DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, BARNALA, PUNJAB.
Complaint Case No: CC/21/2024
Date of Institution: 27.02.2024
Date of Decision: 14.10.2024
1. Satish Kumar aged about 42 year son of Hem Raj;
2. Mamta Rani aged about 41 year, wife of Satish Kumar son of Hem Raj, both residents of #43, Ward No. 13, Gaushala Bhawan Street, Water Works Road, Mansa.
…Complainants
Versus
1. Star Health and Allied Insurance Company Ltd., No. 15, Sri Balaji Complex, 1st Floor, Whites Lane, Roy Apettah, Chennai-600014, through its Authorized Signatory.
2. Star Health and Allied Insurance Company Ltd., Pakka College Road, Near PNB Bank, Handiaya Bazar Branch Barnala through its Branch Manager.
…Opposite Parties
Complaint Under Section 35 of the Consumer Protection Act, 2019.
Present: Ms. Himani Bansal Adv counsel for complainant.
Sh. Romi Sharma Adv counsel for opposite parties.
Quorum.-
1. Sh. Ashish Kumar Grover: President
2. Smt. Urmila Kumari : Member
3. Sh. Navdeep Kumar Garg : Member
(ORDER BY ASHISH KUMAR GROVER PRESIDENT):
The complainants have filed the present complaint under Section 35 of the Consumer Protection Act 2019 against Star Health and allied Insurance Company Limited & others (in short the opposite parties).
2. The facts leading to the present complaint are that the complainant No. 1 Satish Kumar purchased one Health Insurance Policy named as Family Health Optima Insurance Plan vide policy No. P/211229/01/2023/000569 from the opposite party No. 2 for the period from 5.7.2022 to 4.7.2023 in which the complainant No. 1 and his wife and two children are insured for Rs. 5,00,000/- plus bonus of Rs. 1,25,000/- for the next one year for any type of ailment and medical need. Thus, the total limit of coverage is of Rs. 6,25,000/-. It is further alleged that prior to the said policy complainant No. 1 had also previously purchased the same policy in the last year which was valid from 3.7.2021 to 2.7.2022. It is further alleged that in the month of May 2023, complainant No. 2 Mamta Rani suffered from problem and she went for checkup in the empaneled hospital of the opposite parties named Medanta-The Medical Unit of Global Health Private Limited, Gurugram where the hospital conducted medical tests and complainant No. 2 was diagnosed with incidentally detected left renal mass and thus, nephrectomy was suggested by the doctors. It is further alleged that the complainant No. 2 was got admitted in the hospital on 17.5.2023 where she remained admitted from the period from 17.5.2023 to 23.5.2023 and was treated for Left Hilar Renal Mass. The said treatment was started by the doctors with the prior authorization, because the policy purchased by the complainant was cashless and an amount of more than Rs. 8,00,000/- was charged by the said hospital which was paid by the complainant in spite of cashless policy. The complainants approached the opposite parties for submission of claim documents and after completion of all required documents which were accepted by opposite parties for the total claim amount of Rs. 6,25,000/- a claim information No. CIR/2024/211229/0189501 of the said claim and the opposite parties assured that the same will be paid very soon. It is further alleged that the opposite parties have rejected the genuine claim of the complainants vide letter dated 19.7.2023 by mentioning that “It is observed from the submitted medical records and investigation report shows chronic longstanding in nature. Based on the available records our medical team is of the opinion that the insured patient has undergone treatment for above chronic longstanding disease, which is prior to inception of medical insurance policy. At the time of inception of your policy which is from 3.7.2021 to 2.7.2022 you have not disclosed the above mentioned medical history/health details of the insured person in the proposal form which amount to misrepresentation/non-disclosure of material facts”. It is further alleged that the complainant No. 2 has not underwent any alleged renal surgery nor she has any documents regarding the same. The complainants have also sent a legal notice dated 24.7.2023 but opposite parties have not replied the said notice. As such, the act and conduct of the opposite parties comes within the definition of the unfair trade practice as well as deficiency in service. Hence, the present complaint is filed for seeking the following reliefs.-
- The opposite parties may be directed to release the claim amount of Rs. 6,25,000/- alongwith interest @ 18% per annum from the date of admission in hospital i.e. 17.5.2023 till realization and release the claim amount of Rs. 1,13,372/- alongwith interest @ 18% per annum from the date of admission in hospital i.e. 24.8.2023 till realization
- To pay Rs. 1,00,000/- towards mental tension and harassment.
- Further, to pay Rs. 22,000/- as litigation expenses.
3. Upon notice of this complaint, the opposite parties appeared and filed written version by taking legal objections interalia on the grounds that the complainants have no cause of action and no locus-standi to file the present complaint. The present complaint is not legally maintainable. The complainants have not come with clean hands. The complainants have concealed material facts from this Commission.
4. On merits, it is admitted that the complainants have availed the Family Health Optima Insurance plan covering complainant himself and his wife Mamta Rani (Spouse) PALAK GARG and YUV GARG (Dependent Child) for the sum insured Rs. 5,00,000/- vide policy No. P/211229/01/2023/000569 which is valid from 05.07.2022 04.07.2023. Previously the insured has taken the policy no. P/211229/01/2022/000411 for the period from 03.07.2021 to 02.07.2022. The terms and conditions of the above said policy was supplied to the complainants along with insurance policy. It is further alleged that as per claim form the insured file claim for the treatment of complainant no. 2 and the insured requested the opposite parties for cashless and submitted the medical expenses bills of complainant no.2 for hospitalization on 17.05.2023 to 23.05.2023 in towards the treatment of MEDANTA THE MEDCITY GURGAON towards the treatment of LEFT HILAR RENAL MASS. It is alleged that the answering opposite parties rejected the cashless claim and told the insured that opposite parties are unable to ascertain the admissibility at the cashless level and said to the insured that kindly submit for reimbursement with complete workup. It is further alleged that the insured applied for one cashless claim i.e. claim No. CIR/2024/211229/0120204 for admission of Mamta Rani in Max Super Specialty Hospital from 28.04.2023 and diagnosed RENAL MASS and a query letter dated 26.04.2024 sent to the insured to furnish duration of illness and first consultation report and investigation of fibroid and to provide revert with first consultation paper of UTRINE FIBROIDS before Jan., 2022. After that there was no communication made by insured or hospital and the claim is still open for the want of above mentioned documents. It is alleged that after that insured has not approached the opposite parties for reimbursement. Two claims of complainant no. 2 Mamta Rani were registered and both are unpaid. The complainant no. 2 Mamta Rani deleted from the policy due to non-disclosure of PED but the policy is already expired before risk deletion. It is further alleged that from the submitted medical records and investigation report it clearly shows chronic longstanding in nature. Based on the available records our medical team is of the opinion that the insured patient has undergone treatment for above chronic longstanding disease, which is prior to inception of medical insurance policy. At the time of inception of policy of insured which is from 03.07.2021 to 02.07.2022, 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.1 of the policy issued to insured, the policy shall become void and all premium paid thereon shall be forfeited to the Company, in the event of mis-representation, mis- description or nondisclosure of any material fact by the policy holder. As per Condition No.7, the policy is also liable to be cancelled and necessary action will be taken by opposite parties. Hence, the claim was rejected by them and the same was informed to insured vide letter dated 19.07.2023. It is further alleged that the insured has not lodged any claim with regard to any surgery of complainant no.2 from Nitin Hospital Patiala and the complainant no.2 got admitted in Nitin Hospital Patiala from 24.08.2023 to 26.08.2023 and spent Rs. 1,13,372/- on said treatment. The opposite parties have excluded the name of complainant no. 2 from the policy as per terms and conditions of the insurance policy. All other allegations of the complaint are denied and prayed for the dismissal of complaint.
5. Ld. Counsel for complainants on 12.6.2024 suffered the statement that I do not want to file any rejoinder against the version of opposite parties.
6. To prove the case the complainants tendered into evidence affidavit of complainant as Ex.C-1, copy of policy as Ex.C-2 (4 pages) from 5.7.22 to 4.7.23, copy of policy as Ex.C-3 (4 pages) from 5.7.23 to 4.7.24, copy of OPD Notes of Medanta Hospital as Ex.C-4 (7pages), copy of Radiology report as Ex.C-5 (2 pages), copy of Pet CT Scan as Ex.C-6 (2 pages), copy of discharge summary of Medanta Hospital as Ex.C-7 (5 pages), copy of certificate of Dr. Gagan Gautam as Ex.C-8, copies of bills and receipts are Ex.C-9 (15 pages), copy of discharge summary of Nitin Hospital as Ex.C-10, copies of bills and receipts are Ex.C-11 (15 pages), copy of repudiation letter as Ex.C-12 (2 pages), copy of legal notice as Ex.C-13, copies of postal receipts are Ex.C-14 & C-15 and closed the evidence.
7. To rebut the case the opposite parties tendered into evidence affidavit of Sumit Kumar Sharma Senior Manager as Ex.OPs-1, copy of Proposal form as Ex.Ops-2 (4 Pages), copy of Insurance policy as Ex.OPs-3 (4 Pages), copy of Term and Condition as Ex-OPs-4 (6 Pages), copy of request for cash less treatment as Ex.OPs-5 (4 Pages), copy of denial of request as Ex.OPs-6 (3 Pages), copy of claim form OPs-7 (5 Pages), copy of discharge summary as OPs-8 (5 Pages), copy of medical report OPs-9 (5 Pages), copy of OPD report OPs-10, copy of tax invoice OPs-11 (12 Pages), copy of repudiation of claim OPs-12 (3 Pages) and closed the evidence.
8. We have heard the learned counsel for the parties and have gone through the record on the file. Written arguments filed by opposite parties.
9. It is admitted case of the opposite parties that that the complainants have availed the Family Health Optima Insurance plan covering complainant himself and his wife Mamta Rani (Spouse) PALAK GARG and YUV GARG (Dependent Child) for the sum insured Rs. 5,00,000/- vide policy No. P/211229/01/2023/000569 which is valid from 05.07.2022 04.07.2023. Previously the insured has taken the policy no. P/211229/01/2022/000411 for the period from 03.07.2021 to 02.07.2022 (as per Ex.C-2 & Ex.O.Ps-3).
10. Ld. Counsel for the complainants argued that in the month of May 2023, complainant No. 2 Mamta Rani suffered from problem and she went for checkup in the empaneled hospital of the opposite parties named Medanta-The Medical Unit of Global Health Private Limited, Gurugram where the hospital conducted medical tests and complainant No. 2 was diagnosed with incidentally detected left renal mass and thus nephrectomy was suggested by the doctors. It is further argued that the complainant No. 2 was got admitted in the hospital on 17.5.2023 where she remained admitted from the period from 17.5.2023 to 23.5.2023 and was treated for Left Hilar Renal Mass (as per Ex.C-7). It is further argued that the said treatment was started by the doctors with the prior authorization because the policy purchased by the complainant was cashless and an amount of more than Rs. 8,00,000/- was charged by the said hospital which was paid by the complainant in spite of cashless policy. It is further argued that the complainants approached the opposite parties for submission of claim documents and after completion of all required documents which were accepted by opposite parties for the total claim amount of Rs. 6,25,000/- a claim information No. CIR/2024/211229/0189501 of the said claim was generaged and the opposite parties assured that the same will be paid very soon. It is further argued that the opposite parties have rejected the genuine claim of the complainants vide letter dated 19.7.2023 Ex.C-12 by mentioning that “It is observed from the submitted medical records and investigation report shows chronic longstanding in nature. Based on the available records our medical team is of the opinion that the insured patient has undergone treatment for above chronic longstanding disease, which is prior to inception of medical insurance policy”. It is further argued that the complainant No. 2 has not underwent any alleged renal surgery nor she has any documents regarding the same. The complainants have also sent a legal notice dated 24.7.2023 Ex.C-13 but opposite parties have not replied the said notice.
11. On the other hand, Ld. Counsel for the opposite parties argued that as per claim form the insured file claim for the treatment of complainant No. 2 and the insured requested the opposite parties for cashless and submitted the medical expenses bills of complainant No.2 for hospitalization on 17.05.2023 to 23.05.2023 in towards the treatment of MEDANTA THE MEDCITY GURGAON towards the treatment of LEFT HILAR RENAL MASS. It is further argued that the opposite parties rejected the cashless claim and told the insured that opposite parties are unable to ascertain the admissibility at the cashless level and said to the insured that kindly submit for reimbursement with complete workup. It is further argued that the insured applied for one cashless claim i.e. claim No. CIR/2024/211229/0120204 for admission of Mamta Rani in Max Super Specialty Hospital from 28.04.2023 and diagnosed RENAL MASS and a query letter dated 26.04.2024 sent to the insured to furnish duration of illness and first consultation report and investigation of fibroid and to provide revert with first consultation paper of UTRINE FIBROIDS before Jan., 2022 and after that there was no communication made by insured or hospital and the claim is still open for the want of above mentioned documents. It is argued that after that insured has not approached the opposite parties for reimbursement. It is further argued that two claims of complainant No. 2 Mamta Rani were registered and both are unpaid and the complainant No. 2 Mamta Rani deleted from the policy due to non-disclosure of PED but the policy is already expired before risk deletion. It is further argued that from the submitted medical records and investigation report it clearly shows chronic longstanding in nature and based on the available records the medical team is of the opinion that the insured patient has undergone treatment for above chronic longstanding disease, which is prior to inception of medical insurance policy and at the time of inception of policy of insured which is from 03.07.2021 to 02.07.2022, 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. It is further argued that as per Condition No.1 of the policy issued to insured the policy shall become void and all premium paid thereon shall be forfeited to the Company, in the event of mis-representation, mis- description or nondisclosure of any material fact by the policy holder. It is argued that as per Condition No.7, the policy is also liable to be cancelled and necessary action will be taken by opposite parties, hence the claim was rejected by them and the same was informed to insured vide letter dated 19.07.2023 Ex.O.Ps-12. It is further argued that the insured has not lodged any claim with regard to any surgery of complainant No.2 from Nitin Hospital Patiala and the complainant No.2 got admitted in Nitin Hospital Patiala from 24.08.2023 to 26.08.2023 and spent Rs. 1,13,372/- on said treatment.
12. It is the specific case of the opposite parties that the insured had pre-existing disease and this fact has not been disclosed by the insured/complainant at the time of filing the proposal form or at the time of purchasing the policy which amounts to misrepresentation/non-disclosure of material facts. It is further argued that as per Condition No.1 & 7 of the policy issued to insured the policy shall become void and all premium paid thereon shall be forfeited to the company in the event of mis-representation, mis-description or nondisclosure of any material fact by the policy holder the policy is also liable to be cancelled, hence the claim was rejected by them and the same was informed to insured vide letter dated 19.07.2023 Ex.O.Ps-12. We have gone through the repudiation letter dated 19.7.2023 Ex.O.Ps-12 vide which it is mentioned that “It is observed from the submitted medical records and investigation report shows chronic longstanding in nature. Based on the available records our medical team is of the opinion that the insured patient has undergone treatment for above chronic longstanding disease, which is prior to inception of medical insurance policy”. On the other hand, Ld. Counsel for the complainants argued that the insured has suffered from the above said problem in the month of May 2023 and in this regard the complainant No. 2 was got admitted on 17.5.2023 where she remained admitted from 17.5.2023 to 23.5.2023 and was treated for Left Hilar Renal Mass. The complainants to prove this fact have placed on record copy of certificate of doctor of Medanta who treated the complainant No. 2 i.e. Ex.C-8 vide which it is mentioned that “This is to certify that the patient Mrs. Mamta Rani, 42 years old/Female, Patient ID: MM02522093 was a diagnosed with incidentally detected left renal mass. She underwent Left robot assisted partial nephrectomy on 18.05.2023 and was discharged today 23.05.2023. In view of complex left renal tumor. In patient's case (endophytic and hilar location of the tumor) with increased risk of bleeding and conversion to radical nephrectomy, it was preferable and better option to proceed with robotic approach Instead of open or laparoscopic approach. Using robotic approach she had an earlier recovery, there was no need to conversion to radical nephrectomy or open approach hence justifying the robotic approach”. Moreover, we have gone through the Discharge Summary of Patient Mamta Rani of Medanta Ex.C-7 vide which in the Past History mentioned as “Hypertension” and Diagnosis & Co-morbidities mentioned “LEFT HILAR RENAL MASS”. We have also gone through the Discharge Record/Normal Summary of Patient Mamta Rani of Nitin Hospital, Patiala Ex.C-10 vide which in Past History it is mentioned as “laproscopic cholecystectomy, nephrectomy, hypertension”. So, from the perusal of the above said certificate of doctor who treated the insured Mamta Rani Ex.C-8, Discharge Summary of Medanta Ex.C-7 and Discharge Record of Nitin Hospital, Patiala Ex.C-10 it revealed that there is nowhere mentioned that the insured Mamta Rani had any pre-existing disease prior to inception of medical insurance policy as alleged by the opposite parties. Further, the opposite parties (insurance company) have failed to place on record any cogent evidence to prove that they have medically examined the insured at the time of filling the proposal form or at the time of issuing the policy. Further, in the proposal form placed on record by the opposite parties Ex.O.Ps-2 in the column of Health History it is mentioned “None” from which it shows that at the time of issuing the insurance policy in question to the insured/complainant No. 2 the opposite parties have not conducted any medical examination of the insured. So, at this stage how the opposite parties could have raised the objection that the insured had pre-existing disease prior to the policy inception date. We are of the view that it was in the hands of insurance company to see and not to issue the policy where person is not entitled to claim on account of treatment of Pre-existing disease. So, we are of the view that at this stage the opposite parties cannot be escaped from their liabilities by raising these types of unreasonable and unjustified grounds. The learned counsel for the complainant also relied upon the judgment of the Hon'ble Punjab and Haryana High Court (DB) 2012 (1) RCR (Civil)-901 in which the Hon'ble High Court 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. Single judge allowed the claim on the ground that 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. No interference called for in the order of Single Judge. Held the pre-existing condition existed in the year 2002 which was five years prior to acquiring Insurance Policy. Claim cannot be denied. The opposite parties specifically relied upon the proposal but despite ample opportunities of evidence the opposite parties failed to produce the proposal form to support their version.
13. On the other hand, Ld. Counsel for the complainant further argued that the terms and conditions were not supplied to the complainant alongwith policy, therefore the same are not part of contract. We have carefully gone through the copies of policy placed on record by the complainant for the period from 5.7.2022 to 4.7.2023 and for the period from 5.7.2023 to 4.7.2024 i.e. Ex.C-2 & Ex.C-3 which are containing 4 pages and the terms and conditions are not the part of the policy in question. On the other hand, the opposite parties have failed to place on record any postal receipt or any document to prove that they have supplied the terms and conditions of the policy to the insured/complainant alongwith policy in question. Moreover, the opposite parties have also placed on record copy of insurance policy for the period 5.7.2022 to 4.7.2023 i.e. Ex.O.Ps-3 which is also containing 4 pages and the terms and conditions of the policy are not the part of insurance policy. Therefore, the terms and conditions on which the opposite parties have relied upon are not part of the contract. The Hon'ble Supreme Court of India titled Modern Insulators Limited Versus Oriental Insurance Company Limited reported in 2000(1) CPC-596 in which Hon'ble Supreme Court held that “As the above terms and conditions of the standard policy wherein the exclusion clause was included, were neither a part of the contract of insurance nor disclose to the appellant, respondent cannot claim the benefit of the said exclusion clause.” The Hon’ble Supreme Court of India (2019) 6 SCC 212 in case titled Bharat Watch Company Through its Partner Vs National Insurance Company Limited held that “Conditions of exclusion under policy document not handed over to insured by insurer and in absence of insured being made aware of terms of exclusion, held, it is not open to insurer to rely upon exclusionary clauses”.
14. From the above discussion, it is proved that the claim of the complainant No. 2/insured was declined by the opposite parties on unreasonable and unjustified grounds and there is clear cut deficiency in service and unfair trade practice on the part of opposite parties.
15. The complainants to prove their claim have placed on record copies of bill and receipts Ex.C-9 (containing 15 pages) which shows that Rs. 6,06,916.66/- has been spent on the treatment of complainant No. 2 in Medanta Hospital for the period from 17.5.2023 to 23.5.2023 and the complainants have also placed on record copies of bills and receipts Ex.C-11 (containing 15 pages) which shows that Rs. 1,10,972/- has been spent on the treatment of complainant No. 2 in Nitin Hospital, Patiala for the period from 24.8.2023 to 26.8.2023. However, in the present complaint the complainants have alleged that more than Rs. 8,00,000/- has been spent on the treatment of complainant No. 2 but in the relief the complainants have claimed for Rs. 6,25,000/- as per insurance policy. The complainants have produced the repudiation letter dated 19.7.2023 as Ex.C-12. It is clearly mentioned on the 2nd page of the said repudiation letter that;
“As per Condition No. 1 of the policy issued to you, the policy shall become void and all premium paid thereon shall be forfeited to the Company, in the event of mis-representation, misdescription of non-disclosure of any material fact by the policy holder. As per Condition No. 7, the policy is also liable to be cancelled and necessary action will be taken by our Corporate Office”.
From the above said repudiation letter the complainants were conveyed by the opposite parties that the policy had become void. The second treatment from Nitin Hospital, Patiala was taken by the complainant No. 2 from 24.8.2023 to 26.8.2023. As per repudiation letter Ex.C-12 on the date of second treatment the policy was not exists and the complainant No. 2 was not insured under the said policy. Neither the complainants have challenged the above said repudiation letter Ex.C-12 nor sought any relief regarding the cancellation of the policy in question. Therefore, the second time treatment taken by the complainant No. 2 from Nitin Hospital, Patiala is not covered under the policy in question. So, by not settling the 1st treatment genuine claim of the complainants the opposite parties are deficient in service and unfair trade practice on the part of the opposite parties.
16. In view of the above discussion, the present complaint is partly allowed and the opposite parties are directed to pay an amount of Rs. 6,06,916.66/- alongwith interest @ 7% per annum from the date of filing the present complaint till its actual realization to the complainant. The opposite parties are further directed to pay Rs. 10,000/- on account of compensation for causing mental torture, agony and harassment suffered by the complainant and Rs. 5,000/- as litigation expenses to the complainant. Compliance of this order be made within the period of 45 days from the date of the receipt of the copy of this order. Copy of the order be supplied to the parties free of costs. File be consigned to the records after its due compliance.
ANNOUNCED IN THE OPEN COMMISSION:
14th Day of October, 2024
(Ashish Kumar Grover)
President
(Urmila Kumari)
Member
(Navdeep Kumar Garg)
Member
