JUDGMENT

            Complainant has filed this consumer complaint U/s.35 of C.P. Act, 2019 seeking following reliefs;

            “Direct the opposite parties are jointly to be held guilty for doing unfair trade practice by repudiating the reimbursement of the claim of the complainant and for deficiency of service towards the complainant in reimbursement of his claim under the policy, which was paid to the Hospital by the complainant and the opposite parties be directed to pay a sum of Rs.3,91,218/- i.e. Rs.2,91,218/- which was paid by the complainant to Apollo Hospital as per bill and Rs.1,00,000/- towards mental agony and pecuniary loss for claiming amount along with cost of litigation”.

            The brief fact of the complainant is that, complainant is a permanent resident of village Kaliabara, Odiso of Jagatsinghpur district and resides there with his family. The opposite parties are registered insurance company i.e. the Star Health & Allied Insurance Co. Ltd. registered under the IRDA of India bearing Regd. No.129, with corporate identity No.U66010TN2005PLC056649.  The opposite parties floated various health insurance scheme to insure the general public against their health hazards as per the policy condition of the policy issued to them during the policy coverage period and also floated the policy/product of Family Health Optima Insurance Plan 2017. Complainant decided to purchase the insurance product Family health Optima Insurance Plan 2017 with unique identification Plan No.IRDAI/HLT/SHAI/P-H/V.III/129/2017-18 from opposite parties Jagatsinghpur Branch Office and submitted proposal to the opposite parties on 23.3.2020 for purchase of their product, which was accepted by the opposite parties on deposit of Rs.15,290/- towards one time premium amount and subsequently insurance policy was issued to the complainant for the period from 23.3.2020 to 22.3.2021 (midnight) with limit of coverage of Rs.5,00,000/- covering the health hazard of the insured viz. Banoj Mohanty (complainant), Maheswata Mohanty, Prachi Mohanty and Prachuryaa Mohanty, the wife and daughters of the complainant as beneficiary of the policy.

            During the policy coverage period of the above policy, the complainant felt severe chest pain on his person on 29.12.2020, 07.02.2021 and attained Apollo Hospital Bhubaneswar for check up and treatment and as per the advice of the treating physician the complainant under took several investigation on 29.12.2020, 07.02.2021 and 08.02.2021 and there after the complainant got admitted as an indoor patient in the hospital for “Coronary Angiogram” on 09.02.2021 and after the necessary surgery by the doctor, the complainant got cured and was discharged from the hospital on 11.02.2021. For his Coronary Artery Disease (CAD) spent a sum of Rs.2,91,218/-. Soon after hospitalization, the complainant intimated the opposite parties about his hospitalization for “CAD” and after discharge, submitted claim application to the opposite parties for reimbursement of his hospitalization expenses for the treatment and surgery along with copy of bills and other documents, which was registered as claim intimation No.CIR/2021/619005/2241224 by the opposite parties at their end. After repudiation of claim for re-imbursement of the medical expenses for diagnosis, hospitalization and treatment of the complainant, by the opposite parties vide their letter dtd.21.3.2021, the complainant again wrote a request letter on 28.3.2021 for reconsideration of his claim under the policy of health insurance issued to him, but the opposite parties vide letter dtd.23.4.2021 again repudiated the mediclaim of the complainant with the same finding “heart disease is a pre existing disease” expenses for which are not payable for 48 months as per exclusion clause (i).

            Notice was issued to opposite parties on 29.7.2021 and the opposite parties stated as follows in their written statement;

            In the name of complainant opposite parties issued the family Health Optima Insurance Plan being policy No.P/69005/01/2020/000225 for the period from 23.3.2020 to midnight 22.3.2021. On the date of issuance of the policy opposite parties had sent a letter dtd.23.3.20220 to the complainant in which it has been mentioned that the insurance policy is subject to various exclusion including for pre-existing disease and conditions in this policy. If there is suppression of any material fact in the proposal the contract shall become null and void abinitio. On dtd.21.3.2021 complainant has intimated vide letter that, “we have processed the claim records relating to the as above insured patient seeking reimbursement of hospitalization expenses for treatment of coronary aterry disease (CAD).” It is observed that the findings, our medical team is of the opinion that we insured patient has chronic, long standing heart disease existing period to inception of the medical insurance policy. Hence heart disease is a pre existing disease. The present admission and treatment of the insured patient is for the pre existing heart disease. We are therefore, unable to settle complainant’s claim under the above policy and we hereby repudiate the claim.

            As there is a question regarding whether the complainant has pre-existing disease (PED) or not, so this Commission summoned to Dr. Brajraj Das, M.D., Senior Consultant Interventional Cardiology Deptt., of APOLLO Hospital, Bhubaneswar vide No.416 dtd.07.7.2022 to appear personally before this Commission on 21.7.2022 at 1.30 PM with expenses and subsistence allowance for one day borne by complainant.

            Dr. Brajaraj Das, Cardiologist, APOLLO Hospital and the medical expert appeared before this Commission on 21.7.2022 and stated that, “I have given certificate on 09.02.2021 during hospitalization that the patient Banoj Mohanty was not having the pre-existing cardiology before this treatment in APOLLO hospital, which I am producing before this Commission. There is no history of pre existing heart disease or cardiology problem of the complainant”. Dr. Brajaraj Das has also cross examined by the counsel for opposite parties and stated that, “It is not a fact that the complainant has pre existing cardiology patient and it is not a fact that I have prepared the documents to submit the complainant and I am deposing false.”

            It is a admitted fact that complainant has purchased the product of “Family Health Optima Insurance plan, 2017” from the opposite party on consideration i.e. for Rs.15,290/- towards one time premium amount. So the complainant is a relevant consumer of opposite parties as per Sec.2 (7) of the Consumer Protection Act, 2019. Complainant was admitted on 09.02.2021 as an indoor patient in hospital after feeling ill and there surgery was done and he got cured and discharged from the hospital on 11.02.2021 after getting a stable condition. Complainant submitted claim application to the opposite parties for reimbursement of his expenses for his treatment and surgery along with copy of bills and other documents which was registered as claim No.CIR/2021/619005/2241224 with opposite parties who vide his letter dtd.21.3.2021 repudiated the claim of the complainant by giving finding “that the insured patient has chronic long standing heart disease existing prior to the inception of the policy, hence heart disease is a pre existing disease, the present admission and treatment of the insured patient is for pre-existing heart disease.” As per the Hon’ble Supreme Court vide Civil Appeal No.8386/2015 Manmohan Nanda vrs. United India Assurance, “on mediclaim policy insurer cannot reject claim by citing existing medical condition”.

            It is crystal clear from the statement of the medical expert and the then surgeon of the complainant is that the complainant has not any pre existing cardiology disease and it is quite normal that one can fall ill at any time. From this it is clear that the opposite parties have negligence on their part which caused deficiency in service on the part of the opposite parties and even if any disease pre exit that cannot be rejected in view of the decision cited above.

            Hence opposite parties are directed to reimburse all the insurance claim i.e. Rs.2,91,217.94 paisa to the complainant immediately and we impose cost of Rs.20,000/- as compensation for harassment and mental agony and Rs.5,000/- as cost of litigation to be paid to the complainant within 45 days from the date of order.