Haryana

Karnal

CC/403/2019

Neeraj Malhotra - Complainant(s)

Versus

Star Health & Allied Insurance Company Limited - Opp.Party(s)

Dheeraj Sachdeva

21 Jan 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                          Complaint No. 403 of 2019

                                                          Date of instt.10.07.2019

                                                          Date of Decision 21.01.2021

 

Neeraj Malhotra son of Shri Subhash Chand Malhotra resident of House no.1481, Sector-7, Urban Estate Karnal.

                                                                        ……Complainant.

 

                                              Versus

 

1. Star Health and allied insurance company Ltd. SCO 242, First floor, Sector-12, opposite Mini Secretariat, Karnal through its Branch Manager/authorized Person. Also at-SCF 137, Sector-13, near ICICI Bank, Urban Estate, Karnal.

2. Star Health and Allied Insurance Company Ltd. having its Registered & Corporate office at-1, New Tank Street Valluver, Kottam High Road, Nugambakkam, Chennai-600034, Ph-044-28302700/28288800.

 

                                                                        …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act, 1986.  

 

Before    Sh. Jaswant Singh……President.      

      Sh.Vineet Kaushik ………..Member

              Dr. Rekha Chaudhary…….Member

 

 Present:  Shri Dheeraj Sachdeva Advocate for complainant.

                 Shri Naveen Kheterpal Advocate for opposite parties.

                                        

                (Jaswant Singh President)

ORDER:                    

 

                        This complaint has been filed by the complainant u/s 12 of the Consumer Protection Act 1986, on the averments that complainant purchased a health insurance policy from opposite parties (hereinafter referred as to OPs), vide first policy no.P/211114/01/2018/, 25.07.2017 to 25.07.2018. The said policy has been renewed for the second year on 25.07.2018,vide policy no.P/211114/01/2019/003241, valid from 25.07.2018 to 25.07.2019. On 13.03.2019, in the morning complainant got acute pain in abdominal/stomach. Initially, complainant met with doctor at Karnal but till evening, there was no relief in the stomach pain and as the pain was unbearable and was not in control, he rushed to Fortis Hospital Mohali where Doctor Mohinish Chhabra attended complainant. After checkup and after conducting all required tests, doctor found that complainant is suffering from a disease of Cholelithiasis i.e. stone in the stomach and suggested for treatment and complainant got admitted in the Fortis Hospital as per advice of doctor on same day. After that, treatment was started by the doctors, but there another problem occurred and complainant was suffered from high fever problem. The doctor at hospital after all checkup and tests found that complainant is now suffered with acute infection. The doctors suggested to remained admitted as indoor patient for ailment of acute infection and treatment was given by the doctors and as per advice of doctors, complainant remained admitted in that hospital at Mohali from 13.03.2019 to 24.03.2019. At the time of admission, complainant informed the OPs for cashless treatment because the abovesaid policy was cashless policy, but same was rejected on the false ground that the said problem of stone does not cover under insurance. However, complainant has paid premium of insurance in order to secure the expenses. The treatment given by the doctor to complainant for acute infection and not for Cholelithiasis but OPs refused to provide cashless treatment. Finding no other way, complainant paid the charges for treatment to hospital of Rs.3,04,365/- and after that from recovery of said acute infection, complainant was discharge from hospital on 24.03.2019 with suggestion to follow up after one week for treatment of stone.

2.             Complainant again went to the hospital for treatment of stone on 31.03.2019 but this time complainant went to Medanta Hospital at Gurgaon for treatment where he admitted on 31.03.2019. The doctor at Medanta Hospital treated for removal of stone and after whole treatment complainant discharged on 04.04.2019. During treatment at Medanta Hospital, complainant spent an amount of Rs.1,28,758/-on his treatment. Thereafter, doctor also suggested to come after sometime for follow up and for removal of Gal Bladder as there was another stone in the Gal Bladdar and complainant went to Medanta Hospital again on 03.06.2019. On the advice of the doctors complainant admitted in the hospital on the same. The doctors conducted operation for stone on 04.06.2019 and after the whole ailment, complainant discharged on 06.06.2019 and he spent Rs.1,19,499/- on the said treatment. In this way complainant spent Rs.5,52,622/- on his treatment. Thereafter, complainant visited the office of OPs so many times and requested to reimburse the said amount but OPs did not pay any heed to the request of complainant and lastly repudiated the claim of complainant on the false ground. Then complainant sent a legal notice through his counsel in this regard to the OPs but it also did not yield any result. In this way there was deficiency in service on the part of the OPs. Hence complainant filed the present  complaint.

3.             Notice of the complaint was given to the OPs, who appeared and filed written version raising preliminary objections with regard to maintainability; jurisdiction; cause of action and concealment of true and material facts. On merits, it is pleaded that the insured availed Family Health Optima Insurance Plan, vide policy No.P/211114/01/2019/003241 for the period of 25.07.2018 to 24.07.2019 covering Mr. Neeraj Malhotra-Self, Mrs. Tripti Malhotra-Spouse, Master Harshit Malhotra & Ms. Navya Malhotra-Dependent Children for the floater sum insured of Rs.5,00,000/-.  In the 2^nd year of the policy, the insured patient, Mr. Neeraj Malhotra was hospitalized at Fortis Hospital, Mohali on 13.03.2019 for the treatment of Cholecystitis and Type II Diabetes Mellitus and submitted a claim for reimbursement of medical expenses on 27.04.2019 for a sum of Rs.3,04,365/-. On scrutiny of the claim documents submitted by the insured, it is observed that:

         As per the Discharge Summary for the period 13.03.2019 to 24.03.2019, the insured patient is diagnosed with Cholelithiasis with Choledocholithiasis, Actue Gangrenous Cholecystitis and Type II Diabetes Mellitus.

The above findings confirms that the insured was admitted and treated for Cholelithiasis (the presence of gallstones(see the image below), which concretions that form in the biliary tract, usually in the gallbladder), which falls under the waiting period 3, ii, b, i.e. the claim will be covered only after 24 months of the continuous coverage.

 As per waiting period 3(ii)(b) of the policy, “A waiting period of 24 consecutive months of continuous coverage from the inception of this policy will apply to the following specified ailments/illness/disease:- All treatment (conservative, interventional, laproscopic and open) related to Hepato-pancreato-biliary diseases including Gall bladder and Pancreatic calculi. All types of monogement for Kidney and Genitouromaru tract calcull.”

Hence the claim was repudiated and the same was informed to the insured, vide letter dated 11.05.2019. Hence, there is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

4.             Complainant tendered into evidence his affidavit Ex.CW1/A,  insurance policy  for the year 2017-2018 Ex.C1, insurance policy for the year 2018-2019 Ex.C2, copy of rejection letter for cashless treatment Ex.C3, copy of bills of Fortis Hospital Ex.C4, discharge summary of Fortis hospital Ex.C5, claim repudiation letter Ex.C6, copy of bills of Medanta Hospital Ex.C7 and Ex.C8, discharge summary of Medanta hospital Ex.C9, copy of Radiolody report of Medanta hospital Ex.C10, copy of bill dated 06.06.2019 of Medanta hospital Ex.C11, payment receipt Ex.C12, discharge summary of Medanta Hospital dated 06.06.2019 Ex.C13, operation report of Medanta hospital dated 06.06.2019 Ex.C14, x-ray report of Medanta hospital Ex.C15, Radiology report Ex.C16, lab test report dated 03.06.2019 Ex.C17, legal notice Ex.C18 and postal receipt Ex.C19 and closed his evidence on 07.11.2019, vide separate statement.

5.             On the other hand, OPs tendered into evidence affidavit of Rajiv Jain Ex.RW1/A, copy of proposal form Ex.R1, policy Ex.R2 and R3, terms and conditions of the policy Ex.R4, request of cashless Ex.R5, rejection letter for cashless Ex.R6 and Ex.R7, claim form A and B Ex.R8 and Ex.R9, discharge summary Ex.R10, hospital bills Ex.R11, calculation sheet Ex.R12, repudiation letter Ex.R1, reply of legal notice Ex.R14 and closed the evidence on 03.03.2020, vide separate statement.

6.             We have heard the learned counsel of both the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             The case of the complainant, in brief, is that he had purchased a policy from Star health and Allied Insurance Co. since 2017 and same was renewed upto 25.07.2019. On 13.03.2019 the complainant suffered acute pain in his abdomen and got admitted in Fortis Hospital, Mohali. After that, treatment was started by the doctor but there was another problem occurred and complainant was suffering from high fever. After all check-up and tests it was found that complainant was suffering from acute infection. Complainant remained admitted in the Hospital at Mohali from 13.03.2019 to 24.03.2019. Cashless claim of the complainant was rejected by the OPs on the flimsy ground that said problem of stone does not cover under the insurance policy. More so, the treatment at Fortis Hospital, Mohali was given for acute infection and not for Cholelithiasis. The complainant spent Rs.3,04,365/- for treatment of the said acute infection. Complainant raised claim for reimbursement of the said treatment but again OPs repudiated the claim on the ground that the claim of the complainant is not covered as waiting period of 24 months is not completed. The complainant has never intimated regarding any waiting period of 24 months as alleged by OPs in repudiation letter, nor any such condition were intimated or communicated to the complainant at the time of purchasing of  insurance policy.

8.             Further, on 31.03.2019, complainant again admitted in Medanta Hospital, Gurgaon for the problem of stone in abdomen and during treatment an amount of Rs.1,28,758/- was incurred by the complainant.

9.             Further, on 03.06.2019, the Gal Bladder was removed and during the said treatment complainant again spent Rs.1,19,499/-, thus the complainant spent total amount Rs.5,52,622/- in all three treatments.  Learned counsel for complainant placed reliance on Religare Health Insurance Company Limited Versus Ayush Gupta 2018 (1)ConLT 265,  New India Assurancce Co. Ltd Versus Anil Manglunia 2016 (1) CPR 150, Rajesh Singla Versus Max Bupa Health Ins. Co. and others date of decision 24.04.2018, HashmukhhaiIshwariLal Versus LIC of India 2017 3 ConLT 226 and Oriental Insurance Company Ltd. Versus Naresh Sharma and others, 2015 (2) PLR 75.

10.           Per-contra, the case of OPs, in nutshell, is that as per the discharge summary for the period from 13.03.2019 to 24.03.2019, the insured is diagnosed with Choledocholithiasis, acute gangrenous cholecystitis and Type II Diabetes Mellitus.  The complainant was admitted and treated for Choledocholithiasis which fall under the waiting period 3, ii, b, i.e., the claim will be covered only after 24 months of the continuous coverage. The policy was purchased by the complainant on 25.07.2017 and was got admitted in the hospital on 13.03.2019, therefore, the claim of the complainant was rightly repudiated as the time of two years was not completed after purchasing of policy.

11.           Admittedly, the complainant purchased the health policy from the OPs. During the subsistence of the policy, the complainant got admitted in the hospitals for his treatments and spent Rs.5,52,622/-. The claim of the complainant was repudiated on the ground that the complainant was admitted and treated for Choledocholithiasis which fall under the waiting period 3, ii, b, i.e., the claim will be covered only after 24 months of the continuous coverage.

12.           As per the version of the complainant, the complainant has never intimated regarding any waiting period of 24 months as alleged by OPs in repudiation letter, nor any such condition were intimated or communicated to the complainant at the time of purchasing of insurance policy. Moreover, the treatment at Fortis Hospital, Mohali was taken by the complainant for acute infection in his abdomen and not for removal of stone. Furthermore, the terms and conditions and the policy clause were not provided, but only cover note (policy) was issued/provided by the OPs to the complainant.

13.           As per version of the OPs, the terms and conditions were sent to the complainant alongwith policy. But the OPs have failed to produce on record any evidence that they have sent/communicated the same to the complainant at any stage. They further failed to produce any receipt/acknowledgement that the terms and conditions were sent/received by the complainant. Hence, the plea taken by the OPs has no force. In this regard, we relied upon New India Assurance Co. Ltd Versus Anil Manglunia 2016 (1) CPR 150 (NC),wherein Hon’ble National Commission held that OP failed to provide policy clause to the complainant and rejected genuine claim of the complainant. Hence, they do not find any merit in the revision petition and the same is hereby dismissed. We further relied upon Oriental Insurancce Co. Ltd Versus Naresh Sharma and others 2015 (2) PLR 75, wherein Hon’ble Punjab and Haryana High Court held that the exclusion clause has to be read to the benefit of patient in genuine circumstances. Where respondent was admitted in hospital suffering from headache, giddiness and hypertension, his claim cannot be rejected on the basis of exclusion clause.

14.           Furthermore, if the copies of terms and conditions were not provided to the complainant, then these are not applicable to the complainant. Since, the OPs have failed to prove the facts on record that the terms and conditions of the policy were sent and received by the complainant, therefore, the repudiation of claim of the complainant is not justified in the eyes of law.            

15.           Keeping in view of the ratio of above judgments, facts and circumstances of the case, we are of the considered view that act of the OPs amount to deficiency in service.

16.           The complainant has spent Rs.3,04,365/- vide bill Ex.C4, Rs.1,28,758,/- vide bill Ex.C7 and Rs.1,19,499/- vide bill Ex.C11 totaling Rs.5,52,622/-. Hence, the complainant is entitled for the same alongwith compensation and litigation expenses etc.

17.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs Rs.5,52,622/- to the complainant with interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OPs to pay Rs.25,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses. This order shall be complied within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated: 21.01.2021

 

                                                                       

                                                                    President,

                                                      District Consumer Disputes

                                                      Redressal Commission, Karnal.

 

 

 

 (Vineet Kaushik)               (Dr. Rekha Chaudhary)

      Member                               Member