Delhi

North

CC/13/2018

HARSH PAL SINGH - Complainant(s)

Versus

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

30 Nov 2024

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

Consumer Complaint No. 13/2018

In the matter of

Sh. Harsh Pal Singh   

R/o 2983, Aryapura

Sabzi  Mandi, Delhi-110007                                                                             ... Complainant

Versus

Star Health & Allied Insurance Co.

No.15, Sri Balaji Complex

Whites Lane, Ist Floor

Royapettah,Chennai-600014

Through its President

Also at :
Exchange Store Building

Second floor, 13, Alipur Road

Civil Lines, Delhi-110054                                                                                 …Opposite Party

ORDER
30/11/2024

Ms.Harpreet Kaur Charya, Member

Jurisdiction of this Commission has been invoked by Sh. Harsh Pal Singh, the Complainant against Star Health & Allied Insurance Co.Ltd. OP, with the allegations of deficiency in services and unfair trade practice.   

1. Briefly stated, facts as per the complaint are, on 21/03/2017, the complainant purchased a medical health insurance policy bearing No.P/161118/01/2017/017300 from OP for a period from 23/03/2017 to 22/03/2018.
2. The complainant had been regularly paying the premium for three years with the bonafide belief that he and his family members will be entitled to medical cashless policy in case of emergency.  The complainant visited various hospitals such as Aggarwal Hospital, Shakti Nagar, Max Hospital, Shalimar Bagh and Sant Parmanand Hospital with the complaint of pain in his left ear. 
3. After going through the test report, surgery was advised by Dr.Rajesh Mishra, Max Hospital, Shalimar Bagh, Delhi.  Cashless medi-claim for Rs. 40,000/- was approved by OP for surgery in Max Hospital,Shalimar Bagh, Delhi .It was also enhanced from Rs.40,000/- to Rs.1,00,000/- but due to personal problem of the complainant the surgery could not be performed in Max Hospital. 
4. On 19/06/2017, the complainant underwent surgery at Sant Parmanand Hospital, Delhi. Reimbursement claim vide claim intimation number CLI/2018/161118/0117600 was lodged with OP.
5. On 20/06/2017, the final bill of the surgery was sent to OP through hospital and same was rejected by OP stating that the complainant had undergone the ear surgery five years back also, prior to the inception of the medical insurance policy hence, it is against the policy terms and conditions. 
6. A repudiation letter dated 09/08/2017 was issued by OP stating that the complainant did not disclose the pre-existing disease of the said left year and mis-represented the health condition thus violating the terms and conditions.
7. The complainant has further stated that he and his family member were not aware of the left ear disease and it was only for the first time when the complainant felt pain in his left ear and visited the hospital where he was advised surgery thus there is no concealment on his part. 
8. The complainant has alleged that once the OP had sanctioned the cashless treatment there was no reason to reject the reimbursement.  The complainant was constrained to arrange funds for payment of his medical bills. The complainant was discharged on 21/06/2017  upon depositing of cheque bearing no.786803 drawn on Punjab National Bank  in the hospital.
9. The complainant has stated that prior to taking of the medical policy the complainant was never diagnosed with such disease and had never been hospitalized for the said ailment.  It was not in the knowledge of the complainant or his family that there is any ailment or pre-existing disease in the left ear prior to the purchase of medical policy.  It has been further alleged by the complainant that OP not only approved the cashless claim through Max Hospital, Shalimar Bagh but also enhanced the claim amount from Rs.40,000/- to 1,00,000/-
10. Despite written communication for the reimbursement of the claim neither the claim was settled nor the original documents were returned.  The complainant has further submitted that the executive of OP were fully satisfied with the medical tests at the time of issuance of policy and thereafter the policy was issued.  Thus, there is no breach or concealment. 
11. Rejection of the claim for reimbursement of Rs.87,316/- including consultation fees of Rs.1,100/-, chemist bills of Rs.1,772/-  and lab tests of Rs.5,630/- on the ground of pre-existing disease amounted to deficiency in services and unfair trade practice.
12. Legal notice dated 16/10/2017 was served upon OP seeking reimbursement of medical expenses, which was replied vide reply dated 28/10/2017.  Feeling aggrieved by the rejection of his claim for reimbursement the complainant has prayed for directions to OP to pay a sum of Rs.87,316/-; compensation of Rs.1,00,000/- on account of mental agony, torture and harassment and financial losses suffered by the complainant and as well as by  his father, a Senior citizen  and a heart patient and Rs.25,000/- as cost of litigation.
13. The complainant has annexed prescription of Max Super speciality Hospital , prescription of Sant Parmanand Hospital/Aggarwal Hospital, Medicine invoice (colly), receipts of test performed in hospital/labs, Test reports of labs, copy of policy No.P/16/118/01/2017/017300, letter to OP for medical claim reimbursement , various e-mails with OP, Authorisation letter  by OP for enhancement of amount, cancellation of Authorisation letter, form filled at Sant Parmanand Hospital for getting insurance claim , discharge summary from Sant Parmanand Hospital, Bill of Sant Parmanand Hospital, receipts of bill paid by complainant, discharge slip, Repudiation letter of insurance claim , Legal Notice dated 16/10/2017 and Reply of legal notice dated 28/10/2017.
14. Notice of the present complaint was served to OP.  Thereafter, written statement was filed  raising preliminary objections such as:the complainant has suppressed the material facts while obtaining the insurance policy by not declaring/disclosing actual state of affairs in respect of his health;  in the proposal Form the complainant answered negative about the  past diseases/ailments /treatments.  However, on admission in the hospital previous history of the disease was detected.
15. The insurance contract is a contract of utmost good faith; therefore by suppressing the information the complainant has breached the contract.  It has been submitted that the complainant was admitted at Max Super Speciality Hospital, Shalimar Bagh on 08/06/2017 for treatment of Mastoidectomy and pre-authorisation for request for cashless treatment was raised vide claim No.CLI/2018/161118/0107852  and the same was authorised for Rs.1,00,000/- vide letter dated 09/06/2017.  The complainant did not utilize the same, hence it was withdrawn. 
16. On 19/06/2017, the complainant got hospitalized at Sant Parmanand Hospital for treatment of left CSOM and again the pre-authorisation request for cashless treatment was raised but the this time it was denied vide letter date 20/06/2017 on the ground that the patient had a history of left ear surgery in past and also had history of depression and is on anti-depression medicines.
17. Claim for reimbursement was filed, upon scrutiny it was observed that as per discharge summary, the insured was admitted on 19/06/2017 on OPD basis and was diagnosed with Central Perforation with Mastoiditis.  The insured was admitted with the complaint of ear discharge with decreased hearing since 04 to 05 days and procedure done was Tympanoplasty with Mastoidectomy. The pre-anaesthetic record shows that the complainant had history of operation done for left ear but at the time of cashless it was submitted that he had no history of ear surgery.  Even as per the field visit report of doctor appointed by OP, which was also signed by the complainant stated that he had undergone left ear surgery five years ago. Thus, it can be concluded that the complainant did not disclose about surgery undergone five years back and it is a case of re-occurrence of pre-existing condition.
18. As per Exclusion no.1 of the policy terms &conditions, the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease/condition, until 48 months of continuous coverage has elapsed. In the present case the date of commencement of policy is 23/03/2015 and the hospitalization pertains to year 2017.  The pre-existing disease was not declared in proposal form.
19. It has been further submitted that upon receipt of legal notice sent by the complainant, the claim was once again reviewed and replied vide letter dated 28/10/2017. 
20. OP has annexed the proposal form dated 23/03/2015; pre-authorisation request form raised by Sant Parmanand Hospital; query letter for enhancement authorisation by Sant Parmanand Hospital dated 20/06/2017; letter dated 20/06/2017 written by the complainant to the Medical Officer-Claims of OP, pre-anaesthetic record of the complainant;  Claim Form for reimbursement dated 26/06/2017; discharge summary, final bill of Rs.78,814/- of Sant Parmanand Hospital ; rejection of the authorisation for cashless treatment dated 20/06/2017 has been annexed with the written statement. 
21. Evidence by way of affidavit was filed by both the parties.  Complainant has got exhibited the copy of premium receipt as Ex.CW-1/1(colly), copies of prescription/medicine/invoices as Ex.CW-1/2 (colly), copy of final bill raised by Sant Parmanand Hospital as Ex.CW-1/3, copy of form filled at Sant Parmanand Hospital for Insurance claim as Ex.CW-1/4, copy of reimbursement letter for medical claim as Ec.CW-1/5, copy of medical health policy as Ex.CW-1/6, approval letter from Max Hospital for surgery as Ex.CW-1/7, Authorisation letter as Ex.CW-1/8, copy of discharge summary as Ex.CW-1/9 (colly), copy of bill receipts  as Ex.CW-1/10, copy of enhanced amount of cashless treatment as Ex.CW-1/11, copies of emails as Ex.CW-1/12(colly), copy of bills as Ex.CW-1/13(colly), copy of Repudiation letter as Ex.CW-1/14, copy of claim form and bills as Ex.CW-1/15 (colly), copy of the legal notice as Ex.CW-1/16, copy of reply of legal  notice as Ex.CW-1/17, copy of proposal form as Ex.CW-1/18 , copies of emails as Ex.CW-1/19(colly), 
22. Sh.N.Gopalan, Chief Manager of OP has been examined on their behalf.  He has repeated the contents of the written statement. 
23. We have heard the arguments of Ld. Counsel for the parties and have perused the material placed on record.  We have also gone through the written submission filed by the parties.  The issuance of policy and sanction of cashless treatment in Max Hospital, Shalimar Bagh, Delhi is not disputed.
24. The complainant is aggrieved by the Repudiation of his claim for reimbursement vide letter dated 09/08/2017 (Ex.CW-1/14). The claim is repudiated stating :

“It is observed from the pre-anaesthetic record of the above hospital (Sant Parmanand Hospital), the insured patient has history of operation done for left ear; as per field visit report of their doctor which is also signed by the insured patient that the insured patient has undergone left ear surgery 5 years back which is prior to inception of the medical insurance.  Hence, it is a pre-existing condition. The present admission and treatment of the insured patient is for the recurrence of the above pre-existing condition.

As per Exclusion no.1 of the policy issued to you, the Company not liable to make any payment in respect of treatment of the pre-existing disease/condition, until 48 months of continuous coverage has elapsed, since inception of the policy i.e.,23.03.2015.”

25. Though OP in their written statement have also stated that the pre-anaesthetic record bears “H/o depression & on treatment andⓁ ear and LA” and even the field visit dated 19/06/2017, it is handwritten “h/o depression on –RxC duration not mentioned; h/o –ear Sx-5years ago at Hindu Rao Hospital (documents not provided   at the time of visit)”.
26. Hon’ble Apex court in Galada Power and Telecommunication Ltd. Vs. United India Insurance Co. Ltd. and another Etc. VII (2016) SLT 428 held: Insurance Company cannot travel beyond the grounds mentioned in the letter of repudiation. Thus, the defence that the complainant had history of depression and was on anti-depressants cannot be considered, which is not mentioned in the repudiation letter.
27. Confining ourselves to the ground of repudiation as per letter dated 09/08/2017, OP has rejected the claim stating it to be Pre-existing condition/disease. The complainant has denied the same and in support he has filed the OPD prescription dated 10/06/2017 bears “case of ear discharge” and has been advised prescription dated 31/05/2017 of Aggarwal Dharmarth Hospital, Shakti Nagar bears “CSOM LE c̅” which means Chronic Suppurative Otitis Media of left ear. In prescription dated 02/06/2017(EX.CW-1/2(colly), by Dr. Rajesh Mishra, Max Hospital, Shalimar Bagh, Delhi, stating “case of decreased hearing & discharge for 10 days”.  Similarly,
28. Even as per the X-ray report dated 02/06/2017 bears “Few mastoid air cells are opacified at left mastoid region”.   It is admitted case of OP that cashless treatment in Max Hospital, Shalimar Bagh was authorised and subsequently enhanced to Rs.1,00,000/- vide letter dated 09/06/2017. 
29. As per Discharge summary dated 20/06/2017, Ex.CW-1/9 (colly), the complainant was diagnosed with “(L) Central Perforation with Mastoiditis” and the operation performed was “(L) Tympanoplasty with Mastoidectomy done under GA on 19/06/2017 for the chief complaint of (L) Ear Discharge with decreased hearing x 4-5 days”.  Further under the head: History it is mentioned “Patient was admitted with the above-mentioned complain.  No history of Cough, Cold, Fever, Breathlessness, Chest Pain, Vomiting.  Not known case of Diabetes, Mellitus. No past history of Tuberculosis, Bronchial Asthma, CAD, COPD, or any known drug allergy.  No other significant/relevant history”.
30. OP has placed nothing on record in support of their decision to reject the bonafide claim of the complainant. When OP has relied on the pre-anaesthetic record and Field visit report where it has been stated that the complainant had undergone surgery five years ago for left ear at Hindu Rao Hospital, the same could have been verified by OP from Hindu Rao hospital, which has not been done in the present case. In the pre- anaesthetic record also the details as to when the complainant had previous operation are missing. It is settled principle of law that the burden to prove is on the person who alleges.  In the present case the onus was on OP to prove their allegations which they have failed to discharge. 
31. On the other hand, as per the discharge summary the complainant was not suffering from any PED.  The complainant has successfully proved by placing on record the above exhibits that there was neither any concealment nor any pre-existing disease as claimed by OP.   In absence of any documentary evidence the rejection of the claim is arbitrary and on baseless ground.  This act of OP amounts to deficiency in services and unfair trade practice.
32. Hon’ble Supreme Court in the matter of  P. Vankat Naidu Versus Life Insurance Corporation Of India & Anr IV (2011) CPJ 6 (SC) has observed that:-

“7. Since the respondents had come out with the case that the deceased did not disclose correct facts relating to his illness, it was for them to produce cogent evidence to prove the allegation. However, as found by the District Forum and the State Commission, the respondents did not produce any tangible evidence to prove that the deceased had withheld information about his hospitalization and treatment. Therefore, the National Commission was not justified in interfering with the concurrent finding recorded by the District Forum and the State Commission by making a wild guesswork that the deceased had suppressed the facts relating to his illness.”

33. In LIC India v. Smt. G.M. Channabasamma, I (1991) ACC 411 (SC)=(1991) 1 SCC 357, it was held that the onus to establish fraud or fraudulent suppression/,misrepresentation of material facts lay with the appellant which it had failed to discharged.
34. Hon’ble NCDRC in Trilok Chand Khanna vs United India Insurance Co. Ltd ;RP-686/2007 decided on 16/08/2001 held as under :-

In fact, the onus to prove that she had pre-existing disease on the respondent who failed to file any expert medical or credible evidence in support of is case.  Further,  the deceased had been taken mediclaim insurance policy form the respondent right from 1996 and she had also as per the practice, been examined by the doctor of the respondent/insurance company who has nowhere recorded that she had any medical problem relating to the knees.

 

35. In the matter of Sunil Sharma V. National Insurance Company Ltd [II(2015)CPJ46(Del)], Hon’ble Delhi State Commission has observed that Insurance Companies should  be honest & forthright in its approach while settling an insurance claim, factors which are material and germane should be given importance. Insurance claims cannot be rejected on flimsy and technical grounds otherwise confidence of people in insurance companies would be deeply eroded.
36. The IRDA, vide Circular No. IRDA/HLTH/MISC/CIR/216/09/2011 dated 20.09.2011, has also stated that “the insurers' decision to reject a claim shall be based on sound logic and valid grounds.
37. In the light of the above judgments, we observe that in para 15 of the complaint, it has been alleged by the complainant that the policy was issued after the medical check up.  There is no specific denial to the corresponding averment in the written statement of OP, hence, it is deemed to be admitted. Once, the OP has issued a policy where the insured was subjected to medical examination, it implies that the insurer was convinced with the medical condition of the insured/complainant.  At the stage of claim they cannot raise the plea of pre-existing disease.    
38. Thus, from the above discussion, we hold that OP has failed to prove that the treatment undertaken by the complainant was a pre-existing disease. That being so the repudiation dated 09/08/2017 was without any basis or documentary evidence.  Therefore, in the facts and circumstances of the present complaint and in the interest of justice OP is directed to :-

1. Reimburse Rs.87,316/-paid by the complainant for the treatment taken at Sant Parmanand Hospital.
2. Pay compensation of Rs.30,000/- on account of mental agony and harassment.
3. We also award litigation expenses of Rs.15,000/-  

39. The order be complied within a period of 30 days from the date of receipt of this order.  In case of non-compliance, the complainant shall be entitled to interest @7% p.a. on (a)+(b)+(c) from the date of order till realization.

Office is directed to supply the copy of this order to the parties as per rules. Order be also uploaded on the website.  Thereafter, file be consigned to the record room.

 

(Harpreet Kaur Charya) Member

(Ashwani Kumar Mehta)                                Member

(Divya Jyoti Jaipuriar)

President