the legitimate request of the complainant, however the opposite parties against law and facts wrongly repudiated the claim vide letter dated 3.1.2023 (Ex.C-6) on the sole ground that 5 years back the complainant was suffered from Dengue and the same has not been disclosed at the time of purchasing the policy. It is further argued that due to some miscommunication a Nurse in the duty of emergency ward wrongly mentioned that the complainant was diagnosed for dengue fever 5 years back, whereas the complainant has disclosed that he had simple fever 5 years back due to whether change and this information was given to the hospital. It is also argued that there was no serious previous history of any disease to the complainant, however there is no such history of dengue fever of the complainant 5 years back. Ld. Counsel for the complainant further argued that the hospital at the time of issuing discharge summary has nowhere mentioned that there is a previous history of dengue fever to the complainant.
11. On the other hand, Ld. Counsel for the opposite parties argued that the policy is contractual in nature and the claims arising therein are subject to the terms and conditions forming part of the policy. It is further argued that as per the documents received the patient has been suffering from this disease since the age of 4 years which is prior to inception of the first policy, hence it is a pre-existing disease/condition. It is argued that the insured has failed to disclose this in his proposal form at the time of inception of the first policy. It is further argued that as per the waiting period/exclusion No. Excl 01.a of the policy the claim for treatment of the disease/condition is not admissible until the expiry of 48 months from the date of admission 26.11.2022 after 1st October 2020, therefore the opposite parties unable to approve the claim and the authorization already given for cashless treatment of the above diagnosed disease stands withdrawn. It is also argued that the opposite parties requested the insured to furnish the past treatment records of Dengue and Thrombocytopenia, but the insured has not furnished the required documents and details and in the absence of the above said documents insurance company is not able to further process the claim.
12. We have gone through the copy of discharge summary placed on record by both the parties (i.e. Ex.C-3 and Ex.O.Ps-11) vide which it is mentioned that the patient came with complaints of gum bleed X 2 days, CBC showed severe thrombocytopenia and the final diagnosis shows as “Immune thrombocytopenia”. It is nowhere mentioned in the discharge summary that there was previous history of any disease to the complainant. It is also not mentioned that there is such history of dengue fever of the complainant 5 years back. On the other hand, Ld. Counsel for the opposite parties argued that the patient has been suffering from this disease since the age of 4 years which is prior to inception of the first policy and hence it is a pre-existing disease/condition and placed on record O.Ps-7 & Ex.O.Ps-12. But on the perusal of this document it shows that there is no stamp of doctor and the same was not signed by the doctor, so this document is not admissible. Apart from this the opposite parties have failed to place on record any medical record of the complainant to prove this fact.
13. In order to prove his case the complainant has placed on record Final Bill of Deep Nursing Home & Children Hospital and Pharmacy Issue Receipt i.e. Ex.C-5 & Ex.C-6 from which it shows that the complainant has spent an amount of Rs. 84,900/- (i.e. Rs. 84,710 + Rs. 190 = Rs. 84,900/-) on his treatment. We are of the view that it was in the hands of insurance company to see and not to issue policy where person is not entitled to claim on account of treatment of Pre-existing disease. Moreover, there is nothing on record from the side of opposite parties that they have conducted the medical examination/investigation of the complainant and his family members at the time of issuing the policy. So, we are of the view that at this stage the opposite parties cannot escaped from their liabilities by raising these types of unreasonable unjustified grounds. The learned counsel for the complainant also relied upon the judgment of the Hon'ble Punjab and Haryana High Court (DB) 2012 (1) RCR (Civil)-901 in which the Hon'ble High Court held that “Claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the policy. Single judge allowed the claim on the ground that it was for Insurance Company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. No interference called for in the order of Single Judge. Held the pre-existing condition existed in the year 2002 which was five years prior to acquiring Insurance Policy. Claim cannot be denied.
14. From the above discussion, it established that the claim of the complainant was repudiated by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties. Therefore, the present complaint is partly allowed against the opposite parties and the opposite parties are directed to pay Rs. Rs. 84,900/- alongwith interest @ 7% per annum from the date of filing the present complaint till its realization. The opposite parties are further directed to pay Rs. 5,000/- on the account of mental agony and harassment and Rs. 5,000/- on account of litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
5th Day of July, 2024
(Ashish Kumar Grover)
President
(Navdeep Kumar Garg)
Member
