Haryana

Karnal

CC/49/2018

Sushma Sharma - Complainant(s)

Versus

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

Deepak Kumar Sardana

06 Mar 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM KARNAL.

                                                          Complaint No. 49 of 2018

                                                          Date of instt. 01.03.2018

                                                          Date of Decision 06.03.2019

Sushma Sharma wife of Shri Rakesh Kumar resident of House no.362, Gandhi Chowk, Sadar Bazar, Karnal.  

 

                                                                       …….Complainant.

                                                  Versus

 

1. Star Health & Allied Insurance Company Limited through its Authorized Signatory, 1 New Tank Stree, Valluvar Kottam High Road, Nungambakkam, Chennai.

2. Star Health & Allied Insurance Company Limited through its Branch Manager, SCO 242, 1^st Floor, Sector-12, opp. Mini Secretariat, Karnal.  

                                                                                                                                                                        …..Opposite Parties.

 

           Complaint u/s 12 of the Consumer Protection Act. 

 

Before    Sh. Jaswant Singh……President. 

      Sh.Vineet Kaushik ………..Member

                Dr. Rekha Chaudhary…….Member

 

 Present:  Shri Deepak Sardana Advocate for complainant.

                   Shri Naveen Khaterpal Advocate for OPs.

 

                   (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 the complainant had purchased the Health Insurance Policy no.P/211114/2008/004282 by paying a premium amount of Rs.33700/-from the opposite parties (OPs).  The policy covered the complainant herself and her spouse Rakesh Kumar. The said policy was valid from 30.09.2017 to 29.09.2018 covering limit upto Rs.5 lakhs. The agent and the company both had offered the guarantee to the insured person to provide even cashless facilities in case of treatment of health care of any of the policy holder. The policy holder was insured for hospitalization expenses, pre-hospitalization and post-hospitalization expenses, ambulance cover, domiciliary hospitalization, health check-up, recharge of a sum insured, daily allowances. After issuance of the health policy on 30.09.2017 by the OP, the complainant’s husband Rakesh Kumar patient develop hoarseness of voice in mid October, 2017 and he was taken to the hospital “Amritdhara Hospital Private Limited Karnal” on 15.11.2017 and 17.11.2017. Doctors of that hospital have advised :-CECT NECK, DLS Biopsy, Tracheostomy and performed Laryngoscopy. The doctors diagnosed it to be a c/o change in voice.  As verbally advised by the treating doctor at Hospital Amritdhara, the patient was taken to Rajiv Gandhi Cancer Institute and Research Centre, Delhi on 21.11.2017 and advised MRI and Biopsy. As per the lab. report of tests conducted on 23.11.2017, a case of suspected Calarynx/Carcinoma Glottis. The patient was further tested on 6.12.2017. The treating doctor/hospital submitted the pre-authorization request with the Star Health and Allied Insurance Company Limited on 30.11.2017 for cashless facilities to be provided by the Insurance Company and the said claim Intimation no.CLI/2018/211114/00468802 and claim no.CLMG/2018/211114/0393896 were sent to the OPs but the OPs have refused to pay the claim and information was sent to complainant in this regard, vide letter dated 01.12.2017 and 4.12.2017. Briefing that his claim has been refused as per condition no.14 of the policy on the ground that the patient Rakesh Kumar has the pre-existing disease. After receiving the said letters complainant forwarded letter of Doctor Munish Gairola dated 6.12.2017 of Rajiv Gandhi Cancer Institute and Research Centre to the Insurance Company in which it was admitted by them (Rajiv Gandhi Cancer Institute and Research Centre) that “the duration of symptom is one month only. The duration of the symptom stated in our MRI report being 09 month was a typographical error”. The Rajiv Gandhi Cancer Institute and Research Centre also suitably amended the MRI report and replace the erroneous phrase nine months with one month. The complainant sent a letter dated 3.1.2018 and further sent an email on 5.1.2018 to the OPs. In reply dated 6.1.2018 the OPs replied that it is hereby declared and agreed that the policy in respect of Rakesh Kumar stands cancelled with effect from 13.01.2018 due to non-disclosure of PED-CA Glottis.  In consequence thereof the entire policy is cancelled and for the rest of the members, a separate policy is issued for the same period. Therefore, the difference premium is allowed as refund premium without any consent or acceptance from the complainant.  The patient had good health reached to the age of 58 years and was good in health at the time of getting the policy of OPs, then it cannot be taken that he had any pre-existing disease. In this way there was deficiency in service on the part of the OPs in repudiating the claim of the complainant on the false grounds. Hence complainant filed the present complaint.

2.             Notice of the complaint was given to the OPs, who appeared and filed written version raising preliminary objections with regard to jurisdiction; barred by limitation; mis-joinder and non-joinder of necessary parties; complainant is estopped by his own act and conduct from filing the present complaint and concealment of true and material facts. On merits, it is pleaded that the insured availed Star Comprehensive Insurance Policy, vide policy no.P/211114/01/2018/004282 for the period of 30.09.2017 to 29.09.2018 covering Sushma Sharma-self and her spouse for the sum insured of Rs.5,00,000/-. The claim was reported in the 4^th day of the policy. The insured was admitted at Rajiv Gandhi Cancer Institute and Research on 4.12.2017 for the treatment of Glottis Cancer and submitted pre-authorization request for cashless treatment. On perusal of the documents submitted by the treating hospital, it is observed that “As per Pre-Auth Form, the insured was diagnosed as CA Glotis Since 6-7 months. MRI Report dated 23.11.2017 shows patient has history of hoarseness of voice since 9 months, which indicates the patient is symptomatic prior to inception of policy and also not disclosed.”  Hence the cashless authorization was denied on the ground of non-disclosure of material facts and informed to the insured vide letter dated 1.12.2017. Lateron, the insured has submitted the treating doctor letter stating that duration of symptoms stated in MRI Report being 9 months is a typographical error. Hence the cashless was rejected vide letter dated 6.12.2017 stating that the corrected documents are not accepted. In consequences of the same, the policy in respect of Rakesh Kumar stands cancelled with effect from 13.01.2018-due to non-disclosure of PED-CA GLOTTIS. Hence, the entire policy is cancelled and the rest of the members, a separate policy is issued for the same period. Therefore, the difference premium (total premium less for new policy) is allowed as refund premium.  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.

3.             Complainant tendered into evidence her affidavit Ex.CW1/A and documents Ex.C1 to Ex.C31 and closed the evidence on 11.10.2018.

4.             On the other hand, the OPs tendered into evidence affidavit of Rajiv Jain Ex.RW1/A and documents Ex.R1 to Ex.R11 and closed the evidence on 28.1.2019.

6.             We have appraised the evidence on record, the material circumstances of the case and the arguments advanced by the learned counsel for the parties

7.             The case of the complainant is that he had purchased the Health policy by paying a hefty premium amount of Rs.33700/- for the policy, which would cover both the complainant and her spouse. The said policy was valid from 30.9.2017 to 29.09.2018, covering limit upto Rs.5 lakhs. In the mid of October, 2018 the complainant’s husband Rakesh Kumar develop hoarseness of voice and he was taken to “Amritdhara Hospital Pvt. Limited Karnal.” The doctors diagnosed it to be a c/o change in voice.  On the advised of concerned Doctor of Amritdhara Hospital, the patient was taken to Rajiv Gandhi Cancer Institute and Research Centre, Delhi. As per the lab. report of tests conducted on 23.11.2017, a case of suspected Calarynx/Carcinoma Glottis. The treating doctor/hospital submitted  the pre-authorization request with the OPs, on 30.11.2017 for cashless facilities but OPs have refused to authorize cashless treatment, vide letter dated 1.12.2017 and 4.12.2017. The claim has been refused on the ground that insured have not disclosed the pre-existing disease, which is not justified.

8.             On the other hand, the case of the OPs is that the insured availed Star Comprehensive Insurance Policy for the period of 30.09.2017 to 29.09.2018 covering Sushma Sharma-self and Rakesh Kumar spouse for the sum insured of Rs.5,00,000/-. The insured was admitted at Rajiv Gandhi Cancer Institute and Research on 4.12.2017 for the treatment of Glottis Cancer and submitted pre-authorization request for cashless treatment. On the perusal of the documents submitted by the treating Hospital, it is observed that : As per pre-Auth form, the insured was diagnosed as CA Glotis Since 6-7 months. MRI Report dated 23.11.2017 shows patient has history of hoarseness of voice since 9 months, which indicates the patient is symptomatic prior to inception of policy and also not disclosed. The entire policy is cancelled and for the rest of the members, a separate policy is issued for the same period. The difference premium (total premium less for new policy) is allowed as refund premium.

9.             Admittedly, the complainant and her husband namely Rakesh Kumar (patient) had purchased Star Comprehensive Insurance Policy, vide policy no.P/211114/01/2018/004282 for the period of 30.09.2017 to 29.09.2018 covering Sushma Sharma-self and her spouse Rakesh Kumar (patient)  for the sum insured of Rs.5,00,000/-. Complainant and her husband had paid Rs.33,700/- premium for the policy, which covered both he complainant and her spouse. The said policy was valid from 30.09.2017 to 29.09.2018, covering limit upto 5 lakhs. The claim of the complainant was repudiated by OPs on the ground that as per Pre-Auth Form the insured was diagnosed as CA Glotis Since 6-7 months and as per MRI report (Ex.R5) dated 23.11.2017 shows that patient has history of hoarseness of voice since a months.

10.            Further, counsel of the OPs argued that as per the pre-authorization form duly signed by the Hospital and MRI, it is observed that the insured has pre-existing disease and there would not be typo- error in both the documents. The insured has CA prior to the policy and the same was not disclosed in the proposal form. The claim of the complainant is not payable under clause 3 of the policy. As per clause 3 Exclusion: The company shall not be liable to make any payment under this policy in respect of any expenses what so ever incurred by the insured.

11.            Counsel of the complainant argued that as per MRI Report (Ex.C13) Clinical indication: Case of suspected Calarynx. Presents with hoarseness of voice since nine months has been shown by the concerned doctors but it was only typographically error and same error was rectified in (Ex.C21) in which concerned Hospital clearly mentioned that, actual duration of symptom is one month only and the duration of symptom stated in MRI report being 9 months was a typographical error.

12.            The claim of the complainant has been repudiated by the OPs on the basis of  MRI (Ex.C13 & Ex.R5) as patient is having pre-existing disease. Duration of symptom mentioned in MRI (Ex.C13 & Ex.R5) has been rectified by the concerned Hospital, vide letter (Ex.C20) from 9 months to one months. OPs have not rebutted the Ex.C20. Thus, we are of the confirmed view that acts of the OPs are amount to deficiency in service. The complainant produced the bill of Rs.19,81,392/- Ex.C29/1 to Ex.C29/67 but the sum insured amount is only Rs.5 lakhs. Hence the complainant is entitled for the sum insured amount only.

13.            Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay sum insured amount i.e. Rs.5,00,000/- to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OPs to pay Rs.15,000/- to the complainant for mental agony, physical harassment and towards litigation expenses. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:06.03.2019

                                                                       

                                                                  President,

                                                           District Consumer Disputes

                                                           Redressal Forum, Karnal.

               

        (Vineet Kaushik)          (Dr. Rekha Chaudhary)

            Member                               Member