Haryana

Kurukshetra

74/2018

Inder jit Singh - Complainant(s)

Versus

Star Helath - Opp.Party(s)

Amar Raj

14 Jun 2019

ORDER

BEFORE THE DISTRICT CONSUMER DISPTUES REDRESSAL FORUM, KURUKSHETRA.

 

Complaint Case No.74 of 2018.

Date of instt: 04.04.2018. 

                                                                      Date of Decision: 14.06.2019.

 

Inderjeet Singh aged about 56 years son of Shri Dara Singh, resident of House No.290, Ward No.4, Tibba Farm, Pehowa, District Kurukshetra.

 

                                                ……..Complainant.

                        Vs.

1. Star Health and Allied Insurance Company Limited, Branch Office at SCO No.94, Sector-7, Kurukshetra through its Branch Manager.
2. Pardeep Kalra son of Shri Anil Kumar Kalra, Salesman/ Agent of Star Health and Allied Insurance Company Limited, resident of C/o Kalra Insurance Services Opposite ICICI Bank, Kaithal Road, Pehowa.

..………Opposite parties.

 

Complaint under section 12 of Consumer Protection Act.                   

 

Before       Smt. Neelam Kashyap, President.

                Ms. Neelam, Member.

                Sh. Sunil Mohan Tirkha, Member.

 

Present:     Sh. Aman Raj Singh, Advocate for complainant.

Sh. Gaurav Gupta, Advocate for opposite party no.1.

        Opposite party no.2 already exparte.   

ORDER     

 

                   This is a complaint under Section 12 of the Consumer Protection Act, 1986 moved by complainant Inderjeet Singh against Star Health and Allied Insurance Company Limited, the opposite parties.

2.            Brief facts of the present complaint are that complainant has obtained a cashless medical policy bearing No.P/211114/01/2017/007412 on 16.3.2017 from op no.1 through op no.2, which was valid from 16.3.2017 to 15.3.2018 and the complainant paid the entire required premium at that time. It is further averred that at the time of obtaining medical policy, the complainant was aged about 55 years and was quite fit, hale and hearty. He was not suffering from any type of ailment of disease, so as to be disclosed to the ops. Even the officials of op no.1 have got medicolegally examined the complainant from Shree Bala Ji Aroygam Hospital, Kurukshetra being pre-medical check up. That unfortunately on 12.6.2017, the complainant fell ill. On the advise of the Doctor, the complainant got his check up from Columbia Hospital, Patiala and found that his symptoms were typical of coronary artery disease and he was advised to undergo coronary angiography. Thereafter, the complainant got done angiography from Columbia Asia Hospital, Patiala on 24.7.2017 and found that complainant is suffering from coronary artery disease and hypertension and complainant had paid Rs.6000/-.  That an intimation regarding the ill health of complainant was immediately given to the ops and it was assured by the ops that all the medical and treatment bills will be paid by op no.1 as it is a cashless medical policy. It was also informed by ops that SPS Hospital, Ludhiana is in the list of hospitals of ops. It is further averred that thereafter the complainant was admitted in SPS Hospital, Ludhiana on 23.8.2017 and operated on 25.8.2017 and remained admitted there as indoor patient and was discharged on 31.8.2017. The complainant had paid a sum of Rs.1,65,000/- for treatment, operation and medical bills to the hospital and the staff of hospital assured that insurance company/ op no.1 will pay the actual medical and treatment bill of insured complainant, then the said amount will be refunded back to the complainant. But till date op no.1 has failed to refund back the claim amount. It is further averred that after being discharged from SPS Hospital, the complainant and his family members met the ops and enquired about non payment of above mentioned bills, upon which the officials of op no.1 asked the complainant to submit all the original medical bills and complete treatment record of SPS Hospital with them for investigation purposes and it was further assured that the amount of the bill shall be refunded to the complainant shortly. But later on, the complainant was shocked when he received a letter dated 13.1.2018 from op no.1 regarding repudiation of claim on vague reason that it is a pre-existing disease. However, vide the said letter, it was advised to the complainant to represent to Grievance Department of op no.1. It is further averred that though the said denial of claim amount was wrong and arbitrary on the part of op no.1 and that too without any cogent reason, even then the complainant again applied for reconsideration of his claim by filling the claim form but till today the op no.1 has not reconsidered the claim case of complainant nor any another letter of final repudiation of claim has ever been served upon the complainant despite long time. The complainant has also spent an additional amount of Rs.25,000/- on account of medicines, follow up treatment and other misc. expenses after the operation and said amount is also to be reimbursed/ paid by op no.1. That two surveyors of the ops have conducted a thorough inquiry into the matter and they assured that since the case of complainant is genuine, so they will submit the report immediately with their superior officers and the claim of complainant shall be disbursed soon, but to no effect. That the complainant requested the ops time and again for doing the needful in the matter, but the ops did not listen him. Hence, this complaint.

3.             On notice, opposite party no.1 appeared and filed written statement taking certain preliminary objections. It is submitted that the insured was admitted at Columbia Asia Hospital on 12.6.2017 for the treatment of ISHEMIC HEART DISEASE and submitted pre authorization request form for cashless treatment. On perusal of the documents, it is observed that as per progress note, the insured was admitted with the complaints of typical exertional symptoms and DOE Grade II and III. Hence, the serial ECG’s, echo report and cardiac enzymes with current admission case sheet were called for vide letter dated 10.6.2017 which are mandatory to process the claim. But the same were not submitted. Thereafter, the insured has not submitted the claim records for reimbursement of medical expenses. It is further submitted that insured was admitted at Satguru Partap Singh Hospital on 31.7.2017 for the treatment of TVD, CAD and submitted pre authorization request for cashless treatment and the same was denied vide letter dated 3.8.2017 stating that as per Pre Auth Form, it is mentioned in past history, patient was diagnosed with heart disease on May, 2017 and all previous consultation papers, treatment records pertaining to the same are not provided despite queried, hence the exact onset and chronicity of the heart disease cannot be ascertained. Thereafter, the insured has not submitted the claim records even after repeated reminders dated 7.8.2017, 18.8.2017, 2.9.2017 and 17.9.2017. It is further submitted that insured was admitted at SPS Hospital, Ludhiana on 23.8.2017 for the treatment of CAD, HTN and submitted claim records towards reimbursement of medical expenses. The present admission and treatment of the insured person is for the pre existing disease. As per exclusion no.1 of the policy, the company is 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 the date of commencement of the first policy on 16.3.2017. Hence, the claim was repudiated and same was communicated.  In additional pleas, it is submitted that policy issued to the complainant under whom the dispute has been raised is governed by limits of liability as per various clauses. That without any prejudice to whatever has been stated earlier in the written statement, even admitting without conceding that the company is liable to pay the claim in terms of the contract of insurance issued to the claimant and the maximum quantum of liability under the terms of the policy  shall be Rs.1,61,305/-.  With these averments, dismissal of complaint prayed for.

4.             Opposite party no.2 did not appear despite notice and was proceeded against exparte.

5.             The complainant has tendered affidavit Ex.CW1/A and documents Ex.C1 to Ex.C38. On the other hand, op no.1 has tendered affidavit Ex.RW1/A and documents Ex. R1 to Ex.R20.

6.             We have heard learned counsel for complainant as well as learned counsel for op no.1 and have perused the case file carefully.

7.             Learned counsel for the complainant has contended that complainant was not suffering from any type of ailment or disease prior to taking of the policy in question and he suddenly fell ill and was diagnosed with heart disease and the sudden occurrence of coronary artery disease cannot be ruled out. He has further contended that complainant has not suppressed any material fact regarding his previous illness from the ops at the time of taking the policy. He has further contended that ops have not proved through cogent and convincing evidence that complainant was already suffering from a pre existing disease. He has further contended that before issuance of the policy, he was medically examined by the doctor of the insurance company and only after being satisfied that there was no any such pre existing disease, medical policy was issued to him. He has further contended that ops have wrongly and arbitrarily repudiated the claim of the complainant and prayed for acceptance of the complaint. He has also relied upon judgments reported as NIC Vs. Raj Narain, decided on 15.1.2008 (NC), M/s NIC Co. Ltd. vs. Haider Ali, FA No.606 of 2010 decided on 11.8.2011 (State Commission, Mumbai), NIC Vs. Balwinder Singh, FA No.1360 of 2006 decided on 31.5.2011 (SC, Punjab) and UIIC Vs. Jagdish Lal Bhatia, FA No.1584 of 2009 decided on 6.6.2013 (SC Punjab).

8.             On the other hand, learned counsel for the op no.1 has contended that complainant was suffering from chronic heart disease before taking of the policy in question and he has suppressed the material fact of his previous illness, therefore, the ops have rightly repudiated the claim of the complainant as per terms and conditions of the policy and prayed for dismissal of the complaint. He has also relied upon judgments of the Hon’ble Supreme Court in cases titled as Satwant Kaur Sandhu Vs. NIIACL, CA No.2776 of 2002 decided on 10.7.2009, P.C. Chako and another vs. Chairman, LIC of India and others, CA No. 5322 of 2007 decided on 20.11.2007, decisions of Hon’ble National Commission in cases titled as Aman Kapoor vs. NIC, RP No.429 of 2017 decided on 17.4.2017, Tata AIG Life Insurance Vs. Orissa State Co-operative Bank and anr. RP No.1695 of 2012 decided on 20.9.2012 and C.N. Mohan Raj vs. NIAC, RP No.2314 of 2012 decided on 8.10.2012.

9.             We have considered the rival contentions of the parties and have gone through the record as well as judgments relied upon by the learned counsel for the parties.

10.            Admittedly the complainant purchased mediclaim insurance policy from the opposite party no.1 on 16.3.2017 and the complainant and his wife were covered under the policy in question as is evident from policy schedule Ex.C1. According to the complainant at the time of taking the policy in question, he was not suffering from any disease and he was also medicolegally examined before issuance of the policy. It is further case of complainant that unfortunately on 12.6.2017, he fell ill and on investigation he was found suffering from coronary artery disease and was admitted in SPS Ludhiana on 23.8.2017 and was operated upon on 25.8.2017. We also agree with the contentions of complainant in this regard. There is nothing on file to suggest that complainant was suffering from any disease prior to taking of the policy in question and that he was ever diagnosed with heart disease before taking of policy. In the certificate of Columbia Asia Hospital, Patiala (Ex.C16) where his angiography was done it is mentioned that he did not have any past history of CAD at first contact in June 2017. Then in document Ex.C17 of said hospital, it is mentioned that typical exertional symptoms, post prandial symptoms also persistent symptoms since last 1 month. The complainant was admitted in SPS Hospital, Ludhiana on 23.8.2017 and was operated upon on 25.8.2017 and remained admitted there and was discharged on 31.8.2017. It cannot be said that complainant was already suffering from heart disease or that he was aware about any disease prior to taking of the policy in question. It is commonly known that now a days a heart disease can occur immediately to any one. The opposite parties have failed to prove through cogent and convincing evidence that complainant was already suffering from a pre existing disease. Therefore, we are of the considered view that op no.1 has wrongly and illegally repudiated the claim of the complainant. In this regard we are also fortified with the observations of the Hon’ble National Commission in case titled as NIC Vs. Raj Narain (supra) in which it has been held that “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 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. 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^th August, 2000. Since, there were no symptoms, the question of linking up the symptoms with a disease does not arise. In any case, it is the contention of the complainant that he was thoroughly checked up by the doctors who were nominated by the insurance company and at that time he was found hale and hearty. In such set of circumstances, it would be difficult to arrive at the conclusion that the insured had suppressed the pre-existing disease. The above said authority is fully applicable to the facts and circumstances of the present case. The other authorities relied upon by learned counsel for complainant are also applicable in this case because the complainant was got medically examined by the ops before issuance of the policy and the insurance company has also not filed any affidavit of the concerned doctor and merely on the basis of the noting made by the concerned doctor, it cannot be said that there was suppression of material fact regarding pre-existing disease. The authorities cited by learned counsel for op no.1 are not disputed but same are not applicable to the facts and circumstances of the present case. The repudiation of the claim of complainant clearly amounts to deficiency in service on the part of op no.1. The complainant is entitled to the amount of Rs.1,65,850/- spent on his treatment in SPS Hospital, Ludhiana as per cash final bill Ex.C36 and is also entitled to the amount of Rs.6000/- which he spent in Columbia Hospital, Patiala but as complainant himself has claimed amount of Rs.1,71,000/- in round figure (Rs.1,65,000+Rs.6000), we are of the view that complainant is entitled to the amount of Rs.1,71,000/- i.e. round figure. The complainant is also entitled to the amount of Rs.25,000/- which he spent on medicines. As such complainant is entitled to the total amount of Rs.1,96,000/- spent on his treatment besides some compensation for harassment and litigation expenses from op no.1. However, op no.2 is merely an agent of op no.1.

11.            In view of the above, we allow the present complaint and direct the opposite party no.1 to pay an amount of Rs.1,96,000/- to the complainant within a period of 45 days from the date of receipt of copy of this order, failing which the complainant will be entitled to interest @9% per annum from the date of order till actual payment. We also direct the op no.1 to further pay a sum of Rs.10,000/- as compensation for harassment and litigation expenses to the complainant. A copy of this order be supplied to the parties free of costs. File be consigned to the record room.  

Announced in open Forum:

Dt.:14.06.2019.  

                                                                        (Neelam Kashyap)

                                                                        President.

 

 

(Sunil Mohan Tirkha),           (Neelam)       

Member                             Member.