Delhi

East Delhi

CC/47/2017

RAKESH KUMAR - Complainant(s)

Versus

UNITED INDIA INS - Opp.Party(s)

21 Apr 2022

ORDER

DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION (EAST)

GOVT. OF NCT OF DELHI

CONVENIENT SHOPPING CENTRE, FIRST FLOOR,

SAINI ENCLAVE, DELHI – 110 092

 

 

C.C. NO. 47/2017

 

	Rakesh Sharma S/o Shri Brij Nandan Sharma E-56, Mansarovar Park Shahdara, Delhi	….Complainant
Versus
	United India Insurance Co. Ltd. Through its Branch Manager D-8, C.A. Azad Marg, Vikas Marg Laxmi Nagar, Delhi 110092	……OP

 

                                                         

 

Date of Institution: 15.02.2017

Judgment Reserved on: 07.03.2022

Judgment Passed on: 21.04.2022

                  

QUORUM:

Sh. S.S. Malhotra (President)

Ms.Ritu Garodia (Member) – on leave

Sh. Ravi Kumar (Member)

 

Order by :Sh. Ravi Kumar, Member

 

JUDGEMENT

1. Complainant is husband of Smt. Sangeeta Sharma and he in his complaint has contended that he had taken Premium Insurance Policy for himself and his family including his wife from OP vide policy no. 2215002814P105593159 for the period 21.10.2014 to 20.10.2015 by paying appropriate premium for total sum insured of Rs.5,00,000/-. The Complainant received Policy Schedule but was not given any terms & conditions of policy. On 5.3.2015 when Smt. Sangeeta Sharma, his wife, was suffering from breathlessness and she was admitted in Sir Gangaram Hospital, Delhi, due intimation to this effect was given to the OP by the complainant. Hospital sent cashless hospitalization request but the same was not processed by the OP and the complainant was assured that the entire amount will be reimbursed later on. Despite the fact that the cashless reimbursement was denied, the complainant continued with the treatment of his wife. Thereafter, she remained admitted in the hospital till 3.4.2015 where doctors tried their best but the wife of the complainant could not revive from the illness and she died on 3.4.2015 where the total expenses came around Rs.7,60,670/- which was paid by complainant in the Hospital. Although, the Complainant was very much shocked on account of death of his wife yet the complainant filed insurance claim and as per the advice of OP, deposited all the original and relevant documents  with OP, however the Claim was repudiated which amounts to deficiency in service and complainant has prayed this Commission to direct the OP to pay a sum of Rs.7,60,670/- towards the expenses of medical treatment of the wife of the complainant, pay interest @24% p.a. on the above mentioned sum i.e. Rs.7,60,670/-, pay a sum of Rs.1,00,000/- towards damages for harassment, tension and agony undergone by the complainant and pay a sum of Rs.25,000/- towards costs.
2. OP in its reply dated 6.9.2018 stated that Health Insurance Policy as above was issued and the claim under the same raised by the complainant was closed for want of complete paper/documents which were not provided inspite of reminders dated 2.6.2015, 16.9.2015, 28.7.2015, 8.9.2015 and despite specific request made further to Sir Gangaram Hospital under email dated 15.3.2015 particularly for the OPD/consultation papers of T.B. and all past treatment records of T.B. for which wife of the complainant was admitted for treatment in the hospital. The closure of the claim file by the OP was on account of non-cooperation of the complainant and the hospital also failed to supply the information/documents required for the processing the claim.

OP has denied that terms and conditions of policy were not provided to complainant particularly qua pre-existing clause. The complainant was well aware of the fact that if there is pre-existing disease then claim is not payable by OP being 1^st year of Policy. The above facts regarding pre-existing disease are confirmed in the Death Summary of his wife by the doctors of Sir Gangaram Hospital containing the observations of the doctor that ‘chest x-ray showed left side destroyed lung’ which cannot happen to Mrs. Sangeeta Sharma at the time of admission only, in the Hospital rather the disease existed long before the hospitalization at Sir Gangaram Hospital. The Hospital was requested for further information regarding ‘Past OPD paper, KOCHS, first consultation papers regarding the disease’. Earlier also on the receipt of request by the said hospital regarding cashless facility by way of email dated 15.3.2015, such papers were asked but the said hospital was evasive in their reply. The OP was therefore, unable to respond to cashless facility. In the certificate dated 6.6.2015 issued by Doctor of Sir Gangaram Hospital no details were provided for the past history of disease T.B. and therefore, due to non-cooperation of the complainant to provide the details as were required to process the claim resulted in closure of the claim by the OP and there is no deficiency in service on their part. Further para 3.29 which is in the exclusion clause of the Policy reads as under :

•  

3. Complainant in his rejoinder dated 16.10.2018 has stated that he had filed an RTI application which was replied by OP. On the request of the OP the complainant again supplied all related documents on 6.6.2017 after filing the present complaint. The complainant had purchased Platinum Insurance Policy in which all diseases were covered and there is no evidence of any pre-existing disease, details of which, OP had been asking and treating doctor has already issued the certificate regarding disease of patient and the medical treatment and there is no evidence which may show that there was any pre-existing disease. Clause 3.29 of the policy which has been mentioned by the OP is not tenable as that is not applicable. Complainant has further stated that he did not receive reminder letters sent by OP and OP has not filed any proof of dispatch and delivery of such letter. Even otherwise after filing of present complaint, the complainant had filed all the documents vide letter dated 6.6.2017 and therefore, nothing remains qua the contention of OP, regarding documents but even then also OP has not processed his claim. Clause 3.29 of the policy is not applicable because in this case there is no evidence which may show that there was any pre-existing disease to her wife, because for any such disease the patient was not having knowledge and no treatment was taken by the patient for any such disease. Even otherwise only few Terms & Conditions were supplied with the letter which were just part of Policy but no other terms & conditions were ever supplied by the OP to the Complainant. The certificate and the discharge summary are same and OP cannot mislead by putting false averments and the certificate issued by the doctor was as per the actual medical treatment.
4. Complainant has filed his evidence by way of affidavit dated 16.10.2018 alongwith following documents i.e. copy of policy annexure C-2, copy of letter dated 5.3.2015 as annexure C-3, copy of death summary of wife of the complainant as annexure C-4, copy of cashless form as annexure C-5, copy of bill of payment of medical expenses as annexure C-6, certificate of doctor dated 6.6.2017 as annexure C-7, copy of legal notice dated 31.10.2015 as annexure C-8, copy of RTI application filed with rejoinder as R-1 and reply to the same which has been filed with rejoinder as R-2, copy of letter dated 6.6.2017 as annexed with rejoinder as  R-3.
5. OP filed its evidence by way of affidavit dated 17.1.2019 alongwith copy of policy number 2215002814P105593159 for the period 21.10.2014 to 20.10.2015 (first year policy) as exhibit OP-A1 alongwith Terms & Conditions, copy of letter dated 2.6.2015 addressed to Complainant regarding documents called for as exhibit OP-A, letter dated 19.6.2015 as exhibit OP-B, letter dated 28.7.2015 as exhibit OP-C, letter dated 8.9.2015 as exhibit OP-D, request made to Sir Gangaram Hospital under email/letter dt. 15.3.2015 regarding cashless facility as exhibit OP-E.
6. This Commission has gone through the documents on record and heard the Ld. Counsels of both sides.
7. The Complainant has contended that he had purchased Premium Medical Policy from the OP bearing no. 2215002814P105593159 effective from 21.10.2014 to 20.10.2015 and his wife Smt. Sangeeta Sharma was admitted in Sir Gangaram Hospital on 5.3.2015 and despite submitting of all the documents alongwith his claim, the OP has repudiated his case by not assigning any valid reason. Annexure C-4 which is the death summary dated 3.4.2015 of Smt. Sangeeta Sharma reveals that she was admitted with complaint of ‘breathlessness since last two weeks associated with cough with expectoration and low grade fever’. Chest X-ray shows that her left side lung was destroyed and her right lung having mid zone infiltrates. She was suffering from respiratory distress and after initial treatment when her health detoriated she was put on ventilator support. However, despite all medical treatment, she could not be saved and she expired on 3.4.2015. Upon her admission in Sir Gangaram Hospital, on 5.3.2015, the Complainant informed OP (Annexure C-3) and thereafter hospital raised cashless hospitalization request with OP (Annexure C-5). In the said document it is also mentioned that patient was transferred from another hospital and the patient was suffering from altered sensorium for last 4 days, Pulmonary T.B. on CAT II DOTS,she was drowsy not arousable and ATT since December 2014 and had seizure one month ago. On Cashless request OP had raised query on 15.3.2015 by email to Sir Gangaram Hospital wherein certain more information regarding past OPD papers, KOCHS, First consultation paper etc was sought and in the reply the Hospital has stated that patient is diagnosed as a case of pulmonary Tuberculosis as ET AFB was positive. Patient was on ventilator support for airway protection and patient was in sepsis and had metabolic  encephalopathy.
8. The OP on the other hand contended that Death Summary of the Patient Smt Sangeeta Sharma revealed that her left side lung was destroyed which cannot happened to her at the time of admission only but the disease (T.B) had existed long before the hospitalization at Sir Gangaram Hospital and this material fact was concealed by the complainant. To OP’s email dated 15.3.2015, the Hospital was evasive in their reply and failed to reply in respect of past history of disease which resulted in rejection of cashless facility. The letter dated 6.6.2017 issued by the doctor concerned of Sir Gangaram Hospital is incomplete in which no details were provided for past history of disease T.B.
9. No satisfactory reply regarding the pre-existing disease was received alongwith details as to since when she was suffering from T.B. and any record of past O.P.D., KOCHS, First Consultation etc. was not provided by hospital to OP. This resulted in rejection of cashless facility whereas the treatment continued in same hospital and despite best efforts, the patient could not survive and she expired on 3.4.2015. The outstanding bill of hospital to the extent of Rs.760670/- was paid by the complainant and claim of the said amount was raised before the OP under the policy. Thereafter, also OP sent several letters dated 2.6.2015, 19.6.2015, 28.7.2015 and 8.9.2015 to which no reply was given by complainant. However, complainant wrote letter dated 6.6.2017 to the OP stating that he has already submitted the required documents and requested to process his claim and he also produced letter dated 6.8.2015 of Sir Gangaram Hospital with regard to treatment of his wife Smt. Sangeeta Sharma. The contents of the letter read as under:

 

‘This is to certify that Mrs. Sangeeta Sharma, 32 years old Female had complaints of breathlessness since two weeks associated with cough with expectoration for which she was evaluated outside and was found to have sputum AFB positive. She was started on ATT. She developed altered sensorium and seizures, she was evaluated in SGRH casualty where she was found to hypoxic and was in respiratory failure. She was then intubated and was admitted in ICU vide registration no. 1618008 for further management.’

10. From the above it is established that the wife of complainant was suffering from T.B. even prior to getting the insurance policy from OP. There is merit in the contention of the OP that the damages of the lung of the patient through T.B. cannot happen suddenly and there is every probability that she was suffering from T.B. earlier and for that OP has been asking the complainant to submit previous illness/treatment papers. However Complainant did not produce any such previous documents. The preponderance of probability is more inclined against the Complainant keeping in mind the nature of illness his wife was suffering and also from the facts that her left Lung had been fully damaged. If a person is suffering from T.B. and damage is caused to the extent that his/her Lung is damaged then it is very difficult to accept that he/she was not taking any treatment from any Doctor either in OPD or IPD earlier. The Complainant appears to be aware of the fact that as per the Terms & Conditions of the Policy Under Clause 3.29 no claim can be made if the patient had pre-existing disease. Complainant has also contended that he did not receive complete Policy and its Terms & Conditions and was only provided Policy Schedule, however he has enclosed document Exhibit C2 according to which it contains page 1 -17 but only page 1 and page 17 were filed by the Complainant and not all the pages. The reasons behind it are best known to him. Therefore, the contention of the complainant that he was not given complete Terms and Conditions of the policy is not correct.

Clause 3.29 is repeated here even at the risk of repetition and          the same is exclusion clause -

PRE-EXISTING DISEASE - ‘Any condition, ailment or injury or relation condition(s) for which you had signs or symptoms,     and/or were diagnosed, and/or received medical advice/treatment within 48 months to prior to the first policy issued by the insurer’.

11. During the pendency of the case the complainant had filed an RTI application dated 31.3.2017 and he has enclosed letter dated 1.5.2017 of OP between one office or another wherein it is mentioned that reimbursement claim was closed due to non-receipt of documents and cashless claim was denied by invoking exclusion clause of PED as the policy was first year policy and patient was suffering from ‘disseminated T.B. with drug induced hepatitis and as per attached prescription the patient was having KOCH since 12/14. The complainant had not supplied the required information and therefore the claim was closed and was not repudiated.
12. It has to be borne in the mind that the claim made by the complainant has not been repudiated on merits but the same has been closed by the OP as complainant did not provide required information about the pre existing disease. The stand of the complainant is that since his wife was not suffering from pre-existing disease of T.B., therefore, there is no question of providing any document of the same but this stand of the complainant is not satisfactory as according to medical science T.B. grows in stages and symptoms also comes to surface in stages and in the present case left Lung of the wife of the Complainant has already been damaged. This observation of the doctor could have been disapproved by the complainant though previous documents which have not been filed. Further at the time of applying for cashless treatment on 5.3.2015 (Annexure C5) his wife was diagnosed to have been suffering from Pulmonary T.B. It cannot be believed that the complainant was not aware of such ailment or that this disease surfaced all of sudden. This observation of treating doctors has not been disproved by the complainant. Further, it is also mentioned on the said document ‘Transferred from another Hospital’ but no details regarding the same are filed on record by the complainant. Therefore, it cannot be said that the wife of the complainant had suffered the disease T.B. suddenly. No doubt she was hospitalized on 5.3.2015 and she expired on 3.4.2015 and during the course of her treatment at Sir Gangaram Hospital she was given best possible treatment but because of seriousness of her illness she could not recovered and expired.
13. In view of the above this Commission is of opinion that in these circumstances, deficiencies, if any, are on the part of complainant who has not produced complete documents of previous treatment. The adverse inference also goes against the complainant for the reason that if the complainant would have produced these documents they might have been gone against the complainant. Hence, no deficiency in service can be attributed to the OP and this is the reason that  the Claim of the Complainant was not repudiated rather was closed due to want of documents from Complainant and therefore, the Commission concludes as follow-
14. The complaint is dismissed.
15. No order as to cost
16. Copy of the order be supplied / sent to the parties free of cost as per rules.
17. File be consigned to Record Room.
18. Announced on 21.4.2022

DELHI

 

 

(on leave)

(Ritu Garodia) Member

(Ravi Kumar) Member

(S.S. Malhotra) President