BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, SIRSA.
Consumer Complaint no. 169 of 2022
Date of Institution : 15.03.2022
Date of Decision : 26.02.2024
Liladhar Saini aged about 63 years son of Sh. Sheokaran Dass Saini, resident of House No. 20/204, Gaushala Road, Near Ram Dev Mandir, Sirsa, District Sirsa.
……Complainant.
Versus.
1. The Manager/ Authorized Officer, Star Health and Allied Insurance Company Limited, Office at S.C. 149, IInd Floor, CUE-1, Red Square Market, Hisar, Haryana – 125001.
2. Star Health and Allied Insurance Company Limited, Office at New Tank Street, Valluvar Kottam High Road, Nungabakam, Chennai- 600034.
3. Star Health & Allied Insurance Company Limited Branch office at Dabwali Road, Sirsa through its Manager/ Authorized Officer.
…….Opposite Parties.
Complaint under Section 12 of the Consumer Protection Act,1986.
Before: SH. PADAM SINGH THAKUR……. PRESIDENT
MRS.SUKHDEEP KAUR……………MEMBER.
SH. OM PARKASH TUTEJA………..MEMBER
Present: Sh. Ganesh Sethi, Advocate for the complainant.
Sh. Ravinder Monga, Advocate for opposite parties.
ORDER
The complainant has filed the present complaint under Section 12 of the Consumer Protection Act, 1986 (after amendment under Section 35 of the Consumer Protection Act, 2019) against the opposite parties (hereinafter referred as Ops).
2. In brief, the case of complainant is that complainant purchased the health plan namely Family Health Optima Insurance Plan from ops’ company in 2017 and same was got renewed by him time to time. The complainant was issued policy bearing No. P/211119/01/2021/003489 against the annual premium of Rs.25,165/- and now said policy is effective from 07.07.2020 to 06.07.2021 against the lumpsum assured of Rs.5,00,000/- with recharge benefit of Rs.1,50,000/-. That at the time of issuance of the policy, the ops had agreed and undertaken to indemnify the insured for medical expenses for illness including the disease of brain etc. within the period of insurance. The complainant had perfect good health profile with no physical impairment and pre existing disease. It is further averred that details of the benefits and perils covered in the policy documents containing terms and conditions and exclusion clauses were not supplied by the office of the ops to the complainant during subsistence of policy. That complainant suffered mellitus hypertension, left thalamic bleed, residual mild right hemiparesas and slurred speech and as such he was taken to Medanta Hospital at Gurgaon on 29.07.2020 where he was admitted vide patient ID No. MM01544601. He remained admitted there for a long term and also remained admitted in ICU under neurology care and after the treatment, complainant was discharged from hospital. That admission and discharge record of said hospital proves the admission and treatment for the major disease suffered by complainant and during that period he has undergone multiple blood sampling, scanning and other respective diagnose/ treatment regarding the disease. The complainant submitted his claim of approximately Rs.4,50,000/- to the ops and supplied all the relevant record to the ops. That complainant also took treatment from Paras Hospital, Gurgaon and the medical record and bills thereof had already been supplied to the ops’ company and he is still undergoing the follow up treatment for the disease suffered by him. It is further averred that ops’ company in an arbitrary manner have rejected the legal and genuine claim of complainant on the ground that insured has hypertension from the past seven years which confirms that insured has hypertension prior to inception of medical insurance policy and it is a pre existing disease. That the act of repudiation on the part of ops is totally baseless because the alleged oral version of the family member of the complainant regarding the pre existing disease is no ground of repudiation of claim of complainant and this fact has already been clarified even by Dr. Arun Garg, Medanta Hospital, Gurgaon vide certificate dated 05.08.2020, copy of which has already been supplied to the ops but ops have failed to make payment of medical bills and other expenses incurred by the complainant. It is further averred that policy is being renewed since 2017-2018 and there had never been any complaint of any such kind of disease and policy was issued after verification of facts regarding illness of the insured. That earlier the complainant had filed a claim regarding the treatment amount of Rs.63,712/- which has been duly paid by ops on 24.08.2020 but now ops have willfully repudiated the claim of complainant and as such ops have caused unnecessary harassment to the complainant. Hence, this complaint seeking direction to the ops to pay an amount of Rs.4,50,000/- alongwith interest and also to pay amount of Rs.2,00,000/- as compensation for harassment and also to pay litigation expenses.
3. On notice, ops appeared and filed written version raising preliminary objections. It is submitted that complainant availed insurance policy covering himself and Mrs. Raj Dulari Saini spouse commencing from 07.07.2020 to 06.07.2021 for the sum insured of Rs.5,00,000/- which is in continuation since 06.06.2018. The insured before purchasing the policy understood the terms and conditions of the policy. It is clearly mentioned in the policy schedule that insurance under this policy is subject to conditions, clauses, warranty and exclusion clause etc. It is further submitted that insured raised a pre authorization request to avail cashless facility and subsequently submitted medical documents in support of his claim towards the treatment and admission in the hospital from 29.07.2020 to 06.08.2020. On scrutiny of the claim documents, it was observed that insured patient has hyper tension for the past seven years i.e. prior to inception of medical insurance policy. Hence it is a pre existing disease and present admission and treatment of insured was for the complication of the pre existing disease. Hence, pre authorisation request was denied and claim was repudiated as per clause of the policy and same was communicated to the insured vide letters dated 05.08.2020 and 09.12.2020 respectively. Further, he was given an opportunity in the interest of natural justice that in case he is not satisfied with the decision, then he has every right to represent his grievances to the Grievances Department on the address given in the letter but complainant failed to avail the remedies which amounts to abandoning the right for claiming any compensation. It is further submitted that if it is found that ops are liable to pay the claim in terms of the contract of insurance, then the maximum quantum of liability under the terms of the policy shall be Rs.1,39,084/-. Remaining contents of complaint are also denied to be wrong and prayer for dismissal of complaint made.
4. The complainant in evidence has tendered his affidavit Ex. C1 and documents Ex.C3 to Ex.C13 and mark A to mark D.
5. On the other hand, ops have tendered affidavit of Sh. Sumit Kumar Sharma, Senior Manager as Ex.R1 and documents Annexures R1 to R13.
6. We have heard learned counsel for the parties and have gone through the case file carefully.
7. From the policy schedule Ex.C2, it is evident that complainant purchased the health policy in question from ops for the period 07.07.2020 to 06.07.2021 for the sum insured amount of Rs.5,00,000/- with recharge benefit of Rs.1,50,000/- and complainant himself as well as his wife Smt. Raju Dulari Saini were insured under the policy in question. The date of inception of the policy is mentioned as 06.06.2018. From the treatment record placed on file by complainant i.e. discharge summary Ex.C5, it is evident that during the period of policy in question the complainant remained admitted in Medanta Hospital, Gurgaon from 29.07.2020 to 06.08.2020 and was treated for acute right thalamic bleed, acute left parieto occipital infarct, recent left thalamic bleed etc. and according to complainant he has spent about Rs.4,50,000/- on his treatment. The claim submitted by complainant has been repudiated by the ops vide letter dated 09.12.2020 Ex.C3 on the ground that patient insured has hypertension for the past seven years and on the ground of pre existing disease as per exclusion clause stating therein that expenses related to the treatment of a pre existing disease (PED) and its direct complications shall be excluded until the expiry of 48 months of continuous coverage after the date of inception of the first policy with insurer. However, we are of the considered opinion that ops have wrongly and illegally repudiated the genuine claim of the complainant. The said disease of left thalamic bleed occurred to the complainant only on 15.04.2020 i.e. after about three years of date of inception of first policy and as such said disease is not a pre existing disease. There is nothing on file to prove that said disease is the complication of hypertension. Moreover, the concerned doctor Arun Garg who treated the complainant for the above said disease has clarified in his ceritificate dated 05.08.2020 that as per his son Mr. Vikram Saini, patient Mr. Lila Dhar Saini i.e. complainant is suffering from hypertension since last one year and his mother Mrs. Raj Dulari Saini wife of Mr. Lila Dhar Saini gave the history of hypertension from last seven years by mistake, which is not the correct duration of disease. As such the disease of hypertension also cannot be said to be pre existing disease to the complainant. So when the complainant was not suffering from this disease then how he could have disclosed the same to the ops. Moreover, diabetes and hypertension are lifestyle diseases now a days. The ops could have also examined the insured complainant before issuing policy in question but they have failed to do so and therefore, now claim cannot be repudiated on the ground of hyper technical ground of pre existing disease of hypertension. The ops have failed to prove on record through any cogent and convincing evidence that said disease of hypertension is a pre existing disease to the complainant and that he was taking any medicines prior to the purchase of the policy in question. Though complainant has claimed amount of Rs.4,50,000/- from ops and has also placed on file bills and receipts Ex.C6 to Ex.C13 but from perusal of his claim form Annexure R7, it is evident that on 20.10.2020 complainant himself has lodged claim of the amount of Rs.1,76,025.83 to the ops for his treatment from 29.07.2020 to 06.08.2020 and since complainant himself has filed his claim to the sum of Rs.1,76,025.83 to the ops now complainant is estopped by his own act and conduct to claim more than the amount of Rs.1,76,025.83 already claimed by him vide claim form Ex.R7. Though the ops have asserted that maximum quantum of liability under the terms of the policy shall be of Rs.1,39,084/-, but we are of the considered opinion that complainant is entitled to the above said amount of Rs.,1,76,025.83 from ops as claimed vide claim form Ex.R7 and rejection of said claim amount on the part of ops is baseless and is without any substance and ops have also caused unnecessary harassment and deficiency in service towards the complainant by not making payment of the said amount to the complainant.
8. In view of our above discussion, we allow the present complaint and direct the opposite parties to make reimbursement of the claim amount of Rs.1,76,025.83 (in round figure Rs.1,76,000/-) to the complainant alongwith interest at the rate of @6% per annum from the date of filing of present complaint i.e. 15.03.2022 till actual realization within a period of 45 days from the date of receipt of copy of this order. We also direct the ops to further pay a sum of Rs.25,000/- as compensation for unnecessary harassment and Rs.10,000/- as litigation expenses to the complainant within above said stipulated period. A copy of this order be supplied to the parties as per rules. File be consigned to the record room.
Announced. Member Member President,
Dated: 26.02.2024. District Consumer Disputes
Redressal Commission, Sirsa.
