Haryana

Karnal

CC/668/2021

Anil Kumar Gupta - Complainant(s)

Versus

The Branch Manager, Star Health & Allied Insurance Company Limited - Opp.Party(s)

V.K. Sharma

26 Mar 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No. 668 of 2021

                                                        Date of instt.30.11.2021

                                                        Date of Decision:26.03.2024

 

Anil Kumar son of Shri Shiv Parkash, resident of house no.600, Sadar Bazar, Karnal.

 

                                               …….Complainant.

                                              Versus

 

1.     The Branch Manager, Star Health and Allied Insurance Company Ltd. SCF-137,Second Floor, Above ICICI Bank, Sector-13, Karnal.

 

2.     The Managing Director, Star Health and Allied Insurance Company Ltd., New Tank Street, Valluvar Kottam, High Road, Nungambakkam,  Chennai-600034..

       

                                                                 …..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Sh. Jaswant Singh……President.      

      Sh. Vineet Kaushik…….Member

      Dr.  Suman Singh…..Member

 

 Argued by: Shri V.K. Sharma, counsel for the complainant.

                    Shri Naveen Khetarpal, counsel for the OPs.

 

                     (Jaswant Singh, President)

ORDER:   

                

                The complainant has filed the present complaint under Section 35 of the Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant purchased a medical insurance policy bearing no.2876/00036500/000033/000/01, valid from 20.12.2019 to 19.12.2020 for a sum assured of Rs.3,00,000/- from the Chola MS General Insurance. The Ops were having liaison with Chola MS General Insurance Company and the OPs approached the complainant with a suggestion to purchase a top up policy of the OPs and further told the complainant that nowadays corona pandemic disease is spreading day by day and asked the complainant to purchase a top up policy. The OPs further suggested the complainant that if the medical expenses exceeds Rs.3,00,000/-, the Chola MS General Company will pay the said amount and the remaining amount would be paid by the Star Health Pvt. Ltd. On the suggestion of the OPs, the complainant purchased a top up cashless policy bearing No. P/211130/20/2021/001576 valid from 28.08.2020 to 27.08.2021 for a sum of Rs.20,00,000/- and paid Rs.12130/- towards premium. On 25.11.2020, the complainant fell ill due to which he was admitted in Monga Nursing Home, Karnal. After conducting tests, the complainant was referred to Paras Hospital, Panchkula for treatment of Corona virus disease. The complainant was admitted in Paras Hospital on 25.11.2020 and was discharged on 14.12.2020. The complainant had spent an amount of Rs.6,58,204/-  on his medical treatment including medicines and hospitalization charges. The Chola MS Insurance Company paid Rs. 3,00,000/- and the remaining amount of Rs.3,58,204/- was paid by the complainant from his own pocket. On 21.12.2020, the complainant again fell ill and went to the Paras Hospital, Panchkula and was admitted on 21.12.2020 and discharged on 28.12.2020. The complainant had got renewed the policy of Chola MS General Ins. Co. and again lodged the claim with the Chola MS and Chola MS again paid Rs.3,00,000/- to the complainant.  Thereafter, the complainant again fell ill and was admitted in Paras Hospital, Panchkula, on 06.01.2021 and was discharged on 19.01.2021 and the complainant paid Rs.4,06,397/-. On 28.01.2021, complainant again fell ill and was admitted in Monga Nursing Home, Karnal and was discharged on 08.02.2021 and paid Rs.1,90,013/- towards medicines and hospitalization charges. The complainant had already lodged first two claims with the OPs to the extent of Rs.7,64,601/-. The complainant informed the OPs as and when he fell ill and remained admitted in the hospital. It is further alleged that vide letter dated 08.01.2021 and 19.01.2021 and 13.02.2021, the OPs repudiated the claim of complainant on the ground of pre-existing disease. The top up policy issued by the Ops was based upon the policy issued by Chola MS Gen. Ins. Co. and this company never raised such type of objection and paid the medical expenses as per the terms and conditions of the policy. As such, OPs have no right to repudiate the claim of complainant on the said ground. Then complainant sent a legal notice dated 01.11.2021 to the OPs but it also did not yield any result.  In this way there is deficiency in service and unfair trade practice on the part of the OP. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action; locus standi and concealment of true and material facts. On merits, it is pleaded that the complainant availed Star Super Surplus Insurance Policy covering Mr. Anil Kumar Gupta self and Kavita Rani (Spouse) for sum insured of Rs.20,00,000/-, vide policy no.P/211130/01/2021/001576 for the period from 28.08.2020 to 27.08.2021 for the first time with the defined limit of Rs.3,00,000/-. The OPs issued the policy to the complainant on the basis of information disclosed by him in the proposal form by believing in complainant and assuming that the information disclosed by complainant to be true in proposal form without any Pre Medical Screening. It is further pleaded that it is clearly stated in the Special Condition of the policy schedule that the liability under this policy shall attract only when the hospitalization expenses of insured as an inpatient (excluding pre hospitalization) exceeds Rs.3,00,000/- per hospitalization in one stretch, subject to other terms and conditions. Thus, Rs.3,00,000/-, which is a defined limit will be deducted on each claim, if at all the claim is admissible as per the terms and conditions of the policy. It is further pleaded that the complainant in the 3^rd month of the policy submitted the claim documents from reimbursement of medical expenses for hospitalization period of 25.11.2020 to 14.12.2020 Paras Hospitals towards the expenses for Rs.6,58,205/-. Subsequently, the insured sought for pre-authorization request towards the treatment of Covid, Pneumonia at Paras Hospital on 06.01.2021. On scrutiny of both the claim documents, it is noted that

.       As per the discharge summary dated 25.11.2020, it is noted that the insured is diagnosed with Systemic Sarcoidosis (2000), post PPI (2013), Bilateral Pneumonia Covid-19-Sever Respiratory Failure.

.       As per the pre authorization form, the insured has a past history of Sarcoidosis, post PPI and as per the ICP, the insured has Sarcoidosis 20 years before on medrol 1mg per day and h/o post PPI 2013.

.       As per the discharge summary dated 01.03.2013, the insured was diagnosed with HTN, normal coronaries, complete heart block and sarcoidosis and underwent Permanent Packmaker implant on 04.03.2013.

From the above documents received from the complainant, it is observed that “Although the present admission and treatment of the complainant is for bilateral pneumonia Covid-19, severe respiratory failure, it is observed from the submitted medical records of the above hospitalization that the complainant is a known case of sarcoidosis since 2000 and PPI (Permanent Pacemaker Insertion) in 2013 which confirms that the complainant has Sarcoidosis, post PPI prior to inception of medical insurance policy.” It is further pleaded that at the time of inception of policy which is from 28.08.2020 to 27.08.2021, complainant has not disclosed the above mentioned medical history/health details of the complainant in the proposal form which amounts to misrepresentation/non-disclosure of material facts. As per condition no.6, if there is any mis-representation/non-disclosure of material facts whether by the complainant or any other person acting on his behalf, the company is not liable to make any payment in respect of any claim. Hence, the claim is not admissible under the policy issued to the complainant. The claim was rejected and the same was informed to the complainant, vide letter dated 19.01.2021 and 13.02.2021. There is no deficiency in service on the part of the OPs. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of policy of MS Cholamandlam Ex.C1, copy of identity card issued by Star Health Ex.C2, copy of discharge summary of Paras Hospital Ex.C3, copy of bill summary from 25.11.2020 to 14.12.2020 Ex.C4, copy of medicines bill of Paras Hospital Ex.C5, copy of Ambulance charges receipt Ex.C6, copy of letter of reimbursement of Rs.3,00,000/- by MS Cholamandlam Ex.C7, copy of bill summary dated 28.12.2020 Ex.C8, copy of discharge summary from 06.01.2021 to 19.01.2021 of Paras Hospital Ex.C9, copy of patient bill from 06.01.2021 to 19.01.2021 Ex.C10, certificate issued by Dr. Surinder Kumar Associate Director Ex.C11, copy of loan delivery order Ex.C12, copy of discharge summary of Aarogyam Monga Nursing Home dated 08.02.2021 Ex.C13, copy of bill receipt Ex.C14, copies of bill receipts and medical bills of Monga Nursing Home Ex.C15 to Ex.C17, copies of repudiation letters dated 08.01.2021, 19.01.2021 and 13.02.2021 Ex.C18 to Ex.C20, copy of legal notice dated 01.11.2021 Ex.C21, copy of reply of legal notice Ex.C22 and closed the evidence on 15.07.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit Sumit Kumar Sharma Ex.RW1/A, copy of insurance policy Ex.R1, copy of policy schedule Ex.R2, copy of terms and conditions of insurance policy Ex.R3, copy notification regarding Insurance Regulatory and Development Authority of India Ex.R4, copy of request for cashless hospitalization for health insurance Ex.R5, copy of field visit report Ex.R6, copy of query on authorization for cashless treatment Ex.R7, copy of discharge summary of Medanta hospital Ex.R8, copy of HRCT Chest Ex.R9, copy of treatment record Ex.R10, copy of Lama Summary Ex.R11, copy of rejection of authorization for cashless treatment Ex.R12, copy of claim form Ex.R13, copy of case summary Ex.R14, copy of treatment record of Paras hospital Ex.R15, copy of Echocardiography report of Paras Hospital Ex.R16 and Ex.R17,  copy of CT Scan report Ex.R18, copy of patient bill summary Ex.R19, copy of repudiation letter dated 13.02.2021 Ex.R20, copy of bill assessment sheet Ex.R21 and closed the evidence on 16.05.2023 by suffering separate statement.

6.             We have heard the learned counsel for the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for the complainant, while reiterating the contents of complaint, has vehemently argued that complainant purchased a top up medical insurance policy from the OPs, for a sum of Rs.20,00,000/-. As per terms and conditions of the insurance policy, the medical expenses upto Rs. 3,00,000/- will be paid by the MS Cholamandlam General Company and if the amount exceed from 3,00,000/-,  the remaining amount would be paid by the OPs.  The complainant was got admitted in Paras Hospital from 25.11.2020  to 14.12.2020. The complainant had spent an amount of Rs.6,58,204/-. The Chola MS Insurance Company paid Rs.3,00,000/- and the remaining amount of Rs.3,58,204/- was not paid by the OPs. On 21.12.2020, the complainant again fell ill and went to the Paras Hospital, Panchkula and was admitted on 21.12.2020 and discharged on 28.12.2020. The complainant again lodged the claim with the Cholamandlam insurance company and the said company again paid Rs.3,00,000/- to the complainant. The complainant again fell ill and admitted in said hospital on 06.01.2021 and was discharged on 19.01.2021 and the complainant paid Rs.4,06,397/-. On 28.01.2021, complainant again fell ill and was admitted in Monga Nursing Home, Karnal and was discharged on 08.02.2021 and paid Rs.1,90,013/- towards medicines and hospitalization charges. The complainant had already lodged first two claims with the OPs to the extent of Rs.7,64,601/-. He further argued that vide letter dated 08.01.2021 and 19.01.2021 and 13.02.2021, the OPs repudiated the claim of complainant on the ground of pre-existing disease and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version, has vehemently argued that complainant availed Star Super Surplus Insurance Policy from the OPs. He further argued that in the Special Condition of the policy schedule that the liability under this policy shall attract only when the hospitalization expenses of insured as an inpatient (excluding pre hospitalization) exceeds Rs.3,00,000/- per hospitalization. The complainant in the 3^rd month of the policy submitted the claim documents for reimbursement of medical expenses for hospitalization period of 25.11.2020 to 14.12.2020 Paras Hospitals towards the expenses for Rs.6,58,205/-. Subsequently, the insured sought for pre-authorization request towards the treatment of Covid, Pneumonia at Paras Hospital on 06.01.2021. The claim of the complainant has been repudiated by the OPs on the ground that complainant is a known case of sarcoidosis since 2000 and PPI (Permanent Pacemaker Insertion) in 2013 which confirms that the complainant has Sarcoidosis, post PPI prior to inception of medical insurance policy. He further argued that the complainant has not disclosed the above mentioned medical history in the proposal form which amounts to misrepresentation/non-disclosure of material facts. Hence, the claim is not admissible under the policy issued to the complainant and the same was rejected, vide letter dated 19.01.2021 and 13.02.2021

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant has availed the top up health insurance policy from the OPs. It is also admitted that during the subsistence of the insurance policy complainant has taken treatment for Covid-19 from Monga Nursing Home, Karnal and Paras Hospital, Panchkula during the subsistence of the insurance policy. It is also admitted that as per terms and conditions of the said insurance policy the medical expenses upto Rs.3,00,000/- was to be paid by MS Cholamandlam Gen. Insurance and if the expenses exceed Rs.3,00,000/- it would be paid by the OPs. It is also admitted that MS Cholamandlam Gen. Insurance Company has paid Rs.3,00,000/- twice to the complainant.

11.           The claim of the complainant has been repudiated by the OPs, vide repudiation letters Ex.C19 dated 19.01.2021 and Ex.C20/R20 dated 13.02.2021 on the grounds, which are reproduced as under:-

                Reproduction of letter dated 19.01.2021:-

“As per documents received by us, it is observed that the insured patient has been suffering from complete heart block since 2013 and sarcoidosis since 2020 both are prior to policy inception which is prior to inception of first policy. Hence, it is a pre existing disease. But the insured has failed to disclose this in the proposal form at the time of inception of the first policy. This amounts to concealment of material facts. Hence, the claim for the diagnosed disease of covid pneumonia is not admissible due to concealment of material facts.”

Reproduction of letter dated 13.02.2021:-

“We have processed the claim records relating to the above-insured patient seeking reimbursement of hospitalization expenses for treatment of bilateral pneumonia Covid-19, severe respiratory failure, systemic sarcoidosis, post PPI.

Although the present admission and treatment of the insured patient is for bilateral pneumonia Covid-19, severe respiratory failure, it is observed from the submitted medical records of the above hospital that the insured patient is a known case of sarcoidosis since 2000 and PPI (permanent pacemarker insertion) in 2013 which confirms that the insured patient has sarcoidosis, post PPIO prior to inception of medical insurance policy.

At the time of inception of your policy which is from 28.08.2020 to 27.08.2021, you have 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.”

              

 12.          The claim of the complainant has been repudiated by the OPs on the abovementioned grounds. The onus to prove its case was relied upon the OPs, but OPs have miserably failed to prove the same by leading any cogent and convincing evidence. The case of the OPs is based upon the heart block disease since 2013 and sarcoidosis since 2020. Whereas, the OPs have placed on record only the treatment record Ex.R8 dated 01.03.2013 issued by Medanta Global Health Pvt. Ltd., New Delhi, which is pertaining hypertension normal coronaries complete heart block. The OPs have not placed on record treatment report with regard to sarcodosis since 2000 as alleged by them. Moreover, neither doctor of Medanata Global Health Pvt. Ltd, who has issued the said treatment record was examined nor his affidavit was tendered into evidence by the OPs to prove its version. Moreover, said treatment records are only photocopies and same are not admissible in the eyes of law. It was the duty of the OPs, to verify the record from the hospital from where the complainant has taken a treatment as alleged by the OPs in its pleading. In this regard, we relied upon case titled as Sucha Singh Vs. Head Brach Office, HDFC Life and Another 2022 CJ 901 (NC) wherein Hon’ble National Commission held that death due to heart attack-claim repudiated on ground of pre-existing ailment-complaint dismissed by State Commission-Insurance Company cannot travel beyond grounds mentioned in repudiation letter-When policy has been revived, it revives from date when it was originally issued-Insurance Company had failed to prove that insured had concealed his medical conditions on the date when he took policy-There is nothing on record to show that deceased was suffering from chronic alcoholic condition and was suffering with chronic liver disease and that he submitted fake documents at the time of obtaining original policy-State Commission had adopted wrong approach while rejecting complaint-Respondent shall pay to complainant assured amount alongwith 9% interest. Further in case titled as Bajaj Allianze Life Insurance Co. Ltd. and others Vs. Vinod Kumar Kaushik (since deceased) 2021 CJ 956 (NC), Hon’ble National Commission has held that Mediclaim-Family Care First Plan (Medical Policy)- Surgery for total hip replacement- Non-settlement of claim by Insurance Company on ground of pre-existing condition-Complaint allowed by Fora below-Averments made by OP were not supported by documentary evidence-OP relied on treatment record relating to past history of insured, which were neither verified not supported by proper evidence-In absence of any evidence, it cannot be said that insured was having any past history-Petitioners have failed to point any illegality or irregularity in order passed by State Commission, warranting interference in exercise of Revision-Revision Petition dismissed. Further in case titled as SBI Life Insurance Co. Ltd. Vs. Lakshiben Naginbhai Chauhan and others 2020 CJ 110 (NC) and Authorised Signatory, Hon’ble National Commission has held that Insurance-SBI Home Loan Master Policy-Repudiation of death claim on ground of concealment of pre-existing disease-Complaint allowed by fora below-Both District Forum and State Commission had reached to conclusion after going through all documents that medical papers have not been properly proved since neither doctor has been duly examined nor his affidavit has been furnished-National Commission is not expected and required to re-appreciate and re-assess evidences-where on the basis of evidences Fora below have reached to a conclusion which is a possible conclusion, then such conclusion need not be disturbed in Revision Petition-Revision petition dismissed. Further in case titled as Bajaj Allianz Life Insurance Co. Ltd. and 2 others Versus Kanduru Gangadhara Rao in Revision Petition no.1054 of 2020, decided on 07.10.2021 Hon’ble National Commission held that Insurance Law-concealment of disease-Death claim repudiated by insurer on ground that life assured suppressed her health condition of her taking treatment for  placed reliance on the treatment record, ‘Chronic non-specific cervicitis’ prior to obtaining the policy-Hence this complaint-Held, insurance company placed reliance on treatment record, which was a mere photocopy and not certified. The Doctor who treated the Life Assured was also not examined nor was his affidavit filed by the insurance company. Also, insurance company failed to satisfy this Commission that there was any co-relation between death of the Life Assured and the suppression of ailment "Chronic non-specific cervicitis". Complaint allowed.

13.           Furthermore, the claim raised by the complainant is with regard to COVID-19 and there is no nexus between the Covid-19 and alleged treatment taken by him in the year 2013. Moreover, MS Cholamandlam General Insurance Company has already paid Rs.3,00,000/- twice to the complainant for the treatment taken by him. Thus, the repudiation of the claim is based only on the basis of presumption and assumption, which is not admissible in the eyes of law.  In this regard, we are fortified with the observation of Hon’ble State Commission, Delhi, in case titled as Chanda Devi Vs. LIC in complaint no.551/2016, decided on 23.11.2021 wherein it has been held that if the reason of the death is not in nexus with pre-existing disease and there is no evidence placed on record by the OP to show that the death was on account of pre-existing disease of the life assured, then the contention of the OP in the repudiation letter has no merit.

14.  

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy.”

 

 15.          Keeping in view, the ratio of the law laid down in aforesaid judgments, facts and circumstances of the present complaint, we are of the considered view that act of the OPs while repudiating the claim of the complainant amounts to deficiency, which is otherwise proved genuine one. 

16.           The complainant claimed Rs.9,54,614/- and in this regard he has placed on record medical bills Ex.C4, Ex.C10 and Ex.C15 to Ex.C17. The said bills have not been rebutted by the OPs. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

17.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OP to pay Rs.9,54,614/- (Rs.Nine lacs fifty four thousand six hundred and fourteen only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OPs to pay Rs.25,000/- to the complainant on account of mental agony and harassment and Rs.11,000/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:26.03.2024                                                                                    

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 (Vineet Kaushik)       (Dr. Suman Singh)

                          Member                          Member