Haryana

Kaithal

123/20

Bhajan Lal - Complainant(s)

Versus

The New India Assurance Co. - Opp.Party(s)

Sh.Karan Kalra

10 May 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KAITHAL.

                                                     Complaint Case No.123/2020.

                                                     Date of institution: 17.03.2020.

                                                     Date of decision:10.05.2023.

Bhajan Lal S/o Sh. Banarsi Dass r/o H.No.817, Dogran Gate, Kaithal.

                                                                        …Complainant.

                        Versus

1. The New India Assurance Company Limited, through its Branch Manager, above Vijaya Bank, Ambala Road, Kaithal.
2. The New India Assurance Company Limited, Regional Office, through its Regional Manager, SCO No.36-37, Sector-17A, Chandigarh.

….Respondents.

        Complaint under Section 12 of the Consumer Protection Act

CORAM:     SMT. NEELAM KASHYAP, PRESIDENT.

                SMT. SUMAN RANA, MEMBER.

                SH. SUNIL MOHAN TRIKHA, MEMBER.

       

Present:     Sh. Karan Kalra, Advocate, for the complainant.   

                Sh. C.S.Gupta, Advocate for the respondents.

               

ORDER

NEELAM KASHYAP, PRESIDENT

        Bhajan Lal-Complainant has filed this complaint under Section 12 of Consumer Protection Act, 1986 (hereinafter referred to as ‘the Act’) against the respondents.

                In nutshell, the facts of present case are that the complainant alongwith his wife was insured with the respondents under the Health Policy No.35440034172800000655 valid w.e.f. 30.01.2018 to 29.01.2019 and thereafter, it was renewed vide policy No.35440034182800000591 for the period w.e.f. 30.01.2019 to 29.01.2020.  It is alleged that on 03.01.2019, the complainant was firstly taken to Shah Hospital, Kaithal and had given first aid treatment and then the complainant was taken to Amar Hospital, Patiala for better treatment of the complainant of slurring of speech with left side weakness and facial deviation towards right side and the doctors of Amar Hospital, Patiala has treated the complainant and discharged on 07.01.2019.  The complainant has spent Rs.1,50,000/- on his medical treatment, medicines and travelling expenses etc. at Shah Hospital as-well-as Amar Hospital, Patiala.  The complainant lodged the claim with the respondents and submitted all the necessary documents but the respondents repudiated the claim of complainant vide letter dt. 22.02.2019.  The said repudiation of claim is stated to be wrong and illegal.  So, it is a clear cut case of deficiency in service on the part of respondents and prayed for acceptance of complaint.     

2.            Upon notice, the respondents appeared before this Commission and contested the complaint by filing their written statement raising preliminary objections that there is no deficiency in service on the part of respondents and thus, the complainant is not entitled to invoke the jurisdiction of this commission.  The claim was processed and settled by Raksha TPA Pvt. Ltd. (Third Party Administrator).  It needs to be submitted here that the policy in question was issued to the complainant on condition No.4.1 and 4.3 of policy duly agreed by the complainant as the insured was well apprised by the concerned officer about the same at the time of issuance of same which provide that “Pre-existing Disease/condition benefits will not be available for any condition as defined in the policy, until 48 months of continuous coverage have elapsed since, inception of the first policy with them.  Thus, Raksha TPA (Third Party Administrator) Pvt. Ltd. IRDA Licensed Company has processed the claim of complainant and after having processed the claim documents of the complainant a team of doctors of said Raksha TPA found among others that “The patient Bhajan Lal was admitted in Amar Hospital (Patiala) from 04.01.2019 to 07.01.2019 with the complaint of slurring of speech in left side weakness and facial deviation towards right side.  Patient was diagnosed as a case of Hypertension, Severe left ventricular dysfunction (recently detected) and Cerebrovascular accident with left sided Hemiparesis.  Ailment is chronic in nature (Hypertension is pre-existing factor of CVA).  Treatment of same falls under exclusion of 2 years.  The policy is in 2^nd year of inception.  Hence, the claim is being repudiated as per clause 4.1 and 4.3 of policy.  On merits, the objections raised in the preliminary objections are reiterated and so, prayed for dismissal of complaint.

3.             To prove his case, the complainant tendered into evidence affidavit Ex.CW1/A alongwith documents Anneuxre-C1 to Annexure-C28 and thereafter, closed the evidence.

4.             On the other hand, the respondents tendered into evidence affidavits Ex.RW1/A & Ex.RW2/A alongwith documents Annexure-R1 to Annexure-R3 and thereafter, closed the evidence.

5.             We have heard the learned Counsel for both the parties and perused the record carefully.

6.             Ld. counsel for the complainant has argued that the complainant alongwith his wife was initially insured with the respondents vide policy No.3544034162800000530 valid for the period 30.01.2017 to 29.01.2018 as per Mark-A and thereafter, the policy was renewed bearing No.35440034172800000655 valid w.e.f. 30.01.2018 to 29.01.2019 as per Mark-B and then it was renewed vide policy No.35440034182800000591 for the period w.e.f. 30.01.2019 to 29.01.2020 as per Mark-C.  It is argued that the complainant has paid all the premiums on time and is being continuing this medi-claim policy from 30.01.2017.  It is further argued that on 03.01.2019, the complainant was firstly taken to Shah Hospital, Kaithal and had given first aid treatment and then the complainant was taken to Amar Hospital, Patiala for better treatment of the complainant of slurring of speech with left side weakness and facial deviation towards right side and the doctors of Amar Hospital, Patiala has treated the complainant and discharged on 07.01.2019 as per Annexure-C4.  The complainant has spent Rs.1,50,000/- on his medical treatment, medicines and travelling expenses etc. at Shah Hospital as-well-as Amar Hospital, Patiala.  The complainant lodged the claim with the respondents and submitted all the necessary documents but the respondents repudiated the claim of complainant vide letter dt. 22.02.2019 as per Annexure-C1 on the ground that the patient was diagnosed as a case of Hypertension, Severe left Ventricular dysfunction (recently detected) and Cerebrovascular accident with Left sided Hemiparesis.  The said repudiation of claim is stated to be wrong and illegal.  It is further argued that hypertension is not pre-existing disease.  So, it is a clear cut case of deficiency in service on the part of respondents.  Ld. counsel for the complainant has placed reliance upon the case law cited in 2012(1) CPJ 204 titled as Sushil Kumar Jain Vs. UII (Hon’ble National Commission); 2017(2) CLT 437 titled as Kanwaljit Singh Vs. NIC (Hon’ble Punjab State Commission); 2011(3) CLT 549 titled as LIC Vs. Priya Sharma etc. (Hon’ble Punjab State Commission) and 2023(1) MLJ 220 titled as Gokal Chand (D) Thr. Lrs. Vs. Axis Bank Ltd. and another (Hon’ble Supreme Court). 

7.             On the other hand, ld. counsel for the OPs has argued that the claim was processed and settled by Raksha TPA Pvt. Ltd. (Third Party Administrator).  It is further argued that the policy in question was issued to the complainant on condition No.4.1 and 4.3 of policy duly agreed by the complainant as the insured was well apprised by the concerned officer about the same at the time of issuance of same.  It is further argued that as per clause 4.1 “Pre-existing Disease/condition benefits will not be available for any condition as defined in the policy, until 48 months of continuous coverage have elapsed since, inception of the first policy with them.”  It is further argued that as per clause 4.3 “Waiting period for specified diseases/ailments/conditions is 2 years”.  Thus, Raksha TPA (Third Party Administrator) Pvt. Ltd. IRDA Licensed Company has processed the claim of complainant and after having processed the claim documents of the complainant a team of doctors of said Raksha TPA found among others that “The patient Bhajan Lal was admitted in Amar Hospital (Patiala) from 04.01.2019 to 07.01.2019 with the complaint of slurring of speech in left side weakness and facial deviation towards right side.  Patient was diagnosed as a case of Hypertension, Severe left ventricular dysfunction (recently detected) and Cerebrovascular accident with left sided Hemiparesis.  Ailment is chronic in nature (Hypertension is pre-existing factor of CVA).  Treatment of same falls under exclusion of 2 years.  It is further argued that the policy is in 2^nd year of inception.  Hence, the claim is being repudiated as per clause 4.1 and 4.3 of policy.  It is further argued that Annexure-R2 is policy and Annexure-R3 is the terms and conditions of policy.  It is further argued that the policy alongwith terms and conditions were supplied to the complainant.  It is further argued that there is no document on the file from which it could be proved that it was not a pre-existing disease and there is no rebuttal on the report of TPA (Third Party Administrator) which has been introduced by IRDA (Insurance Regulatory and Development Authority).  He has drawn our attention towards the affidavit of Dr. Amandeep Singh (Regional Manager) r/o Raksha Health Insurance TPA Pvt. Ltd. as per Annexure-RW2/A, who has specifically mentioned in his affidavit that ailment is chronic in nature (Hypertension is pre-existing factor of CVA).  Treatment of same falls under exclusion of 2 years.  The policy is in 2^nd year of inception.  During the course of arguments, ld. counsel for the OPs has also drawn our attention towards the exclusion clause 4.1 and 4.3.1 mentioned in the terms and conditions as per Annexure-R3 and  vehemently contended that the expenses incurred on treatment of the illness mentioned at Sr.No.10 ‘Hypertension” as per clause 4.3.1 are not payable to the complainant.  Ld. counsel for the OPs has placed reliance upon the case law titled as The Chairman & Managing Director, City Union Bank Ltd. & another Vs. R. Chandramohan decided by Hon’ble Supreme Court on 27.03.2023.

8.             In rebuttal, ld. counsel for the complainant has argued that  initially the complainant had purchased the policy in the year 2017-18 and thereafter, he renewed the same in the next years from time to time.  It has been further argued that the complainant fell ill in the fag end of two years from purchasing the policy in question.        

9.             We have considered the rival contentions of both the parties.  As per repudiation letter Annexure-C1/R1, it is mentioned that the complainant Bhajan Lal was admitted in Amar Hospital, Patiala from 04.01.2019 to 07.01.2019 and claim was repudiated on the ground of hypertension.  After going through the file, it is clear that as per Annexure-C4, Bhajan Lal was firstly admitted in Shah Hospital on 02.01.2019.  The hospital record is Annexure-C15 from which it is clear that the complainant was admitted on 02.01.2019 and lama date was 03.01.2019.  In the Annexure-C15, it is mentioned as under:-

        “DIAGNOSIS:-

        Ac. lvf.

        CHIEF COMPLAINTS & REASON FOR ADMISSION:-

C/O BREATHLESSNESS SINCE 4 HOURS IRREGULARLY SINCE 3 DAYS

RESTLESSNESS SINCE 2 HOURS

SLURRING OF SPEECH SINCE 2 HOURS

HISTORY OF PRESENTING ILLNESS:-

PT. WAS APPARENTLY ALLRIGHT 2 HOURS BACK.  WHEN HE STARTS FEELING ABOVE MENTIONED COMPLAINT. PT. WAS BROUGHT IN SERIOUS CONDITION BY ATTENDENTS.  POOR PROGNOSIS AS EXPLAINED TO ATTENDENTS.

PAST HISTORY:-

CVA (INFRACT) AS PER ATTENDENTS

NO RECORD AVAILABLE.”

10.            Thereafter, Bhajan Lal was again admitted in Amar Hospital, Patiala on 03.01.2019.  The hospital record is Annexure-C4 from which it is clear that the complainant was admitted on 03.01.2019 and discharged on 07.01.2019, the detail of which is mentioned as under:-

        “Diagnosis:

        HTN (Recently Detected)

        Severe LVD (Recently Detected)

        CVA (1) with Left Side Hemiparesis

        Chief Complaints:

        Patient was admitted with chief complaints of slurring of speech with left side weakness and facial deviation towards right side.

        Vitals at Admission:

        BP-110/70 mm Hg

        Pulse-100/min

        RR-18/min

        Chest-B/L AE+

        CNS-Conscious, oriented

        P/A-Soft, non-tender

        Summary of Treatment:

        Patient was admitted on 03.01.2019 with above mentioned complaints.  All relevant laboratory and radiology investigations were done.  Visit of neurologist was done for CVA (1) and advised was followed.  He was managed with antibiotics, antacids, anti-emetics, diuretics, antiplatelets, anticoagulants and with other supportive treatment.  He was regularly seen by treating consultant and managed with revised treatment.  He responded well to the treatment, hence is being discharged on 07.01.2019 in stable condition.”

11.            From the above treatment record as per Annexure-C4 and Annexure-C15, it is clear that there is no history of hypertension of Bhajan Lal.  In this regard, we rely upon Kanwaljit Singh Vs. NIC (supra), wherein it has been mentioned that Pre-existing disease-Many persons have diseases that one is having without his knowing-The diseases remain dormant in the body for years-Some illnesses have incubation period of anywhere from years to decades-Some diseases wait in body for decades before striking-As per certificate given by the doctor no date for his pre-existing disease suffered by the complainant’s son was given-There is no mention that his son was suffering from pre-existing disease-Thus, complainant held entitled to recover medi-claim bills pertaining to treatment undertaken by his son from PGI for the first time from 24.05.2014 to 19.03.2014 for Rs.5,00,000/-.  Thereafter, he was also entitled to claim the amount of hospitalization for his son’s second admission from 31.08.2014 to 17.10.2014 under the same policy for a sum of Rs.3,14,485/-. 

                Similar support is taken from the another authority laid down in case titled as LIC Vs. Sushma Sharma (supra), wherein it has been mentioned that Suppression of-Plea is that insured was suffering from hypertension and diabetes for last 10 years before death and it was not disclosed-Repudiation of claim under Section 45 of Insurance Act-It is not concealed fact of every fact that gives right of repudiation of claim-Hypertension and diabetes are not material diseases-If these diseases had been material insured would not have survived for 10 years-Complaint allowed by Forum-Payment of insurance amount with interest is directed-Appeal against order is dismissed.

12.            Moreover, the policy was taken by the complainant in the month of January, 2017 and complainant was admitted in the hospital in January, 2019 which clearly shows that near about two years were completed.  No document is produced by the Ops regarding that the complainant was suffering from hypertension at the time of taking the policy.  So far the affidavit of Dr. Amandeep Singh, Ex.RW2/A in evidence is concerned, the said doctor has not attached any document or treatment record which could prove that Bhajan Lal was suffering from hypertension at the time of taking the policy.  The aforesaid authorities submitted by ld. counsel for the complainant are fully applicable to the facts of instant case, whereas the authority submitted by ld. counsel for the Ops is not distinguishable but the same is not applicable to the facts of instant case.  After hearing both the parties, we have been observing that in a number of cases, the insurance companies are issuing policies based on the statements made by the proposer in utmost good faith but when it comes to settlement of claims, they start examining the matter under the microscope.  In a majority of policies issued by the insurance companies they were routed through their agents.  The agents in their anxiety to get their commission and the insurance company in order to do more and more business see that the policies are issued the moment they received the premium amount.  It has also come into knowledge of this Commission that the OPs insurance company does not settle the petty and genuine claims of the customers whereas drag them to knock the doors of the court which clearly amounts to deficiency in service as-well-as unfair trade practice on their part and thereby harass the innocent and poor customers unnecessarily.  So, we are of the considered view that the Ops have wrongly repudiated the claim of complainant.  During the course of arguments, the complainant has placed on record the calculation sheet  amounting to Rs.78,383/-, which is Mark-D on the file.  The complainant has not placed on file any bill regarding travelling charges and physician expenses.  In the interest of justice, we assess the physician expenses to the tune of Rs.5,000/-.  So, the complainant is entitled for the amount of Rs.83,383/- (Rs.78,383/-+Rs.5,000).

13.            Thus, as a sequel of aforesaid discussion, we direct the Ops to pay the amount of Rs.83,383/- to the complainant alongwith interest @ 7% p.a. from the date of filing the present complaint till its realization within 45 days from today.  The Ops are further directed to pay Rs.30,000/- as compensation on account of physical harassment and mental agony as-well-as Rs.5,000/- as litigation charges to the complainant.  Hence, the present complaint is accepted accordingly.

14.            In default of compliance of this order, proceedings shall be initiated under Section 72 of Consumer Protection Act, 2019 as non-compliance of court order shall be punishable with imprisonment for a term which shall not be less than one month, but which may extend to three years, or with fine, which shall not be less than twenty five thousand rupees, but which may extend to one lakh rupees, or with both.  A copy of this order be sent to both the parties free of cost.  File be consigned to the record room after due compliance.     

Announced in open court:

Dt.:10.05.2023.  

                                                                (Neelam Kashyap)

                                                                President.

 

(Sunil Mohan Trikha),           (Suman Rana),          

Member.                            Member.

 

Typed by: Sanjay Kumar, S.G.