DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-I, U.T. CHANDIGARH

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1]  Davinder Kaur wife of Manmohan Singh,

2]  Manmohan Singh, Husband of Davinder Kaur,

Both residents of House No.3011, Sector 19-D, Chandigarh.

…..Complainants

                 V E R S U S

1]  The Oriental Insurance Company Limited, SCO No.99-100, Sector 17-B, Chandigarh, through its Regional Manager/Branch Head.

2]  M/s Raksha TPA Pvt. Limited, SCO No.181, 2^nd Floor, Sector 7-C, Chandigarh, through its Branch Head.

                      ……Opposite Parties

CORAM:   SH.P.D.GOEL                 PRESIDENT

         SH.RAJINDER SINGH GILL       MEMBER

Argued by: Sh.Deepak Aggarwal, Counsel for Complainants.

           Ms.Madhu Sharma, Counsel for OP No.1.

           OP NO.2 already exparte.

PER P.D.GOEL, PRESIDENT

         The complainant NO.1 had obtained a medicalim policy from OPs namely “Happy Family Floater Policy” (Ann.C-1) valid from 15.9.2009 to 15.9.2010, which covers all his family members for any hospitalization expenses.

         It is averred that complainant No.2, on account of sudden chest pain, visited Shivalik Hospital, Sector 69, Mohali.  Some of the tests on the body of complainant No.2 were conducted in the Hospital and some of the tests were got done from outside. Ultimately, complainant No.2 was recommended definitive Invasive and Interventional Coronary Angioplasty (Ann.C-5 to C-6).  Thereafter, complainant NO.2 was admitted as an indoor patient in Shivalik Hospital on 11.9.2010. CART was done on 11.9.2010, which revealed that complainant NO.2 was having single vessel disease. He underwent PTCA, LAD and was discharged from the hospital on 14.9.2010 in a stable condition. A total  bill of Rs.2,95,591/- was raised for the said treatment (Ann.C-7), which was paid by complainants vide Ann.C-9 & C-10, on the assurance that the same will be reimbursed. The Bills have been annexed as Ann.C-11 to C-19. 

         Thereafter, complainants sent the claim form to OPs along with all relevant documents vide Ann.C-20, through courier (Ann.C-21).  But the OPs did not settle the claim, as such complainant sent letters (Ann.C-22 & C-23) to OPs through post (Ann.C-24 & C-25), but the claim has not been settled till date.  Hence, this complaint alleging the above act of OPs as gross deficiency in service and unfair trade practice.

2]       OP No.1 filed reply, stating therein that the policy in question, taken by the complainants from the OP Company, was in 1^st year of its inception and the patient was Diabetic for the last 2-3 years and also Hypertensive (HTN) and CLL as per statement of patient and hospital records, but he did not disclose these facts in the proposal form (Ann.R-1).  It is stated that the claim was Not Payable, so it was Repudiated (Ann.R-2) under Clause No.4.1, 4.3 and Condition No.5.9 of the Policy (Ann.R-3).  It is also stated that complainant NO.2 was having previous history of Diabetes, which he himself has admitted in the statement Ann.R-4. It is submitted that Prime Heart Hospital sent the request to Raksha TPA through Ann.R-5 for cashless facility, which was denied.  As per Ann.R-5, it is clear that the patient was diagnosed as HTN, LAD, VA+ve TMT, which means that he was having history of Diabetic and Hypertension, which was not disclosed in the Proposal Form. Pleading no deficiency in service, it is prayed that the complaint be dismissed.

         OP No.2 did not turn up despite service, hence was proceeded against exparte.

3]       Parties led evidence in support of their contentions.

4]      We have heard the ld.Counsel for the parties and have also perused the record.

5]       The ld.Counsel for the complainant contended that the complainant No.1 purchased Happy Family Floater Policy (Ann.C-1) valid from 15.9.2009 to 15.9.2010. That the complainant NO.2, due to sudden chest pain, got conducted certain test and ultimately, he was recommended definitive Invasive & Interventional Coronary Angioplasty (Ann.C-5 to C-6), so he was admitted as Indoor Patient in Shivalik Hospital on 11.9.2010, where CART was done on 11.9.2010.  It was found that complainant No.2 was having single vessel disease, so he underwent PTCA, LAD and was discharged on 14.9.2010. A total bill of Rs.2,95,591/- was raised on the treatment of complainant NO.2.  The complainant NO.2 submitted the claim form along with all relevant documents. But the OP Insurance Company has illegally repudiated the claim of Rs.2,95,591/- submitted by the complainant.

6]       The ld.Counsel for OP No.1 raised the plea that the policy taken by the complainant was in first years of its inception.  The patient was diabetic for the last 2-3 years and also Hypertensive (HTN) and CLL, per statement of patient and hospital records, but he did not disclose these facts in the proposal form   (Ann.R-1).  It was lately argued that in view of Clause No.4.1, 4.3 and Condition No.5.9 of the Policy (Ann.R-3), the claim was not payable, so it was righty repudiated.  It was also argued that the complainant was having previous history of Diabetes, which he himself has admitted in his statement Ann.R-4. It was further argued that as per Ann.R-5, the patient was diagnosed as HTN, LAD, VA+ve TMT, which means that he was having history of Diabetic and Hypertension.

7]       Now the point for consideration is whether the repudiation of the claim is legal & genuine.  The answer to this is in the negative.

8]       The repudiation letter dated 18.1.2012 (Ann.R-2) shows that the claim has been repudiated under Clause No.4.1, 4.3 and Condition No.5.9 of the policy, as per the details, given below:-

“1. Patient Suffered from coronary Artery Disease – Single Vessel Disease and underwent PTCA+Stenting at Prime Heart & Vascular Institute, Mohali.

2.  Patient is known case of DM (Diabetes Mellitus), HTN (Hypertension) and CLL (Chronic Lymphoid Leukaemia) as per hospital record.

         3.  Policy is in 1^st year of inception.

4.  Patient is Diabetic from 2-3 years and also hypertensive as per the hospital records.

As per clause 4.1 any illness present in the patient before the policy inception including Coronary Artery Disease under such condition, will be excluded from the scope of the policy which reads as under:-

4.1 “Pre-existing health condition or disease or ailment/injuries: Any ailment/disease/injuries/health condition which are pre-existing (treated/untreated, declared/not declared in the proposal form), in case of any of the insured person of the family, when the cover incepts for the first time, are excluded for such insured person upto 4 years of this policy being in force continuously.”

9]       Admittedly, the complainant No.2 is the beneficiary of Happy Family Floater Policy (Ann.C-1) valid from 15.9.2009 to 15.9.2010.  Annexure C-5 is a Report of Prime Diagnostic Centre & Heart Institute, dated 09.09.2010 of Manmohan Singh, Complainant NO.2, wherein it has been stated that there was no evidence clinically to suggest LV dysfunction, systolic or diastolic during exercise.

10]      The OPs have placed on record the report of Prime Heart Hospital, dated 11.09.2010 as Ann.R-5, wherein under the Column of Diagnosis it has been mentioned as “HTN, LAD, UA+ve TMT (6 METs).

11]      Admittedly, the said report is neither the original one nor has been supported by the affidavit of the doctor, who has issued it.  Thus, it looses its evidentiary value.  More so, the said report is dated 11.9.2010, whereas the policy was valid from 15.9.2009 to 15.9.2010.  The OP Insurance Company can succeed in the case, only, if it proves on record that Complainant NO.2 was suffering from pre-existing disease i.e. HTN, LAD, UA+ve TMT, prior to the issuance of the policy i.e. prior to 15.9.2009 (the date of commencement of the policy). Therefore, the OPs cannot draw any advantage from this report dated 11.9.2010.

12]      The claim has been repudiated on the ground that Complainant NO.2 was suffering from pre-existing diseases.  To prove it, the OPs have miserably failed to produce any evidence.  The ld.Counsel for OP NO.1 made a reference to the statement of Manmohan Singh, Complainant NO.2 (Ann.R-4), recorded on 21.1.2011. The said statement is not supported by the affidavit of the person, who recorded it. Otherwise also, Manmohan Singh, Complainant NO.2 specifically stated in the said statement that he has no knowledge with regard to c/o CLL. 

         The matter does not rest here.  The Complainant NO.2, in order to rebut the said statement, has filed his affidavit, wherein at Para No.2, he has specifically denied that he was diabetic for last 2-3 years.  He has also denied that he was patient of Hypertensive (HTN) and CLL, at the time of taking of policy.  He also stated that Ann.R-4 was executed under pressure, threat and constrained circumstances as 4-5 people well build approached him and disclosed that they are affiliated to Crime Branch of UT Policy.  He was made to execute the document Ann.R-4 and the same was dictated by the person, who was heading the team of detectives.  The said affidavit filed by Complainant NO.2 has gone unrebutted & uncontroverted. Thus, it is concluded that the OPs cannot  draw any advantage from the statement of complainant NO.2 (Ann.R-4), which is not supported by the affidavit of its author and more so, it has been rebutted by the affidavit of Manmohan Singh, Complainant NO.2.

13]      In view of the fact, we opine that complainant NO.2 was not suffering from any pre-existing disease. The OPs have failed to produce any evidence to prove the pre-existing disease, thus it is held that the repudiation of the claim is illegal & unjustified.   

14]      The Bill (Ann.C-7) issued by Prime Heart Hospital, dated 14.9.2010, proves that a sum of Rs.2,95,591/- was spent on the treatment of Manmohan Singh, Complainant NO.2, which too goes unrebutted and uncontroverted.

15]      As a result of the above discussion, we allow this complaint against OP No.1.  The OP No.1 – Oriental Insurance Company Limited is directed to pay the medical expenses incurred on the treatment of complainant NO.2 to the tune of Rs.2,95,591/-.  The OP No.1 is also directed to pay compensation of Rs.50,000/- along with litigation cost of Rs.15,000/-.

         This order be complied with by OP-1 within a period of 30 days from the date of its receipt, failing which it shall be liable to pay penal interest @12% p.a. on the awarded amount of Rs.3,45,591/- from the date of filing this complaint i.e. 21.12.2011 till its actual payment, besides paying litigation costs.

         However, the complaint qua OP No.2 stands dismissed.

         Certified copies of this order be sent to the parties free of charge.  The file be consigned.