BEFORE THE DISTRICT CONSUMER DISPUTES
REDRESSAL COMMISSION, JALANDHAR.
Complaint No.241 of 2019
Date of Instt. 04.07.2019
Date of Decision: 08.08.2023
Dr. Bharat Bhushan aged about 68 years S/o Sh. Ved Parkash resident of 273, Lajpat Nagar, Jalandhar.
..........Complainant
Versus
1. The Managing Director, New India Assurance Co. Ltd., Regd. Office at New India Assurance Bidg. 87, Mahatma Gandhi Road, Fort, Mumbai-400001.
2. The Branch Manager, New India Assurance Co. Ltd., Direct Agent Branch, SCO 30-31, 1ST Floor, Guru Ramdas Divine Tower, PUDA Complex, Jalandhar-144001.
….….. Opposite Parties
Complaint Under the Consumer Protection Act.
Before: Dr. Harveen Bhardwaj (President)
Smt. Jyotsna (Member)
Present: Sh. Balram Shakti, Adv. Counsel for the Complainant.
Sh. R. K. Sharma, Adv. Counsel for OPs No.1 & 2.
Order
Dr. Harveen Bhardwaj (President)
1. This complaint has been filed by the complainant, wherein alleged that the complainant has been getting himself medically insured for the last many years. The Mediclaim policy bearing No.36090434180400000006 for the period 18.04.2018 to 17.04.2019 was taken and ID No.P059289537 was provided to the complainant. The complainant has never availed any Mediclaim Policy earlier. The Mediclaim Policy taken by the complainant in the earlier years used to commence in the month of January, but in the year 2018 it commenced in the month of April as the complainant has gone to America in the month of January and after coming back from America could not commence the Policy immediately because of his preoccupation with the profession as the complainant is a practicing Doctor and was busy in clearing the back log of his professional engagements. Thus the policy commenced from 18.04.2018 and was valid upto 17.04.2019. The complainant Dr. Bharat Bhushan on 14.09.2018 developed some pain in the heart and for that he consulted Shriman Superspeciality Hospital and the said Hospital treated the complainant and the problem of Dr. Bharat Bhushan was artery disease (C-AD.) L diagnosed as coronary angiography and for which he was advised to undergo the coronary Angioplasty with stunting. The complainant Dr. Bharat Bhushan got his coronary Angioplasty with stunting and he was discharged from the Hospital on 16.09.2018. He had no history of any previous heart problem. For the treatment provided by the Hospital, Dr. Bharat Bhushan complainant paid a sum of Rs.1 Lakh and since the complainant was insured for the period during which he developed the medical problem and got himself treated, as such as per the Mediclaim policy the opposite party was duty bound to pay the amount of Rs.1 Lakh. The complainant was insured for a sum of Rs.5 Lakh. After discharge from the Hospital, the complainant filed his claim for reimbursement of the medical expenses incurred during the period of Policy which was valid from 18.04.2018 to 17.04.2019 and the treatment was provided to the complainant on 14.09.2018 i.e. well within the validity period of the insurance policy. Right from the beginning the OP had no intention to settle the claim and was postponing the matter on one pretext or the other. They were making queries which had have already been answered and the documents provided in order to cover-up their deficiency in service as well as the unprofessional attitude. They have been sending letters by anti-dating the same; like a letter purported dated 31.10.2018 was allegedly sent but was never received by the complainant. When the complainant approached them personally, then he was told that a query has been made vide letter dated 31.10.2018, but actually no such letter was received and this was received on 12.11.2018. To this query, immediately on 15.11.2018 the requisite papers were sent. Not only this, the reference was also made regarding the e-mails sent to the opp. Party and it finds no mention of the letter dated 31.10.2018. The complainant has been meeting on official namely Rupinder Dhillon, Asstt. Manager and she has been demanding that the documents be sent and when confronted the receipts issued by the OP with regard to having received the document, she had no answer and then consulted their own branch for these lapses. The OP in the above said manner dilly-delayed the matter for more than seven months and refused to reimburse the claim of the complainant. They even did not inform that the claim is not to be paid and thus kept the complainant in limbo. The complainant, as submitted, has been sending e-mails on different occasions i.e. on 01.11.2018, 11.12.2018, 19.01.2019 and 16.02.2019 i.e. almost every month and was sending e-mails by way of reminders to the OP, but absolutely there was no response. This shows the highly unprofessional attitude of the OP. They did not deem it proper even to give reply to these reminders. Ultimately, finding no response from the OP, a legal notice dated 08.04.2019 was served upon the OP, but no satisfactory reply has been filed by the OP. The Doctor treating the complainant was consulted after the receipt of frivolous reply by the OP, the complainant contacted the treating Doctor, who is renowned Cardiologist of the City and is ranked very high in the medical profession. The treating Doctor has given his opinion and has clearly and categorically opined that the mild hypertension of the complainant was unlikely to be a cause for complainant's coronary artery disease. The OP has ignored the fact that no person would file a Mediclaim at the cost of his own health and actually this was the state of affairs for the last so many years, when the complainant have purchased Mediclaim policies from the OP, but did not claim even a single penny. The act of the OPs have made a dent to the prestige of the complainant and as such necessity arose to file the present complaint with the prayer that the complaint of the complainant may be accepted and OPs be directed to make the payment of Rs.5,00,000/- i.e. a sum of Rs.1,00,000/-, which has been paid by the complainant and Rs.4,00,000/- on account of damages of mental tension, harassment, humiliation, agony and deficiency in service and negligence on providing professional services.
2. Notice of the complaint was sent to the OPs, who filed its joint written reply and contested the complaint by taking preliminary objections that the complaint is not maintainable against the OPs No.1 and 2, as such the same is liable to be dismissed. It is further averred that the claim of the Complainant was efficiently handled and processed by the Raksha Health Insurance TPA Pvt. Ltd., the third party administrator under the policy and on recommendation of Raksha Health Insurance TPA Pvt. Ltd. the claim of the complainant was repudiated as per terms and conditions of the insurance policy after due application of mind and the complainant was informed accordingly vide letter of repudiation dated 22-04-2019. It is an admitted fact that the complainant suffering from the Hypertension from last 3-4 years i.e. a known case of Hypertension since 3-4 years. Hypertension (HTN) is predisposing factor of CAD. Policy is five months old and pre-existing diseases are payable after four years, hence the claim of the complainant was repudiation as per Exclusion Clause 4.1 of policy of insurance. Exclusion Clause 4.1 is reproduced hereunder
The company shall not be liable to make any payment under this policy in respect of any expenses whatsoever incurred by any insured person in connection with or in respect of:
4.1 PRE-EXISTING DISEASE/CONDITIONS/BENEFTS will not be available for any conditions as defined in the policy, until 48 months of continuous coverage have elapsed, since inception of first policy with us.
The claim of the complainant has been rightly repudiated per terms and conditions of the insurance policy. It is further averred that there is no deficiency in service or negligence or unfair trade practice on the part of the opposite parties. Repudiating the claim which is not payable as per terms and conditions of the insurance policy does not amounts to any deficiency in service or negligence or unfair trade practice on the part of the OPs. The claim of the complainant has been repudiated as per terms and conditions of the insurance policy after due application of mind vide letter of repudiation dated 22-04-2019. On merits, it is admitted that the complainant got himself medically insured from 2015 onwards till 2018 and it is also admitted that the complainant got a mediclaim policy which was effective from 18.04.2018 to 17.04.2019 and it is also admitted that the complainant was diagnosed as Coronary Artery Disease, but the other allegations as made in the complaint are categorically denied and lastly submitted that the complaint of the complainant is without merits, the same may be dismissed.
3. Rejoinder to the written statement filed by the complainant, whereby reasserted the entire facts as narrated in the complaint and denied the allegations raised in the written statement.
4. In order to prove their respective versions, both the parties have produced on the file their respective evidence.
5. We have heard the learned counsel for the respective parties and have also gone through the case file very minutely.
6. It is an admitted and proved fact that the complainant got himself medically insured from 2015 onwards till 2018 as per Ex.C-1 to Ex.C-3. It has also been admitted and proved fact that the complainant got a mediclaim policy which was effective from 18.04.2018 to 17.04.2019 as per Ex.C-4/O-1. The complainant has alleged that on 14.09.2018, during the subsistence of the policy, the complainant developed some pain in the heart and he was diagnosed as having Coronary Artery Disease (CAD). He got his Coronary Angioplastic with stunting and was discharged from the hospital on 16.09.2018. The complainant has alleged that he paid a sum of Rs.1,00,000/- for his treatment. He filed a claim for reimbursement and the claim was repudiated, vide Ex.C-25.
7. Perusal of Ex.C-25 shows that the OP has disclosed that all the disease/injuries, which are pre-existing when the cover inspects for the first time are not payable as per condition 4.1 of the Policy and the policy is five months old. On this ground the claim of the complainant was repudiated.
8. The contention of the OP is that the complainant was suffering from hypertension for the last 3-4 years and this is a pre disposing factor of CAD. He has referred clause 4.1 of the terms and conditions of the policy. The OP has produced on record the indoor patient record of the complainant Ex.O-3 dated 14.09.2018. As per this, the complainant was feeling pain in Hypogastrium from 1-2 months and there was a history of hypertension from 3-4 years. To rebut this contention, the complainant has proved certificate of doctor. The doctor has given the certificate Ex.C-12 stating therein that the patient was admitted in this hospital on 14.09.2018 for Coronary Angiography undergone Coronary Angioplasty with Stenting and he was not having any past history of CAD and HTN i.e. hypertension and the complainant has also produced on record the certificate of Dr. V.P. Sharma dated 27.05.2019 Ex.C-26. Perusal of the Ex.C-26 shows that the doctor has given the certificate that the complainant was not a known case of diabetes and was not on any treatment for diabetes. He was suffering from mild hypertension which was very controlled for the last 3-4 years. Since, he himself is physician and was well informed, he managed his BP well. He has further clarified that this mild hypertension is very unlikely to be a cause of his coronary artery disease that too for unstable angina as in the case of the complainant. He has further clarified that mild well controlled BP of short duration has a very weak co-relation with coronary artery disease. This certificate has been issued by the doctor, who is an expert in Cardiology, on 27.05.2019. The history mentioned in Ex.O-3 has been clarified by the opinion of expert doctor. To rebut this certificate, the opinion of any other doctor has not been filed on record by the OPs. No history of any pre-existing disease as alleged has been mentioned in the discharge summary produced and proved by the complainant. Mainly, the claim of the complainant has been repudiated on the ground that he was having history of hypertension. It has been held by the Hon'ble National Commission in 2016 (1) CPR 753, titled as ‘Satish Chander Madan Vs. M/s Bajaj Allianz General Insurance Co. Ltd.’ that ‘Hypertension is a common ailment and it can be controlled by medication and it is not necessary that person suffering from hypertension would always suffer a heart attack- Treatment for heart problem cannot be termed as claim in respect of pre-existing disease-Claim was wrongly repudiated’. It has been held by Hon’ble Punjab & Haryana High Court in 1999 (1) R.C.R. (Civil) 646, case titled as ‘Veena Sharma Vs. Life Insurance Corporation of India’ that ‘Mere non-mentioning of insured being a patient of hypertension did not amount to suppression of material facts, so as to entitle the respondents to repudiate the policies- Personal statements filed by insured nowhere indicate if he was specifically asked as to whether he was a patient of hypertension.’
But in the present case, it has been clarified by Dr. V. P. Sharma that there is no nexus between mild hypertension and CAD. So, from the overall circumstances, it is proved that there is deficiency in service and unfair trade practice on the part of the OP by not reimbursing the claimed amount, thus, the repudiation order is set-aside and the complainant is entitled for the relief.
9. In the light of above detailed discussion, the complaint of the complainant is partly allowed and OP is directed to pay Rs.1,00,000/- to the complainant. Further, OP is directed to pay a compensation of Rs.10,000/- for causing mental tension and harassment to the complainant and Rs.5000/- as litigation expenses. The entire compliance be made within 45 days from the date of receipt of the copy of order. This complaint could not be decided within stipulated time frame due to rush of work.
10. Copies of the order be sent to the parties, as permissible, under the rules. File be indexed and consigned to the record room.
Dated Jyotsna Dr. Harveen Bhardwaj
08.08.2023 Member President
