Haryana

Karnal

CC/202/2020

Ved Parkash - Complainant(s)

Versus

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

Davinder Singh Choudhary

04 Aug 2022

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL  COMMISSION, KARNAL.

 

                                                          Complaint No. 202 of 2020

                                                          Date of instt.08.06.2020

                                                          Date of Decision 04.08.2022

 

Ved Parkash son of Shri Karori Mal, resident of old Anaj Mandi, Nissing, Sub Tehsil Nissing, District Karnal.

                                                …….Complainant.

                                              Versus

 

1.     Star Health and Allied Insurance Company Ltd. SCO 101, 102 & 103 2^nd floor, Batra Building, Sector-17-D, Chandigarh-160017, through its Divisional Manager.

 

2.     Star Health & Allied Insurance Company Ltd. IRDA Registration no.129, 2^nd floor, SCF Sector 13, Urban Estate, near ICICI Bank Karnal, through its Branch Manager.

 

                                                                      …..Opposite Parties.

 

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

      Dr. Rekha Chaudhary…..Member

       

 Argued by: Shri D.S. Chaudhary, counsel for the complainant.

                    Shri Naveen Khetarpal, counsel for the OPs.

 

                    (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 as to ‘OP’) on the averments that complainant purchased a mediclaim policy namely ”Family Health Optima Insurance Plan” from the OP, vide policy no.P/211114/01/2019/005326, valid from 28.09.2018 to 27.09.2019. In the month of September, 2019 the complainant fell ill and approached Fortis Memorial Research Institute Gurgram (Haryana) for the treatment of pain in bilateral legs with difficulty in walking and he was admitted in the said hospital on 06.09.2019 and his disease was diagnosed as “Acute Stroke with Neuropathy” on examination there was found-Blood pressure 120x80 mm Hg. Pulse Rate 80/min, confused drowsy, cardio Vascular system-SI, S2 heard, Chest-Bilateral clear, Abdomen Soft and the complainant was consulted with Dr. Praveen Gupta Department Neurology and was discharged from the Hospital on 10.09.2019. At the time of admission, the complainant informed the OP about the same so that the complainant to get treatment of the said disease and to pay the expenses of the hospital out of his own pocket and they assured the complainant that lateron, OPs would pay all expenses for the treatment to the complainant. On the assurance of the OPs, complainant paid Rs.3,03,709/-for the treatment of the abovesaid disease. Thereafter, complainant lodged his claim with the OPs to pay the abovesaid amount, but OPs did not pay the same and repudiated the claim of the complainant, vide letter dated 06.02.2020 on the ground of misrepresentation of facts regarding his pre-existing disease. The claim of the complainant has been repudiated by the OP illegally as the complainant started suffering from the abovesaid disease during the subsistence of the policy. The complainant never suffered from the abovesaid disease prior to the inception of the medical insurance policy. The complainant submitted all the requisite documents with the OPs as per their demands. In this way there is deficiency in service on the part of the OPs. Hence this complaint.

2.             On notice, OPs appeared and filed its 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 the Family Health Optima Insurance Covering Ved Parkash-self, Indra Devi-Spouse for the sum insured Rs.4,00,000/- for the first time, vide policy no.P/211114/01/2019/005326 for the period from 28.09.2018 to 27.09.2019. The terms and conditions of the policy were explained to the complainant alongwith the policy schedule. The complainant has accepted the policy agreeing the being fully aware of such terms and conditions and executed the proposal form.

That the insured in the 1^st year of the policy reported 2 claims vide claim no.CLI/2020/211114/0417839 & CLI/2020/21111/0469283 for reimbursement of Rs.1,43,542/- and Rs.72071/-, towards alleged hospitalization of Fortis Memorial Research Institute on 05.09.2019 and 21.09.2019 towards the treatment Acute Gastroentritis and Acute Stroke with Neuropathy-

.       It is observed that from the indoor case record dated 08.09.2019 of the above hospital that the insured patient is a case of HBsAg for the past 15 years;

.       The gastroscopy report dated 09.09.2019 shows cirrhosis of liver, (Cirrhosis is a late stage of scarring (fibrosis) of the liver caused by many forms of liver diseases and conditions, such as hepatitis and chronic alcoholism).

.   The findings of MRI report dated 07.09.2019 confirms old   hemorrhage in right basal ganglia and right frontal region, multiple small micro hemorrhages in bilateral cerebral hemisphere and brain stem; (Cerebral microbleeds (MBs) are small chronic brain hemorrhages which are likely caused by structural abnormalities of the small vessels of the brain).

 

Based on these findings, our medical team is of the opinion that the insured patient has the above chronic, longstanding diseases existing prior to inception of the first medical insurance policy. At the time of inception of the policy which is from 28.09.2018 to 27.09.2019, the insured has not disclosed the above mentioned medical history/health details of the insured-person in the proposal form which amounts to misrepresentation/non-disclosure of material facts. As per condition no.6 of the policy issued to complainant, if there is any misrepresentation/non-disclosure of material facts whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim. Hence, the claim for reimbursement of medical expenses was repudiated, vide letter dated 07.02.2020 and 27.02.2020. The insured person was suffering from all the above ailment prior to the commencement of policy and same was evident from the Indoor Case Papers and medical investigation reports submitted by the insured, whereas these facts were not disclosed at the time taking the policy which amounts to non-disclosure of materials. It is further pleaded that as per contract of insurance, it is the duty of the proposer to disclose all the material facts to the insurer so that the insurer evaluates the material facts and decide whether to accept the proposal or not, as the insurance contract is based on utmost good faith. In case of health insurance contracts, disclosure of health details are the material facts. Insured has to disclose all his past medical history in the proposal, which is material fact for issuing policy to the insured. Because of non-disclosure, the OP was deprived an opportunity to evaluate the risk and reject the proposal.  Further, as per condition no.12, the company may cancel this policy on grounds of misrepresentation, fraud, moral hazard, non-disclosure of material fact as declared in the proposal form and/or claim form at the time of claim and non-cooperation of the insured by sending the insured 30 days notice by registered at the insured person’s last known address. Thus, the policy was cancelled and same was communicated to the insured. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied by the OPs and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for complainant has tendered into evidence his affidavit Ex.C1, copies of bill of Fortis Memorial Research Institute Gurugram Ex.C2, copy of retail invoices Ex.C3 and Ex.C4, copies of bill of Fortis Memorial Research Institute Gurugram Ex.C5 to Ex.C20, copy of family health optima insurance plan Ex.C21 and closed the evidence on 28.04.2021 by suffering separate statement.

5.             On the other hand, learned counsel for OPs has tendered into evidence affidavit of Rajiv Jain Chief Manager Ex.RW1/A, copy of proposal form Ex.R1, copy of insurance policy Ex.R2, copy of terms and conditions of the insurance policy Ex.R3, copy of gazette notification Ex.R4, copy of letter to insured Ex.R5, copy of claim form Ex.R6 and Ex.R7, copy of discharge summary Ex.R8, copy of ills Ex.R9, copy of MRI report Ex.R10, copy of Gastro-Duodenoscopy Report Ex.R11, copy of progress note Ex.R12, copy of repudiation letter Ex.R13, copy of claim form Ex.R14, copy of discharge summary Ex.R15, copy of bill Ex.R16, copy of repudiation letter Ex.R17, copy of assessment sheet Ex.R18, copy of endorsement schedule Ex.R19, copy of letter to insured Ex.R20, copy of Dr. certificate Ex.R21 and closed the evidence on 06.10.2021 by suffering separate statement.

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

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant purchased a mediclaim insurance policy from the OP. In the month of September, 2019 the complainant fell ill and approached Fortis Memorial Research Institute Gurgram (Haryana) for the treatment of pain in bilateral legs with difficulty in walking and he was admitted in the said hospital on 06.09.2019 and was discharged on 10.09.2019. At the time of admission, the complainant informed the OPs about the said disease and to pay the expenses of the hospital i.e. Rs.3,03,709/-of his treatment. Thereafter, complainant lodged his claim with the OPs to pay the abovesaid amount, but OPs did not pay the same and repudiated the claim of the complainant, vide letter dated 06.02.2020 on the ground of misrepresentation of facts regarding his pre-existing disease. The OPs have illegally repudiated the claim of the complainant as the complainant had suffered from the abovesaid disease during the subsistence of the policy. The complainant never suffered from the abovesaid disease prior to the inception of the medical insurance policy and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued the insured availed the Family Health Optima Insurance covering complainant himself and his spouse for the sum insured Rs.4,00,000/-. The insured reported 2 claims vide claims for reimbursement of Rs.1,43,542/- and Rs.72071/-, towards alleged hospitalization of Fortis Memorial Research Institute on 05.09.2019 and 21.09.2019 towards the treatment Acute Gastroentritis and Acute Stroke with Neuropathy. He further argued that on the opinion of medical team that the insured patient has the above chronic, longstanding diseases existing prior to inception of the first medical insurance policy. At the time of inception of the policy, the insured has not disclosed the above mentioned medical history. He further argued that the claim for reimbursement of medical expenses was rightly repudiated, vide letter dated 07.02.2020 and 27.02.2020 and lastly prayed for dismissal of the complaint.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, the complainant purchased a mediclaim policy namely ”Family Health Optima Insurance Plan”, from the OPs. It is also admitted during the subsistence of the insurance policy, complainant fell ill and taken the treatment from Fortis Memorial Research Institute, Gurugram and disease was diagnosed as “Acute Gastroentritis and Acute Stroke with Neuropathy”.

11.           The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.R13 dated 07.02.2020 and Ex.R17 dated 27.02.2020 on the grounds, which reproduced as under:-
Ex.R13-

“our medical team has perused your representation and has noted the contents. The team which re-examined the claim records has observed from the indoor case record dated 08.09.2019 of the above hospital that th e insured patient is a case of HBs-Ag for the past 15 years, the findings of MRI report dated 07.09.2019 confirms old hemorrhage in right basal ganglia and right frontal region, multiple small microhemorrhages in bilateral cerebral hemisphere and brain stem, the gastroscopy report dated  09.09.2019 shows cirrhosis of liver. Based on these findings, our medical team is of the opinion that the insured patient has the above chronic, longstanding diseases existing prior to inception of the first medical insurance policy. Hence the claim is not admissible as per condition no.6 of the above policy issued to you and cancellation of policy invoking condition no.12 is in order. The clarification now given by the insured is not acceptable.

We are therefore unable to consider your claim favourably under the above policy and we inform you that repudiation of your claim is in order.

Ex.C17-

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

Although the present admission of the insured patient is for treatment of acute gastroenteritis, it is observed from the indoor case record dated 08.09.2019 of the above hospital submitted vide our claim no.CLI/2020/211114/ 0417839 that the insured patient is a case of HBsAg for the past 15 years, the findings of MRI report dated 07.09.2019 confirms old hemorrhage in right basal ganglia and right frontal region, multiple small microhemorrhages in bilateral cerebral hemisphere and brain stem; the gastroscopy report dated 09.09.2019 shows cirrhosis of liver. Based on these findings, our medical team is of the opinion that the insured patient has the above chronic longstanding disease existing prior to inception of the first medical insurance policy.

At the time of inception of your policy which is from 28.09.2018 to 27.09.2019, you have not disclosed the above mentioned medical history/health details of the insured person in the proposal form which amounts to misrepresentation/non-disclosure of material facts.

As per condition no.6 of the policy issued to you, if there is any misrepresentation/non-disclosure of material facts whether by the insured person or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim.

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

 

The claim of the complainant has been repudiated by the OPs on the ground that complainant was having chronic, longstanding disease existing prior to inception of the first medical insurance policy.

12.           The onus to prove its version relied upon the OPs but OPs have miserably failed to prove its version by leading any cogent and convincing evidence. OPs have relied upon the MRI report Ex.R10 dated 07.09.2019 wherein it has been mentioned that old hemorrhage in right basal ganglia and right frontal region. Multiple small microhemorrhages in bilateral cerebral hemisphere and brain stem. OPs further relied upon Gastro Duodenoscopy report Ex.R11 dated 09.09.2019 wherein it has been mentioned that Indication? Cirrhosis of liver.

13.           No doubt, as per report of MRI Ex.R10, complainant was having old hemorrhage in right basal ganglia and right frontal region. Multiple small microhemorrhages in bilateral cerebral hemisphere and brain stem but complainant has approached the hospital of Fortis Memorial Research Institute, Gurugram for the treatment of pain in bilateral legs with difficulty in walking. This fact is also proved from the statement of Amit Goel Ex.R5. Hence, it has been proved on record that complainant has taken the treatment of pain in bilateral legs with difficulty in walking. Except the report of MRI, no other documents have been placed on file by the OPs to prove that complainant was having any disease prior to inception of the insurance policy. This fact with regard to having brain disease firstly came in the knowledge of the complainant when he went for treatment for bilateral pain in legs. Hence question of concealment of any pre existing disease does not arise at all. Furthermore, there is no nexus between the disease mentioned in Ex.R10 and Ex.R11 and present disease for which complainant has lodged the claim with the OP, then the claim of the complainant cannot be repudiated.

14.  

                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.

 15.          Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OPs while repudiating the claim of the complainant amounts to deficiency, which is otherwise proved genuine one. 

16.           The complainant claimed Rs.3,03,709/- but he has placed on record medical bills Ex.C2 to Ex.C20 amounting to Rs.2,54,708/-. Hence, the complainant is entitled for the amount of Rs.2,54,708/- alongwith interest, compensation for mental harassment and litigation expenses etc.

17.           Thus, as a sequel to abovesaid discussion, we partly allow the present complaint and direct the OPs to pay Rs.2,54,708/- (Rs. two lakhs fifty four thousand seven hundred eight only) 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.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 with 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:04.08.2022.

                                                                       

                                                        President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

       

                (Vineet Kaushik)        (Dr. Rekha Chaudhary)      

                      Member                        Member