DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SANGRUR .
Complaint No. 41
Instituted on: 01.02.2019
Decided on: 13.06.2024
1. Randhir Singh son of Sukhminder Singh resident of village Kalaudi, Tehsil & District Sangrur.
2. Baljeet Kaur wife of Randhir Singh son of Sukhminder Singh resident of village Kalaudi, Tehsil and District Sangrur.
…. Complainants.
Versus
1. Star Health and Allied Insurance Company Limited Regd. & Corporate Office:1, New Tank Street, Valluvarkottam High Road, Nungambakkam, Chennai-600034, through its Managing Director.
2. Star Health and Allied Insurance Co. Limited, SCO no.70, 2nd Floor, New Leela Bhawan, Above HDFC Mutual Funds, Patiala Tehsil and District Patiala through its Manager.
3. Star Health and Allied Insurance Co. Limited Near Dr. Uggarsain, Sunami Gate, Sangrur, Tehsil and District Sangrur through its Manager.
4. Mrs. Ram Murti wife of Vijay Kumar resident of Preet Colony, Near New Bus Stand, Bhawanigarh, Tehsil and District Sangrur.
….Opposite parties.
QUORUM
JOT NARANJAN SINGH GILL: PRESIDENT
SARITA GARG : MEMEBR
KANWALJEET SINGH : MEMBER
For the complainant : Shri Sonu Markan, Advocate
For the Ops no.1to3 : Shri Rohit Jain, Advocate.
For the OP no.4 : Shri K.S.Toor, Advocate.
ORDER
KANWALJEET SINGH, MEMBER
1. The brief facts of the case are that on 30.04.2016, on the recommendation of Vijay Kumar, who is known to the Complainant No.1. OP no.4 alongwith Mr. Lalit Mohan Sudan ( official of OPs no.1 to 3) visited the office of Complainant no.1 and made proposal of Family Health Optima Insurance Plan. The complainant no.1 and his wife ( complainant no.2) and his son were insured for a sum of Rs.5,00,000/- alongwith other benefits of Rs.1,50,000/- . The complainant no.1 put his signature on blank papers. Shri Lalit Mohan told to the complainant no.1 that the rest of the policy will be filled by him at the time of submission of documents as he is busy in some other assignments. The complainant and his family medically examined by doctors. The complainant no.1 paid the premium through cheque no.394107 dated 30.04.2016 of Rs.8628/-. The OPs issued a cashless policy bearing no. P/211115/01/2017/000086 was issued to the complainant no.1 but the terms and conditions were not provided by the OPs. Complainant no.1 paid premium of Rs.11,506 for renewal the policy for the year of 2018-2019. On 22.12.2016, the complainant no.2 was taken to Vinayak Hospital, Jakhal Road, Sunam due to severe headache and the medical tests were conducted by the doctor and kidney problem was detected in the medical test and the complainant no.2 was referred to Nephrologist by the doctor there after the complainant no.2 was normal for few months and was getting medicine. In January 2017, ultrasound was conducted of the complainant no.2 and Renal disease was detected. The complainant no.2 was on dialysis twice a week at Santokh Hospital, Sector 38-A, Chandigarh from 01.05.2017. The complainant no.1 contacted to Mr. Lalit Mohan Sudan ( official of op 1to 3 )and OP no.4 when the dialysis were started of complainant no.2 but they said that the dialysis were not covered under the health policy. The complainant no.1 again contacted to OP no.4 regarding the payment of bill of Rs.5000/- but they said this is the minor bill. If you pay this bill then benefit is given to you at the time of transplant. The complainant no.1 paid the amount of Rs.5000/- at Santokh Hospital Chandigarh. On 09.10.2017, the complainant got appointment of Dr.Baldev Singh Aulakh ( urologist) DMC Ludhiana. After checking the complainant no.2 Dr. suggested that the kidney transplant is the only option for the treatment of complainant no.2. The complainants decided to get the kidney transplant of complainant no.2 at IVY Hospital, Sector 71, Mohali. All the test were conducted at IVY Hospital Mohali, the donor Harjit Singh was declared fit to donate the kidney to complainant no.2 and the date of kidney transplant was fixed on 25.01.2018. The complainant no.1 submitted documents/ claim documents which were filled by the complainant no.1. The concerned official sent for cashless facilities emailed documents to OPs no.1 to 3 on 19.01.2018 including the case history of the treatment of complainant no.2 on 22.01.2018 as demanded by them. The OPs no.1 to 3 again emailed to the IVY Hospital, Mohali on 24.01.2018 and refused to give cashless treatment to the complainant no.2. The complainant no.1 informed to OP no.4 who said the claim amount will be reimbursed after operation and after submission the bills to the OPs no.1 to 3. The complainant no.2 and donor Harjeet Singh were admitted in the IVY Hospital, Mohali on 24.01.2018. The donor Harjeet Singh was discharged on 29.01.2018 and the complainant no.2 was discharged on 09.02.2018. The complainant no.1 paid the amount of Rs.6,82,762/- in total medical expenses of complainant no.2 and Rs.60544/- in total of donor Harjit Singh during the admission period. The surveyor was appointed by the OPs and he found all the documents are correct of both donor and recipient. The OPs no.1 to 3 emailed to Lalit Mohan to submit the original documents and he visited the office of complainant no.1 at Sangrur and demanded documents as per query and the complainant no.1 issued letter dated 4.7.2018 to Lalit Mohan who had received the original documents which were endorsed by him and the same were submitted to the surveyor. The Ops repudiated the claim vide letter dated 06.09.2018 and 07.09.2018. The OPs committed unfair trade practice and deficiency in service qua the complainant. The complainants have lastly prayed that the Ops no.1 to 3 may kindly directed to pay Rs.6,50,000/- alongwith interest @18% per annum and Rs.One Lac on account of mental tension and Rs.11000/- as litigation expenses.
2. Upon notice of this complaint, the opposite parties appeared and filed written version separately. In reply of Ops no.1 to 3, taking preliminary objections that the complainant has not come to the Commission with clean hands. On merits, the OPs admitted the complaint to be correct to the extent that the complainant got health insurance policy for himself, his wife and his son and paid premium of Rs.8628/-. The OPs issued a cashless policy bearing no. P/211115/01/2017/000086 to the complainant no.1. The true facts of the case are that the complainant was availed the policy in question for a sum of Rs.5,00,000/- and the terms and conditions of the policy were explained and provided to the complainant. The insured submitted the claim in the second year of the policy. The insured patient was hospitalized in IVY Hospital, Mohali since 25.01.2018 to 09.02.2018 and was diagnosed with Renal Allograft recipient , HTN and Acute Graft Dysfunction-AMBR+ Patchy Cortical necrosis ( 10%) and as per the claim form, the insured claimed of Rs.8,45,182/- whereas the sum insured was Rs.5,00,000/- . The claim for reimbursement is not payable under PED exclusion clause. On scrutiny of the claim documents, it is observed that the investigation report dated 22.12.2016 submitted during cashless processing the serum creatinine value is 5.0mgs/d1 and the submitted claim from the duration of the illness is mentioned as 2 years , it was tampered and corrected as one year. From the above findings, it is observed that the insured has the pre existing disease and the same was not disclosed and the claim was rejected vide letter dated 6.09.2018. This is violation of condition no.8 of the terms and conditions of the policy. The OPs no.1 to 3 further pleaded that the complaint is admitted to be correct to the extent that the complainant no.1 received letter dated 6/7.9.2018 which was received from Lalit Mohan Sudan insurance agent of OP no.1 that claim of complainants was repudiated on different grounds. If this Commission comes to the conclusion that the claim of the complainant needs to be allowed, the same shall be subject to the terms and conditions of the policy. The remaining allegations are denied by the OPs. The prayer clause of the complaint is denied and lastly prayed the complaint may kindly be dismissed with special costs.
3. In reply of Op no.4, the OP no.4 pleaded that the complaint is correct to the extent that the OP no.4 has arranged the meeting with the official of OPs no.1 to 3 and the complainant after getting knowledge regarding insurance plan the complainant had consented for family health insurance in question. It is correct that the complainant and his family medically examined by the doctors as per the instructions of Mr.Lalit Kumar Sudan.(official of op.No.1 to 3) The complainants had approached the OP no.4 for reimbursement of the claim amount. The OP no.4 tried her best for the reimbursement but the insurance company had repudiated the claim of the complainant on technical ground and same was informed to the complainants by OP no.4. It is correct that the complainant has approached to OP no.4 regarding the repudiation and cancellation of policy in question but despite various efforts by OP no.4 with OPs no.1 to 3 no fruitful results are made out. The remaining allegations are denied. The complaint may kindly be dismissed with costs.
4. In support of their case the complainants submitted Affidavit of Complainant No.1 which is Ex.C-1 another affidavit of complainant No.2 which is Ex. C-2 and documents Ex.C-3 to Ex.C-33 and tendered into additional evidence Ex.C-34 to Ex.C-36 and closed evidence.
5. On the other hand, to rebut the case of the complainants, the opposite parties no.1 to 3 have submitted documents Ex.Ops1to3/1 affidavit of Sh.Rajiv jain chief manager of Ops and Ex.Ops1 to 3 /2 to Ex.Ops1to 3/17 and closed evidence. Similarly, OP no.4 tendered into evidence Ex.OP4/1 affidavit and closed evidence.
6. We have heard the learned counsel of the both the parties and gone through the record file carefully with the valuable assistance of the learned counsel for the parties. Arguments of the parties are similar to their respective pleadings, so there is no need to reiterate the same to avoid repetition.
7. Now, come to major controversy, whether the complainants are liable for relief as claimed by him/her in his prayer or not?
8. It is not disputed that the health insurance policy in question has been obtained by the complainant for himself including his wife and his son and paid premium of Rs.8628/- vide cheque no.394107 dated 30.04.2016. The OPs issued a cashless policy bearing no. P/211115/01/2017/000086 to the complainant no.1. which was valid from 30.04.2016 to 29.04.2017. As per Ex.C-6 the sum insured by the insurer of Rs.5,00,000/- in first health policy (supra). It is not disputed that the insured submitted the claim in the second year policy. The second year policy was valid from 30.04.2017 to 29.04.2018 and the renewed policy bearing no. P/211115/01/2018/000085. As per Ex.C-8 the limit of coverage has shown as Rs. 6,25000/-. It is specifically pleaded by OPs no.1 to 3 reply on merit in para no.3 (H) that the wife of the complainant admitted in IVY Hospital, Mohali on 25.01.2018 to 09.02.2018 and diagnosed with Renal Allograft recipient , HTN and Acute Graft Dysfunction-AMBR+ Patchy Cortical necrosis ( 10%) and as per the claim form, the insured claimed of Rs.8,45,182/- whereas the sum insured was Rs.5,00,000/- . As per Ex.C-23 dated 22.01.2018 query on pre authorization issued by OPs to IVY hospital, Mohali required the documents as per consultation paper dated 22.12.2016 of Vinyanak Hospital, Sunam mentioned as serum creatinine is 5 kindly send letter from treating doctor when exactly patient diagnosed CKD. Further, it transpires from perusal of Ex.C-24 denial of pre-authorization for cashless treatment OPs issued a letter dated 24.01.2018 to the IVY Hospital, Mohali regarding diagnosis of insured patient has shown as CKD stage 5 on MHD. It is mentioned in the letter (supra) the patient is chronic kidney disease in the consultation paper dated 22.12.2016. The patient had creatinine value of 5 and the exact onset of kidney disease cannot be ascertained in cashless and cashless cannot be processed. The OPs issued letter dated 23.07.2018 to the complainant which is Ex.C-26. In this letter OPs demanded additional information from the complainant no.1. It has shown in Ex.C-26 the diagnosis “ Renal allograft recipient /HTN Acute Graft Dysfunction. The complainant is asked to provide documents related to menorrhagia and USG report done at the time of all previous pregnancy/cesarean documents including USG abdomen report. Complainant no.1 has given the reply dated 16.08.2018 of query documents has already been handed over to the surveyor.
9. To trace out the veracity of truth, this Commission has considered the primary issue for determination “ whether before issuance of health insurance policy in question i.e. 30.04.2016 the complainant no.2 having any pre existing kidney disease or not ? “ .
It transpires from the prusal of Ex.C-30 repudiation letter dated 06.09.2018 in the letter Ops observed that the insured seeking reimbursement of hospitalization expenses for treatment of renal allograft recipient, hypertension, acute graft Dysfunction. It is further mentioned in the letter that it is observed from the investigation report dated 22.12.2016 submitted during cashless processing the serum creatinine value is 5.0mgs/dl and submitted claim form the duration of illness is 2 years. It was tampered and corrected as one year. OPs medical team is of the opinion that the insured patient has long standing kidney disease prior to date of commencement of first year policy. The corrected documents are not acceptable. During first year policy which was valid from 30.04.2016 to 29.04.2017. The complainants have not disclosed the medical history of the insured person in the proposal form which amounts to misrepresentation of material facts. From the perusal of Ex.C-31 letter dated 07.09.2018 issued by Ops regarding non-disclosure of pre-existing disease of the insured. In this letter (supra) the condition no.15 of the policy clause reproduced as under:-
“ The company may cancel this policy on grounds of misreprestation, fraud, moral hazard, non disclosure of material fact as declared in the proposal form at the time of claim or non cooperation of the insured person by sending the insured 30 days notice by registered letter at the insured person’s last known address and no refund of premium will be made.
10. It transpires from the perusal of Ex.C-36 letter dated 22.01.2018 by Dr.Raka Kaushal of IVY hospital, Mohali advised to the insured Baljit Kaur ( complainant no.2) for Renal transplant surgery. Duration of illness since one year before transplant. Dr. Raka put their signatures in English language and embosses the stamp on the same. From the perusal of Ex.OPs1 to 3/8 pre authorized request form dated 17.01.2018. In this letter it is specifically mentioned “ CKD-V on MHD since 2016. Old record not available. HTN since 2016 Renal disease mentioned as CKD since 2016 ( 01.05.2017 on MHD). We feel from the perusal of Ex.OPs1 to 3/8 on page no.3 there is cutting in the year 2017. Further, on page 5 Ex.OPs 1 to 3/8 in the date 28.01.2018 the year is cutting and corrected. This Commission has the considered view regarding cutting on the year is not proved on behalf of the complainant no.1. We feel that complainant no.1 put his signatures on page no.3 of Ex.OPs1 to 3/8 in English language. These are the clerical mistakes only. It is writ large on the file Ex.C-12 and Ex.OPs1 to 3/14 are the same document of Vinayak Hospital, Sunam dated 22.12.2016. Dr. Simpy Jindal has checked the insured patient on 22.12.2016. Patient Baljit Kaur ( complainant no.2 ) approached to doctor ( supra) regarding severe headache. After examining the reports of the insured patient the concerned doctor noted the blood pressure was 180/110, Hemoglobin was 7gm, against normal range (12-16) blood urea was 127 against normal range (13-47 ) mg/dl, serum creatinine was 5.0 against normal range ( 0.6-1.4) mg/dl. This Commission has the considered view with regard to referred the insured patient to nephrologists. Doctor (supra) put their signature in running hand and embosses the stamp on the same in Punjabi language. It is writ large on the file Dr. Simpy Jindal referred the insured on 22.12.2016 on the basis of Ex.C-13 National Diagnostic Laboratory report dated 22.12.2016. This Commission has no hesitation to hold that the diagnosis identified by concerned doctor on 22.12.2016. It is incumbent upon the OPs to produce relevant, material cogent and trustworthy evidence regarding pre-existence disease of the insured was in existence prior to avail the health insurance in question i.e. 30.04.2016 as ops pleaded specifically in the reply in para no. 3(J). Moreover, as per Ex.C-12 Dr. Simpy Jindal first time referred the insured on 22.12.2016 meaning thereby after availing the first health policy in question i.e. 30.04.2016. Furthermore, as per Ex.C-30 repudiation letter dated 6.09.2018 shown that the medical team opined regarding insured patient has long standing kidney disease prior to commencement of first policy is unjust, improper, ineffective, inoperative and illegal before the eye of law in absence of documentary evidence. We feel that OPs medical team on the basis of which document produced on record regarding the pre-existence kidney disease in existence prior to avail the first insurance policy in question. In this context, in the absence of single piece of evidence produced by OPs are not proved this factum that there is any pre existing kidney disease occurred to the complainant no.2 prior to availing the first policy i.e. 30.04.2016. So the stand of OPs is not believable with regard to pre existence kidney disease is in existence prior to issuance of the policy in question. It is writ large on the file that complaint no.1 spent an amount of Rs.8,45,182/- as pleaded by ops. 1to 3 in their reply . Moreover, from the prusal of evidence of complainant as per Ex.C-19 on page 17 complainant paid the medical treatment expenses by the credit card of the yes bank dated 09.02.2018 of Rs.10,000/- to the Ivy hospital, Mohali. We hold from the perusal of pleadings of both the parties, evidence by way of affidavit available on record, the prima facie case is made out of the aggrieved complainant. In this juncture, the Ops no.1 to 3 are liable for deficiency in service qua the complainant no.2. The complainant no.2 is out rightly liable for relief.
- This Commission observed that the middle class family members are availed the medical health service/insurance policy after deposited the hard earned money as premium to the health insurance companies. In case of serious health problem occurred to the consumer as and when the condition of the person is deteriorating, who having not enough money for treatment in emergency cases. In this critical situation the health insurance policy plays an utmost important role to save the life of an ordinary person. We feel that ops are duty bound to examine and not to issue medi-claim policy when the consumer is suffering from pre-existing disease, Ops firstly assess the fitness of the person and after complete satisfaction, then they should issue the health policy. In the light of celebrity judgment in Civil Appeal No.7437 of 2011 titled as "P.Vankat Naidu Vs LIC of India". The Hon'ble Supreme Court of India held that 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. The appeal is allowed. In LPA No. 1537 of 2011 titled as “Iffco Tokio General Insurance Company Ltd. Vs Permanent Lok Adalat Gurgaon and others” 2012(1)R.C.R.(Civil) 901:2012(2)PLR 547 decided on 26.08.2011. The Hon'ble Punjab and Haryana High Court held that the law is well settled with regard to the standard form of contracts. When the bargaining powers of the parties is unequal and consumer has no real freedom to contract. The Courts would strike down such unfair and unreasonable clause in a contract, where parties are not equal in bargaining power. It was also held that claim of the petitioner denied on the ground that he was suffering from the disease prior to taking of the policy and was therefore covered under the exclusion clause of the Policy. It was for insurance company to see and not to issue policy where person is not entitled to claim on account of treatment of existing disease. Claim cannot be denied. In case titled as Bajaj Allianz General Insurance Co.Ltd. Versus Kamal Kumar Rateria in Revision petition No.4484 of 2010 decided on 10.07.2012. Hon’ble National Consumer Commission held that Insurance ( Mediclaim ) - problem in respect of prostate lesion- Surgery performed – Reimbursement of medical expenditure - claim repudiated – District Forum dismissed the complaint – State Commission reversed the order- Revision against-No evidence adduced by insurance Company that the said ailment existed at the time of taking policy-Complainant has produced medical reports that the said ailment did not exist earlier and was diagnosed for the first time after obtaining the policy – Repudiation not justified - Revision dismissed.
- (A) It is duty of the Consumer Commission to redress the grievances of the aggrieved Consumer in the light of Consumer Protection Act, 2019. On the above discussion, this Commission has the considered opinion that Ops are liable for unfair trade practice and deficiency in service qua the complainant. Furthermore, Health Insurance companies meant money from their innocent consumers by way of receiving the premium in crores throughout the country. On the other hand, phenomenon is toward the health insurance companies are avoiding by one pretext to another to pay the liability of health insurance claim to the aggrieved consumers, we feel that an insurance contract is known as a contract of “ uberrima fides” based on “utmost good faith ” which is fully applicable in the present complaint. This is a fit case to redress the grievances of the complainant.
12. Resultantly, keeping in view of the peculiar facts and circumstances of the case in hand and with careful analysis of the evidence available on record and in the light of judgments pronounced by Hon’ble Supreme Court of India, Hon’ble Punjab & Haryana High Court and Hon’ble National Consumer Commission, New Delhi (supra), we partly allow the complaint and direct the Ops no.1 to 3 to pay to the complainant no.2 an amount of Rs.6,25,000/- limit of coverage, as prayed alongwith interest @7% p.a. from the date of filing the complaint till realization. Further, the OPs no.1 to 3 are directed to revive the policy of the complainant no.2 after receiving the requisite premium from the complainant no.2 and to pay a sum of Rs.33000/- as compensation and Rs.11000/- as litigation expenses.
13. This order of ours shall be complied within 45 days from the receipt of copy of the order.
14. The complaint could not be decided within the statutory time period due to heavy pendency of cases.
15. Copy of this order be supplied to the parties free of cost. File be consigned to the records after its due compliance.
Announced.
June 13,2024.
( Kanwaljeet Singh) (Sarita Garg) (Jot Naranjan Singh Gill)
Member Member President
BBS/-
