Delhi

North

RBT/CC/245/2022

VIJAY KUMAR - Complainant(s)

Versus

STAR HEALTH & ALLIED INSURANCE COMPANY LTD - Opp.Party(s)

24 Apr 2023

ORDER

District Consumer Disputes Redressal Commission-I (North District)

[Govt. of NCT of Delhi]

Ground Floor, Court Annexe -2 Building, Tis Hazari Court Complex, Delhi- 110054

 

RBT/CC No/245/2022

In the matter of

Vijay Kumar

S/o Sh.Shiv Ram Singh

R/o Plot No.824, Flat No.1,

Second floor, Mangal Bazar Road

Indira Vihar, near CNG Petrol pump,

Khora Colony, Ghaziabad (U.P)                                      ……Complainant

 

Versus

Star Health & Allied Insurance Company Ltd.

Through Branch Manager

Unit No.709-710, 7^th floor,

GD ITL North Tower

A-09, Netaji Subhash Palace, Pitampura

New Delhi-110034                                                                   …Opposite Party

                                                      

 

ORDER
24/04/2023

Ms.Harpreet Kaur Charya, Member

The present complaint has been received by way of transfer vide order No.F.1/SCDRC/Admn./Transfer/2022/330 dated 16/04/2022 of Hon’ble Delhi State Consumer Dispute Redressal Commission where the matter was transferred from DCDRC-V (North West) to this Commission. 

1. This complaint has been filed by Sh.Vijay Kumar under Section 12 of the Consumer Protection Act, 1986 against Star Health & Allied Insurance Company Ltd. with the allegations of deficiency in services and unfair trade practice.
2. Briefly stated the facts of the present complaint are that the complainant had taken Family Health Optima Insurance Plan bearing No.P/161211/01/2018/008057 for a period  20/01/2018 to 19/01/2019 with a Basic floater sum insured of Rs. 4,00,000/-.  The complainant along with his wife, son and two daughters were also the insured under the above-mentioned policy.
3. On 04/03/2018, the complainant was admitted in Metro Hospital and Heart Institute, Noida and was discharged on 07/03/2018. It has been stated by the complainant that inspite, of having cashless medical policy, he was compelled to pay the expenses incurred for treatment as his pre-authorisation for cashless treatment was rejected by the OP. Thus, he had to pay the total expenses of Rs.36,109/- incurred on his  treatment .  Thereafter, the claim for reimbursement along with relevant document was filed with OP, which has not been released on one pretext or the other.
4. The complainant received a Repudiation letter dated 02/05/2018, where the claim of the complainant had been rejected on the ground of Condition 3. ‘Waiting period’ stating that the company was 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 20/01/2018.
5. The complainant has alleged that despite several requests/visits the claim for reimbursement was not settled, which has caused great mental tension, agony, harassment, inconvenience and loss.  Feeling aggrieved by the act/omission on the part of OP, the complainant has prayed for directions to OP to release the claim amount of Rs.36,109/- along with interest @24% p.a.; compensation of Rs.2,00,000/- on account of mental agony, physical harassment and Rs.15,000/- as cost of litigation.   
6.  The complainant has annexed the policy document for the period from 20/01/2018 to 19/01/2019 as Annexure A, Discharge Summary dated 07/03/2019 as Annexure B1, Claim form as Annexure C1, copy of bills as Annexure C1 to Annexure C6 and Repudiation letter 02/05/2018 as Annexure D1.
7. Notice of the present complaint was served upon OP.  Thereafter Written Statement was filed on their behalf.
8. The issuance of policy bearing No.P/161211/01/2018/008057 has been admitted.  It has been submitted that in the second month of above-mention policy, the complainant was hospitalised so pre-authorisation request for cashless treatment was raised but the same was denied vide letter dated 06/03/2018 on the ground that as per the medical record the disease/condition was of long standing nature and had not been disclosed in the proposal form.
9. It has been admitted that a claim for reimbursement was filed and as per the Discharge summary, it was found that the complainant was admitted with the complaint of high grade fever, vomiting with poor oral intake for 5 days and was diagnosed with Left Pleural Effusion- Tubercular. An X-ray chest report dated 05/03/2018 showed homogeneous Opacification in Left lower and middle Zone and along left lateral chest wall, left CP angle and left heart border indicating Pleural Effusion and left hila obscured.  Thus, based on the above findings it was confirmed that the complainant was suffering from long standing lung disease which takes more than two month to develop, so, it was prior to the inception of medical insurance policy thus it was a pre-existing disease. 
10. As per Condition 3, of the policy terms and conditions ‘Waiting Period (III)’ the OP was not liable to make any payment in respect to expenses incurred for the treatment of the pre-existing disease/condition until 48 months of the continuous coverage had elapsed since the inception of the policy date i.e 20/01/2018.  The claim was repudiated and communicated to the complainant vide letter dated 02/05/2018. 
11. They have further submitted that in case the Commission found OP liable to pay the claim, then without conceding and prejudice to their submissions,  the maximum quantum of liability under the terms of the policy may be limited to Rs. 32,671/- as the policy issued to the complainant is governed by limits of liability as per various clauses. Rest of the contents of the complaint have been denied with the prayer for dismissal of the present complaint with exemplary cost. 
12. The copy of the request for cashless hospitalization for medical insurance, Field Visit Report (FVR) dated 06/03/2018, query on pre-authorisation, denial of pre-authorisation for cashless treatment, Claim form dated 18/03/2018, Discharge summary dated 07/03/2018, Examination reports and bills, Repudiation letter dated 02/05/2018, Common proposal form dated 16/01/2018 along with terms and conditions have been annexed with the written statement.
13. Rejoinder to the Written Statement of OP was filed by the complainant, where the contents of the complaint have been reaffirmed and those of the written statement have been denied. 
14. Evidence by way of affidavit was filed by the complainant, where the averments made in the complaint have been reiterated.  The complainant has relied upon the documents annexed with the complaint and has got them exhibited.   The mediclaim policy as Ex.CW-1/A, the discharge summary and bills are Ex.CW-1/B-1, B-2 and Ex.CW-1/C-1 to C-6 respectively. The Repudiation letter dated 02/05/2018 has been exhibited as Ex.CW-1/D-1, D-2.
15. Sh.P.C.Tripathi, Zonal Manager was examined on behalf of OP. The contents of the written statement have been repeated in the evidence by way of affidavit.  They have also relied upon the documents annexed with their Written Statement. 
16. We have heard the submission made by the Ld. Counsel for the complainant and the Ld. Counsel for the OP and have perused the material placed on record and the written arguments filed on behalf of both the parties. The complainant is aggrieved by the repudiation of his claim for reimbursement of medical expenses of Rs.36,197/- by OP ,on the ground that the same was not payable as per    Condition 3 of the policy terms and conditions as there was a waiting period of 48 months from the date of inception of policy i.e 20/01/2018.
17. As per the Discharge Summary (Ex.CW-1/B-1, B-2), the complainant was admitted to Metro Multi-speciality hospital, Noida on 04/03/2018, with the complaint of high grade fever, vomiting with poor oral intake for 5 days. If we look at the ‘Significant Past medical and surgical history, if any, the answer is NO.
18. In Ex.CW-1/B-1, B-2,(Repudiation letter), the ground for repudiation as mentioned is :

“it is observed that the X-ray Chest report dated 05.03.2018 shows homogeneous opacification in left lower and middle zone and along left lateral chest wall, left CP angle and left heart border indicating pleural effusion and left hila obscured.Based on these findings, are medical team is of the opinion that the insured patient has chronic, long standing lung disease prior to inception of the medical insurance policy.Hence, it is a pre-existing disease.The present admission and treatment of the insured patient is for the pre-existing disease.”

 

Thus, the rejection is based on the X-ray chest report dated 05/03/2018, which is after the date of inception of the policy even the Discharge Summary does not raise the iota of doubt that the Complainant had a history/ complaint of left pleural effusion-tubercular for which he was hospitalised and treated. The Discharge Summary (Ex.CW-1/B-1, B-2) is not disputed, there were no symptom of at the time of admission it was only as the final diagnosis the said disease was detected. It is settled principle of law that onus is on the OP to prove that the complainant had a pre-existing disease. In support of their contention, OP has not filed any documentary evidence (X-ray report)/expert medical opinion/literature in support of its case to show that the complainant was suffering from left pleural effusion-tubercular before the inception of policy date ie 20/01/2018. On the other hand OP has filed the Proposal form dated 16/01/2018, where in response to questions in clause 5 is ‘NO’.

19. The Hon’ble NCDRC in National Insurance Co. Ltd. vs. Rai Narain-2008 NCT 559 (NC)- held as under:

Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the Insurance Company relies on their clause 4.1 of the policy in a mala-fide manner to repudiate all the claims. No claim is payable under the medi-claim policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him which he is genuinely unaware of them. Hindsight everyone relies much later that he should have known from some symptom. If this is so every person should do medical studies and further not take any insurance policy.

20. The Hon’ble NCDRC in the matter of “Praveen Damani versus Oriental Insurance Company Ltd.” as reported in IV [2006] CPJ 189 (NC) has held as under:

“....If this interpretation is upheld, the Insurance Company is not liable to pay any claim, whatsoever, because every person suffers from symptoms of any disease without the knowledge of the same. This policy is not a policy at all, as it is just a contract entered only for the purpose of accepting the premium without the bonafide intention of giving any benefit to the insured under the garb of pre-existing disease. Most of the people are totally unaware of the symptoms of the disease that they suffer and hence they cannot be made liable to suffer because the Insurance Company relies on their clause 4.1 of the policy in a malafide manner to repudiate all the claims. No claim is payable under the mediclaim policy as every human being is born to die and diseases are perhaps pre-existing in the system totally unknown to him which he is genuinely unaware of them. Hindsight everyone relies much later that he should have known from some symptom. If this is so every person should do medical studies and further not take any insurance policy. Even on the facts on record, there is no material to show that the petitioner had any symptoms like chest pain etc. prior to 11.08.2000.”

21.      Thus, from analysis of the Discharge Summary and Proposal form, it can be adduced that the Complainant had no symptoms of Left Pleural Effusion- Tubercular at the time of filling of the proposal form at the same time, OP has failed to prove that the complainant was suffering from Left Pleural Effusion- Tubercular and it was a pre-existing disease. Hence, we hold that OP has indulged in deficiency in services and unfair trade practice by rejecting the claim of the complainant on the pretext  of the pre-existing disease. 

Therefore, in the facts and circumstances of the present complaint and in the interest of justice, we direct OP to:-

1. Reimburse an amount of Rs.32,671/- on account of the medical expenses borne by the complainant. (as mentioned in para 21 of the written statement)
2. Pay an interest @7% p.a.  on Rs.32,671/-from the date of filing of the present complaint till realization to the complainant. 
3. Pay compensation of Rs.12,500/- on account of mental agony and harassment, inclusive of litigation expenses.

The order be complied within 30 days from the receipt of this order. In case of non compliance, the complainant shall be entitled to receive an interest @9% p.a. on Rs.45,171/- (Rs.32,671/-+Rs.12,500/-) from the date of filing of complaint till realisation.

Office is directed to supply the copy of this order to the parties as per rules.  Order be also uploaded on the website.  Thereafter, file be consigned to the record room.

 

 

(Harpreet Kaur Charya) Member

(Divya Jyoti Jaipuriar)                     President