Chandigarh

DF-I

CC/546/2023

MADAN LAL - Complainant(s)

Versus

THE ORIENTAL INSURANCE COMPANY LIMITED - Opp.Party(s)

DEVINDER KUMAR

03 Jul 2024

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION-I,

U.T. CHANDIGARH

                                     

Consumer Complaint No.	:	CC/546/2023
Date of Institution	:	22.11.2023
Date of Decision	:	03/07/2024

 

Madan Lal s/o BanarsiDass, aged about 64 years, r/o Village: MullanpurGaribdass, District: SAS Nagar, Mohali.

Complainant

VERSUS

1. The Oriental Insurance Company Limited, SCO No. 109-110-111, Sector 17- D, Chandigarh through its Branch Manager.

2. Medi Assist Insurance TPA Private Limited, SCO-61, Phase -7 Chandigarh- 160062 through its Branch Manager.

… Opposite Parties

CORAM :	SHRI PAWANJIT SINGH	PRESIDENT
	MRS. SURJEET KAUR	MEMBER

 

                                                                               

ARGUED BY	:	Sh. Sh. Devinder Kumar, Advocate for complainant
	:	Sh.Krishna Kant, Advocate for OPs.

Per Pawanjit Singh, President

1. The present consumer complaint has been filed by the complainant under Section 35 of the Consumer Protection Act 2019 against the opposite parties (hereinafter referred to as the OPs).The brief facts of the case are as under :-

1. It transpires from the averments as projected in the consumer complaint that in the month of November 2019 the agent of the OPs approached the complainant and explained about the features of health insurance policy and by relying upon the  assurances of the said agent of the Ops, the complainant agreed to purchase health insurance policy for himself and his wife. Accordingly, the complainant purchased the Group Health Insurance policy Annexure C-1 valid from 27.11.2019 to 26.11.2020 on payment of premium to the OPs, covering the complainant and his wife Smt. Shobna Rani by disclosing about the pre-existing ailments from which the complainant was suffering i.e. BP, Sugar and heart related problems. The complainant continuously got the subject policy renewed annually from the OPs by disclosing about the aforesaid pre-existing diseasesand the copies of policies renewed for the year 2020-2021, 2021-2022, 2022-2023are annexed as Annexure C-2 to C-4 which included the  subject policy valid w.e.f.27.11.2022 to 26.11.2023. Right from the day when the complainant purchased the first policy till June 2023,  the complainant did not raise any claim  with the OPs  and regularly paid the premiums to the OPs. In the month of June 2023, the complainant had faced health problem and he immediately approached Max Hospital, Mohali (hereinafter referred to be as treating hospital) and under the directions of the doctors various tests of the complainant were conducted and the complainant was admitted in the treating hospital on 8.6.2023 and Patent OMI+LAD stents S/P PTCA and Stening to LCX was done on 9.6.2023. Thereafter the complainant was discharged on 11.6.2023 and copy of the discharge summary is annexed as Annexure C-5. The treating hospital has raised bill of  ₹2,87,748.32  and the copy of bills  are annexed as Annexure C-6. Thereafter the treating hospital submitted the required documents for the cashless facility with the OPs. On receiving the said documents, the OP No.2 had raised certain queries and demanded documents from the Max Hospital vide letter Annexure C-7 and thereafter  the treating hospital  submitted all the required documents  for processing the claim. However, instead of providing the cashless claim to the complainant, the OPs denied the cashless facility to the complainant vide letter Annexure C-8 dated 11.6.2023 on the ground that the complainant was having T2DM, CAD Post PCI, LAD and OM since 2011  and was suspecting pre-existing disease before the inception  of the policy. On receipt of repudiation letter  the complainant visited the office of OP No.1 and explained about the fact with the request to settle the genuine claim but with no result. In this manner, the  aforesaid act amounts to deficiency in service and unfair trade practice on the part of OPs. OPs were requested several times to admit the claim, but, with no result.  Hence, the present consumer complaint.
2. OPs resisted the consumer complaint and filed their written version, inter alia, taking preliminary objections of maintainability, cause of action, concealment of material facts. On merits, it is admitted that the complainant has obtained the first policy in the year 2019  and got the same renewed without any break but the complainant has concealed the treatment of pre-existing disease(PED)  and as the complainant suffered complications within 48 months of continuous coverage after  the date of inception of the first policy, the claim of the complainant was rightly repudiated as per terms and  conditions  of the subject policy being fallenunder exclusion clause 4.1A. On merits, it is also admitted that the complainant had disclosed about the pre-exiting disease before obtaining the Istpolicy i.e.Sugar, BP and heart related problem regarding which reference has been given in the policy but since the entire claim of the complainant  falls  under exclusion clause 4.1A, the claim of the complainant was rightly repudiated. On merits, the facts as stated in the preliminary objections have been re-iterated. The cause of action set up by the complainant is denied.  The consumer complaint is sought to be contested.
3. In replication, complainant reiterated  the claim put forth in the consumer complaint and prayer has been made that the consumer complaint be allowed as prayed for.

2. In order to prove their case, parties have tendered/proved their evidence by way of respective affidavits and supporting documents.
3. We have heard the learned counsel for the parties and also gone through the file carefully.
   1. At the very outset, it may be observed that when it is an admitted case of the parties that the complainant had purchased the group health insurance policy from the Ops vide Annexure C-1 which was valid w.e.f. 27.11.2019 to 26.11.2020, covering the complainant and his wife Smt. Shobna Rani and before the issuance of the policy by the OPs, the complainant had disclosed about the pre-existing diseases  from which he was suffering, regarding which reference has also beenmade in the policy Annexure C-1 and  the saidpolicy was continuously got renewed by the  complainant without any break till the issuance of the subject policy on payment of premium as is also evident from copies of policies Annexure C-2 to C-4 and the complainant  had taken treatment from the treating hospital i.e. Max Hospital Mohali   for heart related disease and stent were inserted  as is also evident from discharge summary Annexure C-5 and the hospital  has raised bill of ₹2,87,748/-  as is also evident from copy of bill Annexure C-6 (colly) and the cashless facility of the complainant was rejected by the OPs  vide letter Annexure C-8 dated 11.6.2023 on the ground that the complainant was suffering from pre-existing disease  since 2011   and finally the claim of the complainant was repudiated  by the Ops vide letter Annexure OP1-2/3 dated 18.12.2023 on the ground that the claim of the complainant falls under the exclusion clause 4.1A, the case is reduced to a narrow compass as it is to be determined if the Ops are unjustified in repudiating the claim of the complainant and the complainant is entitled for the relief as prayed for as is the case of the complainant or if the Ops have rightly repudiated the claim of the complainant  as per terms and  conditions of the policy and the complaint is liable to be dismissed as is the defence of the Ops.
   2. Admittedly the  firstinsurance policy was issued to the complainant by the OPs in the year 2019 which was valid w.e.f.27.1.2019 to 26.11.2020  as is evident from Annexure C-1 and the subject  policy Annexure C-4 was issued by the OPs valid w.e.f.27.11.2022 to 26.11.2023 .
   3. Perusal of Annexure C-4 the subject policy clearly indicates that the complainant has disclosed about the pre-existing diseases i.e. Sugar, BP and heart related  problem which also findsreferencein  the subject policy. Thus one thing is clear  on record that the OPs knowing fully well about the factum of pre-existing disease  from which the complainant was suffering had agreed to issue the subject policy to the complainant  by charging higher premium amount from the complainant since 2019 when the first time the policy was issued to the complainant. Hence, the OPs wrongly denied the cashless facility to the complainant vide Annexure C-8 on the ground that the complainant was suffering from the pre-existing disease  since 2011.
   4. It is the defence of the OPs that the claim of the complainant was denied vide repudiation letter exhibit OP-1-2/3 on the ground that the claim of the complainant falls under the exclusion clause 4.1A as the complainant had been suffering from pre-existing disease 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. Thus the clause 4.1A  and the repudiation letter dated 18.12.2023 are required to be scanned carefully. The relevant portion of clause 4.1A available at page 39 of Exhibit OP1-2/2 is reproduced as under:-

4. GENERAL EXCLUSIONS:

4.1 The company shall not be liable to make any payment under this Policy in respect of any expense whatsoever incurred by any Insured Person in connection with or in respect of:

5. A. Pre-existing Diseases - code -Excl. 01

a). 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 the insurer.”

Similarly relevant portion of repudiation letter Annexure OP-1-2/3 is reproduced as under:-

“This has reference to the claim papers submitted to M/S Medi Assist Insurance TPA Pvt. Ltd. under policy No. 231494/48/2023/417, On scrutinizing the submitted claim documents it had been observed that this 64 years old male patient was admitted with complaints/diagnosis ACS S/P PTCA & underwent name of CAG PTC done. Patient had a previous diagnosis which was operated on 2011 of previous surgery as evident from discharge summary Since policy inception date is 2019 & the present diagnosis is a complication of the previous operation which is prior to the inception of the policy, the claim is considered for repudiation as per exclusion clause no 4.1.Α.

4.1 A. a). 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 the insurer. b). In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase. c). If the Insured person is continuously covered without any break as defined under the portability norms of the extant IRDAI (Health Insurance) Regulations, then waiting period for the same would be reduced to the extent of the prior coverage. d). Coverage under the policy after the expiry of 48 months for any pre-existing disease is subject to the same being declared at the time of application and accepted by insurer.

Keeping in view the above, as per terms and conditions of the policy, the said claim in inadmissible and not payable. We regret to inform that your claim is repudiated.”

 

6. Thus one thing is clear from the terms and condition of the subject policy as well as the repudiation letter dated 18.12.2023 that  the OPs have repudiated the claim of the complainant simply on the ground that the complainant had been suffering from pre-existing diseases  much prior to the inception of the subject policy and on the ground that the claim of the complainant 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 the insurer and as such the claim of the complainant is not payable.
7. When it is an admitted case of the Ops that the complainant had disclosed about the pre-existing diseases of BP, sugar and relating to heart  even before the inception of the policy  to the OPs and the OPs had agreed to issue the subject policy to the complainant by charging higher premium amount to cover the complainant and his wife and thereof terironically inserted a unilateral clause 4.1A in the terms and condition of the policy favouring the OPs, the same is   bad in the eyes of law and needs to be held illegal. It is a common sense  that  a prudent person who is already suffering from pre-existing disease  when takes an health insurance policy from the insurance company after disclosing his pre-existing disease would not accept clause 4.1A as the same would not allow him to take benefit of claim in case of any complications occurred during the currency of policy till the expiry  of 48 months.  Hence, in our opinion the OPs have firstly in order to grab handsome premium from the complainant issued him the subject policy knowing fully well about pre-existing ailment from which the complainant was suffering and  accepted huge premium amount from the complainant from 2019 to 2023 but when the complainant filed his genuine claim, the OPs resorted to the unilateral and illogical clause of 4.1A  just to frustrate the genuine claim of the complainant, which is a clear cut unfair trade practice on the part of the OPs. Had the OPs properly explained  theaforesaid exclusion clause to the complainant, certainly he would not have purchased the subject health policy.   The OPs have failed to prove on record that they have properly explained the aforesaid exclusion clause to the complainant before issuing the policy in question.
8.  Thus, it is proved on record that the  OPs have wrongly repudiated the genuine claim of the complainant by resorting to  unilateral exclusion clause, which proves deficiency in service and unfair trade practice on the part of the OPs. Hence, the instant consumer complaint deserves to be allowed.
9. So far as the claim amount is concerned, the complainant has proved on record bill Annexure C-6 that he has spent ₹2,87,748.32 , thus the complainant is entitled for the said amount.

4. In the light of the aforesaid discussion, the present consumer complaint succeeds, the same is hereby partly allowed and OPs are directed as under :-

1. to pay ₹2,87,748.32 to the complainant alongwith interest @ 9% per annum (simple) from the date repudiation  i.e. 18.12.2023 till onwards.
2. to pay an amount of ₹10,000/- to the complainant as compensation for causing mental agony and harassment to him;
3. to pay ₹10,000/- to the complainant as costs of litigation.

5. This order be complied with by the OPs jointly and severally within a period of 45 days from the date of receipt of certified copy thereof, failing which the amount(s) mentioned at Sr. No. (i) & (ii) above shall carry penal interest @ 12% per annum (simple) from the date of expiry of said period of 45 days, instead of 9% [mentioned at Sr.No.(i)], till realisation, over and above payment of ligation expenses.
6. Pending miscellaneous application(s), if any, also stands disposed off.
7. Certified copies of this order be sent to the parties free of charge. The file be consigned.

Announced 03/07/2024			Sd/- [Pawanjit Singh] President
mp
			Sd/-
			[Surjeet Kaur] Member