BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR.

Consumer Complaint No. 557 of 2015

Date of Institution: 08-09-2015

Date of Decision: 09-03-2016  

Gurdip Singh (aged 74 years) son of Sh.Sohan Singh, resident of 4651, Guru Nanak Wara, Khalsa College, Amritsar.

Complainant

Versus

1. Star Health and Allied Insurance Company Limited, New Tank Street, Vollvarkottam High Road, Nungambakkam, Chennai-60003 through its Director.
2. Branch Manager, Star Health and Allied Insurance Company Limited, SCO 25, First Floor, Ranjit Avenue, Amritsar.
3. Anil Kumar, Sales Manager, Star Health and Allied Insurance Company Limited, through Branch Manager, Opposite Party No.2.
4. Miss/ Mrs. Inderjeet Kaur, Star Health and Allied Insurance Company Limited, through Branch Manager, Opposite Party No.2.

Opposite Parties

Complaint under section 11 and 12 of the Consumer Protection Act, 1986.

Present: For the Complainant: Sh. Mohinder Singh, Advocate

              For the Opposite Parties: Sh.S.S.Salaria, Advocate

Quorum:

Sh.Bhupinder Singh, President

Ms.Kulwant Kaur Bajwa, Member

Mr.Anoop Sharma, Member  

Order dictated by:

Sh.Bhupinder Singh, President.

1. Present complaint has been filed by Sh.Gurdip Singh  under the provisions of the Consumer Protection Act alleging therein that he purchased Star Senior Citizens, Red Carpet Insurance Policy, vide  No.P/211111/01/2014/003732 valid for the period from 26.2.2014 to midnight of 25.2.2015 from Opposite Party No.1 against the premium paid Rs.9500/- vide cheque No. 627757 dated 25.2.2014. Complainant alleges that during the continuation of the policy in question, he suddenly felt problem of breathlessness on 8.8.2014 and he was taken to Care Well Heart & Super Specialty Hospital, Model Town, G.T.Road, Amritsar. After preliminary diagnosis, the complainant was advised by the doctors during examination, that the complainant was suffering from Hypertension at that time and was required the diagnosis of CAD-HTN-NSTEMI. Necessary information regarding hospitalization of the complainant was given to Opposite Party No.2 on 9.8.2014. Opposite Party No.2 deputed Dr.Parveen Narang to examine and verify about the admission and ailment of the complainant. Dr.Parveen Narang visited at the said hospital, where the complainant was admitted in ICU. The attendant of the complainant gave detailed information about health of the complainant and also employees of the hospital to Dr.Parveen Narang. The complainant submitted all the required documents/ records and information to Opposite Parties No.1 and 2 by 17.11.2014. On 23.12.2014 the complainant received online information that his claim has been declined by Opposite Parties No.1 and 2 on the ground of pre existing disease prior to inception of the medical insurance policy.  Alleging the same to be deficiency in service, complaint was filed seeking directions to the opposite parties to pay a sum of Rs.two lacs for reimbursement out of medical expenses incurred on treatment of complainant as per limited liability of Opposite Parties  upto two lacs alongwith interest @ 18% per annum from the date of submission of the claim till realization. Compensation and litigation expenses were also demanded.
2. On notice, Opposite Parties appeared and filed written version in which it was submitted that the complainant obtained the policy in question. However, the claim was lodged by the complainant within six months of the policy. On perusal of the claim records sent to the Opposite Parties relating to the complainant seeking reimbursement of hospitalization expenses for treatment of Coronary Artery Disease ‘Single Vessel Disease’ and on scrutiny of the claim records, it was observed that as per the field visit report the complainant is known case of Hypertension since 7-8 years. As per discharge summary the complainant is known case of Hypertension under medication. Present ailment is a squeal of long standing hypertensive coronary artery disease with evidence of left  Ventricular  Hypertrophy in ECHO and gross ecstatic changes in coronaries denoting chronicity of the disease which is prior to inception of policy. Single vessel disease cannot occur within six months of the policy period.  As per the exclusion clause No.1 of the policy, the company is not liable to make any payment during the first year of operation of policy, in respect of the pre-existing disease for which treatment or advice was recommended or received during the immediately proceedings 12 months from the date of policy. So, the claim of the complainant was repudiated vide letter dated 16.12.2014. However, even admitting without conceding that the company is liable to pay the claim in terms of the contract of insurance issued to the claimant, it is submitted that the maximum quantum of liability under the terms of the policy shall be Rs.1,17,000/-. While denying and controverting other allegations, dismissal of complaint was prayed.
3. Complainant tendered into evidence his affidavit Ex.C1 alongwith documents Ex.C2 to Ex.C10 and closed the evidence on behalf of the complainant.
4. Opposite Parties tendered into evidence affidavit of Sh.Rajnish Kohli, Assistant Vice President Ex.OP1,2,3,4/1 alongwith documents Ex.OP1,2,3,4/2 to Ex.OP1,2,3,4/17 and closed the evidence on behalf of the Opposite Parties.
5. We have carefully gone through the pleadings of the parties; arguments advanced by the ld.counsel for the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsel for both the parties.
6. From the record i.e. pleadings of the parties and the evidence produced on record by the parties, it is clear that the complainant obtained Star Senior Citizens, Red Carpet Insurance Policy, bearing  No.P/211111/01/2014/003732 (Ex.C3)  for the period from 26.2.2014 to midnight of 25.2.2015 from Opposite Party No.1 by making payment of  premium of Rs.9500/- vide cheque dated 25.2.2014 (Ex.C4). Complainant   felt problem of breathlessness on 8.8.2014 and was taken to Care Well Heart & Super Specialty Hospital, Model Town, G.T.Road, Amritsar and was required diagnosis CAD-HTN-NSTEMI and he was admitted in aforesaid hospital on 8.8.2014. Intimation regarding the hospitalization of the complainant was given to Opposite Party No.2 on 9.8.2014 and Opposite Party No.2 deputed Dr.Parveen Narang to examine and verify the fact regarding admission and ailment of the complainant who collected detailed information about health of the complainant. The complainant was discharged from the hospital on 11.8.2014 as per discharge summary Ex.C7. Opposite Party No.2 sent letter dated 11.9.2014 Ex.OP12 advising the complainant to submit the claim alongwith documents in support of his claim. The complainant spent Rs.3,73,100/- on his medical treatment as detailed in the claim form Ex.OP5. Complainant lodged claim and submitted all the relevant documents and information to Opposite Parties No.1 and 2 through claim form Ex.OP5. On 23.12.2014 the complainant received online information (Ex.OP13)  that  claim of the complainant  has been declined by Opposite Parties No.1 and 2 on the ground  that insured patient is known case of Hypertension and the present ailment is a complication of long standing hypertensive coronary artery disease and was  existing  prior to inception of medical policy and it is pre-existing disease and as per exclusion clause No.1 of the policy, the company is not liable to make any payment during the first year of operation of policy, in respect of the pre-existing disease. Moreover, the complainant has not disclosed pre-existing disease of Hypertension in the proposal form before taking the policy.  Ld.counsel for the complainant submitted that this ailment occurred to the complainant for the first  time during the continuation of the policy in question and not existing at the time of submission of the proposal form Ex.C5/OP3. Apart from this, hospital authority of Care Well Heart & Super Specialty Hospital, Model Town, G.T.Road, Amritsar issued certificate dated 15.11.2014 certifying that the complainant was admitted to their hospital on 8.8.2014 with diagnosis of CAD-HTN-NSTEMI. He was  suffering with Hypertension for past approximately 3 months. The proposal form Ex.OP3 was filled in and signed by the complainant on 25.2.2014. So this disease was not pre-existing disease and was not in the knowledge of the complainant at the time he filled in and signed the proposal form to take the policy in question from Opposite Parties No.1 and 2. Opposite Parties No.1 and 2 have wrongly repudiated the claim of the complainant upto the insured amount of Rs.2 lacs.   Ld.counsel for the  complainant submitted that all this amounts to deficiency of service on the part of Opposite Parties.
7. Whereas the case of the Opposite Parties is that the complainant has suppressed the true and material facts. The complainant obtained the Star Senior Citizens, Red Carpet Insurance Policy for the period from 26.2.2014 to 25.2.2015. However, the claim was lodged within six months of the policy seeking reimbursement of hospitalization expenses for treatment of Coronary Artery Disease (Single Vessel Disease). On scrutiny of the claim records, it was observed that as per the field visit report the complainant is known case of Hypertension for the last 7-8 years. As per discharge summary the complainant is a known case of Hypertension. Present ailment is a squeal of long standing hypertensive coronary artery disease with evidence of left Ventricular Hypertrophy in ECHO and gross ecstatic changes in coronaries denoting chronicity of the disease which is prior to inception of policy. Single vessel disease cannot occur within six months of the policy period.  So, as per  exclusion clause No.1 of the policy, the company is not liable to make any payment during the first year of operation of policy, in respect of the pre-existing disease. So the claim of the complainant was rightly repudiated  and was communicated to the insured vide letter dated 16.12.2014 Ex.OP14.   Ld.counsel for the Opposite Parties  submitted that there is no deficiency of service on the part of the Opposite Parties.
8. From the entire above discussion, we have come to the conclusion that the complainant got Star Senior Citizens, Red Carpet Insurance Policy  bearing  No.P/211111/01/2014/003732 (Ex.C3)  with sum assured Rs.2 lacs, for the period from 26.2.2014 to 25.2.2015 from Opposite Party No.1. On 8.8.2014 the complainant felt problem of  breathlessness and he was admitted in Care Well Heart & Super Specialty Hospital, Model Town, G.T.Road, Amritsar and  was diagnosed CAD-HTN-NSTEMI  i.e. Coronary Artery Disease (Single Vessel Disease). The complainant was medically treated and  was discharged on 11.9.2014 as per discharge card Ex.C7/Ex.OP10.  Opposite Party No.2 was informed on 11.9.2014 regarding the hospitalization of the complainant and the Opposite Parties deputed Dr.Parveen Narang who visited the said hospital to examine and verify about the admission and ailment of the complainant. The complainant spent Rs.3,73,100/- on his medical treatment and the complainant lodged claim with Opposite Parties  vide claim form Ex.C8/ OP5 alongwith all the relevant documents, bills, etc. and submitted to Opposite Parties No.1 and 2, but Opposite Parties No.1 and 2 repudiated the claim of the complainant vide letter dated 16.12.2014 Ex.OP14 on the ground that the insured patient is known case of Hypertension and the present ailment is a complication of long standing hypertensive coronary artery disease with evidence of left Ventricular Hypertrophy in ECHO and gross ecstatic changes in coronaries denoting chronicity of the disease which is prior to inception of policy i.e. existing prior to the inspection of the medical policy, hence it is pre existing disease and as per  exclusion clause No.1 of the policy, the company is not liable to make any payment during the first year of operation of policy.
9. Opposite Parties No.1 and 2 could not produce any document i.e. any medical treatment of the complainant that the complainant was suffering from Hypertension prior to the inception of the policy and even at the time when the complainant filled in and signed the proposal form Ex.OP3 nor Opposite Parties No.1 and 2 could examine any medical practitioner/ doctor, to prove that he treated the complainant for the disease of Hypertension prior to  the inception of the policy, whereas the medical authority of Care Well Heart & Super Specialty Hospital, Model Town, G.T.Road, Amritsar under the signatures of Dr.Rohit Kapoor, issued certificate dated 15.11.2014 Ex.C10 in which he has categorically stated that the patient/ complainant was admitted to this hospital on 8.8.2014 with diagnosis of CAD-HTN-NSTEMI. He was suffering from hypertension for the past  approximately 3 months. The complainant filled in and signed the proposal form Ex.OP3 for taking the policy in question on 25.2.2014 whereas the complainant was admitted in Care Well Heart & Super Specialty Hospital, Model Town, G.T.Road, Amritsar on 8.8.2014 and the treating doctor has issued certificate Ex.C10 that the patient was suffering from hypertension for the past approximately 3 months i.e. since the month of May, 2014, whereas the complainant filled in and signed the proposal form Ex.OP3 for taking the policy in question on 25.2.2014. So, neither the complainant was suffering from this disease of Hypertension at the time of filling in and signing the proposal form Ex.OP3 nor he had any knowledge about this disease Hypertension on the date when he filled in and signed the proposal form Ex.OP3 dated 25.2.2014.
10. Resultantly, we hold that the Opposite Parties No.1 and 2 have wrongly repudiated the claim of the complainant on this ground that the complainant was suffering from disease Hypertension prior to the inception of the policy.
11. Consequently, we allow the complaint of the complainant with costs and the Opposite Parties No.1 and 2 are directed to pay the insured amount to the complainant i.e. Rs.2 lacs (Two lacs only), within one month from the date of receipt of copy of this order, failing which the Opposite Parties No.1 and 2 shall be liable to pay interest @ 9% per annum on the insured amount of Rs.2 lacs, from the date of filing of the complaint till the payment  is made to the complainant. Opposite Parties No.1 and 2 are also directed to pay to the complainant  the litigation expenses to the tune of Rs.2,000/-.  Copies of the order be furnished to the parties free of cost. File is ordered to be consigned to the record room. Case could not be disposed of within the stipulated period due to heavy pendency of the cases in this Forum.

Dated: 09.03.2016.                                                                  (Bhupinder Singh)                                                                                                                                                                                                    President

hrg                                                (Anoop Sharma)     (Kulwant Kaur Bajwa)   

                                                 Member                         Member