Chandigarh

DF-I

CC/880/2022

DARSHAN SINGH SETHI - Complainant(s)

Versus

STAR HEALTH & ALLIED INSURANCE CO. LTD. - Opp.Party(s)

PAWAN KUMAR

02 Nov 2023

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/880/2022
Date of Institution	:	18/10/2022
Date of Decision	:	02/11/2023

 

Darshan Singh Sethi son of Shri Attar Singh, aged about 72 years, resident of House No.3467, Sector 38-D, Chandigarh.

… Complainant

V E R S U S

1. Star Health & Allied Insurance Co. Ltd., Sri Balaji Complex, 15, Whites Road, Chenai-600014 through its General Manager/Authorised Signatory.
2. Star Health & Allied Insurance Co. Ltd., SCO 5A, 2^nd Floor, Madhya Marg, Sector 7C, Chandigarh through its Regional Manager. 

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	SHRI SURESH KUMAR SARDANA	MEMBER

                                                                               

ARGUED BY	:	Ms. Gurpinder Kaur, Advocate Proxy for Sh. Pawan Kumar, Advocate for complainant
	:	Sh. Inderjit Singh, Advocate for OPs

 

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Darshan Singh Sethi, complainant against the aforesaid opposite parties (hereinafter referred to as the OPs).  The brief facts of the case are as under :-

1. It transpires from the allegations as projected in the consumer complaint that on 24.11.2020, complainant had purchased a health insurance policy namely “Senior Citizens Red Carpet Health Insurance Policy” (hereinafter referred to as “subject policy”) from the OPs which was valid w.e.f. 24.11.2020 to 23.11.2021. Thereafter, the subject policy (Annexure C-2) was got renewed by the complainant w.e.f. 24.11.2021 to 23.11.2022 (Annexure C-3).  On 26.6.2022, the complainant suddenly suffered severe stomach pain and vomiting due to which he was admitted at Santokh Nursing Home, Sector 38A, Chandigarh (hereinafter referred to as “treating hospital”) w.e.f. 26.6.2022 to 29.6.2022 for the cashless treatment.  The complainant was diagnosed with Irritable Bowel Syndrome (IBS) and acute gastritis.  The treating hospital had requested the OPs for the cashless approval, but, the same was rejected by the OPs vide letter dated 28.6.2022 (Annexure C-4 colly.). Thereafter the complainant regularly approached the OPs for reimbursement of his medical claim, but, the same was repudiated by the OPs vide email dated 19.7.2022 (Annexure C-7) on the ground that the complainant had not furnished the requisite documents and details as asked by the OPs, despite of the fact that all the requisite documents were submitted by the complainant to the OPs.  It is further alleged that the genuine claim of the complainant was repudiated by the OPs on flimsy grounds and the said act amounts to deficiency in service and unfair trade practice on their part. OPs were requested several times to admit the claim, but, with no result. Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, concealment of facts and that the consumer complaint is premature.  However, it is admitted that the subject policy was purchased by the complainant from the OPs which was subsequently renewed w.e.f. 24.11.2021 to 23.11.2022.  It is further alleged that the request for cashless approval was received, but, the same was refused, as the requisite documents were not submitted by the complainant.  It is further alleged that the claim was enquired and as per the field verification of the OPs, insured had HTN for two years, Hypothyroidism for five months and chronic kidney disease (CKD) regarding which he was asked to submit record of all his previous treatment, but, as he failed to furnish the said record to the OPs, the claim of the complainant was rightly repudiated by the OPs. However, it is alleged that the maximum quantum of liability under the terms of the policy shall be ₹17,971/- after applying 30% co-pay. On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainant re-asserted the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully, including the written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had purchased the subject policy from the OPs which was valid w.e.f. 24.11.2020 to 23.11.2021 and subsequently renewed from 24.11.2021 to 23.11.2022, as is also evident from Annexure C-2 and C-3, and further that during the subsistence of the subject policy, complainant remained admitted at the treating hospital w.e.f. 26.6.2022 to 29.6.2022, as is also evident from the discharge summary (Annexure R-10) where he was diagnosed with “IBS Acute gastritis” and also that the claim of the complainant was not processed by the OPs on the ground that the complainant has not submitted documents pertaining to his previous treatment/pre-existing disease, the case is reduced to a narrow compass as it is to be determined if the OPs are unjustified in repudiating the genuine claim of the complainant and the complainant is entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainant, or if the OPs are justified in repudiating the claim of the complainant and the instant consumer complaint is liable to be dismissed, as is the defence of the OPs. 
   2. In the backdrop of the foregoing admitted and disputed facts on record, one thing is clear that the entire case of the parties is revolving around the terms and conditions of the subject policy, medical record and the repudiation letter, and the same are required to be scanned carefully.
   3. Annexure R-3 is the subject policy containing the terms and conditions for dealing with the claims pertaining to pre-existing diseases and the relevant portion of the same is reproduced as under :-

        “Pre-Existing Disease means any condition, ailment, injury or disease ;

i.      That is/are diagnosed by a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement

                or

ii      For which medical advice or treatment was recommended by, or received from, a physician within 48 months prior to the effective date of the policy issued by the insurer or its reinstatement.”

4. Annexure R-6 is the prescription slip on which the medical officer has specifically mentioned that the patient was having previous history of HT/SCH/ Prediabetes/CKD.  Annexure R-10 is the discharge summary which clearly indicates that the complainant was diagnosed with IBS Acute gastritis with past history of K/C/O Hypothyroidism since 5 months, CKD (recently diagnosed) and hypertension since two years and the relevant portion of the same is reproduced as under :-

        “DIAGNOSIS       IBS

                                Acute gastritis

PAST HISTORY    K/C/O HYPOTHYROIDISM SINCE 5 MONTHS

                                K/C/O CKD (RECENTLY DIAGNOSED)

                                ON TAB THYRONORM 37.5 MCG ONCE A DAY

                                K/C/O HYPERTENSION SINCE 2 YEARS ON TAB OLMICIP AM 25 MG ONCE A DAY

                                TAB STARPRESS XL 50”

5. Annexure R-16 is repudiation letter dated 23.9.2022 vide which the claim of the complainant was rejected and the relevant portion of the same is reproduced as under:-

“We acknowledge receipt of medical records, in response to our letter dated 19.07.2022, seeking re-consideration of your claim.

Our medical team has perused the representation and has noted the contents.  The team which re-examined the claim records has observed from the despite of our request the insured has not submitted the exact duration of chronic kidney disease and IBS complaints, previous consultation papers and investigation reports. In the absence of the above documents/ details, we are not able to further process your claim.

As per Condition No.2 of the above policy, the insured person has to submit all the required document and details called for by us.

We are therefore unable to consider your representation favorably and we inform you that repudiation of your claim is in order.”

 

6. Close scrutiny of the aforesaid evidence led by the parties clearly indicates that the OPs have wrongly repudiated the genuine claim of the complainant after receiving all the relevant documents from the complainant as it has come on record that the complainant suffered from Hypothyroidism (since 5 months) and CKD (recently diagnosed) i.e. after the purchase of the subject policy and the same cannot be termed as pre-existing diseases.
7. So far as the defence of the OPs that the complainant was suffering from hypertension since two years before his admission i.e. prior to the purchase of the subject policy is concerned, it has been held by the Hon’ble State Commission, Delhi, in the case titled S.S. Jaspal Vs. National Insurance Co. Ltd. & Ors., IV (2022) CPJ 26 (Del.) that common lifestyle disease like diabetes and hypertension, cannot be treated as pre existing diseases and cannot be a ground of repudiation of claim by Insurance companies. The relevant portion of the order is reproduced as under :-

 “Consumer Protection Act, 1986 - Sections 2(1)(g), 14(1)(d), 15 - Insurance (Mediclaim) -Angioplasty and Stenting - Suppression of pre-existing disease alleged - Repudiation of claim Deficiency in service - District Forum dismissed Complaint - Hence Appeal - Complainant experienced pain in chest and remained admitted in Hospital from 24.6.2004 to 30.6.2004, where he had undergone Angioplasty and Stenting, by incurring Rs.3,20,126 on treatment - Previous medical history is based upon information provided by family of patient - Respondents failed to show any evidence regarding pre-existing disease suffered by insured at time of getting policy - Common lifestyle disease like diabetes and hypertension, cannot be treated as pre existing diseases and cannot be a ground of repudiation of claim by Insurance companies - Respondents failed to show any evidence that any medical tests or examination was done, before issuing said policy in question - Respondents are directed to pay a sum of Rs.3,20,126 (Cost of Medical Expenses) to Appellant along with interest @ 6% p.a.”

8. Similarly, the Hon’ble National Commission in the case titled Sunil Kumar Sharma v. Tata AIG Life Insurance Company and Ors., Revision Petition No.3557 of 2013 decided on 1.3.2021, while dealing with the issue of pre-existing disease, has held as under:-

“14.   Moreover the claim had been repudiated only on the ground that the insured was suffering from diabetes for a long time. So far as life style diseases like diabetes and high blood pressure are concerned, Hon'ble High Court of Delhi in Hari Om Agarwal Vs. Oriental Insurance Co. Ltd., W.P.(C) No.656 of 2007, decided on 17.09.2007 held as under:

"Insurance – Mediclaim -Reimbursement-Present Petition filed for appropriate directions to respondent to reimburse
expenses incurred by him for his medical treatment, in accordance with policy of insurance - Held, there is no dispute that diabetes was a condition at time of submission of proposal, so was hyper tension - Petitioner was advised to undergo ECG, which he did - Insurer accepted proposal and issued cover note. It is universally known that hypertension and diabetes can lead to a host of ailments, such as stroke, cardiac disease, renal failure, liver complications depending upon varied factors. That implies that there is probability of such ailments, equally they can arise in non-diabetics or those without hypertension. It would be apparent that giving a textual effect to Clause 4.1 of policy would in most such cases render mediclaim cover meaningless. Policy would be reduced to a contract with no content, in event of happening of contingency. Therefore Clause 4.1 of policy cannot be allowed to override insurer's primary liability. Main purpose rule would have to be pressed into service. Insurer renewed policy after petitioner underwent CABG procedure. Therefore refusal by insurer to process and reimburse petitioner's claim is arbitrary and unreasonable. As a state agency, it has to set standards of model behaviour; its attitude here has displayed a contrary tendency. Therefore direction issued to respondent to process petitioner's claim, and ensure that he is reimbursed for procedure undergone by him according to claim lodged with it, within six weeks and petition allowed."

9. Moreover, when it has come on record that whatever ailment from which the complainant was suffering prior to the purchase of the subject policy i.e. Hypothyroidism since 5 months, CKD (recently diagnosed) and hypertension since two years has no connection with the disease with which the complainant was diagnosed by the treating hospital i.e. IBS and acute gastritis and remained admitted w.e.f. 26.6.2022 to 29.6.2202 in the treating hospital and also for which he was treated, hence the act of the OPs in repudiating the claim of the complainant certainly amounts to deficiency in service and unfair trade practice. Here we are strengthened by the order passed by the Hon’ble National Commission in Neelam Chopra Vs. Life Insurance Corporation of India & Ors., IV (2018) CPJ 321 (NC) and the operative part of the same reads as under :-

                12. In the present case, clearly the cause of death is cardio respiratory arrest and this disease was not existing when the proposal form was filled. Clearly, there is no suppression of material information in respect of this disease, which is the main cause of death. The other disease of LL Hansen, which was prevailing for five weeks on the date of admission on 1.8.2003 was also not existing when the proposal was filed by the DLA. The fact of DLA having been treated in the year 2002 for LL Hansen is not supported from any direct evidence though PGI Chandigarh in its certificate has mentioned that disease was treated in 2002. Moreover, this disease does not have any correlation with the cause of death in the present case. Hon’ble Supreme Court in Sulbha Prakash Motegaonkar and Ors. v. Life Insurance Corporation of India, Civil Appeal No.8245 of 2015, decided on 5.10.2015 (SC) has held the following:

        “We have heard learned Counsel for the parties.

                It is not the case of the Insurance Company that the ailment that the deceased was suffering from was a life threatening disease which could or did cause the death of the insured. In fact, the clear case is that the deceased died due to ischaemic heart disease and also because of myocardial infarction. The concealment of lumbar spondylitis with PID with sciatica persuaded the respondent not to grant the insurance claim.

                We are of the opinion that National Commission was in error in denying to the appellants the insurance claim and accepting the repudiation of the claim by the respondent. The death of the insured due to ischaemic heart disease and myocardial infarction had nothing to do with this lumbar spondylitis with PID with sciatica. In our considered opinion, since the alleged concealment was not of such a nature as would disentitle the deceased from getting his life insured, the repudiation of the claim was incorrect and not justified.”

10. In view of the foregoing discussion and the ratio of law laid down above, it is clear that the OPs have not been able to connect the previous diseases/ ailments with the present diseases/ailments, for which he had taken treatment from the treating hospital.  Hence, it is unsafe to hold that the OPs were justified in repudiating the claim of the complainant and the present consumer complaint deserves to succeed. 
11. Now coming to the quantum of relief to be awarded to the complainant, since the complainant has proved the claim form/bills (Annexure C-5) amounting to ₹33,485/-, it is safe to hold that OPs are liable to pay the said amount to the complainant alongwith interest and compensation etc. for the harassment suffered by him.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹33,485/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim i.e. 23.9.2022 onwards.
2. to pay an amount of ₹15,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs within forty five days from the date of receipt of its certified copy, failing which, the payable amounts, mentioned at Sr.No.(i) & (ii) above, shall carry interest @ 12% per annum from the date of this order, till realization, apart from compliance of direction at Sr.No.(iii) above.
6. Pending miscellaneous application(s), if any, also stands disposed of accordingly.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 02/11/2023 hg		Sd/- [Pawanjit Singh] President
		Sd/- [Suresh Kumar Sardana] Member