Haryana

Karnal

CC/317/2022

Parveen Kumar - Complainant(s)

Versus

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

Jagdeep Singh

24 Oct 2024

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

 

                                                        Complaint No.317 of 2022

                                                        Date of instt 31.05.2022

                                                        Date of Decision: 24.10.2024

 

Parveen Kumar son of Shri Maha Singh, resident of village Picholia, District Karnal.

                                                                        …….Complainant.

                                              Versus

 

1. The Branch Manager, Star Health and Allied Insurance Co. Ltd., 2^nd floor, SCF 137, Sector 13, Urban Estate, Karnal through its Branch Manager at Karnal.
2. Star Health and Allied insurance Co. Ltd. no.15, Sri Balaji Complex, 1^st floor, whites Lane, Royapettah, Chennai-600014                     through its Director/authorized person.

…..Opposite Parties.

 

Complaint under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President.     

              Ms. Neeru Agarwal…….Member

      Ms. Sarvjeet Kaur…..Member

 

Argued by:  Shri Jagdeep Singh, 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 medi claim policy from the OPs and was regularly paying the premium amount. On 16.07.2021, son of complainant namely Krish fell ill and got admitted in St. Stephen’s Hospital, Delhi for treatment and he remained admitted as indoor patient and was discharged on 17.07.2021. The hospital charged a sum of Rs.34,439.29 from the complainant on account of admission charges, hospitalization charges, room charges, doctor fee, nursing charges and counseling charges etc. The complainant also spent huge amount on various tests. Complainant informed the OPs in this regard and applied for reimbursement of hospitalization and other expenses which were incurred on treatment of his son but very surprisingly, OP rejected/repudiated the claim of the complainant vide letter dated 28.09.2021 on the ground that disease “bilateral quinocavovarus deformity with tethered cord syndrome” for which the reimbursement has been claimed has a history of spinda bifida operated before 9 years which is prior to inception of medical insurance policy and it was not disclosed. The complainant requested the OPs so many times to settle the claim of complainant but they did not pay any heed to the request of complainant and ultimately refused to pay the claim. In this way there is deficiency in service and unfair trade practice on the part of the OPs. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to concealment of true and material facts; jurisdiction; cause of action; etc. On merits, it is pleaded that policy is contractual in nature and the claims arising therein are subject to terms and conditions forming part of the policy. The insured preferred claims in the 3^rd year of policy. Previous claim was initially approved for Rs.10,000/- on 30.11.2020 for treatment of equines deformity (LT) Ankle secondary totacontr actur. The insured raised cashless request for hospitalization on 16.07.2021 in St. Stephens Hospital towards the treatment of EQUINO CAVUS DEFORMITY of B/L FOO. As per documents received, it was observed that insured patient has been suffering from Spina Bifida disease/ condition for the past 9 years 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 first policy.  Subsequently, the insured has submitted claim for reimbursement, it is observed from the submitted documents, patient diagnosed as bilateral equinocavovarus deformity with tethered cord syndrome. As per discharge summary, patient has a history of spina bifida operated before 9 years which is prior to inception of medical insurance policy. Hence, it is pre existing disease. As per policy terms and conditions, if there is any misrepresentation/ non disclosure of material facts, whether by the insured person 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 insured. Hence, the claim was rejected and the same was informed to the insured vide letter dated 28.09.2021. There is no deficiency in service and unfair trade practice 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 repudiation letter Ex.C2 dated 28.09.2021, copy of claim form Ex.C3, copy of discharge summary Ex.C4, copy of medical bills Ex.C5, copy of legal notice Ex.C7, postal receipts Ex.C7 and closed the evidence on 25.04.2023 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Sumit Kumar Sharma Senior Manager Ex.RW1/A, copy of proposal form Ex.OP1, copy of insurance policy Ex.OP2, copy of term and conditions of the insurance policy Ex.OP3, copy of IRDA guidelines Ex.OP4, copy of preauthorization request Ex.OP5, copy of preauthorization query letter dated 17.07.2021 Ex.OP6, copy of preauthorization rejection letter dated 17.07.2021 Ex.OP7, copy of claim form Ex.OP8, copy of discharge summary dated 17.07.2021 Ex.OP9, copy of indoor case papers Ex.OP10, copy of final bill Ex.OP11, copy of repudiation letter dated 28.09.2021 Ex.OP12, copy of policy cancellation letter dated 19.07.2021 Ex.OP13, copy of endorsement schedule dated 04.09.2021 Ex.OP14, copy of billing assessment sheet Ex.OP15 and closed the evidence on 12.01.2024 by suffering separate statement.

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

7.             Learned counsel for complainant, while reiterating the contents of complaint, has vehemently argued that complainant had purchased a Health Insurance policy from the OPs, which was renewed without any break. On 16.07.2021, son of complainant was admitted in St. Stephen’s Hospital, Delhi for treatment and complainant spent Rs.34439.29/- on his treatment. Thereafter, complainant lodged his claim with the OPs for reimbursement of the abovesaid amounts but OPs did not pay the claim and denied the same on the false and frivolous ground and prayed for allowing the complaint.

8.             Per contra, learned counsel for OPs, while reiterating the contents of the written version, has vehemently argued that son of complainant was hospitalized and discharged on 17.07.2021. Complainant lodged the claim with the OPs for reimbursement of the medical expenses. As per documents received, it was observed that insured patient has been suffering from Spina Bifida disease/ condition for the past 9 years which was prior to inception of first policy, hence, it was a pre existing disease. Thus, the claim of the complainant was rightly repudiated, vide letter dated 28.09.2021 by the OPs and lastly prayed for dismissal of the complaint.

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

10.           Admittedly, insured had availed the health insurance policy from the OPs. It is also admitted that during the subsistence of the said policy son of complainant was admitted in St. Stephen’s Hospital, Delhi 16.07.2021 and was discharged on 17.07.2021 and spent Rs.34,439.29/-.

11.           The claim of the complainant has been repudiated by the OPs, vide repudiation letter Ex.C2/OP12 dated 28.09.2021 on the grounds which is reproduced as under:-

“We have processed the claim records relating to the above insured patient seeking reimbursement of hospitalization expenses for treatment of BILATERAL     EQUINOCAVOVARUS DEFORMITY WITH TETHERED CORD SYNDROME..

It is observed from the submitted documents, patient diagnosed as bilateral equinocavvarus deformity with tethered cord syndrome.

As per discharge summary, patient has a history of spina bifida operated before 9 years which is prior to inception of medical insurance policy and it is not disclosed. Hence, it is pre existing disease. The present admission and treatment of the insured patient is for the non disclosed pre existing disease.

Kindly note, previous claim CIR/2021/211114/2096663 has been approved as the facts was not disclosed in that claim and hence recovery of said amount is now communicated.

We, therefore, unable to settle your claim under the above policy and we hereby repudiate your claim”.

 

12.           The claim of the complainant has been repudiated by the OPs on the above mentioned ground. The onus to prove its version was relied upon the OPs, but OPs have miserably failed to prove its version by leading any cogent and convincing evidence. The case of the OPs is based upon the discharge summary Ex.C4/OP9 dated 17.07.2021, wherein in the column of complaint and history “it is mentioned that K/C/O Spina Bifida Non operated 9 years back H/o Trauma 1.5 years back managed outside now presenting with bilateral foot deformity” and in the column of treatment given it is mentioned that “right jones transfer (EHL to IST Metatarsal) and Bilateral steincelers release under GA by Dr MV/NA/VR on 16.07.2021”. There is no nexus between the treatment taken by the insured patient and past treatment as alleged by the OPs. The said discharge summary is a photocopy.  Moreover, OPs neither examined the doctor who has issued the said discharge summary nor tendered his affidavit in evidence to prove its version. Thus, the said discharge summary has no weightage in the eyes of law. In this regard, we are fortified with the observation of Hon’ble Supreme Court in case law titled as Sulbha Prakash Motegaoneka Versus Life Insurance Corporation of India, in civil appeal no.8245 of 2015, decided on 05.10.2015; wherein Hon’ble Supreme Court held that the suppression of information regarding any pre-existing disease, if it has not resulted in death or has no connection to cause of death it would not disentitle the claimant for the claim. Further, in Chanda Devi Vs. LIC in complaint no.551/2016, decided on 23.11.2021 of Hon’ble Delhi State Commission wherein Hon’ble State Commission, Delhi 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. Further, in case 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 Authorized 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.

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 as genuine one. 

16.           The complainant has spent Rs.34439/- on the treatment of his son and has placed on file medical bills Ex.C5. The said bills neither rebutted nor denied 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 OPs to pay Rs.34439/- (Rs. Thirty four thousand four hundred and thirty nine only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of 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: 24.10.2024.

                                                         President,

                                                   District Consumer Disputes

                                                   Redressal Commission, Karnal.

       

                (Neeru Agarwal)            (Sarvjeet Kaur)     

                      Member                       Member