Haryana

Karnal

CC/107/2020

Anooj Kumar - Complainant(s)

Versus

The Regional Manager, Star Health & Allied Insurance Company Limited - Opp.Party(s)

P.S. Rana

15 May 2023

ORDER

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION, KARNAL.

                                                        Complaint No. 107 of 2020

                                                        Date of instt.17.02.2020

                                                        Date of Decision:15.05.2023

 

Anooj Kumar son of Shri Ram Kumar Garg, resident of house no.192B, ward no.9, near Daya Ram Mandir, Taraori, District Karnal.

                                               …….Complainant.

                                              Versus

 

1.     The Regional Manager, Star Health and Allied Insurance Company Ltd. SCO no.5A, 2^nd floor, Sector-7C, Chandigarh-160019.

 

2.     The Branch Manager, Star Health and Allied Insurance Company Ltd. 2^nd floor, SCF-137, Urban Estate, near ICICI Bank, Karnal-132001 (Haryana)

                                                                      …..Opposite Parties.

 

Complaint Under Section 12 of the Consumer Protection Act, 1986 and after amendment Under Section 35 of Consumer Protection Act, 2019.

 

Before   Shri Jaswant Singh……President

              Shri Vineet Kaushik…..Member

              Dr. Rekha Chaudhary…..Member

                   

Argued by: Shri Gulshan Galhotra, counsel for complainant

                   Shri Naveen Khetarpal, counsel for the OPs.

 

                    (jaswant singh, president)

ORDER:    

          

                The complainant has filed the present complaint Under Section 12 of the Consumer Protection Act, 1986 as after amendment under Section 35 of Consumer Protection Act, 2019 against the opposite parties (hereinafter referred to as ‘OPs’) on the averments that complainant had purchased a family health insurance plan from the OPs on 24.03.2017. Prior to this the OPs got medically examined the complainant from the doctor concerned, who are working on penal basis for the company and being satisfied for health condition of the complainant, the OPs had issued family health insurance plan, vide policy no.P/211114/01/2017/007672 to the complainant. On 22.03.2018,  the complainant had deposited second installment amounting to Rs.15,287/-. Similarly, the complainant further deposited third installment amounting to Rs.15,287/- on 22.03.2019. Unfortunately, complainant suffered some problem in his both eyes and he further medically checked up from Eye Surgeon of City Karnal like Dr. Nageshwar Gupta, Eye Specialist, Railway Road, Karnal and Dr. Nageshwar Gupta have opined that the complainant should take treatment of his both eyes either from Chandigarh/Delhi or from any other city. The complainant had not visited to Chandigarh/Delhi for his treatment since he came to know that Dr.P.S. Hardia and Dr. Rajeev Hardia c/o Dr. P.S.Hardia Advanced Eye Surgery & Research Institute, Rau (Indore). The complainant alongwith his mother Smt. Narbader Kumari and son Sushobit went there by train after spending an amount of Rs.25000/-. Besides this, complainant stayed there eight days continuously and both eyes of the complainant were operated by Dr. P.S. Hardia at Indore (MP). Rs.50,000/- had been charged from the complainant by the said hospital at Indore for operating the disease of glaucoma in both the eyes of the complainant. Accordingly, complainant had submitted his medical bills, journey expenses, hotel charges etc. to the office of OPs at Karnal and completed all other formalities. Thereafter, complainant requested the OPs so many times to settle the claim but OPs did not settle the same and lastly repudiated the genuine claim of complainant, vide letter dated 28.08.2019 without any sufficient cause or reason. Then complainant sent a legal notice dated 26.11.2019 to the OPs but it also did not yield any result. In this way there is deficiency in service and unfair trade practice. Hence this complaint.

2.             On notice, OPs appeared and filed its written version raising preliminary objections with regard to maintainability; cause of action; mis-joinder and non-joinder of necessary parties and concealment of true and material facts. On merits, it is pleaded that the insured Anooj Kumar availed the Family Health Optima Insurance plan covering Mr. Anooj Kumar-self, Mrs. Neeru Bala- spouse, Mr. Ashish Garg and Sushobit Garg-dependent children for the floater sum insured of Rs.5,00,000/-, vide policy no.P/211114/01/2018/009751 for a period 24.03.2018 to 23.03.2019. The terms and conditions of the policy were explained to the complainant at the time of proposing policy and the same was served to the complainant alongwith the policy schedule. The complainant has accepted the policy agreeing and being fully aware of such terms and conditions and executed the proposal form. It is further pleaded that insured patient, Mr. Anooj Kumar was hospitalized at Dr. P.S. Hardia Advanced Eye Surgery & Research Institute-Nihalpur, Mundi on 01.05.2019 for the treatment Glaucoma and submitted a claim for reimbursement of medical expenses of Rs.45,201/-. On scrutiny of the claim documents submitted by the insured, it is noted that the insured was diagnosed with Glaucoma, Glaucoma is the result of damage to the optic nerve. As this nerve gradually deteriorates, blind spots develop in your visual field. Our medical team is of the opinion that the ailment of the insured patient is long standing and presents prior to date of commencement of first year policy and hence it is a pre-existing disease. As per waiting period clause no.3(iii) of the policy, “Pre-existing diseases as defined in the policy until 48 consecutive months of continuous coverage have elapsed, since inception of the first policy with any Indian General/Health Insurer.” Hence, the claim is not liable under waiting period clause no.3(iii) of the policy. The present admission and treatment of the insured patient is for pre-existing disease. Therefore, it is evident that that the present admission and treatment is for the complication of the pre-existing disease. Hence, claim was repudiated, vide letter dated 29.08.2019. There is no deficiency in service and unfair trade practice on the part of the OP. The other allegations made in the complaint have been denied and prayed for dismissal of the complaint.

3.             Parties then led their respective evidence.

4.             Learned counsel for the complainant has tendered into evidence affidavit of complainant Ex.CW1/A, copy of Aadhar card Ex.C1, copy of repudiation letter dated 29.08.2019 Ex.C2, copy of 1^st policy receipt dated 24.03.2017 Ex.C3, copy of authorization letter to OP Ex.C4, copy of claim form Ex.C5, copy of rejection of claim letter Ex.C6, copy of 1^st policy dated 24.03.2017 Ex.C7, copy of 2^nd policy and third policy Ex.C8 and Ex.C9, copy of legal notice dated 25.11.2019 and 26.11.2019 Ex.C10 and Ex.C11, copy of bill receipt dated 01.05.2019 and 02.05.2019 Ex.C12 and Ex.C13, copy of certificate of Dr. P.S. Hardia dated 17.05.2004 Ex.C14, copy of bills receipt dated 13.07.2018, 13.07.2018, 02.05.2018, 01.05.2018, 01.05.2018, 01.05.2018, 01.05.2018, 02.05.2018, 02.05.2018, 02.05.2018, 03.05.2018 and 01.05.2019 Ex.C15 to Ex.C26 and closed the evidence on 03.02.2022 by suffering separate statement.

5.             On the other hand, learned counsel for the OPs has tendered into evidence affidavit of Rajiv Jain, Chief Manager Ex.RW1/A, copy of proposal form Ex.R1, copy of insurance policies Ex.R2 to Ex.R4, copy of terms and conditions of the insurance policies Ex.R5, copy of claim form Ex.R6, copy of treatment chart Ex.R7, copy of bill Ex.R8, copy of letter dated 28.05.2019 Ex.R9,  copy of 1^st reminder dated 12.06.2019 Ex.R10, copy of 2^nd reminder dated 27.06.2019 Ex.R11, copy of letter dated 12.07.2019 regarding rejection of claim Ex.R12, copy of letter dated 31.07.2019 regarding requirement of additional documents Ex.R13, copy of letter dated 15.08.2019 regarding requirement of additional documents Ex.R14,  copy of repudiation letter dated 29.08.2019 Ex.R15, copy of coronavirus covid-19 latest news and information Ex.R16, copy of bill assessment sheet Ex.R17 and closed the evidence on 21.12.2022 by suffering separate statement.

6.             We have heard the learned counsel of the parties and perused the case file carefully and have also gone through the evidence led by the parties.

7.             Learned counsel for complainant, while reiterating the contents of the complaint, has vehemently argued that complainant had purchased a family health insurance plan from the OPs on 24.03.2017. To continue the said policy, complainant has deposited second installment on 22.03.2018 and third installment on 22.03.2019. Complainant suffered some problem in his both eyes. The complainant took the treatment of his eyes from Dr.P.S. Hardia and Dr. Rajeev Hardia c/o Dr. P.S.Hardia Advanced Eye Surgery & Research Institute, Rau (Indore) and spent an amount of Rs.50,000/- on his treatment.  After discharge from the hospital, complainant had submitted his medical bills, journey expenses, hotel charges etc. to the office of OPs at Karnal and completed all other formalities and requested the OPs so many times to settle the claim but OPs did not settle the same and lastly repudiated the genuine claim of complainant, vide letter dated 29.08.2019 without any sufficient cause or reason and lastly prayed for allowing the complaint.

8.             Per contra, learned counsel for the OPs, while reiterating the contents of written version has vehemently argued that complainant availed the Family Health Optima Insurance plan covering himself and his family members for the sum insured of Rs.5,00,000/- from the OPs. He further argued that complainant was hospitalized at Dr. P.S. Hardia Advanced Eye Surgery & Research Institute-Nihalpur, Mundi on 01.05.2019 for the treatment Glaucoma and submitted a claim for reimbursement of medical expenses of Rs.45,201/-. On scrutiny of the claim documents, it is found that the insured was diagnosed with Glaucoma and the medical team of the OPs is of the opinion that the ailment of the insured patient is long standing and exists prior to date of commencement of first year policy and hence it is a pre-existing disease. Thus, claim was repudiated, vide letter dated 29.08.2019.

9.             We have duly considered the rival contentions of the parties.

10.           Admittedly, complainant has availed the health insurance policy from the OPs. It is also admitted that during the subsistence of the insurance policy complainant was hospitalized at Dr. P.S. Hardia Advanced Eye Surgery & Research Institute-Nihalpur, Mundi on 01.05.2019 for the treatment Glaucoma.

11.           The claim of the complainant has been repudiated by the OP, vide repudiation letter Ex.C2/Ex.R15 dated 29.08.2019 on the ground, which reproduced as under:-

“We have processed the claim records relating to the above insured-patient seeking reimbursement of hospitalization expenses for treatment of glaucoma.

It is observed that as per submitted medical records, our medical team is of the opinion that above ailment of the insured patient is long standing and present prior to date of commencement of first year policy and hence it is a pre-existing disease. The present admission and treatment of the insured patient is for pre-existing disease.

As per waiting period 3(iii) of the policy issued to you, the company is not liable to make any payment in respect of expenses for treatment of the pre-existing disease/condition, until 48 months of continuous coverage has elapsed, since inception of the policy with the company on 24.03.2018.

We are, therefore, unable to settle your claim under the abovesaid policy and we hereby repudiate your claim.

 

12.           The onus to prove its version was relied upon the OPs, but OPs have miserably failed to prove the same by leading any cogent and convincing evidence. OPs have placed on record, treatment record of complainant Ex.R7, on perusal of the abovesaid treatment record, it is nowhere mentioned that complainant was taking treatment prior to inception of the insurance policy. Except the said record, there is no other medical record on the file to ascertain that the complainant was having any pre-existing disease. The repudiation of claim of complainant is only on the basis of presumption and assumption. Thus, the repudiation letter is totally arbitrarily, unjustified, biased, based on the presumptions and assumptions.  

13.            Further,  Hon’ble Punjab and Haryana High Court in case titled as New India Assurance Company Ltd. Versus Smt. Usha Yadav & others 2008 (3) RCR (Civil) 111, has held as under:-

“It seems that the Insurance Companies are only interested in earning the premiums which are rather too stiff now a days, but are not keen and are found to be evasive to discharge their liability. In large number of cases, the Insurance companies make the effected people to fight for getting their genuine claims. The Insurance Companies in such cases rely upon clauses of the agreements, which a person is generally made to sign on dotted lines at the time of obtaining policy. This is, thus pressed into service to either repudiate the claim or to reject the same. The Insurance Companies normally build their case on such clauses of the policy, but would adopt methods which would not be governed by the strict conditions contained in the policy”.

 14.          Keeping in view, the ratio of the law laid down in aforesaid judgment, facts and circumstances of the present complaint, we are of the considered view that act of the OPs while repudiating the claim of the complainant amounts to deficiency in service and unfair trade practice.

15 .          The complainant has spent Rs.45,201/- on his treatment, this fact has been proved from the copy of bill assessment sheet Ex.R17. Hence, the complainant is entitled for the said amount alongwith interest, compensation for mental harassment and litigation expenses etc.

16.           Thus, as a sequel to abovesaid discussion, we allow the present complaint and direct the OPs to pay Rs.45,201/- (Rs. forty five thousand two hundred one only) to the complainant alongwith interest @ 9% per annum from the date of repudiation of the claim till its realization. We further direct the OPs to pay Rs.10,000/- to the complainant on account of mental agony and harassment and Rs.5500/- towards the litigation expenses.  This order shall be complied with within 45 days from the receipt of copy of this order. The parties concerned be communicated of the order accordingly and the file be consigned to the record room after due compliance.

Announced

Dated:15.05.2023                                                                     

                                                               

                                                                  President,

                                                     District Consumer Disputes

                                                     Redressal Commission, Karnal.

 

 (Vineet Kaushik)       (Dr. Rekha Chaudhary)

                          Member                           Member