Haryana

Karnal

CC/195/2020

Pritpal Kaur - Complainant(s)

Versus

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

R.K. Kumar

14 Dec 2021

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL  COMMISSION, KARNAL.

 

                                                         Complaint No. 195 of 2020

                                                          Date of instt. 03.06.2020

                                                          Date of Decision:14.12.2021.

 

Pritpal Kaur wife of late Sh. Rattan Singh, aged about 62 years, resident of House No.47, Sector-10, Village & P.O. Indri, District Karnal.

 

                                                 …….Complainant.

                                      Versus

 

Star Health and Allied Insurance Company Limited, Branch Office SCO 242, Ist Floor, Sector-12, Karnal, through its Manager.

                                                                      …..Opposite Party.

 

Complaint Under section 12 of the Consumer Protection Act, 1986 as amended Under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.       

      Sh. Vineet Kaushik…….Member

 

Present: Shri Deepak Vohra, counsel for complainant.

                Shri Gaurav Gupta, counsel for opposite party.

 

                    (Jaswant Singh President)

ORDER:

 

                The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 as after amendment Under Section 35 of Consumer Protection Act, 2019 against the opposite party (hereinafter referred to as ‘OP’) on the averments that on 30.10.2017, complainant took a mediclaim insurance policy from OP. The complainant continued the policy and had paid a sum of Rs.36,137/- as premium for the period from 31.10.2019 to 30.10.2020 and the policy was issued for that period vide policy no.P-211117-01-2020-002493. The product name of the policy is star comprehensive insurance policy and the sum insured under the said policy was Rs.7,50,000/-. It is further averred that at the time of issuance of said policy, the agency of the company assured that in case of hospitalization, company will pay total claim to the Hospital as the policy was cashless policy. The agent also assured that if any problem arose regarding health in future, the complainant has not to pay money for that and the company will pay the charges of the hospital which are on the penal of the company. That suddenly in the month of November, 2019, the complainant suffered severe pain in her both knees and there was problem in walking and climbing. She was taken to Fortis Hospital Mohali for the check up and was got admitted there on 03.12.2019 and the operation of her knees was conducted on 09.12.2019 and both the knees were replaced. She was discharged on 10.12.2019. The complainant paid a sum of Rs.3,91,294/- to the hospital for treatment i.e. operation fees, cost of implant, medicine and hospitalization apart from other expenses. It is further averred that complainant submitted claim covered under the policy before the OP and also submitted all the requisite documents. The OP assured that the claim will be processed and will pay the claim within one month and after passing of one month, the complainant visited to the office of OP and asked about the claim but the officials of OP postponed the matter on the pretext that the claim is under process. That ultimately OP sent a letter dated 01.02.2020 to the complainant regarding repudiation of claim on the false grounds that claimant had the above said disease prior to inception of first medical policy. That from the perusal of repudiation letter, it is clear that OP in order to avoid its liability to pay the claim, repudiated the claim on false and frivolous ground. It is further averred that though the policy was cashless but due to serious illness of complainant and circumstances, the complainant submitted the claim with the OP after the discharge from the hospital, yet the OP did not bother to pay the claim covered under the policy, which amounts to deficiency in service and unfair trade practice on the part of op. That son of complainant visited to OP so many times and requested to make the payment of claim but the officials of OP postponed the matter on one pretext or the other. Hence, this complaint.

2.             On notice, OP appeared and filed written version raising certain preliminary objections regarding suppression of material facts: limitation; jurisdiction; cause of action; estoppal and that complainant is bound by terms and conditions of the policy. It is submitted that 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 policy schedule. Moreover, it is clearly stated in the policy schedule that insurance under this policy is subject to conditions, clauses, warranties, exclusions etc. Policy is contractual in nature and claims arising therein are subject to the terms and conditions forming part of the policy. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. It is further submitted that the insured requested a cashless of medical expenses towards the treatment of advanced B/L OA knee at Fortis Hospital, Mohali on dated 22.11.2019. On perusal of the cashless request, it was observed that the exact duration of the ailment could not be ascertained with the available documents and also further evaluation required to ascertain the exact onset of OA knee. Hence, the cashless authorization was denied calling the insured for reimbursement of medical expenses and the same was communicated to the treating hospital as well as the insured vide letter dated 30.11.2019. Subsequently, the insured submitted claim documents for reimbursement. On scrutiny of claim documents for reimbursement, it is observed that “The findings of X-ray report dated 14.11.2019, show a tricompartment osteoarthritis. Joints space reduction, sclerosis are in favour of chronic long standing Osteoarthritis. Based on the x-ray findings, our medical team is of the opinion that the insured patient has the above disease prior to inception of the first medical insurance policy. Hence, the above diagnosis is a pre existing disease. The present admission and treatment of the insured patient is for the pre existing disease.” It is further submitted that as per exclusion No.1, 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, since inception of the policy i.e. from 31.10.2017. Hence, the claim for reimbursement of medical expenses was again repudiated vide letter dated 01.02.2020. Lastly, it is submitted that policy issued to the complainant under which the dispute has been raised is governed by limits of liability as per various clauses. With these averments, dismissal of complaint prayed for.

3.             The parties then led their respective evidence.

4.             The complainant tendered in evidence affidavit of complainant Ex.C1, copy of treatment record Ex.C2, copy of discharge summary Ex.C3, copy of bill and receipts of treatment record Ex.C4, copy of repudiation letter Ex.C5, cover note Ex.C6 and closed the evidence on 29.07.2021 by suffering separate statement.

5.             On the other hand, OP tendered into evidence affidavit of Sh. P.C. Tripathy, Zonal Manager as Ex.RW1/A, copy of policy terms and condition Ex.R1, copy of medical article Ex.R2, copy of all policy schedule Ex.R3, copy of proposal form Ex.R4, request letter for enhancement of sum insured Ex.R4/A, request for cashless hospitalization for medical insurance policy Ex.R5, copy of pre authorization query letter dated 23.11.2019 Rx.R6 and Ex.R6/A, copy of pre authorization denial letters dated 30.11.2019 Ex.R7, copy of denial of pre-authorization request for cashless treatment Ex.R7/A, copy of claim form Ex.R8, copy of discharge summary dated 10.12.2019 Ex.R9, Ex.R10 and Ex.R10/A, copy of x-ray reports dated 14.11.2019 alongwith x-ray film Ex.R10/B, copy of final bill Ex.R11, copy of expert opinion Ex.R12, copy of claim repudiation letter dated 01.02.2020 Ex.R13, copy of billing assessment sheet Ex.R14 and closed the evidence on 03.09.2021 by suffering separate statement.

6.             We have heard learned counsel for the parties and have perused the case file carefully.

7.             Admittedly, on 30.10.2017 the complainant purchased medi claim insurance policy from the opposite party and said policy was also got renewed by complainant from 31.10.2019 to 30.10.2020 by paying premium amount of Rs.36,137/- to the OP and the sum insured under the said policy is Rs.7,50,000/-. It is the case of the complainant that suddenly in the month of November, 2019, she suffered severe pain in her both knees and she was having problem of walking and climbing stairs etc. Then on 03.12.2019, she was taken to Fortis Hospital, Mohali for treatment where on 09.12.2019 operation of her both knees was conducted and both the knees were replaced and on 10.12.2019 she was discharged from the said hospital. According to complainant, she has spent an amount of Rs.3,91,294/- on her above said treatment. Though, the policy was a cashless policy, but the OP denied the cashless treatment to the complainant and also repudiated the claim of the complainant on 01.02.2020 despite submitting claim to the OP alongwith requisite documents on false and frivolous ground of pre existing disease.         

8.             The OP has repudiated the claim of the complainant vide repudiation letter dated 1.2.2020 Ex.C3, the relevant portion of which is reproduced as under:-

“It is observed that the findings of X-ray report dated 14.11.2019 confirms chronic, longstanding disease. Based on the x-ray findings, our medical team is of the opinion that the insured patient has the above disease prior to inception of the first medical insurance policy. Hence the above diagnosis is a pre existing disease. The present admission and treatment of the insured patient is for the pre existing disease.

                As per Exclusion No.1 of the above policy issued to you, 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, since inception of the policy i.e., from 31.10.2017. We are therefore, unable to settle your claim under the above policy and we hereby repudiate your claim”.

9.             Though, the OP has repudiated the claim of complainant on the ground of pre existing disease but however, OP has not placed on file any document/ medical record of the complainant to show that complainant was already having the disease of knees and was under treatment prior to taking of the policy in question. From the copy of discharge summary of Fortis Hospital placed on file by complainant as Ex.C3, it is evident that doctor of said hospital mentioned in the discharge summary that patient present with complaints of pain in both knee joint, associated with difficulty in walking or climbing stairs from last six months. So, in absence of any other previous medical record of the complainant, it cannot be said that complainant was having disease of both knee joint prior to purchase of policy in question, rather it is proved on record that she suffered with said disease six months prior to the month of November, 2019 i.e. after one and half years after purchase of the medi claim insurance policy from the OP. So, the OP has wrongly, illegally and arbitrarily declined the cashless treatment and has also wrongly repudiated the claim of the complainant. In this regard, we are also fortified with the observations of Hon’ble Punjab State Consumer Disputes Redressal Commission, Chandigarh in case titled as Aditya Birla Health Insurance Co. Ltd. & anr. Versus Deepinder Singh & anr. I 2021 CPJ 156 (Punjab) in which it has been held as under:-

                “Consumer Protection Act, 1986- Sections 2(1)(g), 14(1)(d), 15- Insurance Regulatory and Development Authority (Protection of Policy holders’s interest) Regulations, 2017- Regulation 10- Insurance (Mediclaim)- Surgery of shoulder- Alleged non-disclosure of pre-existing disease- Repudiation of claim- Deficiency in service- District Forum allowed complaint- Hence appeal- Respondent/ complainant was admitted to hospital on 10.10.2018 with problem of right shoulder pain and after surgery was discharged on 21.10.2018 in satisfactory condition- Expenditure of Rs.81,595/- was incurred on said treatment- Complainant lodged reimbursement claim for Rs.82,981/- and same was repudiated- Except medical record of ailment, OPs have not placed on record any independent evidence that insured had knowledge or that he had been taking treatment of disease, before purchasing this policy- In absence of any specific evidence on record how disease, if any, to which insured does not have knowledge can be termed as pre-existing disease- Repudiation not justified- Complaint was rightly allowed.

10.           The above said authority is fully applicable to the facts and circumstances of the present case. In the present case, the OP has only relied upon alleged opinion given by Dr. B.Pasupathy, Consultant Orthopaedic, Arthroscopic, Paediatric Orthopaedic Surgeon, Madras Medical College, Chennai as Ex.R12 on the basis of which the claim of complainant has been repudiated. In the said document Ex.R12, it has been mentioned that according to X-ray report dated 14.11.2019, x-ray both knees anterior posterior and lateral views shows tricompartment osteoarthritis, medial joint space reduction. The above disorders are in favour of longstanding degenerative arthritis of both knees more than policy duration. But, the said alleged opinion placed on file by OP as Ex.R12 does not carry any evidentiary value because no affidavit of said doctor B.Pasupathy has been placed on file by OP in support of his above said opinion and plea of the OP. The OP has not placed on file any authentic and reliable evidence in support of its plea and therefore, said opinion allegedly given by Dr. B. Pasupathy which is also a mere photostat copy and has not been corroborated by reliable and convincing evidence cannot be relied upon in evidence. In absence of any previous medical history/ record regarding said disease of complainant, it cannot be said with certainty that complainant was having disease of knees prior to purchasing of the policy in question. Rather from the medical record of Fortis Hospital, Mohali, it is proved on record that complainant suffered above said disease of knees only in the month of May, 2019 i.e. after one and half years of purchase of policy in question. So, it cannot be said that complainant was having pre existing disease or was in knowledge of that pre existing disease. In this regard, we can also rely the observations of the Hon’ble National Commission made in judgment dated 31.05.2019 rendered in RP No.2097 of 2017  case titled as Reliance Life Insurance Company Ltd. & Anr. vs. Tarun Kumar Sudhir Halder in which it is observed as under:-

“12. From the above entry, it seems that either the doctor filling up this form has not clearly given the date or somebody has made cutting after the word ‘since’. Thus, no conclusion can be drawn in respect of the period since when the DLA was suffering from diabetes. From the entries in the Medical Attendant Certificate it is clear that the DLA first complained about illness only on 22.06.2021. This entry clearly denies pre existing disease of Diabetic Ketoacidosis. The insurance company has not filed any evidence to show that the DLA was taking treatment for the disease prior to filling up of the proposal form. Even if there was disease inside the body, but the life insured did not know about the disease and was not taking any treatment for the same, the insurance claim cannot be denied on mere presumption that the life assured might be suffering from pre-existing disease. Thus, on merits, I am convinced on the basis of the entries in the Medical Attendant Certificate that the disease was complained for the first time by the DLA on 22.06.2021, which is much after the date of the proposal form. The onus to prove the pre-existing disease lies on the Insurance Company and no supporting documents have been filed by the Insurance Company in support of their assertion.”

•  

                It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.

 11.          The above said authorities are also fully applicable in this case. In the present case also, the OP has not placed on record any treatment record of complainant regarding receiving treatment of the above said disease prior to taking of policy in question. Rather it is proved on record that complainant was not having any past history of above said disease. So, it is proved on record that OP has wrongly and illegally repudiated the claim of complainant. As per medical receipt Ex.C4 the complainant has spent Rs.3,91,294/- for her treatment and said bill has not been rebutted by OP. Hence, complainant is entitled to the above said amount of Rs.3,91,294/-from the OP which has been deposited by her to Fortis Hospital, Mohali and non- payment of this amount clearly amounts to deficiency in service on the part of OPs.

12.  

Announced

Dated:14.12.2021

                                                                       

                                                                  President,

                                                       District Consumer Disputes

                                                       Redressal Commission, Karnal.

 

 

(Vineet Kaushik)       

                            Member