Punjab

Ludhiana

CC/18/516

Kiran Arora - Complainant(s)

Versus

Star Health & Allief Ins. - Opp.Party(s)

Puneet Chhabra adv

15 Feb 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, LUDHIANA.

                                                Complaint No: 516 dated 20.08.2018.                                                        Date of decision: 15.02.2022.

 

Kiran Arora W/o. Rajinder Mohan, R/o.240, Sector 32-A, Chandigarh Road, Ludhiana.                                                                                                                                                                                               ..…Complainant

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1. Star Health & Allied Insurance Co. Limited, Registered & Corporate Office at 1, New Tank Street, Valluvar Kottam High Road, Nungambakkam, Chennai-600034 through its Director/partner/ proprietor/Authorized person/s in capacity.
2. Star Health & Allied Insurance Co. Limited, Branch at 2716, 1^st Floor, Gagan Complex, Backside Majestic Park, Ludhiana through its Director/partner/proprietor/Authorized person/s in capacity.                                                                                               …..Opposite parties 

Complaint under Section 12 of the Consumer Protection Act, 1986.

QUORUM:

SH. K.K. KAREER, PRESIDENT

SH. JASWINDER SINGH, MEMBER

COUNSEL FOR THE PARTIES:

For complainant             :         Sh. Puneet Chhabra, Advocate.

For OPs                          :         Sh. Rajeev Abhi, Advocate.

 

ORDER

PER K.K. KAREER, PRESIDENT

1.                Shorn of unnecessary details, the case of the complainant is that she availed a health insurance policy bearing No.P/211200/01/2018/000732 under which her husband Rajinder Mohan was also covered. The policy was renewed up to 17.06.2018. At the time of issuing and renewing the policy, proper medical check-up was conducted by the doctors of the OPs. The husband of the complainant was hospitalized from 21.10.2017 to 31.10.2017 regarding which a claim No.CLMG/2018/21200/0323691 was lodged with the OPs, but the same was rejected vide letter dated 2004.2018 on the ground of non-disclosure of pre-existing disease of obstructive airway disease (OAD) and the policy was also terminated. As a matter of fact, the complainant and her husband never suppressed any fact at the time of taking the policy nor the husband of the complainant was suffering from any such disease. Therefore, the rejection of the claim on the part of the OPs amounts to deficiency of service as well as unfair trade practice on the part of the OPs. A legal notice dated 15.05.2018 served upon the OPs also failed to evoke a positive response from the OPs. Hence the complaint whereby it has been requested that the OPs be directed o revive the policy and be also made to reimburse the claim in respect of the treatment of the husband of the complainant along with compensate of Rs.1,00,000/-.  

2.                The complaint has been resisted by the OPs. In the joint written statement filed on behalf of the OPs, it has been, inter alia, pleaded that the complaint is not maintainable. The claim lodged by the complainant was immediately registered and processed. The availment of the insurance policy from 18.06.2016 to 17.06.2017 and its renewal from 18.06.2017 to 17.06.2018 has been admitted. According to the OPs, as per clauses 6 and 12 of the policy, the company is not liable to make any payment if information furnished at the time of proposal is found to be incorrect or false and the company has right to cancel the policy on the ground of mis-representation, fraud, non-disclosure of material facts in the proposal form or even the claim form. The claim in question was lodged in the second year of the policy for reimbursement of the expenses incurred on the treatment of Rajinder Mohan who was admitted at Fortis Hospital, Ludhiana on 21.10.2017 for the treatment of Bilateral Pneumonitis with Sepsis. A pre-authorization request was raised by the Fortis Hospital on behalf of Rajinder Mohan regarding which a query was raised with the said hospital and the pre-authorization request for cashless treatment was denied vide letter dated 24.10.2017. Subsequently, the claim for reimbursement was submitted and on scrutiny of the claim, it was found that as per the discharge summary, the patient was diagnosed for Bilateral Pneumonitis with Sepsis, septic shock, diabetes mellitus 2 and recent onset of bronchial asthma. However, as per the discharge summary of Fortis Hospital for the period of 21.05.2016 to 25.05.2016, the insured was found to have been admitted with past history of OAD (Obstructive Airway Disease) for 3 years and DM-II for 10 years. Thus, it was confirmed that Rajinder Mohan had COAD prior to inception of the medical insurance policy but he did not disclose the above mentioned medical history/health details in the proposal form which amounts to mis-representation/non-disclosure of material facts. Therefore, as per condition 6 of the policy, the OPs were entitled to repudiate the same and the repudiation was communicated vide letter dated 17.03.2018. Thus, there has been no deficiency of service on the part of the OPs. The other allegations made in the complaint have been denied as wrong and a prayer for dismissal of the complaint has also been made.

3.                In evidence, the complainant No.1 submitted her affidavit as Ex. CA along with documents Ex. C1 to Ex. C10 and closed the evidence.

4.                On the other hand, learned counsel for the OPs tendered affidavit Ex. RA of Sh. Rajiv Jain, Chief Manager of OPs along with document Ex. R1 to Ex. R25 and closed the evidence.

5.                We have heard the learned counsel for the parties and the written submissions made on the part of the parties and have also gone through records.

6.                During the course of arguments, the counsel for the complainant has contended that the OPs have wrongly rejected the claim and the repudiation of the claim is not sustainable in the eyes of law. The counsel for the complainant has contended that even otherwise there is no nexus of OAD with the disease with which Rajinder Mohan was diagnosed with. Therefore, the rejection of the claim is totally arbitrary and unjustified.

7.                On the other hand, the counsel for the OPs has argued that the claim has been rightly repudiated as per clauses 6 and 12 of the policy terms and conditions which are Ex. R23 on the file.

8.                We have thoughtfully considered the above contentions raised by the counsel for the parties and gone through the record.

9.                As per record, the complainant obtained the policy for the first time on 18.06.2016 and it was valid up to 17.06.2017 as is evident from the policy document Ex. C4. The policy was further renewed from 18.06.2017 to 17.07.2018 as shown in the policy Ex. C2. The complainant has not placed on record the discharge summary in respect of the hospitalization of Rajinder Mohan from 21.10.2017 to 31.10.2017 which has been proved on record by the OPs as Ex. R7. In Ex. R7, Rajinder Mohan is said to have been diagnosed with Bilateral Pneumonitis with Sepsis, septic shock, diabetes mellitus 2, and recent onset of bronchial asthma. Under the column of past history, it is mentioned that the patient has been suffering from diabetes mellitus for 5 years and wheezing and cough for 3 months. After the receipt of the claim, the investigation was conducted by the OPs and the authorization letter Ex. C6 was obtained from Rajinder Mohan to have access to the medical report of Fortis Hospital, Ludhiana where the patient had been treated. During the course of investigation, it was found that Rajinder Mohan was previously hospitalized with the same hospital from 21.05.2016 to 25.05.2016 and in respect of the said hospitalization, discharge summary is Ex. R8. In the discharge summary Ex. R8, diagnosis is mentioned as LRTI, DM-II, DKA, Dyselectrolytemia. Under the column of past history, it is mentioned in the discharge summary Ex. R8 that the patient has been suffering from OAD (Obstructive airway Disease) and was on Rotacaps since 3 years and he was also suffering from DM-II for the last 10 years and was on OHAS (Administered Antihyperglycemic Agents). It means that the patient was on medication for OAD (Obstructive Airway Disease) for the past 3 years and DM-II for the past 10 years as on 21.05.2016. Admittedly, these facts were not disclosed by the complainant in the proposal form Ex. R15 and in the proposal form, as against column No.4, Rajinder Mohan, specifically answered  in negative with regard to the query as to whether he was suffering from Tuberculosis, asthma and other respiratory infections. Thus, there is a clear-cut non-disclosure of the material fact. If Rajinder Mohan suffered from OAD since the year 2013 as is evident from the discharge summary Ex. R8, he was under an obligation to disclose the same in the proposal form at the time of inception of the policy.  

10.              Now the question arises whether the disease of OAD (Obstructive Airway Disease) has any nexus with Bilateral Pneumonitis with Sepsis, septic shock etc. for which the patient Rajinder Mohan was diagnosed on 21.10.2017 as shown in the discharge summary Ex. R7. Here it is pertinent to point out the contradiction in the discharge summary Ex. R7 and Ex. R8. On 21.05.2016, Fortis Hospital, Ludhiana is stating that Rajinder Mohan is suffering from OAD for the last 3 years and is also on medication for the said disease and DM-II for the last 10 years. However, in the discharge summary Ex. R7, the same hospital has reduced the duration of Diabetes Mellitus from 10 years to 5 years. Surprisingly enough, the hospital which earlier had written the past history of the same patient to be suffering from OAD for 3 years as stated in the discharge summary Ex. R7, has mentioned in Ex. R8 that Rajinder Mohan was suffering from diabetes mellitus for 5 years and wheezing (which in medical term means breathing noisily) and cough for 3 months. Thus, the past history stated in the two discharge summaries is surprisingly self contradictory. Apart from that, the disease of Bilateral Pneumonitis with Sepsis is definitely linked with OAD (Obstructive Airway Disease). Bilateral Pneumonitis is double pneumonia infection of both lungs whereas OAD which is also called COPD (Chronic obstructive pulmonary disease) is a chronic inflammatory lungs infection and the symptoms including breathing difficulty, cough and wheezing. As per information available on internet people with COPD are more likely to develop pneumonia  because the possibility of such infection is more common when the lungs are already weakened. Therefore, it cannot be said by any stretch of imagination that the disease Bilateral Pneumonitis is not at all linked with Obstructive Airway Disease (OAD) which, in fact, is also known as COPD. In these circumstances, when it is a clear cut case of non-disclosure of pre-existing conditions from which the patient Rajinder Mohan has been suffering since the year 2013 and was hospitalized in May 2016 as well. Therefore, the repudiation of the claim by invoking clause 6 of the policy cannot be said to be arbitrary or unjustified.

11.              As a result of above discussion, the complaint fails and same is hereby dismissed. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

12.              Due to rush of work and spread of COVID-19, the case could not be decided within statutory period.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:15.02.2022.

Gobind Ram.

Kiran Arora Vs Star Health and Allied Insurance                      CC/18/516

Present:       Sh. Puneet Chhabra, Advocate for complainant.

                   Sh. Rajeev Abhi, Advocate for OPs.

 

                   Arguments heard. Vide separate detailed order of today, the complaint fails and same is hereby dismissed. However, there shall be no order as to costs. Copies of the order be supplied to the parties free of costs as per rules. File be indexed and consigned to record room.

 

                             (Jaswinder Singh)                            (K.K. Kareer)

                    Member                                           President

 

Announced in Open Commission.

Dated:15.02.2022.

Gobind Ram.