Chandigarh

DF-I

CC/489/2023

ANIL KHURANA - Complainant(s)

Versus

STAR HEALTH & ALLIED INSURANCE COMPANY LIMITED - Opp.Party(s)

SUDHIR GUPTA

01 Jul 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                               

Consumer Complaint No.	:	CC/489/2023
Date of Institution	:	05/10/2023
Date of Decision	:	01/07/2024

 

1. Anil Khurana, aged 52 years son of Sh. Harbans Lal Khurana.
2. Mrs. Ashu Khurana, aged about 49 years wife of Sh. Anil Khurana.

Both residents of House No.57, Sector 15, Panchkula 134113 (Haryana).

… Complainants

V E R S U S

1. Star Health & Allied Insurance Company Limited, SCO No.5-A, 2^nd Floor, Madhya Marg, Sector 7-C, Chandigarh 160019, through its Branch Manager.
2. Star Health & Allied Insurance Company Limited, registered & corporate office, #1 New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034 (Tamil Nadu) through its Managing Director.

… Opposite Parties

 

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

                                                                               

ARGUED BY	:	Sh. Devinder Kumar, Advocate, Proxy for Sh. Sudhir Gupta, Advocate for complainants
	:	Ms. Surabhi Grover, Advocate for OPs

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by Anil Khurana & Mrs. Ashu Khurana, complainants 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, in the year 2019, complainants had taken a health mediclaim insurance policy from the OPs and got the same renewed annually without any break. Before the issuance of the aforesaid policy, agents of OP-1 got the proposal form signed as the same was in small letters and not legible.  It was also informed by the agent/advisor of the OPs that all the benefits would be provided to the complainants from day one.  On being satisfied, OPs issued the insurance policy namely “Family Health Optima Insurance Plan” valid w.e.f. 4.10.2019 to 3.10.2020 (Annexure C-1) in the name of complainant No.1 covering the risk for a sum of ₹5.00 lacs per person per year with allied benefits.  Thereafter the complainants got the said policy renewed annually w.e.f. 4.10.2020 to 3.10.2021 (Annexure C-2), 4.10.2021 to 3.10.2022 (Annexure C-3) and finally the subject policy from 4.10.2022 to 3.10.2023 (Annexure C-4). 

In the month of November 2022, complainant No.2 faced some health problem relating to continuous bleeding and she visited the Chakravarty Nursing Home, Sector 10, Panchkula on 28.11.2022 for consultation with a gynecologist.  The treating doctor advised her some medicines alongwith rest and was again asked to visit on 7.12.2022. Thereafter the complainants visited the said hospital on 7.12.2022 and 9.12.2022 with reports (Annexure C-5 to C-7), but, the said problem of bleeding continued, as a result of which the complainants visited the Fortis Hospital, Mohali (hereinafter referred to as “treating hospital”) on 12.12.2022, where various tests were also conducted and copies of prescriptions and test reports are Annexure C-8 (Colly.).  Later on, complainant No.2 was advised to undergo D&C, which is a procedure in which cervix lower narrow part of the uterus is dilated to remove abnormal tissues which led to bleeding and the same is not at all a disease. For that procedure, complainant No.2 was admitted at the treating hospital on 23.12.2022 and was discharged on the same day and copy of admission and discharge summary is Annexure C-9 (Colly.). For this treatment, complainants had spent total amount of ₹72,050/-, including tests, medical procedure, medicine and accordingly the agents of the OPs namely Amit Sachdeva & Sandeep were informed and all the documents i.e. bills and receipts (Annexure C-12 Colly.) for reimbursement of the claim were also submitted to the OPs, which were acknowledged vide Annexure C-11.  On 24.12.2022 (Annexure C-13) complainants received an endorsement schedule from the OPs in which they declared that the case of complainant No.2 fell under the head of pre-existing disease and later on the OPs repudiated the claim of the complainants vide letter dated 14.1.2023 (Annexure C-14).  In this manner, the act of the OPs in illegally and wrongly repudiating the genuine claim of the complainants amounts to deficiency in service and unfair trade practice. 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, cause of action and jurisdiction.  However, it is admitted that the subject policy was purchased by the complainants in the year 2019 and the same was got continuously renewed from time to time.  It is alleged that, in fact, the complainants have suppressed material facts qua the pre-existing disease from which complainant No.2 was suffering and was taking treatment even prior to the purchase of the first policy from the OPs and since the pre-existing disease falls under the exclusion clause of the policy, the provisional cashless approval of ₹18,000/-, which was initially given for treatment of complainant No.2, was rejected later on.  It is further alleged that when certain clarifications were sought from the complainants through documents, it was informed by them about the Dilation and Cutterage surgical procedure undergone in 2014, which made it clear that complainant No.2 was suffering from pre-existing disease. As the complainants have purchased the subject policy in the year 2019 and complainant No.2 had taken treatment for the said disease in the year 2022 i.e. within 48 months from the date of commencement of the first policy, the claim of the complainants falls under the exclusion clause and was rightly repudiated.  On merits, the facts as stated in the preliminary objections have been reiterated. The cause of action set up by the complainants is denied.  The consumer complaint is sought to be contested.
3. In rejoinder, complainants 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 written arguments.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainants had purchased the first policy from the OPs in the year 2019, as is also evident from Annexure C-1, which was valid w.e.f. 4.10.2019 to 3.10.2022 and the same was continuously renewed annually from the OPs till the subject policy (Annexure C-4) w.e.f. 4.10.2022 to 3.10.2023 and the complainant No.2 had taken D&C procedure in the year 2022 firstly from the Chakravarty Nursing Home and thereafter from the Treating Hospital, as is also evident from the medical record (Annexure C-5 to C-9 colly.) and for the entire treatment complainants had spent an amount of ₹72,050/- as is also evident from the medical bills/receipts (Annexure C-12 colly.) and the claim of the complainants was repudiated by the OPs on the ground of suppression of material facts qua the pre-existing disease, the case is reduced to a narrow compass as it is to be determined if OPs are unjustified in repudiating the genuine claim of the complainants and the complainants are entitled to the reliefs prayed for in the consumer complaint, as is the case of the complainants, or if the OPs have rightly repudiated the claim of the complainants and the consumer complaint of the complainants, being false and frivolous, 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 subject policy as well as its terms and conditions, medical record and repudiation letter and the same are required to be scanned carefully for determining the real controversy between the parties.
   3. As it is the defence of the OPs that complainant No.2 was suffering from pre-existing disease for which she had taken treatment even prior to the commencement of the policy (Annexure C-1), it is to be seen if complainant No.2 was suffering from pre-existing disease and complainants are not entitled for the claim as prayed for. 
   4. Perusal of the subject policy (Annexure C-4) clearly indicates that the same was valid w.e.f. 4.10.2022 to 3.10.2023 with basic floater sum assured of ₹5.00 lacs covering the complainants and their daughter.  Perusal of the customer information sheet (Ex.OP-3) defines the pre-existing disease and the relevant portion of the same is reproduced as under :-

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

1. 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

b) 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.”

 

5. Annexure C-14 is copy of letter through which claim of complainants was repudiated by the OPs on account of non-disclosure of pre existing disease. The relevant portion of the said letter is reproduced below for ready reference :-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of ABNORMAL UTERINE BLEEDING.

It is observed from the medical records that the insured patient has the above disease which is prior to inception of the first medical insurance policy. Hence it is a pre-existing disease. The present admission and treatment of the insured patient is for the pre existing disease.

As per Exclusion - Pre-existing disease - Code Excl-01 of the policy issued to you, the Company is liable to make payment for any pre-existing disease only after the expiry of 48 months from 23.12.2022.

We are therefore unable to settle your claim under the above policy and we hereby repudiate your claim.”

 

6. As per the defence of OPs, complainant No.2 had taken treatment for the same disease in the year 2014, as is also evident from Ex.OP-6 (Pg.69) which indicates that complainant No.2 was suffering from bleeding problem in the said year.  However, nothing has come on record if complainant No.2 had ever suffered from the said disease in between 2014 to 2019 when the said policy commenced for the first time. As it stands proved on record that complainant No.2 had taken treatment for the said disease on 28.1.2014 and the first policy purchased by the complainants from the OPs had commenced w.e.f. 4.10.2019 i.e. much prior to the stipulated period of 48 months, it is clear that the treatment taken by complainant No.2 in the year 2014 is not a pre-existing disease as it was more than 48 months prior to the commencement of the policy. Hence, it is safe to hold that the denial of claim of the complainants by the OPs on the ground of non-disclosure of material facts qua pre-existing disease is not only against the terms & conditions of the subject policy but also illegal and arbitrary.
7. Moreover, it has come on record that at that time no D&C procedure was conducted which was first time conducted in the year 2022, hence it is safe to hold that the complainant No.2 has not suffered from the said disease in the year 2022 from which she had earlier suffered in the year 2014.
8. Here we are fortified by the order passed by the Hon’ble Delhi State Commission in Oriental Insurance Co. Ltd. & Ors. Vs. Hans Raj Khurana, Appeal No.162 of 2004 in which it was held as under:-

        “Consumer Protection Act, 1986 Sections 2 and 14 Medical Insurance Claim - Medical claim was rejected by appellant/company on ground of ‘non-disclosure' of pre-existing disease - Surgery of gall bladder stones - At time of taking policy in question, there was no pre- existing disease since earlier operation was done seven years back - Failure to produce papers of previous illness - Held - If, same problem developed after seven years it cannot assume a character of pre-existing disease or non-disclosure of pre-existing disease - Facts and circumstances considered - Insurance company directed to pay Rs.45,007/- towards medical expenses and Rs.15,000/- towards mental agony and harassment - Appeal partly allowed.”

 

9. Further in the order dated 22.3.2018 passed by our own Hon’ble State Commission in Manish Goyal Vs. Max Bupa Health Insurance Company Limited, it was held as under :-

B. Consumer Protection Act, 1986 Section 2(1)(g) Insurance claim - Rejected on ground that insured not disclosed the pre-existing disease and doctor recorded the past history of illness - Age of insured was more than 45 years at the time policy issued - No medical examination got conducted by Insurance Company - Held, if the opposite parties themselves, failed to adhere the instructions issued by Insurance Regulatory and Development Authority of India (IRDAI), by putting the insured to thorough medical examination, being her age more than 45 years, and were interested in collecting premium from the complainant, as such, now at this stage, they cannot evade their liability - Complaint partly allowed.”

10. In view of the foregoing discussion and the ratio of law laid down above, it is unsafe to hold that OPs/insurers were justified in repudiating the claim of the complainants qua the subject policy and the present consumer complaint deserves to succeed. 
11. Now coming to the quantum of amount, since the complainants have proved the bills/receipts (Annexure C-12 colly.) amounting to ₹72,050/-, it is safe to hold that the OPs/insurers are liable to pay the said amount to complainants alongwith interest and compensation etc.

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 ₹72,050/- to the complainants alongwith interest @ 9% per annum (simple) from the date of repudiation of the claim i.e. 14.1.2023 onwards.
2. to pay ₹20,000/- to the complainants as compensation for causing mental agony and harassment;
3. to pay ₹10,000/- to the complainants as costs of litigation.

5. This order be complied with by the OPs, jointly and severally, within a period of 45 days from the date of receipt of certified copy thereof, failing which the amounts mentioned at Sr.No.(i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
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.

01/07/2024 hg	Sd/- [Pawanjit Singh] President
	Sd/- [Surjeet Kaur] Member