THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, AMRITSAR

Complaint No. 186-14

Date of Institution : 3.4.2014

Date of Decision : 11.2.2015

Sh. Anil Kumar S/o Sh. Tilak Raj, Resident of H.No. 1374/13, Gali Jandi Wali, Nimak Mandi, Amritsar

.....Complainant

Vs.

1. The National Insurance Company Ltd having office at Office VII, Third Floor, 104, Bharat House, Mumbai Samachar Marg, Mumbai 400023 also having branch at Divisional Office II, Court Road, Amritsar through its Managing Director/CEO/Manager/Officer in Charge

2. Dedicated Healthcare Services TPA (India) Pvt.Ltd having office at Cambata Building (Eros Theater Building) East Wing, 2^nd Floor, 42, Maharshi Karve Road, Churchgate, Mumbai 400020 through its Managing Director/CEO/Manager/Officer in Charge

3. Fortis Escorts Hospital, A unit of Fortis Hospitals Limited, Majitha-Verka Byepass Road, Amritsar 143004 through its Medical Superintendent/Manager/Officer in Charge

.....Opp.parties

Complaint under section 12/13 of the Consumer Protection Act, 1986

Present : For the complainant : Sh.Sandeep Kapoor, Adv

For the opposite party No.1: Sh. P.N.Khanna,Adv.

For opposite party No.2 : Ex-parte

For opposite party No.3 : Sh. Sanjeet Singh,Adv.

Quorum : Sh. Bhupinder Singh, President,

Ms.Kulwant Kaur Bajwa,Member

Order dictated by :-

Bhupinder Singh, President

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1. Present complaint has been filed by Anil Kumar under the provisions of the Consumer Protection Act alleging therein he obtained mediclaim policy namely Healthfirst Floater Policy bearing No. 251100/46/12/8500001901/140555 for the period from 26.11.2013 to 25.11.2014 for his family including complainant himself, his wife Smt.Usha and his son Nitin Kumar from opposite party No.1 by making payment of premium Rs. 3735/- and mediclaim premium and Rs. 3090/- as Health First Membership Fees. Prior to this policy, the complainant obtained similar mediclaim policy on 26.11.2010 vide No. 250700/46/10/8500000078/026620 valid till 25.11.2011, thereafter the complainant got renewed the policy for the period from 26.11.2011 to 25.11.2012 and 26.11.2012 to 25.11.2013. The total sum assured was Rs. 1,00,000/- . According to the complainant on 21.12.2013 he started having chest pain. The complainant was immediately brought to opposite party No.3 hospital , where Dr. H.P. Singh advised admission of the complainant in emergency as there was immediate need of Angiography due to blockage in the arteries. Accordingly, complainant was admitted in opposite party No.3 hospital on 21.12.2013 , where Angiography of the complainant was done and the complainant was found tripple vessel disease and was recommended for PTCA and stent LAD & RCA and the Angioplasty was done by the doctors at opposite party No.3 hospital on 21.12.2013. The opposite parties No.1 & 2 were informed for the claim as the policy was cashless , but the opposite parties refused to cashless facility vide letter dated 21.12.2013 for the reason that the present illness is a complication of the pre existing disease. The complainant was discharged from the hospital on 23.12.2013.. The complainant had to pay Rs. 2,77,430/- on his treatment to opposite party No.3. After his discharge, claim was lodged with the opposite parties and submitted all the requisite documents. But the opposite parties vide letter dated 3.3.2014 repudiated the claim for the alleged non disclosure of material facts. Thereafter complainant requested the opposite parties

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No.1 & 2 number of times to settle his claim, but to no avail. Alleging the same to be deficiency in service complaint was filed seeking directions to the opposite parties to release the claim amount of Rs. 1,00,000/- alongwith interest. Compensation of Rs. 1,00,000/- alongwith litigation expenses were also demanded.

2. On notice, opposite party appeared and filed written version in which it was submitted that cashless facility was rejected by the opposite party as the present illness of the complainant was a complication of a pre-existing disease. Thereafter detailed repudiation letter was written to the complainant by the TPA dated 3.3.2014 clearly stating that on scrutiny of documents and information received and the panel of doctors is of the opinion that claim is in-admissible on the ground that the patient was admitted in Fortis Escort Hospital for Tripple Vessel Coronary Artery Disease and Hypertension and as per discharge card, claimant is a known case of hypertension for the last three years . The date of policy inception is 26.11.2010 . As the past history was not revealed by the complainant to the opposite party at the time of taking the policy, hence, the claim was rejected under non-disclosure and concealment of material facts under clause 18 of the policy. While denying and controverting other allegations, dismissal of complaint was prayed.

3. Opposite party No.3 in its written version has submitted that complainant was admitted in the hospital of opposite party No.3 on 21.12.2013 with complaint of chest pain where he was admitted, by Dr. H.P. Singh. As per routine when the patient is admitted his history is recorded and when the patient was asked about the period of hypertension the same was stated to be three years. The patient was admitted, various tests were done. Lab. Investigations done indicated raised level of Cretinine Kinasa. Angiography was done which showed Triple Vessel Disease and the patient was advised PTCA. The patient was earlier admitted under cash category., After Angiography it transpired that the patient required PTCA. The

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complainant intimated the staff of opposite party No.3 that he has some cashless medical health insurance as such necessary assistance was given by the staff seeking cashless facility from insurance company. However, Insurance company vide its letter dated 21.6.2013 refused the claim of cashless facility. The patient was later discharged on 23.12.2013. However to facilitate the insurance claim of the complainant, he was given all the documents required by him to take up the claim with the insurance company.

4. Complainant tendered into evidence hhis affidavit exbt.C-1 alongwith documents Ex.C-2 to C-16.

5. Opposite party No.1 tendered affidavit of Sh. H.S. Chawla, Sr.D.M exbt.OP1/1,affidavit of Sh.Charandeep Singh,Executive of dedicated healthcare service (TPA) Ex.OP1/2 alongwith documents Ex.OP1/3 to Ex.OP1/8.

6. Opposite party No.3 tenderd affidavit of Dr. Pinak Moudgil ,Director of Fortis Escort Hospital Ex.OP3/1A alongwith documents Ex.OP3/1 to Ex.OP3/9.

7. We have carefully gone through the pleadings of the parties arguments advanced by the ld.counsels for both the parties and have appreciated the evidence produced on record by both the parties with the valuable assistance of the ld.counsels for both the parties.

8. From the record i.e. pleadings of the parties and the evidence produced on record by both the parties, it is clear that complainant obtained mediclaim policy namely Healthfirst Floater Policy bearing No. 251100/46/12/8500001901/140555 for the period from 26.11.2013 to 25.11.2014 Ex.C-2.Not only this complainant hadbeen getting policies continuously from the opposite parties No.1 & 2 for the last about four years i.e. from 26.11.2010 to 25.11.2011 Ex.C-4 and from 26.11.2011 to 25.11.2012 Ex.C-5 and from 26.11.2012 to 25.11.2013 Ex.C-6 with terms and conditions of the policy Ex.C-7 which fully prove that the complainant has been renewing the insurance policy from the opposite parties since 26.11.2010

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i.e for the last about four years. The total sum assured was Rs. 1,00,000/- . On 21.12.2013 complainant felt chest pain. He consulted Dr. H.P. Singh of opposite party No.3 hospital, who advised admission of the complainant in emergency as there was immediate need of Angiography due to blockage in the arteries. Accordingly, complainant was admitted in opposite party No.3 hospital on 21.12.2013 , where Angiography of the complainant was done and the complainant was found tripple vessel disease and was recommended for PTCA and stent LAD & RCA and the Angioplasty was done by the doctors at opposite party No.3 hospital on 21.12.2013. The opposite parties No.1 & 2 were informed for the claim as the policy was cashless , but the opposite parties refused to cashless facility vide letter dated 21.12.2013 Ex.C-12 on the ground that the illness is a complication of the pre existing disease. The complainant was discharged from the hospital on 23.12.2013 as per discharge summary Ex.C-11. After discharge regular claim was lodged with the opposite parties, but the opposite parties repudiatd the claim of the complainant vide letter dated 3.3.2014 Ex.C-14 on the ground that claim is in-admissible because complainant was admitted in the hospital for Tripple Vessel Coronary Artery Disease and Hypertension on 21.12.2013 and was discharged on 23.12.2013 and as per the discharge card claimant is a known case of hypertension since three years. The date of policy inception is 26.11.2010. The past history was not revealed by the complainant at the time of taking the policy. So the claim was rejected under clause non-disclosure and concealment of material facts i.e. Clause 18. Ld.counsel for the complainant submitted that the complainant was not suffering from any hypertension or CAD (Coronary Artery Disease) at the time of taking the policy nor the opposite party had produced any previous medical treatment record of the complainant nor produced any affidavit of the doctor, who treated the complainant for the aforesaid diseases. Apart from this the complainant had been under continuous insurance policy of opposite party No.1 for the 4^th year

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i.e. since 26.11.2010. So more than three years have already elapsed . The rejection of the claim of the complainant by the opposite party on these frivolous grounds amounts to deficiency of service on the part of the opposite party.

9. Whereas the case of the opposite party is that cashless facility was rejected by the opposite party as the present illness of the complainant was a complication of a pre-existing disease. Thereafter detailed repudiation letter was written to the complainant by the TPA dated 3.3.2014 Ex.OP1/4 clearly stating that on scrutiny of documents and information received and the panel of doctors is of the opinion that claim is in-admissible on the ground that the patient was admitted in Fortis Escort Hospital for Tripple Vessel Coronary Artery Disease and Hypertension and as per discharge card claimant is a known case of hypertension for the last three years . The date of policy inception is 26.11.2010 as the past history was not revealed by the complainant to the opposite party at the time of taking the policy. Hence, the claim was rejected under non-disclosure and concealment of material facts under clause 18 of the policy. Ld.counsel for the opposite party submitted that there is no deficiency of service on the part of the opposite party qua the complainant.

10. Whereas case of the opposite party No.3 is that complainant was admitted in opposite party No.3 hospital on 21.12.2013 with complaint of chest pain, where he was examined by Dr. H.P. Singh as a routine. At the time of his admission the history of the patient was recorded whereas tests of the patient were done in opposite party No.3 hospital. The Lab investigations indicated raised level of Cretinine Kinasa. Angiography was done which showed Triple Vessel Disease and the patient was advised PTCA. Opposite party No.3 gave proper treatment to the complainant. Intimation regarding the admission of the complainant was given to opposite parties No.1 & 2 as the complainant has claimed cashless facility of insurance from opposite parties No.1 & 2. But opposite parties No.1 & 2 vide their letter dated 21.6.2013 refused the claim of cashless facility. Ld.counsel for the

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opposite party No.3 submitted that there is no deficiency of service on the part of opposite party No.3 .

11. From the entire above discussion particularly from the perusal of the record i.e. Insurance policy obtained by the complainant from opposite parties No.1 & 2, it stands fully proved on record that complainant had been getting insurance policies namely Healthfirst Floater Policy from opposite parties No.1 & 2 since 26.11.2010 i.e. policy for the period 26.11.2010 to 25.11.2011 Ex.C-4, policy for the period from 26.11.2011 to 25.11.2012 Ex.C-5, policy for the period from 26.11.2012 to 25.11.2013 Ex.C-6 and the policy for the period from 26.11.2013 to 25.11.2014 Ex.C-2. The total sum assured was Rs. 1,00,000/-. All this fully proves that the complainant had been under the insurance of opposite parties No.1 & 2 for the last more than three years. The complainant felt chest pain on 21.12.2013. Resultantly he was admitted in opposite party No.3 hospital on 21.12.2013 where various tests of the complainant were conducted which included Angiography and the complainant was found having Triple Vessel Disease and was recommended for PTCA and stent LAD & RCA. Resultantly Angioplasty was done by the doctors at opposite party No.3 hospital on 21.12.2013. The insurance policy was having cashless facility. Intimation regarding admission of the complainant in opposite party No.3 hospital was given to opposite parties No.1 & 2, but opposite parties No.1 & 2 vide their letter dated 21.12.2013 refused the cashless facility to the complainant on the ground that the present illness is a complication of a pre-existing disease. Resultantly the complainant had to pay Rs. 2,77,430/- to opposite party No.3 hospital from his own pocket. After his discharge from opposite party No.3 hospital on 23.12.2013 , the complainant lodged claim with opposite parties No.1 & 2 and submitted all the requisite documents. But opposite parties No.1 & 2 vide their letter dated 3.3.2014 repudiated the claim of the complainant on the ground of non-disclosure of material facts. Opposite party alleges that as per the

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history recorded by opposite party No.3 at the time of admission of the complainant on 21.12.2013, the complainant was recorded as known case of hypertension for the last about three years as per discharge summary of the patient issued by opposite party No.3 Ex.OP3/6. Whereas the complainant alleges that he had no knowledge about the hypertension at the time of taking of the policy from opposite parties No.1 & 2 on 26.11.2010. Opposite party relied upon the history of the patient recorded at the time of admission of the patient in opposite party No. 3 hospital on 21.12.2013. But the opposite party could not produce any evidence in the form of medical treatment record of the complainant that he had been suffering from this disease of hypertension for the last about three years nor the opposite parties No.1 & 2 could produce any affidavit of any doctor or medical practitioner that he ever treated the complainant for hypertension before taking the policy by the complainant from the opposite parties No.1 & 2 . Apart from this the complainant had been taking the insurance policies from the opposite parties for the last more than three yeas from the date of his admission in opposite party No.3 hospital on 21.12.2013. As such it stands fully proved on record that the complainant had no knowledge of hypertension at the time when he took the policy from the opposite parties on 26.11.2010. It has been held by the Hon'ble National Commission in case LIC Insurance Corporation of India & Anr. Vs. Naseem Bano 2013(1) CPC 491 that where the only ground of repudiation of claim is that insured had concealed material fact of diabetes or hypertension, held that evidence based on “bed head ticket' only not sufficient to prove concealment of disease. No other medical record was produced by the insurance company. So repudiation of the claim on this ground is not justified .Same view has been taken by the Hon'ble National Commission in case Bajaj Allainz Life Insuance Company Ltd. Vs. Sowbhagyalaxmi and Ors. 2013(1) CPC 128 that repudiation of claim on ground of pre-existing disease was unfounded on report of investigator which was not

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supported by any evidence or affidavit. Hon'ble National Commission in case LIC of India and Others Vs. Kunari Devi 2009(2) CPC 107 has held that only evidence relied upon by the insurance company was the history recorded in hospital's bed head ticket which cannot be treated as a material evidence. Petitioner could not produce any evidence showing any proof of treatment taken by deceased insured from any doctor, repudiation of the claim was held not sustainable. Our own Hon'ble State Commission in case Life Insurance Corporation of India & Anr. Vs. Murti Devi 2012(3) CPC 375 has held that where petitioner has not produced any record of medical treatment of the insured to prove that he had taken medical treatment from any doctor regarding disease prior to the insurance policy. It cannot be held that complainant has suppressed any material fact . Examination of doctor who checked patient prior to obtaining of policy, some treatment papers, some prescriptions, etc., should have been produced by the opposite party. The Hon'ble National Commission in case Sahara India Life Insurance Co. Ltd. & Anr Vs. Hansaben Deeepak Kumar Pandya IV(2012) CPJ 13(NC) has held that where the opposite party insurance company has failed to produce on record any evidence to show that deceased insured ever consulted doctor for taking treatment of heart disease, the repudiation of the claim on the ground of suppression of material fact is totally illegal.

12. So from the entire above discussion, we are of the opinion that the opposite parties have wrongly repudiated the claim of the complainant vide letter dated 3.3.2014 on the ground of non-disclosure of material facts, fully knowing that the complainant has been under insurance of the opposite parties for the last more than three years and this complication occured to the complainant in the 4^th year of policy. Apart from this as per clause 4 of the terms and conditions of the policy even those diseases will be covered under the policy after two contionous or more claim free policy years depending upon the special exclusion mentioned in the

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policy certificate based on the medical condition at the time of proposal.

13. No doubt the complainant spent Rs. 2,77,430/- on his medical treatment in opposite party No.3 hosital as per inpatient bill Ex.C-13, but the sum assured under the policy is Rs.1,00,000/-.

14. The entire above discussion fully proves that the opposite party had intentionally to harass the complainant repudiated his genuine claim by setting-aside all the norms of prudence, terms and conditions of the policy and fully knowing the fact that the complainant has been taking the Insurance policy from the opposite party for the last more than three years continuously.

15. Resultantly we allow the complaint with costs and the opposite parties No.1 & 2 are directed to pay the sum assured Rs. 1,00,000/- to the complainant within one month from the date of receipt of copy of orders. Opposite parties No.,1 & 2 are also directed to pay compensation of Rs. 50000/- for undue harassment of the complainant by the opposite parties .Opposite parties No.1 & 2 are also directed to pay litigation expenses Rs. 2000/- to the complainant. Copies of the orders be furnished to the parties free of costs. File is ordered to be consigned to the record room.

16. Case could not be disposed of within the stipulated period due to heavy

pendency of the cases in this Forum.

11.2.2015 ( Bhupinder Singh )

President

/R/ ( Kulwant Kaur Bajwa)

Member